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tive is the correct one. Dr. SCOTT includes within hisgroup non-toxin-producing strains which cannot beexcluded by ordinary morphological and culturalcharacters. If the agglutination characters of thebacilli are as labile as the forementioned considerationswould suggest this does not seem quite justifiable.After reading his paper, and in view of Hartley’sshowing that all pathogenic diphtheria bacilli producethe same kind of toxin, we are more satisfied thanever that the only satisfactory final criterion of thediphtheria bacillus, not for clinical diagnosis but forpractical bacteriological differentiation, is its abilityto produce toxin.

Annotations.

ALCOHOL INJECTIONS FOR NEURALGIA.

"Ne quid nimis."

AT a recent meeting of the Section of Otology ofthe Royal Society of Medicine Mr. Arthur H. Cheatleshowed three patients who had sustained damage tothe ear following the injection of absolute alcoholthrough the face for the cure of neuralgia. In twothere was injury to the middle ear and in one to theauditory nerve. The first was a man aged 71, whohad severe deafness and some discharge from the leftear immediately after the injection a year previously.He did not have pain, giddiness, or tinnitus, butthere was temporary paralysis of the facial nerve.The second case was that of a man aged 72, who,following a similar injection two years previously,had severe deafness, tinnitus, and a slight discharge.There was no giddiness, pain, or facial paralysis. Theneuralgia was cured. No doubt in this case thealcohol entered the Eustachian tube and reached themiddle ear. Both these cases had a general anaestheticfor the operation, and Mr. Cheatle pointed out thatif it were done under local anaesthesia, accordingto the custom of Dr. Wilfred Harris, the patientcould give warning of anything wrong. The thirdcase was that of a woman aged 22, who hadeomplete deafness on the left side following the spiritinjection under a general anaesthetic nine monthspreviously. There was also immediate giddiness andparalysis of the sixth and seventh nerves. She hadbeen very ill in bed for five months, and her neuralgiawas not cured. Subsequently, the Gasserian ganglionwas removed ; this cured the pain, but entailed theloss of an eye. Apparently the spirit had reached thesubarachnoid space and directly injured the sixth,seventh, and eighth nerves. In all the three cases theinjection was carried out by experts. At the samemeeting Mr. T. B. Layton described a case in which theinjury produced on a middle-aged man by injectionof alcohol for the same purpose was much more severe.He had lost the left eye, and on the right he hadcorneal ulceration ; he spoke in a high falsetto voice,and he was very deaf. The left side of his face wasparalysed. In all he had had ten injections, most ofthem in the Far East. Mr. Sydney Scott, the presidentof the section, said he had heard of such cases buthad not seen any. He had used absolute alcohol fordestroying the internal ear. As the spirit spreadrapidly, it was necessary to use only a minimalquantity so that none was allowed to reach the middleear. The measure was only carried out by him inextreme necessity. Sir William Milligan said he hadnot much experience of these injections, but he knewof cases in which they had done irreparable damage,some in which it had been necessary to remove aneye. Relief in some cases he knew of lasted from9 to 18 months, but others gained no relief by it at all.

The avoidance of accidents when alcohol is injectedfor the cure of trigeminal neuralgia deserves closeattention. Pricking the Eustachian tube should be awell-known danger to those accustomed to giving such

injections. Under local novocaine anaesthesia thepatient will always complain of a pain deeply situatedin the ear if the needle reaches the Eustachian tube,and when this occurs the needle should be withdrawnabout an inch and then pushed slightly forward.Novocaine probably does no permanent injury ifinjected into the Eustachian tube, and if the rulebe scrupulously followed not to inject spirit until anaes-thesia results from the preliminary novocaine, no harmwill come. Thus to secure safety under general anws-thesia, novocaine alone should be injected in one spotonly, and the patient allowed to come round sufficientlyfor testing the two sides of the face with a pin, while theinjecting needle is left in situ. If the desired anaesthesiais found to have resulted, then the alcohol syringe isfitted on and the injection completed, a furtherwhiff of general anaesthetic being given if thoughtdesirable. If no anaesthesia has resulted from thenovocaine, then no spirit should be injected, but afresh search made for the nerve. Usually it is unneces-sary to give much further anaesthetic for this. Thepractice of making a rapid injection in the directionof the foramen ovale under a general anaesthetic, andassuming that by doing so one has injected thethird division of the trigeminal nerve, is to berejected. The procedure is not by any means so easythat it can be done without care, but the nerve isthere to be found if the operation be conducted withpatience and deliberation, and there should bepractically never any failure. In the third case

described by Mr. Cheatle the catastrophe appears tohave happened after the needle had penetrated theforamen ovale in the endeavour to inject the Gasserianganglion under general anaesthesia, the sudden injec-tion of a quantity of alcohol into the subarachnoidspace causing widespread and permanent paralysis ofcranial nerves. Had the injection been done a fewdrops at a time, after letting the patient come roundpartially from the anaesthetic, the operator would havebeen warned of danger by the appearance of nystagmus,vertigo, and commencing facial paresis. Then withthe cessation of the injection the symptoms wouldalmost certainly have passed off in a few minutes oran hour at most. The duration of relief from theneuralgia is, we would suggest, better than Sir WilliamMilligan suggests. In an article on the technique of theseinjections contributed to our columns last yearDr. Wilfred Harris states that freedom from theneuralgia may practically be guaranteed for 12 monthsif the nerve has been properly hit, and in the majorityof his cases the immunity from pain was muchlonger, ranging up to 13 years in one case. Four andfive years was a common period for the immunityto last in his experience. In the Gasserian injectionsthere is no reason why permanent relief should notbe expected, the anaesthesia obtained being as

complete as that after Gasserectomy.

MEDICAL MILITARY PREPAREDNESS.

MILITARY medicine will never flourish unless themedical student becomes interested in it during hisyears of training. In the November issue of theMilitary Surgeon, the first number entirely edited byMajor E. E. Hume, U.S.M.C., an active service officer,the best way of training the medical student to under-stand the work of the military medical officer isdiscussed by Lieut.-Colonel H. H. Rutherford. Hethinks this can be done, in spite of the already crowdedtime-table, if he can get specially good instructors, avery high-class text-book, and is allowed to pick onlyhigh-grade students for the course, which will occupy240 hours in the early years and a spell in camp at theend of the last year. In the same issue Major L. H.Bauer, Commandant of the School of AviationMedicine, sketches the training given to the reservemedical officers of the U.S. Air Service. They aredivided into three classes-flight-surgeons, examiners,and specialists. These all belong to the outsideprofession ; they are busy men, and while they must

1 THE LANCET, 1922, ii., 123.

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be instructed, it is most important that their timeshall not be wasted; accordingly the first class aregiven two correspondence courses through twowinters, with a short basic course of practical work inthe summer. The first winter’s course deals with theeye and ear, the heart, and neuropsychiatry ; thesecond course develops these subjects further andtakes the student over Air Service administration, Iall this by correspondence, but everything is gone overagain, practically, in the summer basic course. It isfelt that the reserve officer will now be a betterpractitioner than before, and, if he passes the examina-tion after the first year, he will be allowed to make thephysical examination for flying, and having passedafter the second course will be rated flight-surgeon.Selected officers will have a six weeks’ training at theAviation School. Those who succeed will be qualifiedas examiners. The third class are research workers,physiologists, eye specialists, and the like, who will becalled to act as instructors in the school. It is hopedthat " by the time of another emergency " Americawould have flight-surgeons, physical examining units.and specialists ready to step in and aid in the rapidexpansion of the Air Service. In a third article ColonelG. M. Blech, one of the founders of the MedicalOfficers’ Reserve Corps, explains to young members,already highly educated doctors, why they shouldinterest themselves in learning something of tactics,how much more useful that knowledge will make themin battle, and how easily the necessary knowledge maybe acquired. The whole number is full of the need forpreparedness. ____

INTERNATIONAL CONGRESS ON INDUSTRIAL

HEALTH.

A GROUP of Swiss medical men interested in industrialhealth questions met at Berne last October and con-stituted themselves as the Swiss Organising Committeefor an International Congress on Industrial Healthto be held at Geneva from July 18th-20th, 1924. Thecommittee consists of Prof. W. von Gonzenbach(Zurich), Prof. W. Silberschmidt (Zurich), Prof. H.Zangger (Zurich), Dr. A. Rossi (Lugano), Dr. H.Carriere, Director of the Public Health Service, andProf. H. Cristiani (Geneva), the last named beingchairman. This first congress will deal with the follow-ing questions : industrial lighting and eyestrain ;impure air in factories ; the value of fatigue tests.The committee has asked prominent men of sciencewho have given special attention to these questions todraw up reports on them, and three such reports willbe presented for each question. The office of thecommittee is at the Institut d’Hygiene of theUniversity of Geneva, and all persons wishing to takepart in the congress should communicate with thecommittee at that address, from which further infor-mation may be obtained.

ACTINOMYCOSIS OF THE HEAD AND NECK.

IN a recent communication to the Pacific North-west Medical Association, Dr. Gordon B. New andDr. Fred A. Figi,l of the Section on Laryngology,Oral and Plastic Surgery of the Mayo Clinic, illus-trated the frequency with which actinomycosis ofthe head and neck escapes recognition. They gave thefollowing statistics. During the decennium 1913-22inclusive 157 patients with actinomycosis were

examined at the Mayo Clinic. In 107, or 68’1 percent., the disease involved the head and neck, butonly seven of these patients were being treated foractinomycosis at the time of their admission to theclinic. The disease is much commoner in males thanin females, 98 of the 107 cases being in males. The

ages ranged from 9 to 66 years, but the majority ofthe patients were in early adult life. As regards themethod of infection, 45 out of 80 patients, or 56’1 percent. from whom information could be obtained,stated that they had not come into contact with the

1 Surgery, Gynecology, and Obstetrics, November, 1923.

disease in animals. The remaining 35, or 43’7 percent., had been more or less closely associated withthe disease in animals before they developed sym-ptoms themselves. In no case was there evidence ofdirect transmission from one person to another.The clinical picture of actinomycosis of the headand neck varies according to the virulence of theinfection and the amount of secondary infection.The commonest symptoms are stiffness in the regioninvolved, pain, and swelling. The jaw may beginto tighten and even become completely ankylosed.Pain is sometimes severe, or may be completelyabsent until the mass breaks down. In some cases

dysphagia may be an early symptom, especially ifthe base of the tongue or anterior cervical region isinvolved. Sore throat, stiffness of the neck, andearache are occasional symptoms. The activity ofthe process varies from a slow indolent condition,which takes months or years to reach its full develop-ment, to a fulminating one of a few weeks’ duration.The commonest type is that of an indurated masswhich breaks down forming multiple superficialabscesses. The disease is liable to be mistaken, aswas illustrated in the writers’ series, for malignantgrowth, tuberculous adenitis, osteomyelitis of thelower jaw, thyroglossal duct sinus, subperiostealabscess, and tuberculous thyroiditis. The mostimportant factor in the treatment is early diagnosis.In advanced cases intracranial extension may developor the chest may become involved. In addition toiodides, which are almost specific and should beused in progressively increasing doses, radium hasproved beneficial by causing a breaking down of thegranulomatous masses and clearing up the indura-tion. Surgical treatment consists in opening upwidely all pockets, packing them with iodoformgauze, and swabbing the wounds with iodine. Of85 cases which could be traced by the writers, 60, or70 per cent., were well five years or less after theirdischarge, 7 were dead, and 18 were still undertreatment.

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OPIUM AND DYSPNŒA.

THE term dyspnoea is one which is difficult to defineexactly, but it may be taken to mean a conditionin which the normal sequence, rhythm, and characteref the acts of respiration are disturbed, whethersubjectively or objectively. In the healthy subject,the normal control of respiration lies in the activityof the respiratory centre of the medulla. This centreis regarded as being capable of automatic activityand of sending rhythmic efferent impulses to themuscles that perform the movements of respiration.The activity of the centre is known to be affected byfour influences which are independent of volition-namely, (1) the pressure of C02 in the blood suppliedto the centre, (2) the H-ion concentration of theblood supplied to the centre, (3) the pressure of oxygenin the blood supplied to the centre, and (4) the afferentimpulses reaching the centre, which may come fromthe higher centres, as shown in the effects of volitionand emotion. Many investigators have worked onthe problems presented by these several factors, andtheir results show that disturbances of the respiratorymechanism can result from (1) alteration in theCO2-content of the blood supplied to the respiratorycentre-increase in this content causes increasedbreathing, with acidsemia and raised CO pressure ;(2) alteration in the fixed acids in the blood, so

that increase in the acids causes increased breathing,with acidaemia and lowered CO2 pressure ; and (3)alteration in the oxygen in the blood supplied tothe centre, so that deficiency causes increasedbreathing, with alkalaemia and lowered CO pressure.Oxygen-lack causes mainly increase in the frequencyof breathing, while increased CO pressure andincreased fixed acids cause mainly increase in thedepth of breathing.Among the investigations reported on clinical

cases of cardiac dyspnoea, each of these threetypes of chemical change has been found, plus