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CLINICAL AND LABORATORY NOTES was positive, showing organisms which were morphologically diphtheria bacilli. i When he was seen on admission he was desperately ill. The face was pale and the cheeks showed a pinkish flush. was " bull-neck " enlargement of the cervical glands BY E. ASHWORTH UNDERWOOD, B.SC., M.B. GLASG., There on both sides, and this appeared to be the cause of considerable dyspnoea ; no rib recession was noticed, nor were there D.P.H., laryngeal symptoms throughout the course of the illness. DEPUTY MEDICAL OFFICER OF HEALTH, COUNTY The parotid glands were normal. Blood had dried on the BOROUGH OF ROTHERHAM. lips, and there was a slight exudation of blood from the gums. Slight rhinorrhcea was present, and the nostrils were somewhat excoriated. Fcetor was marked. A dirty, foul-smelling DIPHTHERIA presents a marked contrast to scarlet membrane covered the whole of the left side of the fauces fever in that in the former disease ear conditions as and soft palate and extended forward on to the hard palate. Membrane was also present on the right tonsil and on the complications are uncommon and mastoiditis is pillars. The membrane was greyish in colour with black now very rare. Rolleston1 does not mention the patches, and separation caused considerable bleeding. latter condition as a complication of primary faucial oedema of the soft parts resulted in the uvula being pushed down into the throat. The heart was normal in size. The diphtheria; nor is there any reference to it in the sounds were regular and pure, but soft. Apart from slight works of C. B. Ker,2 of Allbutt and Rollestonor roughness of the respiratory murmur, the lungs showed 4 of Nothnagel.4 Schamberg and Kolmer11 state that nothing of note. The liver and spleen were not enlarged otitis media is sometimes a complication, but they or tender, but there was some slight tenderness in the right iliac fossa. The abdominal reflexes and the do not mention mastoiditis. In these circumstances were present, but not active, and the pupils were knee-jerks equal and the case here reported may be of interest. reacted to light. There was no sign of any paralysis. On admission the temperature was 1004° F., the pulseBane,6 in his paper published in 1917, stated that 120, the respiration-rate 24. The patient had received " the literature of diphtheria of the ear is not volum- rate 6000 units of antidiphtheritic serum before coming to inous." One of the earlier references to the condition hospital. On admission, 30,000 units were given immediately In 1901 Lewin published by the intramuscular route. was by Billington in 1889. On the day following admission (seventh day of illness) a long paper dealing with an investigation of 60 cases had fallen to 99-2°F., the pulse-rate was of diphtheria and of diphtheria with co-existent the temperature 104-120, and the respiration-rate 22-26. The membrane, scarlatina. From his discussion of the literature though still very adherent to the fauces and tonsils, was now it is evident that the majority of the cases reported separating slightly from the soft palate. There was still marked f cetor, but the faucial oedema had subsided slightly. up to that date were really cases of scarlet-diphtheria The patient now showed profuse, thick, sanguineous nasal and not of genuine diphtheria. He showed from his discharge. The enlargement of the cervical glands was examination of pathological material that diphtheritic slightly less than on the previous day. There was no increase affection of the ear was fairly common in an anatomical in the area of cardiac dullness and the heart sounds were though rapid and somewhat soft. Palpation sense, though clinically the condition was often not regular, showed slight increase of resistance in the right iliac fossa, Lewin concluded that diphtheritic but the abdomen was otherwise normal. Examination of recognisable. otitis was usually due to a blood-spread of the virus the lungs still revealed generalised roughness of the and not to a direct spread from the throat via the respiratory murmur. During the course of this day the patient again received 30,000 units of antidiphtheritic Eustachian tube. There is no reference to mastoid serum. disease in Lewin’s paper, though he does mention a On the following day (eighth of the illness) there was a slight improvement in the general condition, and 24,000 case of leptomeningitis. of serum were injected intramuscularly. On the ninth In 1907 Kerrison 8 reported the case of a female units of the disease the patient showed a very definite day patient (aged 19 years) who was suffering from genuine improvement. The colour of the face had improved and was now absent. The throat was cleaning diphtheria. Otitis developed on the sixth day, and rhinorrhoea rapidly, and the faucial oedema had disappeared. The on the twelfth day acute mastoiditis was unmistakable. heart sounds were rather but there was no evidence of At operation the vertical limb of the sigmoid sinus cardiac dilatation. The soft, temperature was now 98° F., Part the pulse-rate varied between 104 and 120, and the respirawas exposed and sinus thrombosis followed. of the jugular vein had to be excised before the tion-rate between 16 and 20. The progress was uninterrupted until the twenty-seventh condition cleared. In 1911 Barnhill and Wales9 of the disease, when the patient vomited in the evening. day divided the otitis media caused by the Klebs-Lomer On the following day there was a slight but definite enlargebacillus into three classes-viz. (a) primary diph- ment of the liver, and the lower border of this organ was theritic inflammation ; (b) otitis arising by extension tender. The area of superficial cardiac dullness was normal. showed extra-systoles, but the tone was from the nasopharynx; (c) secondary middle-ear The heart sounds quite good. There was no epigastric pulsation. The pulseinfection accompanying diphtheria of the throat- rate varied from 108 to 120. On the twenty-ninth day the most common form. In 1926 Gowen 10 investi- epigastric pulsation was present, and the area of superficial dullness was enlarged to the right. Right otorrhoea gated the incidence of otitis in 15,000 infectious cases cardiac on the thirty-fifth day. The discharge became developed at the Philadelphia Hospital for Contagious Diseases. rapidly purulent, but there was no tenderness or oedema He found that otitis occurred in diphtheria only over the mastoid process. On the thirty-eighth day when this disease was co-existent with scarlet fever palatal paralysis was noticed. This complication was very and fairly marked. By the sixty-seventh day and measles; the incidence of otitis was then 50 per persistent of the illness the patient’s general condition had improved cent. and of mastoiditis 12 per cent. considerably and the heart sounds were normal. There had The literature all points to the conclusion that, been no ocular or pharyngeal paralysis, and the palatal was then only slightly marked. The purulent while in an anatomical sense diphtheritic affection paralysis otorrhoea still persisted, however, in spite of treatment. of the middle ear may be fairly common, a clinically During this period there had been no elevation of temperature recognisable acute otitis is infrequent. Further, and there was at no time any oedema over the mastoid this form of otitis very rarely spreads to the mastoid process. On the seventy-third day the temperature rose to 1004°, and on the following day the patient had pain in cells. the ear and a suspicion of oedema over the mastoid. The RECORD OF A CASE. ear discharge remained copious and purulent. The patient (aged 12 years) was a high-school boy of During the next week the temperature oscillated between excellent general physique. He was admitted to hospital 98° and 101°. There was slight tenderness over the mastoid suffering from diphtheria, and from the history he appeared region, and the oedema became more marked but was never to be in the sixth day of the illness. On the day of admission very pronounced. There appeared to be a possibility that

MASTOIDITIS AS A COMPLICATION OF DIPHTHERIA.

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the condition would resolve without operative interference, Thereafter the and surgical advice upheld this view. temperature remained only slightly elevated (about 99°) until the eighty-seventh day, when it began to rise. The oedema and tenderness over the mastoid persisted but were never very marked. During this period swabs from the throat and from the right ear were negative for diphtheroid organisms. It became rapidly evident that the condition would not resolve without surgical interference. On the ninety-second day of the illness the patient was transferred to the Rotherham General Hospital, where the incomplete mastoid operation was performed by Dr. W. S. Wildman. At the operation considerable erosion of bone was found.

improvement have not relapsed. The shows the results at a stance :—

shown

I Of those that

were

been in for

over

following

discharged from hospital, four had two years without showing any

while the others were more recent admissions. Those classified as greatly improved were men who became clean in their habits and were able Recovery was uninterrupted. to show some keenness in the work of the hospital, The patient was examined recently and was found to be in very good health. There was no evidence that he had ever and who before treatment had lived the lives of had palatal or cardiac paralysis ; the hearing was excellent, vegetables. Their discharge in the future is possible. and showed no diminution on the side previously affected. Technique and Dosage.-It has been my practice use a 1 per cent. solution of sulphur in sterile to COMMENTARY. olive oil, and to start the course of treatment by The case is interesting in that the patient recovered 1 c.cm. into the muscles on the outer side of completely, although he was extremely ill when he giving the thigh and to increase the dose by 1 c.cm. until was admitted on the sixth day of the disease. During the patient has had 12 injections. As the temperature his illness he showed two types of diphtheritic usually starts to rise about 12 hours after the injecparalysis, in addition to the otitis media and the rare tion, it is advisable to give the treatment at about mastoid complication. There was no evidence that 6 o’clock in the evening, so that the night’s sleep is an intercurrent disease-such as scarlet fever-was not interfered with by constant temperature recording, present and had caused the mastoiditis. which is done every half-hour until the maximum The insidious course of the ear condition is to be is reached, and then every four hours. The fever is noted. The otorrhcea had persisted for 59 days at its height about 18 hours from the and the mastoiditis for 19 days before the case came generally time of the injection and may rise to 105° F., with to operation. During this period the patient was or without rigors. In 48 hours it has usually returned not as ill as might have been expected. This slow Two injections are given each week, to normal. but persistent progress of the pathological process so that a full course takes six weeks, during which in the mastoid antrum may be compared with the time the patient is kept in bed but is encouraged to similar condition following scarlatina, in which the himself, which I think is an all-important development is usually more acute. The mastoiditis occupy factor. In the large number of injections that have appears to have been a true complication of faucial been given in these hospitals not one case has shown diphtheria, although definite proof of the inter- the slightest inflammatory local reaction ; the only relation was not forthcoming. complaint heard is of stiffness in the muscles into which the sulphur has been injected, but this passes off in a REFERENCES. It is advisable to warm the oil 1. Rolleston, J. D.: Acute Infectious Diseases, London, 1925. few days’ time. 2. Ker, C. B.: Infectious Diseases, Oxford, 3rd edition. before using it, as it will then flow through the needle 3. Allbutt, C., and Rolleston, H. : System of Medicine, London, A three-inch needle is the most conmore easily. vol. i., 1911. 4. Nothnagel’s Encyclopædia of Practical Medicine: Diph- venient to use. theria," by W. P. Northrup, Philadelphia and London, In a few cases I have given a second course of 12 1902. 5. Schamberg, J. F., and Kolmer, J. A. : Acute Infectious injections after an interval of about two months, Diseases, London, 2nd edition, 1929. but in no case has any further improvement been 6. Bane, W. C.: Laryngoscope, 1917, xxvii., 626. 7. Lewin, L. : Arch. f. Ohrenheilk., 1901, lii., 168 ; contd. in shown in the mental state. vol, liii., p. 1. Reaction.-When the temperature begins to rise 8. Kerrison, P. D.: Arch. Otology, 1907, xxxvi., 412. 9. Barnhill and Wales: Modern Otology, 1911 ed., p. 72. the patient usually starts to sweat, loses his appetite, 10. Gowen, F. V.: Laryngoscope, 1926, xxxvi., 799. and in a few cases has become delirious, but these symptoms have never given rise to any real anxiety. In all cases there is a marked leucocytosis, and in THE SULPHUR TREATMENT OF one patient the white blood count rose to 73,600 at the height of his fever. The extent of the leucocytosis DEMENTIA PRÆCOX. appears to give no indication of the ultimate prognosis. The liver does not seem to be affected by the sulphur, BY P. C. COLLINGWOOD FENWICK, L.M.S.S.A., as there have been no cases of jaundice, and in every EAST SUSSEX MENTAL ASSISTANT MEDICAL OFFICER, HOSPITAL, HELLINGLY. patient the van den Bergh reaction has been negative. The mental reaction has varied. One or two patients have definitely stated during their course of treatment DuBiNG a course of research work at the East that they thought the injections were doing them Sussex County Mental Hospital and the London good and have asked for further treatment ; others County Council Mental Hospital, West Park, Epsom, have lain like logs during the whole of the six weeks, I have treated 30 cases of schizophrenia with sulfosin, whilst others have passed gradually from a world of a preparation of sulphur in olive oil, as described by to a world of reality but have needed Knud Schroeder.! All the cases I have treated have phantasy constant guidance in their new world. It is of great been males, and their ages have varied from 13 to 33. to attempt to re-educate these schizoSome were recent admissions to hospital, others had importance on the days that their temperatures are phrenics been in for several years and had shown no improvenormal during their course of treatment, and I think ment. They were of all types and conditionsthe results obtained have in no small way been stuporous, katatonic, grossly demented, and impul- due good to the interest and trouble that has been taken sive. The treatment has been carried out over a the nursing staff. period of a year, and so far those cases that haveI byOne patient ran a temperature up to 102° F. for "

1

THE LANCET, 1929, ii., 1081.

improvement,