made since then, and that any physician can make for himself even now in the sporadic cases of influenza, justify the conclusion that this epidemic infectious disease occupies an important place in the etiology of aural complications. It was learned by the statistics of Ludwig and Jansen that a rapid increase in middle-ear diseases occurred during the months of November and December, 1889, and January, 1890, and this increase was attributed to the epidemic which was prevalent at that time. It is important to note that the increase did not affect middle-ear diseases in general, but was limited exclusively to inflammations of the middle ear. Thus, in the Halle Ear Clinic the number reached 137 during the months of the epidemic, as against 41 or 44 during the same months of the preceding years; and, according to Gruber, there were 625 cases from November, 1889, to January, 1890, as against 238 and 84 during the same period of the preceding years. Jansen's statistics are most convincing in this respect: they show that the percentage of acute inflammations of the middle ear, which in the first eleven months of the year 1889 amounted to from 10% to 17.7%, rose to 37% in December, 1889, 29% in January, and 20.6% in February 1890, although there was no appreciable increase in the frequency of simple catarrh of the middle ear. The discrepancy can not be explained as an ordinary increase in the frequency of the disease due to the season of the year, since the comparison with the months of November, December, and January of the five preceding years shows a percentage ranging from 8.1 to 21.5, and in only one winter a percentage as high as 25.5. In spite of the increase in this particular form of disease the total number of patients was not appreciably increased, as might have been expected from the general prevalence of disease during the epidemic. Leichtenstern's objection, that "the statistics of specialists merely show the enormous distribution of the influenza," is quite irrelevant. On the contrary, if we examine the statistics of specialists, we find that the great frequency of certain ear diseases such as acute inflammation and suppuration of the middle ear which are known to follow in the wake of other infectious diseases-and their abnormally rapid and malignant course during an epidemic of influenza, are not merely accidental, but directly dependent on the epidemic. With regard to the frequency of aural complications of influenza in general we possess only general statistics, according to which from 0.5% to 2% of all cases are complicated with disease of the ear; but these figures are probably below the true percentage, as the milder cases of influenza remain only a short time in the hospital, and the aural disease therefore appears only as a sequel. The otitis in influenza makes its appearance in the form of an acute suppuration of the middle ear from a few days to several weeks after the beginning of the primary disease. As influenza is an infectious disease with a special preference for the upper air-passages, it is probable that a large proportion of the aural affections are due to infection from the nasopharynx through the tubes, and, as such, appear under the form of an ordinary purulent otitis media. There is, in addition, another manifestation of influenza which possesses a distinct hemorrhagic character, and is by many regarded as a pure form of influenza otitis. These two varieties can not be accurately distinguished in practice, as the typical appearance in the latter form disappears after the first few days and is replaced by the picture of an ordinary otitis media. The finding of the bacillus of influenza-which was first positively reported by Scheibe, and after him by several other investigators, although never with any regularity-is of very little importance, as sooner or later in any form of suppuration from the middle ear there develops a mixed infection in which other microorganisms may supplant the primary disease germ. As regards the clinical course of influenza otitis, it was formerly universally believed that hemorrhages were to be regarded as a regular symptom of the disease in the acute form, in accordance with the first descriptions given by Patrzek, Schwabach, Dreyfuss, and Jankau; Schwartze, however, adheres to his opinion that the hemorrhages are not observed with any greater frequency than in inflammations from other causes. We find ecchymoses, varying from the size of a pinhead to that of a split pea, either single or multiple, on the ear-drum and on the walls of the external meatus; or we may have bluish-red extravasations of varying extent, sometimes covering the entire ear-drum. Körner1 speaks of secondary circular hemorrhages which he saw through the ear-drum after hypertrophy of the 1 "Zeitschr. f. Ohr.," XXVII, p. II. mucous membrane. The hemorrhages often take the form of villous or pouch-shaped diverticula in the tympanic mucous membrane, due to marked swelling of the mucous membrane of the middle ear, and, after perforation, prolapse through that structure into the external meatus. They show a special tendency to recurrence, and frequently reform after simple cauterization. Some observers speak of perforation taking place in a definite portion of the eardrum, but the statements are so contradictory that it is not worth while to repeat them; isolated involvement of the cupola (infundibulum cochleæ) in influenza, mentioned by Kosegarten and Haug, must be very rare. The discharges are bloody on the first day, and hemorrhages may occur even later without leading to suppuration, while in other cases the bloody discharge is replaced by serosanguineous fluid, which is eventually followed by suppuration. The statement that purulent otitis media in influenza is more severe than other forms of suppuration from the middle ear is based on the frequent implication of the mastoid process (according to Jansen, in 57 out of 105 cases, 25 of which necessitated trephining). The complication leads to suppurations in the bone and to periosteal abscess, which are greatly to be dreaded on account of the intensity of the process and its rapid extension. According to Körner, Eulenstein, and Lemcke, primary myelitis of the mastoid process with secondary involvement of the middle ear may occur; but the opposite direction, from the middle ear to the mastoid process, is probably to be regarded as the regular mode of infection. The internal ear is very rarely involved, and the nature of the condition is not known. Lannois 1 and Barnick 2 described cases of labyrinthine deafness after influenza. According to the former, the prognosis as regards restoration of the hearing is bad; according to the latter, favorable. Gradenigo 3 mentions difficult hearing after influenza, which he interprets as a neuritis of the auditory nerve.4 The occurrence of otalgia tympanica is occasionally mentioned, and although the condition can hardly be diagnosed 1 Rev. de lar., d'ot. et de rhin.," 1890, No. 17. 2" Arch. f. Ohr.," 38, p. 183. 3 See "Arch. f. Ohr.," 36, p. 141. 4 Comp. Leyden and Guttmann, "Die Influenzaepidemie," Wiesbaden, 1892, p. 132; and Ebstein, "D. Arch. f. klin. Med.,” vol. LVIII, p. 14. with certainty, it may be accepted as a possible complication through the trifacial nerve, in view of the frequency of other neuralgic manifestations in influenza. 7. PAROTITIS EPIDEMICA (MUMPS). In this obscure epidemic disease, which belongs to the class of infectious diseases, the general infection manifests itself in various parts of the body, showing that the typical swelling of the parotid gland is only a local expression of the general disease. The commonest complication—that of orchitis and epididymitis-is as little understood as the occasional involvement of the ear. The aural complication usually takes the form of labyrinthine deafness, appearing, as a rule, during the first days of the disease, along with other symptoms of Ménière's complex, and offering an obstinate resistance to every mode of treatment, while the accompanying symptoms of vertigo, tinnitus aurium, and disturbances of the equilibrium subside. Like the complications in the sexual organs, those in the ear show a predilection for the age of puberty, being most frequent between the tenth and twentieth years.1 The total number of cases reported is very small. In 1884 Connor was able to collect 34 cases, and in 1883 Gradenigo could report only 38 positive observations of deafness due to mumps. One or both ears may be affected, and there appears to be no connection with the situation of the primary disease if the latter has been unilateral. There have even been reported rudimentary cases in which orchitis and deafness were present without glandular swelling (Gradenigo's case). As the prognosis is absolutely unfavorable, the disease may, if it be bilateral and occurs in early infancy, lead to deafmutism, the frequency of which is given as 0.3% by Mygind, in the Saxon deaf and dumb statistics, and as 0.5% by American statisticians. The otoscopic picture is in every respect negative, and there is absolutely no proof that inflammations of the tympanic membrane and exudations in the middle ear have anything to do with the disease. Functional test shows. deafness or marked reduction in the hearing of the internal 1 Gradenigo, "Schwartze's Handb.," II, p. 440. ear, while, according to Moos,1 the power of hearing for the lower notes and bone conduction may be preserved. Numerous attempts have been made to explain the deafness of infectious parotitis, but they are all more or less improbable, and therefore of no interest. The subject will be found discussed at length in papers by Rossa, Moos, Haug, Gradenigo,5 and Alt.6 2 3 Pilatti describes a case of parotitis in which tracheotomy was required on account of edema of the larynx. 8. ACUTE RHEUMATOID ARTHRITIS (POLYAR THRITIS RHEUMATICA ACUTA). One of the first diseases in which the tonsils were recognized as the port of entry for a general infection was acute articular rheumatism. The importance of angina in the etiology of this disease was first pointed out by Lagranère, Boeck, Loebl, Mantle, and others, all basing their assertions on clinical observations. But the confusion that still prevails with regard to the cause of acute articular rheumatism was not removed by the bacteriologic examination of cases of rheumatoid angina, for the greatest variety of microorganismsstaphylococcus aureus, pyogenic streptococci, streptococcus citreus, and pneumococci-was found. As this is not the place for a detailed theoretic discussion of the relation between the angina and rheumatism,—which will be found, together with a complete report of all the cases in the literature, in the works of Buss, 8 Suchannek, and Bloch, 10 -I shall merely refer briefly to the clinical observations that have been reported. Any one of the varieties of tonsillitis, both catarrhal and follicular, may appear either as a forerunner of rheumatism before the joints are affected, or as a feature of the fully developed clinical picture. The complication can not at the present time 1" Berlin. klin. Wochen.," 1884, No. 3. 9 3 Schwartze's Handb.," I, p. 584. 4. Die Krankh. des Ohres," etc., p. 75. 6" Mon. f. Ohr.," 1896, p. 525. See "Semon's Centralbl.," VIII, p. 149. 8 D. Arch. f. klin. Med.," vol. LIV. 9 Bresgen's Sammlung, vol. I, H. 1. 1066 Münch. med. Wochen.," 1898, Nos. 15, 16. |