The ear is involved by a direct extension of the inflammation from the pharynx through the Eustachian tube. Nearly every child suffer ing from influenza complains of more or less severe earache. Often this is simply a neuralgic otalgia. Inflammation of the external auditory canal may occur. On inspection in most cases a dark opaque redness of the drum membrane is seen, while in the severe cases either small or large hfemorrhages may be detected. This middle ear inflammation may develop into a purulent otitis media. When this occurs there is bulging of the drum, a secondary rise in temperature, and severe pain. Relief is immediate after paracentesis, and influenza bacilli may be detected in the discharge. Three-fourths of all cases are unilateral. Mastoiditis is not an uncommon termination. Exceptionally there may be severe labyrinth disease (IIabermann had a ease in a two year-old child).
Influenza is often accompanied by a severe and painful tonsillitis which may become follicular and covered with an exudate.
Gastrointestinal symptoms were not formerly regarded as a part of the clinical picture of influenza. The earlier writers regarded influenza only as an infectious catarrh of the upper air-passages. Now the diges tive apparatus plays an important part in young children and infants and in many cases the whole course of the disease may simulate an acute febrile gastro-intestinal catarrh.
In adults we find loss of appetite, vomiting and diarrhoea as pro dromal symptoms. The younger the patient the more marked are these symptoms. Dyspepsia of varying severity is present in nearly all cases in children. The anorexia, coated tongue, and vomiting are sus picious of meningeal irritation. A transient constipation followed in a few days by diarrhoea is quite common. The stools are fetid, become more frequent and fluid and together with the other symptoms, marked prostration is produced. These intestinal symptoms may become so severe as to simulate typhoid fever.
The intestinal symptoms, which arc an extension of the inflamma tory process, prepare these parts for the development of secondary in fections and the resulting systemic toxremia.
Enlargement of the spleen is irregular in influenza and is never marked.
Albuminuria occurs in from six to ten per cent. of children suffer ing from influenza. An acute nephritis may develop similar to that in scarlet fever, and cases of the acute hmnorrhagic type have been reported. A case of secondary pyclitis following influenza has been observed. Amnia may occur due to a paralysis of the bladder
muscles (m. detrusor) resulting from the effect of the toxin on the nervous system.
The effect of the toxmemia is especially noticeable in the involve ment of the heart. In the early stages of the disease this is shown by arrhythmia and tachycardia. Later on the heart action becomes slower and there is a slight dilation with indistinct murmurs. This may result in cyanosis and collapse. The toxtemia shows a close similarity to that of diphtheria in its effect upon the innervation of the heart and in the parenchymatous degeneration of the heart muscle.
This relative heart weakness must be borne in mind for a long time in severe cases. True and even severe endocarditis has been observed after influenza.
The third group of symptoms—nervous influenza—are found in all well-marked cases. The severe depression, the aching bones, the weari ness, the pain in the limbs and muscles, and the sensitiveness of the spine are all included in the term nervous or rheumatoid influenza. Localized peripheral nerve tenderness is frequent; but true, long-continued neu ralgias are uncommon in children.
Of much greater importance is the involvement of the brain and its membranes. A diagnosis from diseases of the meninges is uncertain in the beginning of an infectious disease with high fever as in influenza. Meningeal irritation or meningismus occurs easier and much oftener in young children. From this to severe inflammation of the meninges we find all degrees of involvement diminishing in intensity with age.
These symptoms are usually due to the toxin except in the fortu nately rare eases where there is an exudative, purulent, or parenchy matous change in the meninges. This toxic irritation is the cause of the severe headaches with the exception of the congestions, the eelamp tic seizures and the various irritative symptoms (laryngospasmus) so easily developed on the unripe nervous system of the child. In young children where the entire family is affected, a stuporous condition is often present alternating with eclaniptic seizures. A slight opacity of the meninges was the only post-mortem finding in two such fatal cases.
True meningitis as a result of the infection is either due to the influenza bacillus or is secondary to a secondary infection from the middle ear.
The bacillus of influenza has frequently been found in the meninges and has been obtained by lumbar puncture in the living.