258

passed along the lumen of the laryngoscope in orderto obtain material for culture.

If suction is to be applied an aspirating tube ispassed until its tip lies about an inch beyond thevocal cords. These suction tubes are of a specialmake and cannot be obtained from the ordinaryinstrument-maker. They are plain brass tubes14 inches long and, about six inches from the proximalend, they are bent at an angle of 140 degrees so thatthe surgeon’s hand does not obstruct his view. Theproximal part is widened to make a handle, on whichis provided a nipple for connexion with the rubbersuction tube. The tip of the tube is carefully bevelledoff. Like the laryngoscopes, the tubes are unplated.They are used in three sizes: (1) small; internaldiameter of main stem 3 mm. ; external diameter,5 mm., internal diameter of tip 2 mm., and externaldiameter 4 mm. ; (2) medium ; external diameter ofmain stem 6 mm., and of tip 5 mm., internal diameterof tip 3 mm. ; (3) large ; external diameter of mainstem 7 mm., and of tip 6 mm., internal diameter oftip 4 mm. Dr. J. D. Smith, the director of hospitalsat the Willard Parker, prefers a special type of tubewhich resembles a male catheter ; it has a blind end,with a hole measuring 10 by 3 mm., placed 12 mm.from the tip. The portable suction apparatus isrun off the hospital current and two sets should beavailable in case of emergency.Between the applications of the suction tube, water

is drawn through it, so that its lumen is kept clearand the surgeon can see how much membrane hasbeen removed. Finally, the larynx is inspected, andif there is a raw, oozing surface it is swabbed withadrenalin.A supply of sterile laryngeal swabs is kept in

readiness for making direct cultures and for applyingadrenalin. The swabs are inserted by means ofclamped artery forceps. To prevent the woolbecoming detached in the larynx the pledget isfixed to the swab stick by collodion.The nose and mouth of the operator are protected

by a mask and his eyes by plain glass spectacles. Thewhole operation only takes a few minutes and shouldnot cause the patient more than a little discomfort.No anaesthetic is necessary. As soon as the procedureis finished the patient is sent back to bed and givendiphtheria antitoxin.

Advantages of 4piratio7z.The first advantage claimed for this method is the

accurate diagnosis which can be made after directinspection and direct culture. The diagnosis alsoaids prognosis ; the workers at the Willard ParkerHospital believe that laryngeal diphtheria has abetter prognosis than other forms of acute laryngitiswith obstruction. Secondly, the direct removal ofthe membrane by suction restores the air-way whichhas been partly or completely blocked by it. At thestage at which patients usually come to hospital themembrane is detached easily and there is little oedemaand no haemorrhage. Earlier in the illness there isusually a good deal of oedema and the membrane isvery adherent ; if the symptoms are not urgentexpectant treatment is adopted. Later in the illness,when relief is urgently needed, direct intubation isperformed, but suction, its supporters claim, oftenobviates the necessity for intubation, and in any casediminishes the incidence of broncho-pneumonia.

Dr. Joe’s report gives the tables which he was ableto compile from the records of the Willard Parker,Kingston-avenue, and Queensboro Hospitals. Theseinstitutions have 864 beds between them. Unfor-tunately the figures only date from 1927. At theWillard Parker Hospital there was a progressivedecrease in the death-rate of intubated cases of diph-theria from 54 per cent. in 1922 to 25 per cent. in 1926,followed by a considerable drop-to 16-6 per cent.-in 1927. Making allowance for the reduced severityof diphtheria from 1922 to 1926, Dr. Joe thinks thatat least part of the decrease was fairly attributableto the introduction of the suction method. Since1927 the percentage of mortality has shown an

increase to 28-5 in 1928, and 37-5 in the first ninemonths of 1929. Dr. Joe points out that thesefigures are not quite fair to the suction method, asthey only represent the percentage of deaths afterintubation, and the suction method has been steadilyreducing the number of cases which require intubation.Moreover, the increasing accuracy of diagnosis mayalso be related to the increased death-rate. Thefigures do not supply an answer to the question ofhow far the new method has reduced the need forintubation. Before 1927 laryngeal diphtheria wasnot separated from the other cases of diphtheria, butthere has been a steady fall in the percentage of allcases of diphtheria which required intubation. SinceDr. Joe’s return to England he has received fromDr. Smith the information that in the year 1918-11)the Willard Parker Hospital admitted 697 cases ofcroup, and that of these 286, or 41 per cent., requiredintubation, while the mortality after intubation was41-6 per cent. In 1928, 407 cases of laryngealdiphtheria were admitted ; of these, 77, or 4 per cent.,only were intubated.

Cases Seen Personally by Dr. Joe.Of the 11 cases seen by Dr. Joe while he was in

New York six were finally diagnosed as laryngealdiphtheria. Two of them were not treated by suctionas there was no membrane in the larynx ; two morehad a moderate amount of obstruction, but Dr. Joeremarks that he would not have considered themserious enough for operative interference, while theremaining two were very severe, and he would haveperformed tracheotomy or intubation on them atonce. The two milder cases gradually recoveredwithout any dramatic alleviation of their symptoms,but the two severe cases demonstrated the value ofthe aspiration method very forcibly, and Dr. Joegives the details of them.The first was a boy, aged 5, who had extensive membrane

on the fauces, and was exhausted and livid, with a rapid,thready, pulse and marked recession of the soft parts.Laryngoscopy revealed a good deal of membrane on theepiglottis and larynx and flapping about in the trachea.On the first application of suction, several pieces of membranewere brought out, and the second application removed acomplete cast of the trachea and proximal half-inch ofboth bronchi. All obstructive symptoms disappeared,the patient’s colour and pulse improved, and he was asleepwhen carried out of the theatre. Symptoms of moderateobstruction appeared again 22 hours later; aspiration wasrepeated, several more fragments removed, the symptomsagain completely relieved, and recovery was uneventful.

Dr. Joe’s conclusion is that the method is safe andinvolves, in the hands of a skilled operator, littlemore than temporary discomfort, and certainly muchless shock than tracheotomy. He sees no reason

why aspiration should not be employed as an’ ‘

adjunct to tracheotomy as well as to intubation.

WESTMINSTER HOSPITAL.OPENING OF THE RADIUM TREATMENT ANNEXE.

THE Radium Annexe, which was formerly openedby Viscount Lee of Fareham last Wednesday,Jan. 29th, at 66, Fitzjohn’s-avenue, London, N.W.,owes its origin to the fact that while public recog-nition of the value of radium was still lacking twomunificent gifts, one from Mr. Austin Taylor, laterchairman of the hospital, the other from the Pru-dential Assurance Company, enabled progress tobe made in 1925 with the radium treatment ofcertain types of cancer. The house committee of thehospital desiring, in 1927, to make the treatmentavailable to all who might benefit from it, an appealfor funds realised nearly z25,000, which was imme-diately used for the purchase of radium, and by theend of 1928 the hospital possessed three-quarters ofa gramme in the form of needles and one grammewhich could be used as a unit for the treatment offorms of cancer which had hitherto been regarded asbeyond surgery. The problem of accommodation forthe increasing numbers of patients then arose, and

259

it became clear that further progress depended uponthe cooperative efforts of teams of specialists andsurgeons, pathologists, radiologists, physicists, andtechnical engineers, all working together under oneroof. To meet this twofold need it was resolved toestablish a separate Annexe, and this was partiallymade possible by two anonymous donations of 24000and 25000 each. A building in Fitzjohn’s-avenue,Hampstead, was purchased, and plans were madefor its adaptation and equipment. Funds were

quickly forthcoming, and there is a list of 845 founders,headed by the name of H.R.H. the Prince of Wales.’The National Radium Commission recently decidedto entrust to the hospital four grammes of radium,on loan from the Union Miniere Belge, for use in asingle unit. This " bomb " has now been purchasedhy the Radium Trust and will be in use day and nightAt the Annexe.

Accommodation.In the basement is (1) a pathological laboratory, in

which portions of growth are microscopically examinedto determine their original nature and the effects uponthem of radiation ; examinations of blood are alsoconducted to serve as a measure of the amount ofradiation received by a patient-experimental workon the genesis of cancer is being undertaken; (2) abiochemical laboratory : determination of a patient’stolerance to sugar is here conducted as a measure ofhis or her reaction to irradiation-an investigationinto the cause of cancer from the point of view ofthe action of fat-soluble agencies is also being carried-out; and (3) a physics laboratory : here researchis being conducted with a view to the determinationof the best means of utilising the supply of radiumboth in the " bomb " and in the form of needles inorder to obtain the maximum destructive power ona growth without injury to the normal surroundingtissues. Here is also (4) the emanation room, con-taining apparatus for the preparation of radium" seeds," and (5) the deep X ray set room, containingthe apparatus necessary for generating at 230,000 voltsthe X rays used in the deep therapy departments.On the ground floor is (1) the radium bomb room,

lined with barium for the protection of workers inadjacent rooms ; by means of specially constructedapparatus its rays are directed on two patientssimultaneously ; (2) the deep X ray therapy depart-ment for the irradiation of deep-seated malignantgrowths, to be compared with irradiation by meansof the bomb ; (3) the X ray diagnostic department,’chiefly used for locating and localising tumourspreparatory to their treatment ; (4) the dark room,the walls of which, in accordance with modern practice,are painted cream and all work is done by reflectedlight. On this floor is the male ward with six bedsand the female ward with four beds for those unableto contribute, as well as the medical officers’ consultingroom.

On the first floor are seven rooms for the accom-modation of paying patients, one three-bedded andone two-bedded ward for the accommodation ofthose able to contribute not more than 23 3s. to 24 4s.per week (no medical fees being charged) ; also theoperating theatre, sterilising room, and anaestheticroom.

On the second floor is accommodation for twosisters, ten nurses, and four maids. The nurses havetheir dining and sitting rooms on the ground floor.

Opening Ceremony.In asking Lord Lee to open the Annexe, the chair-

man of the hospital, Mr. K. A. Wolfe Barry, said ’,that although separated geographically, the Annexewould be as much a part of the hospital as any wardor special department of the main building. Theirsurgical staff, after visiting those centres on theContinent where radium treatment of cancer was

being practised, had persuaded the governors of thehospital to take their courage in both hands and toestablish a separate department where, alongsidetreatment by all radium methods, research might becarried out not only into the cause of the disease but

also, what was as important, into improved methodsof technique. The building, with 22 beds for patients,special rooms for a radium bomb and deep X raytherapy, a theatre, accommodation for the nursingand domestic staff, and all the necessary laboratoriesfor routine and research purposes, was being openedfree from debt, although they were not withoutanxiety for maintenance and running cost. If theyhad the means they would house the nursing staffin an adjacent building and give up the top floor tofurther accommodation for patients. This was, headded, the first time that such a mass of radium asfour grammes had been used as one unit in thiscountry, and the hospital was proud to be entrustedwith it.

Administrative Conintittee.The committee which has been selected to administer

the Annexe consists of eight members, two of thembeing surgeons to the hospital-namely, Mr. R. H.Thorpe (chairman), Mr. H. M. Clowes (vice-chairman),Mr. Wolfe Barry and Lieut.-Colonel U. C. Bulkeley(ex officio), Mr. William Turner, F.R.C.S., Mr. E.Rock Carling, F.R.C.S., Mr. J. D. C. Couper, andMajor S. R. Stott.

NOTES FROM INDIA.

(FROM OUR OWN CORRESPONDENT.)

Medical Research.THE recommendation of Sir Walter Fletcher’s

Committee that Dehra Dun should be selected forthe Imperial Research Institute seems now to havebeen definitely adopted, in spite of the local claimsof the presidency towns. There has been acrimoniousdiscussion in the Legislative Assembly and else-where, and no doubt there would be advantages inthe vast amount of clinical material which thehospitals in the large cities are in the position to supply,but the existing research laboratories in Calcutta,Bombay, and Madras will still have their opportunities,and the recently issued report for 1928 of the HaffkineInstitute in Bombay furnishes a good example of thevariety of work with which they have to deal. Duringthe year under report the Institute has been investi-gating sprue, various forms of anaemia (particularly inrelation to pregnancy), and tuberculosis. An inquiryhas been conducted into the possibility of improvingthe mode of preparation of plague vaccine, with whichBombay supplies the whole of India, and the examina-tion of indigenous drugs, which has now been going onfor some years has been continued, as well as an inquiryinto the factors which give rise to earth-eating. Theplague investigation has not led to any modificationin the process of manufacture, but as so often happensin such- cases a result has been indirectly arrived atwhich will prove very useful. The discovery thatblood agar is the best medium for the growth of theplague bacillus has facilitated the detection of con-taminating organisms in the vaccine. Ansemia isvery prevalent in Bombay, and the researches haveshown that the forms associated with sprue andpregnancy bear a close resemblance to perniciousanaemia. It is thought that the anaemia of pregnancyis not a distinct entity, as has sometimes been sug-gested. The Institute also serves as a centre forantirabic treatment. The report closes with an

expression of regret that the Institute is still crampedfor funds, and that no further advance has been madein the direction of establishing a school of tropicalmedicine in connexion with it.

Cholera in a Hill Tract.Evidences of progress in medical work are to be seen

just now in the Punjab, where a large number of freshrural dispensaries have been established during thelast few years, and the public health report of theprovince for 1928 is full of interest. The year was anexceptionally healthy one, the death-rate being24’72 per mille, as against a birth-rate of 46’30-