Diphtheria infection of the middle ear and mastoid. Report of two cases

396

American Journal of Surgery

Progress

7. The deIayed-flap method of suture of the paIate may be indicated in certain cases and in every case of faiIure to obtain union a secondary suture should be made during the second postoperative week. COSTEN, JAMES B., St. Louis. Diphtheria infection of the middle ear and mastoid. Report of two cases. Arch. Otolaryngol., Feb., 1927, v, rrg. In both of the cases reported, the compIete soIution of the infantiIe mastoid structure and repIacement with organized pyogenic membrane indicated an infection of Iong duration. In one case the cIinica1 course of the chiId for a year previous to the diagnosis of diphtheria of the mastoid, and the coincidence of the mother’s pharyngeal diphtheria with the beginning of the chiId’s vague troubles, is strong evidence that the patient had carried the diphtheria as a primary infection in the middIe ear space without any signs in the nose or pharynx or symptoms referabIe to the ear. The symptomatoIogy of diphtheria of the middIe ear is so atypica1 that it probabIy accounts for the conviction that it is a rare occurrence. AIthough aImost every surgeon sends out a swab of the wound for cuIture at operation, it is not grown on specia1 media unIess requested. The extent of destruction in the middIe ear and mastoid is much greater than the severity of symptoms wouId indicate. EDWARDS, A. TUDOR, EngIand. The surgica1 treatment of phthisis and bronchiectasis. Brit. M. J., Jan. I, 1927, i, g. Thoracoscopy and cauterization of adhesions are a vaIuabIe aid to artificia1 pneumothorax treatment, especiaIIy in cases where cavities are prevented from coIIapsing by adhesions of the band-Iike or string-Iike type, not thicker than I cm. The number of cases is comparativeIy smaI1. PneumoIysis can be used as an independent procedure or as suppIementary to other operations; it is of no use in bronchiectasis, where basa1 coIIapse is required and there is no point of counterpressure. It is most vaIuabIe for uncoIIapsed apica cavities foIIowing thoracopIasty for tubercuIosis. Fat appears to be the idea1 medium if enough can be obtained. As an independent procedure the resuIts are not satisfactory as the coIlapse is too IocaIized. or rather radica1 phrenicoPhrenicotomy,

in Surgery tomy, is of value, as an independent procedure, occasionaIIy in the more acute forms of phthisis, where major operations are contraindicated, and in earIy and, on the worse side, in biIatera1 bronchiectasis. It is of vaIue as a test of the activity of tubercuIous disease in the so-caIIed “better” Iung previous to thoracopIasty. As a suppIementary procedure it is usefu1 in cases treated by artificia1 pneumothorax, either where diaphragmatic adhesions are present, or, by reducing the capacity of the hemithorax, it may prevent reopening of cavities when the Iung is aIIowed to expand at the end of pneumothorax treatment. SuppIementary to thoracoplasty, it is of much vaIue where the compression of the major operation is found to be insuffIcient. Hemoptysis from basa1 cavities can sometimes be controIIed by this operation. ThoracopIasty offers considerabIe hope of ameIioration or actua1 cure in chiefly uniIatera1 tubercuIous disease of the Iung, where artificia1 pneumothorax treatment is impossibIe or unsatisfactory, and where the disease is progressing in spite of carefu1 medica treatment. It is of use aIso in cases of tubercuIous empyema without secondary infection. In the septic tubercuIous empyemas the resuIts are not good, but the disease is otherwise aImost invariabIy fata1. ConsiderabIe improvement, amounting to cure in some cases, can be obtained by thoracoplasty in uniIatera1 bronchiectasis, but this operation wiI1 not coIIapse the Iarger bronchi near the hiIum, and in some cases a non-odorous mucoid sputum remains after the operation. Pneumotomy shouId be reserved for IocaIized tubercuIous abscesses which are not draining we11 through the bronchus, and in cases in which the generalized tubercuIous process appears to be inactive. In bronchiectasis it shouId onIy be used in those cases of Iarge IocaIized abscess formation, and not in the diffuse variety. Bronchostomy is occasionaIIy of great vaIue folIowing drainage of Iarge abscesses; a partia1 pIastic operation on the chest waI1 should be performed subsequentIy. Pneumectomy appears to be aImost totaIIy contraindicated in phthisis. In bronchiectasis, aIthough apparentIy the idea1 procedure, it is foIIowed at present by an aImost prohibitive mortaIity ($0 per cent). Further improvements in the technique may eventuaIIy make it the operation of choice. The more recent cautery