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less severe and gradually shifted their time of onset untilthey were occurring regularly every morning about an

hour after leaving bed.By superficial mental analysis I was surprised to find that

the patient, who is known to be outwardly calm, is a neuroticperson who has been subject to vague fears since childhood.He readily admitted this after first agreeing to the suggestionthat the mild attacks of his illness resembled very much thestate of a frightened or anxious person. These fears hadtheir origin in infancy when he was often threatened withdevils and other weird beings by an ignorant nurse. Heused to be particularly afraid of staying or walking in thedark, and therefore was in the habit of having a light inhis room all night. About the age of 14 or 15 those fearsseemed to have centred about his father, who was anunreasonably severe parent.The boy would wake up with the impression that a person

dressed in a red gown or cloak, like the one used by hisfather, was standing by, or advancing towards, his bed,and he used to feel very frightened, covering up his faceand holding his breath until the apparition moved away.Up till the time I saw him the patient could not put out thelight while alone in his room and he became panicky if heheard the slightest sound outside during the night.

Further questioning brought out what I consider the realexplanation for the onset of the attacks of asthma 18 monthsbefore. This was an incident, about a fortnight before theonset of the illness, in which the emotion of fear wasprominent. It appears that his wife was one evening passinga room in their fiat where soiled linen was kept, and havingbecome the victim of an illusion that a turbaned strangerwas in that room, she screamed and shouted for help. Thepatient came along and though he armed himself with abroomstick and tried his best to overcome his timidity, hecould not bring himself to enter the room. At last neigh-bours-chiefly women-came on the scene and entered theroom to find that the turbaned person was nothing morethan soiled clothes thrown carelessly on the edge of abasket.

During further interviews I ascertained that theyoung man was experiencing dreams causing him tofear for the life of his child or for his own safety, andthat he often woke up in a state of terror ; afterleaving bed in the morning he found himself in astate of anxious expectation which was relieved byan attack of asthma. He also noticed that his fearand anxieties were much less after his illness started.These observations are interesting as they tend toconfirm those of Millais Culpin. Another fact broughtout during analysis supports W. McDougall’s state-ment that fear alone probably does not producephobia ; the incident causing it must be such as toevoke self-reproach, shame, or a sense of guilt. Inthe present case fear was admittedly accompaniedby a sense of shame occasioned by the patient showingcowardice before his wife and women neighbours.

Treatment followed the lines of explanation,persuasion, and re-education, and in three weeks thepatient gave up all medicines and was leaving homeevery morning for his work without waiting-as heused to-for the attacks to show themselves. For overa year his condition has been almost normal.

CASE 2.-In January, 1928, I saw a nurse, aged 17,working at a mental hospital, who gave nine years’ historyof typical attacks of bronchial asthma which came on onceevery week or fortnight, each lasting from one to four days.By superficial analysis I was surprised to find that aboutthree months before the onset of her illness she was on anerrand to her people’s neighbours one afternoon when a bigdog attacked her in a closed hall with no way of escape,and bit her in the leg. She was in a state of terror and felldown unconscious, and when she recovered ten minuteslater she felt a sense of suffocation. She then stayed in bedfor three months with disturbed sleep and a frequentsensation of fear whenever anyone entered her room atnight ; at the same time she used to have fearful dreams,waking up in a state of terror and with a feeling of suffocation.After leaving bed and getting about she began to get typicalattacks of asthma.

In a later interview the patient said that the attacksoften came on a few hours after being approached andthreatened by a certain inmate of the hospital, who wasparticularly big and violent-a situation resembling that ofthe previous accident. She also said that before joining theservice she used to get the attacks after any sort ofunpleasant surprise-e.g., after becoming unexpectedlyaware of another person standing behind or following her,or after anyone suddenly entered her room while she wasill in bed. She had never related her fear-evoking experi-

ences to anyone, because she always thought it a greatshame to feel afraid. I ascertained that she was delicate inhealth long before the accident and that as a child she wassubject to vague fears, especially of darkness. She ascribesthese to the way she was brought up during childhood, whenthe belief in mythical and weird beings was constantlyingrained in her impressionable mind.

These and similar points in the patient’s historygave me the clue to the lines on which to treat herpsychologically, and by persuasion and explanationmany of her faulty ideas and beliefs were corrected.She has now been free from attacks for a year.

These two cases represent almost my whole experi-ence of bronchial asthma, which makes the points ofsimilarity between them seem the more curious.Both patients are of neurotic constitution and gavehistories of attacks of fear or anxiety ; and there islittle doubt that if the analysis were carried furtherwith them more material would be forthcoming toexplain much that is abnormal in their disposition.Both developed their asthma after incidents in whichfear showed itself prominently and evoked-throughthe accompanying feeling of shame-an acute internalconflict which was solved by the onset of a bodilyillness, this largely substituting itself for the attacksof anxiety. Why they should develop asthma ratherthan another illness is a pertinent question whichleaves open the possibility of a pre-existing physicaltendency. Both have undergone some sort of psycho-therapy which resulted in more or less complete relief.The general practitioner is much more liable to meet

with cases of bronchial asthma than the psycho-therapist and I am writing these notes with the hopeof interesting him in an aspect of the disease, whichmay often be the deciding factor in its caustion or inthe precipitation of its attacks.

Medical Societies.MEDICAL OFFICERS OF SCHOOLS

ASSOCIATION.

A MEETING of this Association took place in therooms of the Medical Society of London, Chandos-street, on Oct. 4th. In the absence of the President,Dr. L. R. LEMPRIERE took the chair.Mr. SYDNEY ScoTT opened a discussion on the

SCHOOL-BOY’S EAR IN CLINICAL PRACTICE.

He projected on to the screen a number of diagramsshowing the auro-nasal regions and their relations,and photographs of pathological conditions of thoseparts. The most important aspect of the subjectwas the early recognition of acute infections of theear. Most people now recognised the advisabilityof incising the drum membrane in acute inflammations.Probably it had often escaped incision in the pastbecause it was not inspected with a sufficiently stronglight. Now that excellent means of examinationwere available, the drum should be systematicallyexamined by the practitioner in all cases of ear

trouble. Students should carry specula and mirrorsfor this purpose, and should not consider the exami-nation of a patient complete until these had beenused. The need of such a routine examination wasespecially great in fever hospitals. Many childrenwith otitis media did not complain of pain, and werenot sufficiently deaf to call attention to the ears,though the membrane was found to be bulging.Others, of course, were noticeably deaf.

Mr. Scott described the case of a boy who complained ofslight pain in his ear ; a little oil was put into it, and nofurther treatment was given. The temperature rose andwas accompanied by a good deal of head pain ; the schooldoctor thought he must have meningitis, and asked aneurologist to see him. For a week his temperature wasbetween 103° and 104° F. Absence of opisthotonos andreflex signs excluded meningitis, and the neurologist hadthe patient’s ears examined. One drum was bright red and

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bulging, though the boy said he had no pain in tho ear.On puncturing the drum pus spurted 10 inches, and onlyafter its release was pain felt. Evidently tho pent-up pushad caused aneasthesia and the absence of local pain gavea false sense of security. A mastoid operation and othertreatment became necessary, since the patient had septicaemiaand an infected cerebro-spinal fluid, but eventually horecovered.In Mr. Scott’s student days attendance at the ear

department was not compulsory, and the generalimpression was that all the needed instruction couldbe obtained from a book-a very fallacious idea.One practitioner had estimated that 25 per cent. ofhis cases required some experience in ear work.There existed a curious optimism with regard to earcases among practitioners. A shrewd observer hadassured him that practically all his ear cases got wellwithout trouble ; there was earache, then ’discharge,and finally recovery. Ear surgeons, however-prob-ably because the severe cases came to them-took amore pessimistic view. Mr. Scott gave the followingexample of the kind of case not infrequently seen bythe otologist :-The patient, a boy who had just left school, had been

bathing and said that some water had entered his ear,which was not inspected. He went to the theatre thatevening and in the night he awoke with intense ear pain.On the following evening the ear began to discharge, but thetemperature was more or less normal. On the next eveninghe felt tired, and two days later he was comatose, and diedin that condition without any active steps having beentaken. Mr. Scott had been called in, but much too late,since death occurred before the boy could be put on to theoperating table. At the post-mortem examination the wholetympanic cavity and all the air cells were found to be fullof pus, which, even after death, was under considerablepressure, and the whole cerebro-spinal system, from thefrontal lobe to the cauda equina, was oedematous. Thepresence of streptococci was demonstrated.Cases of acute otitis media thus called urgently for

recognition and attention in the early stages ; theyshould be drained at once without waiting for complications; they should, in fact, be dealt with on thesame principles as any other accumulation of septicmaterial. It was a great mistake to wait for the pusto burst through ; it might not do so, but might takea more dangerous course. Conservative treatmentwas not nowadays justifiable. It could not be tooclearly emphasised that incision of the drum did notitself cause deafness, and parents’ objection to incisionon this score could safely be set at rest. The ideaarose from the fact that in the past incisions werenot made until disease had produced changes in theligaments of the ossicles or destruction of the roundwindow. In some cases the drum membrane did notbulge, but with a good light the observer could some-times see pus on the other side of the drum ; in thesecases the prognosis after the fluid had been releasedwas very good. If delay in evacuating fluid hadoccurred it was desirable to open the mastoid.

Discussion.The CHAIRMAN referred to the need of a campaign

against unclean noses, since congested and dirtyconditions of the nose were the origin of many casesof ear trouble. In his experience of public school-boysotitis media could undoubtedly exist without anycomplaint having drawn attention to the ears. In36 per cent. of his cases of acute otitis media the firstear complaint was of otorrhcea, especially at nighttime, pus being seen on the bed linen in the morning.Inspection of the ear should be carried out, not oncebut from day to day. Eight per cent. of the caseseventually needed a mastoid operation. Ear caseswere among the most serious which occurred in schools,and the question arose whether paracentesis oughtto be done on every patient who complained ofearache. Clearly it was needed for the virulently redand bulging drum, but a large number of cases hadan abscess of the ear which resolved without inter-ference. Fully 60 per cent. of his cases were of thatkind. In young people of school age the meatusmight be very narrow or abnormally curved ; hencea proper examination was difficult or impossible, and

one could not be sure whether the lesion was due toboils close to the drum or to some other trouble suchas an accumulation of wax. He would like to knowjust when a mastoid operation was indicated. In hispractice, if otorrboea persisted more than three daysand the temperature remained raised, he called in asurgeon, but it was not feasible to call in an otologistto every doubtful case. What was the significanceof a sagging postero-superior wall ? He asked foropinions on the value of otalgin ; he regarded it asdangerous because it constricted the vessels.

Dr. G. E. FRIEND said he would like to hear moreclearly defined the kind of cases which it was safeto leave without performing paracentesis. During11 years he had done the operation on every case ofear trouble except where the drum looked normal.The average time of healing after the puncture wasthree to four days, the only other treatment beingswabbing out with spirit and boric drops. Of344 cases, only three had required a radical mastoidoperation. He would like to know what was the besttreatment for a chronically discharging ear, in theabsence of a raised temperature or localising signs.He had had good results from insufflations of bismuthsubnitrate.

Dr. J. LAMBERT asked whether a general anes-thetic was always necessary for paracentesis, or

whether a local anaesthetic sufficed. He agreed as tothe unclean condition of the noses of most of theschool population, and thought preventive measuresshould be directed chiefly to the nose, and especiallyto the correct way of blowing the nose. Boys whohad had ear or sinus trouble should be warned not todive or swim under water.

Dr. F. G. HoBSON asked about the value of regularmorning gargles or snuffles. He had thought this avaluable procedure, but Dr. J. A. Glover did notrecommend it.

Dr. A. I. SIMEY said there must be many cases ofear trouble which got well without paracentesis, andspoke of the value of applying ice-bags in cases ofacute inflammation of the ear.

Dr. GRAHAM FORBES asked whether the leechbehind the ear was at all extensively used now inthese cases. He would be glad to hear Mr. Scott’sexperience on the frequency of ear trouble followingvisits to a swimming bath. A surgeon in Freiburgtraced a number of cases to swimming baths, par-ticularly to those containing unclean water. Dr.Hastie had carried out experimental work on guinea-pigs, injecting the middle ear of the animal withwater from a swimming bath, and had in that wayproduced acute otitis. No doubt the lowered resistanceinduced by the cold water favoured the onset of theinflammation.

Dr. G. L. BUNTING asked the significance of acontinued high temperature after paracentesis ; alsowhether the persistent pulsation afterwards had anyserious import.

Dr. W. ATLEE said that a particular kind of earseen in epidemics was that in which the boy com-plained of earache for an hour or two, and showed avery dark bleb on the drum. Shortly after the drumruptured and the boy became comfortable. Hewanted to know whether these drums should beincised. He added that for many years the Thameshad not been so dirty and empty as this year, nor hadso many people bathed in it ; yet there had beenfewer " acute ears " this summer than for a numberof years past. He thought that medical practitionersshould carry auroscopes.

Reply.Mr. Scor, in reply, said he never incised a drum

unless he saw some adequate reason, some changewhich was not present in the normal membrane. Insome acute cases one was quite justified in waitingbefore incising. When inflammation of the middleear was present, the exudation drained much betterdown the Eustachian tube in some cases than inothers. Anatomical differences and varieties of bonesadded to the difficulties. He had incised a drum

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within seven hours of the onset of otitis, but that didnot prevent his having to operate later for severemastoid disease. In some cases it was not safe towait a week after incising the drum before operatingon the mastoid. It was a good working rule to holdone’s hand for about five days ; whether the mastoidoperation should be done earlier depended on whetherthe patient was very toxic. A good rule was thatif the deep part of the meatus sagged the mastoidmust be opened. He did not intend to deal with thechronic ear on this occasion. The cessation of an eardischarge was sometimes due to the bursting of abulla. He did not pin his faith to any particularmaterial for swabbing and syringing the ear. Incases which were painful syringing should be deferredfor a few days. For incising the drum he now alwaysused a general anaesthetic. He did not think thewrong method of blowing the nose caused otitismedia ; if the drums were intact when the nose wasblown, infective material could not be injected alongthe Eustachian tube and into the ear. The routineuse of gargles and snuffles was a matter which didnot come into his experience ; medical officers ofschools were themselves in a position to supplyvaluable information on those points. He hadordered leeches only once in 25 years ; he did notfavour their use.

ROYAL SOCIETY OF MEDICINE.

SECTION OF THERAPEUTICS.

A MEETING of this Section was held on Oct. Sth,when Dr. P. HAMILL delivered a presidential addressentitled

SOME PRINCIPLES OF THERAPEUTICS.

He pointed out that an accurate appreciation of theunderlying conditions is essential as a basis forrational treatment. Departures from the normalphsyiology may be but manifestations of compensatoryprocesses and attempts at

" correction " are notthen helpful but may hinder recovery. A highblood pressure may be necessary in a given case;nitrites will then be harmful. Antipyretics are littleused in fever nowadays; on the contrary fever,artificially induced, may even be beneficial, for

example in the treatment of general paralysis bymalaria, and in those conditions which are improvedby protein shock therapy. Many conditions whichcall for treatment are the result of previous illness.Damaged organs must be sustained and protectedfrom further injury, and here lies the importance oferadicating septic foci-e.g., the removal of infectedtonsils in rheumatic heart disease. Where part of agland of internal secretion has been destroyed, theeffects of the loss may sometimes be circumvented ifits active substance can be isolated and easily adminis-tered ; thyroid gland or thyroxin givenformyxcedema,and insulin for diabetes, are good examples. Dis-orders of infective origin well illustrate therapeuticprinciples, for elimination of the cause lies for themost part within the sphere of preventive medicine.In the therapeutic sphere direct attack on organisms iwithin the body has been made with success in manyprotozoal infections-e.g., malaria and amoebicdysentery. Organic arsenic preparations haveproved valuable in syphilis and relapsing fever, andantimony compounds in leishmaniasis. In bacterialinfections direct attack has been less fruitful ; urinaryantiseptics and mercurochrome are but partialsuccesses, but the results obtained with sanocrysin intuberculosis and chaulmoogra in leprosy augur wellfor the future of chemotherapy. To confer or exaltimmunity is perhaps the ideal method of coping withinfection if the cause cannot be eliminated or directlycombated. Prophylactic immunisation and serum

therapy have been very successful in many infections,but fail to fulfil all demands, owing to their inherentspecificity, and in some cases owing to the briefduration of the immunity conferred. We have

as yet no Mithridatium. For many infectionsimmunising agents of sufficient potency have not yetbeen developed, and the body must, therefore, rely onits own powers of resistance.To raise resistance to a high pitch and maintain it

there should be our constant aim. Can it be saidthat adequate attention is devoted to the problemsinvolved ? Nutrition, elimination, rest, and generalhygiene are the foundations on which resistance toinfection and the power of developing immunityare based. Observations by Edward Mellanby andhis colleagues indicate that deficiency of vitamin Ain the dietary lowers resistance to infection in experi-mental animals, and a generous supply of this vitaminto patients with puerperal septicaemia is said to havelowered the mortality to zero in a series of cases. Ina London business house during the influenza epidemicof the early part of this year a preparation rich invitamins was supplied to those who desired to takeit. There was hardly an absentee owing to influenzaor " cold " amongst those who availed themselvesof the offer. The conclusion that diet is a large factorin controlling resistance to infection and the develop-ment of immunity may fairly be drawn, and thecomplete proof of this proposition will be a therapeuticadvance of the first magnitude. The consumptionof milk, dairy products, and oily fish in this countryis far too small; incidentally, advocacy by themedical profession of dietary improvement willbenefit agriculture as well as the health of the com-munity. Rest is still underrated as a factor intreatment. The widespread use of hypnotics isdisquieting; the avoidance of the necessity for theiruse is desirable. In spite of the importance of quiet,especially for the sick, hospitals and nursing homesstill mention the fact that " trams pass the door

"

as a recommendation rather than a drawback. Therebuilding of hospitals in the inner zones of largetowns is surely not consistent with the requirementsof rest and hygienic surroundings. The removal ofwards to the outskirts of the towns, and the erectionof less permanent buildings which can be rebuiltand modernised every 40 or 50 years according tothe advance of knowledge and changing conditions issurely a way of progress that demands consideration.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING IN MANCHESTER.

(Continued from p. 713.)

SECTION OF TUBERCULOSIS.

Apical and Subapical Tuberculosis.Dr. D. P. SUTHERLAND (Manchester) presiding,

Dr. MAURICE FiSHBERG (New York) opened thediscussion. Pathological anatomists and clinicianshad, he said, long known that the number of peoplewith tuberculous lesions in the lungs was much higherthan recorded. The vast majority of tuberculouslesions were found in the apex of the lung andremained in that region. Nearly all cicatrised

lesions which remained inactive and gave no troubleduring life were in the apex. These lesions were oftenfound clinically, and with the aid of X rays duringperiodical examinations of healthy persons, whichwere becoming the vogue in the United States. Inpatients with non-pulmonary tuberculous lesions,sent for chest examination, changes in resonance werealmost invariably found at the apex of the lung,along with altered breath sounds and, perhaps, smalladventitious signs ; but such patients hardly everoffered significant pulmonary symptoms. In thesecases, if death ensued because of the tuberculousinfection, it was the result of acute pneumonic phthisisor more commonly miliary tuberculosis. Similarapical lesions were found among persons who sufferedfrom frequent colds"; they might spit blood and