ASPIRATION OF DIPHTHERITIC MEMBRANE.

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ACUTE OTITIS MEDIA.

anaesthetic should be given, for it causes intense pain If symptoms persist for an acutely inflamed ear. more than a few days after free drainage of the has been established, the probable cause tympanum is obstruction of drainage at the aditus or in the mastoid cells, and a mastoid operation is desirable. In a few cases a profuse discharge continues in the absence of other symptoms ; if this remains without abatement over some three or four weeks, it is probably due to partial obstruction in the mastoid, and also calls for operation in order to avoid chronic in

inflammation of the middle’-ear cavity, at all times, is especially prevalent at this time of year, and it is therefore appropriate - two pass in brief review the salient features of this important affection. In the overwhelming majority ’of cases the infecting organisms gain access to the ’middle-ear cleft from the nasopharynx along the Eustachian tube. The inflammation is not confined to the cavity of the tympanum, but involves the whole -of the tract of the middle ear; for the Eustachian suppuration. tube itself, the tympanum, the antrum, and the mastoid cells are all implicated. The infection may be caused by a great variety of ASPIRATION OF DIPHTHERITIC MEMBRANE. IT is related that on one famous occasion Stalky organisms, but in any individual case it is usually due to one variety only-that is, an organism is fulfilled his threat to get even with the Head for - obtained in pure culture from the middle ear. When a lickin’ from King, 500 lines, and a gating," and perforation of the membrana tympani has taken place, the method of his revenge was the publication of the secondary infection with the organisms present in Head’s gallantry in applying the aspiration method the meatus can readily occur ; this is believed to be to the diphtheritic membrane of Stettson major, a the principal cause of failure of resolution and mere day boy. Certain workers in America have been consequent chronicity, and its prevention is one of attempting to perfect a routine by which aspiration the important aims of treatment. In some epidemics ! technique can be applied to diphtheria in the larynx of the acute specific fevers, notably scarlet fever, as well as in the fauces, and without the element of measles, and influenza, the infection is of extraordinary personal risk which provided Stalky with his triumph. -virulence, and rapidly involves the bony walls of the The procedure, which was initiated in 1922, is associated cavities, and produces by extension the well-known with the name of Dr. HARDMAN, now of the Ontario and dreaded intracranial complications. But in State Public Health Service, and has been gradually the great majority of cases the virulence is far less developed. For the last four or five years it has been severe, the bone is not seriously affected, and the used regularly in several American hospitals and inflammation is almost confined to the mucous references to it have appeared from time to time in the lining of the aural cavities. As the entire cleft of the Weekly Bulletin of the Health Department of the City middle ear is involved in the inflammation, it follows of New York. No paper, however, has yet appeared that in any case of acute otitis with earache, tenderness giving full details of the technique and an adequate is likely to be present over the mastoid, either over statistical estimation of its value. The chief medical the antrum or the mastoid tip, or in both situations; officer of the Metropolitan Asylums Board therefore but at this stage such tenderness does not imply that decided to draw the attention of his Board to the surgical opening of the mastoid cavity is indicated. desirability of obtaining first-hand information on the The key to the cure of inflammation of these cavities, value of the method, and Dr. ALEXANDER JOE, medical as of most other inflammatory diseases, is free and superintendent of the North-Western Hospital, was unobstructed drainage. In the earliest stage the sent out to New York to investigate it on behalf of the fluid secreted can drain down the Eustachian tube, Board. His report, which has been published, was the and many cases of mild inflammation of the middle subject of discussion at a meeting of the Fever Hospital ear do drain and get well in this way. But in severer Medical Service Group of the Society of Medical cases the tube is obstructed by swelling of its mucous Officers of Health last week. lining, perforation of the membrana tympani occurs, The aspiration method employed at the Willard and drainage by this route with subsequent healing Parker Hospital, New York City, was described results. Sometimes, again, there may be a block in detail in our last week’s issue (p. 257). The at the aditus, or at the neck of a mastoid cell, or apparatus required is simple and inexpensive and group of cells, with the result that the mastoid consists of a laryngoscope ; a portable suction becomes surgically involved. apparatus, run off the hospital current ; a number These facts should form the basis of the treatment of sterile laryngeal swabs fixed to the swab-stick of all inflammations of the middle ear. In the by collodion and held in artery forceps ; a tongue mildest forms, with little or no pain, but with a feeling depressor ; and the special brass suction tubes, of fullness and some impairment of hearing, gentle which can be made for a few shillings. The American inflation with the Eustachian catheter will often authorities recommend that none of the apparatus re-establish the patency of the tube and hasten should be because of the risk of roughening plated When earache is present the prompt or recovery. scaling of the plating after much cleaning. The use of an antiseptic in the meatus is of value to patient is wrapped in a sheet and held by a nurse, sterilise the canal and prevent secondary infection while another nurse steadies the head in such a should the membrane perforate or have to be incised ; way that it hangs backwards over the end of the a 5 per cent. solution of phenol in glycerin is fre- table with the medial plane at right-angles to quently employed and has the additional advantage of the table. The laryngoscope is introduced so that acting as a local sedative. But when pain is severe it rests on the upper teeth in the mid-line, bearing and accompanied by fever, a timely incision of the on the roof of the epiglottis. After a thorough inspecdrum membrane is the best of all therapeutic measures, tion of the a swab is passed for direct culture, larynx and in a very large proportion of cases is speedily and the aspirating tube is then used once or twice followed by cessation of the earache and recovery as required. The operation lasts a few moments only, from the inflammation ; there is no need to wait for bulging of the drum. This little operation is 1 Metropolitan Asylums Board, Infectious Hospitals DepartReport on the Aspiration Method of Treating Laryngeal not difficult to perform, and is much more often ment. Office of the Diphtheria. By Alexander Joe, M.D., D.P.H. postponed too long than done too soon, but a general Board : Victoria Embankment, E.C. AcuTE

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305 In a recent pamphleti by Dr. J. R. LORD the wholeand-provided the operator is reasonably skilledcauses the patient no more than a little discomfort. question of the procedure for the admission of persons. At the Willard Parker Hospital no anaesthetic was suffering for mental illness is discussed. Dr. LORD given for its performance. It is particularly useful at would discard the justice’s order and in its place the intermediate stage of membrane formation, the substitute the approval of " a panel of approved stage at which the patient usually enters hospital. citizens," appointed by the local authority. There. The membrane is then readily detachable and there would be no formal order, but the approved citizens would merely endorse the medical certificate. It is is little oedema and no haemorrhage. The statistics available are unfortunately inadequate doubtful whether this procedure would satisfy the to provide any reasonable indication of the value of liberty-of-the-subject enthusiast, whether it would be this method, but it is always true that the personal more acceptable to the relatives of patients, or whetherimpressions of good clinicians are worth more than in practice the " approved citizen " would be in any many volumes of figures and Dr. JOE found that the way preferable to the magistrate. But while saying. physicians in New York and Boston who had followed this we are grateful to Dr. LORD for directing attention. the progress of the work were unanimously in its to a subject that deserves serious study. Everyone favour. It is no derogation of a new technique to say with experience knows that the justice’s order is really that the personal element enters very considerably into little or no safeguard against improper detention. its success, and Dr. JOE found that the technique Some justices are complaisant, taking little trouble. is not difficult and should be equally successful in when the parties concerned are known to them ; the hands of anyone with the dexterity to perform some are so oppressed with the responsibility of It seems to be safe, and the signing orders that grievous delay in treatment occurs;. a direct laryngoscopy. on record is the loss of a milk tooth. some find the duty thrust upon them by the State soonly mishap in America it has always been used as a unwelcome that they rely entirely on the clerk. Although substitute for or accessory to intubation, Dr. JOE Incidentally the refusal of a justice to recognise a case sees no reason why it should not be equally valuable of high-grade deficiency may and does lead to the in cases where tracheotomy is the operation of choice ; procreation of illegitimate children. The position, indeed, aspiration through the tracheotomy tube is often most painful when a patient under care might turn an apparent failure into a success. The exercises his right to see a justice after his admission. introduction of diphtheria antitoxin marked such a A medical officer of long experience tells us he cannot tremendous advance in the campaign against the recall a single case in which this did any good, unless toxic aspect of diphtheria that the obstructive aspect it be called doing good to be in a position to tell the is apt to be forgotten by those who do not constantly patient afterwards, " Well you had your chance and have to deal with these distressing cases. The saw the justice." All this is wrong in principle ; it aspiration technique, if it proves as safe, simple, and emphasises the detention, and ignores the medical inexpensive as Dr. JOE suggests, will certainly deserve aspect of the case. The value of the intervention of the justice should most serious consideration by all who are concerned be examined afresh by a select committee or some with the treatment of croup. other impartial body. It may not be remembered that Lord SHAFTESBURY, who probably more than. MENTAL PATIENTS AND THE JUSTICE’S anyone in his day contributed to the reform of ourmental institution, who was responsible for the passing ORDER. of the 1845 Acts (often called the Magna Charta of IN the Mental Treatment liill as it comes before the the insane), and who was one of the first lunacy comHouse of Commons no justice’s order is required for missioners, protested to the end against the introtemporary treatment. It is not easy for the medical duction of the justice, and when overridden by the profession to form an unbiased opinion on the necessity Act resigned his commission. Now nearly 40 years. for the justice’s order before the reception of mental have elapsed and the question arises whether, after patients in hospitals or into private care. The welfare all, Lord SHAFTESBURY may not have been right. of the patient is the doctor’s first thought, and when he If he was it follows that the procedure which seems is satisfied that immediate treatment is necessary he now to be embedded in English law is really unneceschafes at the delay that the application to a justice sary and is retarding the treatment of mental disease. involves, and he sympathises with the unwillingness We are glad the Ministry takes the view that a justice’s, of the friends to make the application. When this order for temporary treatment would defeat its own, means a revision of the case he is impatient, and object. resents the interference of a layman in what he 1 Reprint from the Journal of Mental Science for Oct., 1929. considers a purely medical matter. Familiar with London : Adlard and Son. 2d.

the

procedure in infectious disease he sees no reason why mental illness should not be treated in like manner. Conscious of singleness of purpose in regard to the welfare of his patient, he is convinced that the medical profession can be trusted to discharge its duty properly. On the other hand, the sacredness of liberty is so important in the minds of those with whom the freedom of the subject is a religion, that they feel that, even if treatment be delayed in some cases, even if now and then patients commit suicide when the justice declines to sign the order, and even if the procedure is painful to relatives, yet the welfare of the community justifies the present procedure. If they are told that the recent Royal Commission found no single person improperly detained, they will reply that this is because the present procedure is successful.

FREEMASONS

HOSPITAL

AND

NURSING HOME.-

year the pressure upon accommodation was. so great that the staff had to be provided for in five separate buildings. The " case daysincreased from 14,772 to 15,872. Large extensions are to be made at a cost of £250,000, of which oE100,000 is in hand ; the land has already been paid for. There were 640 in-patients during the year,. 32 of whom came from over-sea.

During the past

HOSPITALS AND MOTOR ACCIDENTS.—Motor accidents last year cost Altrincham General Hospital 21050. Many of the injuries were sufficiently serious to necessitate prolonged stays in the hospital. In the three months ending with October last the motor accident cases treated at. the Royal United Hospital, Bath, numbered 21 in-patients. and 26 out-patients. The in-patients remained for atotal of 235 days at a cost of £94, of which 217s. 6d.was

repaid.