with the tube. Diphtheric membranes are found adhering to the mucous membrane of the tympanic cavity or covering the ossicles or lining the cells in the bone. In a case of acute purulent otitis media after diphtheria, reported by Lommel,1 beginning membrane formation was found in individual mastoid cells.

The symptoms of the disease are those of any acute otitis media, rise of temperature and pain being the most prominent; the pain is aggravated by the fact that the eardrum shows no tendency to spontaneous perforation, so that expulsion of the membranes into the external meatus occurs only after paracentesis has been performed.

The course of a croupous disease of the ear following diphtheria appears to be the same as that of one following scarlet fever; both diseases are considered equally malignant as regards destruction of the walls and of the ossicles in the middle ear, the production of extensive caries in the temporal bone, and extension to the labyrinth, so that the prognosis must be regarded as unfavorable.

Nothing definite is known in regard to the frequency of true diphtheria in the ear. It is certainly very rare, and does not bear any proportion to the frequency of scarlatinal diphtheria.

3. It has been demonstrated by anatomic investigations— among which those of Wendt and Lommel 2 are worthy of special mention that even without clinical appearances, and certainly without any involvement of the drum membrane, certain alterations are regularly found in the middle ear of diphtheric cadavers which we must regard as due to catarrhal otitis media with or without serous exudation, catarrhal otitis media without purulent but with mucous secretion, or acute purulent otitis media. Although Lommel found pus in the middle ear in one-half of his cases, the ear-drum was never perforated nor even markedly congested, showing that a clinical diagnosis based on the appearance of the otoscopic image would have been impossible.

This explains why the anatomic findings of Lommel in regard to the frequency of aural complication in diphtheria are in direct opposition to clinical observations. While, on

1 "Zeitschr. f. Ohr.," XXIX, cases VII and XXIV, p. 301.

2

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Zeitschr. f. Ohr.," XXIX, p. 301.

the one hand, Lommel found the ear intact in only I out of 25 autopsies of diphtheric cadavers, and therefore laid down. the rule that otitis media forms an integral part of the clinical picture of "diphtheric disease of the respiratory organs," Baginsky, on the other hand, reports that although he examined the ears of his diphtheria patients with the greatest care, he found only from 5% to 6% in which an inflammation was present. Hence we must not overestimate the significance of these findings from a clinical point of view, and as in my cases the reports show that the alterations in the mucous membrane of the middle ear were very slight and analogous to those which are found in other infectious diseases,-especially measles (Rudolf and Bezold),—we must assume that they undergo regeneration without giving rise to any clinical symptoms.

As has been stated in connection with croupous inflammation of the middle ear, the tube may remain intact. Lommel found that the cartilaginous extremity was rarely attacked, while the "main central portion" was regularly free from any inflammatory process, even in one case where there was a diphtheric exudate about the orifice itself. Hence, direct extension of the inflammation from the pharynx to the middle ear is to be regarded as unusual, the middle-ear disease being rather the expression of the general infection; and I may remark that, in harmony with this statement, consecutive ear disease after nondiphtheric tonsillitis, whether of the catarrhal, lacunar, or suppurative variety, is rare, notwithstanding the fact that those diseases are usually referred to in the text-books as frequent etiologic factors in suppuration of the middle ear.

Lastly, it appears that nerve deafness may occur after diphtheria; it is probably due to toxic influences, and belongs to the class of postdiphtheric palsies. The cases reported are so few 2 3 and so incomplete that it is impossible to draw any conclusions from them.

1"Diphtherie und diphtheritischer Croup," in Nothnagel's "Spec. Path. u. Ther.," Bd. 11, 1. Th., p. 258.

2 Kretschmann, "Arch. f. Ohr.," XXIII, p. 236. Haug, "Die Krankh. des Ohres," etc., p. 69.

10. ERYSIPELAS.

Primary erysipelas of the mucous membrane of the upper air-passages is a very rare occurrence, and its pathology and clinical course can not readily be distinguished from those of other infectious diseases of the mucous membrane attended with high fever, redness, swelling, edema, and leading finally to abscess formation. Indeed, various authors have objected to applying the term erysipelas to any disease of the pharynx or larynx. Kuttner1 and Semon 2 are probably quite right in advocating the adoption of the general term "acute septic inflammations of the larynx," rejecting the terms erysipelas of the pharynx and larynx, phlegmon, angina (Ludovici), or acute edema of the pharynx and larynx as being merely synonymous terms for the same clinical picture. Cases of undoubted erysipelatous infection of the mucous membranes of the throat, while rare, are none the less of the highest importance, as primary erysipelas of the mucous membrane of the nose, pharynx, larynx, and mouth may, by extension to the external skin, give rise to secondary facial erysipelas. This once occurred in Schwartze's ear clinic: a patient who had had a pharyngeal tonsil removed went to see an erysipelatous patient and contracted erysipelas of the nasopharynx, which spread through the tubes to the middle ear, and from there to the external meatus, the auricle, and the face. Rendu 4 saw a case of erysipelas, where the diagnosis was confirmed by bacteriologic examination, in a man suffering with syphilitic glossitis; there was a fresh rise in the temperature when the erysipelas spread to the face. Garel 5 describes a case of erysipelas which began in the tongue and reached the face by way of the pharynx and nose.

3

Erysipelas occasionally occurs as a remote consequence of disease of the anterior nares, of the auricle, and of the external auditory meatus, for excoriations and rhagades due to chronic eczema may form the port of entry for the germs of the disease. That this is the mode of infection is proved by the subsequent extension of the erysipelas, which in

1 "Larynxödem und submuköse Laryngitis," Berlin, 1895, Georg Reimer. 2. Med. chirurg. Transactions," vol. LXXVIII, 1895.

3" Arch. f. Ohr.," vol. XXXVIII, p. 213.

4" France méd.," 1892; see "Semon's Centralbl.," x, p. 131. 5 Ann. des malad. de l'oreille," etc., 1891, No. 5.

such cases first appears in the neighborhood of the nose and ear, and gradually extends from those points to the skin of the face and head. This variety often shows a tendency to recurrence, and habitual facial erysipelas 1 is usually due to chronic eczema of the nose or of the ear.

This etiologic sequence is important from a therapeutic point of view, as the occurrence of erysipelas can be guarded against only by combating the eczema and the basal disease which is responsible for the eczema, such as chronic rhinitis or suppuration from a neighboring cavity or from the ear.

A suppuration from the middle ear due to erysipelas, like any other suppuration, may extend to the labyrinth and produce symptoms in that locality, as shown in a case reported by Schwartze. I can not imagine what Haug 2 means when he says that "the internal ear itself probably escapes, in some cases at least, in so far as the inflammation does not extend to the labyrinth; at most there may be signs of a temporary congestion," nor am I much impressed by the elegant phrase that "erysipelas not rarely reaches its terminal phase in the periauricular lymphatic glands."

11. MALARIA.

We find numerous statements in regard to the occurrence of vasomotor rhinitis and hydrorrhoea nasalis in malaria. Chapell has collected a series of cases in which the hydrorrhea occurred periodically, corresponding to the malarial attacks.

Whether epistaxis is to be regarded as a characteristic symptom of the disease or not, is still a matter of doubt.

According to Löri, we rarely have in malaria the "typical occurrence of aphonia." On various occasions he observed hoarseness or aphonia, synchronous with the attack, occurring as early as the algid stage and disappearing as the temperature fell. In these "intermittent aphonias" he always found, "on laryngoscopic examination, paralysis of all the muscles supplied by the recur

1 Comp. Friedrich, "Pachydermie im Anschluss an habituelles Gesichtserysipel," "Münch. med. Wochen.," 1897, No. 2. 2 Die Krankh. des Ohres," etc., 1893, p. 107. 3 See "Semon's Centralbl.," XI, pp. 395 and 508. 4" Die Veränderungen des Rachens," etc., p. 156.

rens

-sometimes only on one side, sometimes on both.” Edema of the larynx, according to him, is an occasional symptom of the malarial cachexia.

Haug has given us a comprehensive presentation of malarial diseases of the ear in which the literature is fully quoted. Protozoic origin has been assumed for certain diseases of the ear which occur in periodic attacks, corresponding to the type of malaria, at intervals of from one to three days, and present the picture of an acute inflammation of the middle ear or of nervous deafness without being necessarily accompanied by other malarial symptoms. Even the older physicians were well aware of the fact that intermittent otalgia sometimes occurred in the course of intermittent fever, and Schoenlein 2 states that the neuralgia may be localized in the posterior auricular nerve and in the chorda tympani, which, as Voltolini adds in explanation, "shows that the pain is felt in the interior of the ear, as the chorda tympani itself is not capable of giving rise to neuralgia."

As Weber-Liel 3 was the first to point out the connection between "otitis intermittens" with malaria, and gave clinical histories in support of his assertion, I shall quote his description of the form of malaria which is attended with acute irritation of the ear: "After an attack of tonsillitis and catarrh of the nasopharynx, at least in most cases, the aural affection usually appears toward evening or during the night, accompanied by chills, which may be more or less marked or only barely perceptible. At first there is only an uncomfortable sense of fullness and buzzing in the ears, while not rarely a feeling of pressure in the head and vertigo are among the first symptoms. The patient passes a restless night, perspires profusely, but feels quite well on the following day." These phenomena recurred after the manner of malaria for two or three days; the ear-drum and the external meatus were very hyperemic; the middle ear was the seat of a serous or serosanguineous exudate corresponding in quantity to the frequency of the attacks, and in some cases perforation of the ear-drum occurred, followed by serosanguineous or purulent discharge, as was also observed by Haug. For an explanation of this symp

1 Die Krankh. des Ohres," etc., p. 145.

2 Quoted by Voltolini, "Mon. f. Ohr.," 1878, p. 57. 3 Mon. f. Ohr.," 1871, p. 125.

4 Mon. f. Ohr.," 1878, p. 59.