294 THE RESERVOIR SIGN OF ACUTE MASTOIDITIS

Did the noble Lords, I wonder, contemplate thatthe births of future members of their House would befacilitated by the " adjustment of their Ladyships’spinal lesions’ " Do they really think that

hunting men, footballers, and others go to osteopathsto have their spines twisted when they sprain themuscles and ligaments of their limbs or displace theirsemilunar cartilages (I have seen a woman who hadher spine manipulated almost daily for 18 months-for flat-foot !) Do they realise that in the strict

interpretation of this Bill, Sir Herbert Barker’s

practice would be illegal, unless he chose to subscribeto the doctrine of the spinal " lesion " ? ‘? This mightimpress them more than the fact that it would alsobe illegal for an orthopaedic surgeon to practisemanipulative surgery.

Finally, do they realise that this is a purely Americanstunt, and that, despite all the protests to the contrary,the British element in osteopathy is absolutelynegligibel.—I am. Sir. vours faithfully.

London, Jan. 28th. A. S. BLUNDELL BANKART.

THE RESERVOIR SIGN OF ACUTE MASTOIDITIS

To the Editor of THE LANCET

SIR,—In drawing attention to the reservoir signas an early clinical sign of acute mastoiditis, I

deliberately avoided the question of when to operate.Mr. E. Watson-Williams has sought for the heelof Achilles but his quotation from my paper is

misleading. I wrote as follows :-

" After the third day from perforation or myringotomythe presence of a positive reservoir sign is diagnostic ofacute mastoiditis "-deliberately omitting, at this stage,the question of operation. Further on I said " a positivereservoir sign alone, elicited one month after perforation,is absolutely diagnostic of mastoiditis ... [here is inter-polated a typical case]... The more rapid the reaccumula-tion is the more urgent is the indication for immediateoperation on the mastoid."The last sentence refers to the case of one month’sduration, and not as quoted by Mr. Watson-Williams.

Deafness, per se, is of little routine diagnostic value,especially in infants and young children, in whomacute mastoiditis is commonly present withoutearache, tenderness, or swelling (a very late sign).Even a temperature may be interpreted in terms ofthe causal influenza, infectious fever, or serum

reaction. Yet the otorrhcea with a positive reservoirsign implicates the mastoid as a source of infection.Four days ago I saw a child of 2i years who nine dayspreviously had developed scarlet fever and an otitismedia. The membrane was incised. The temperatureremained at 101° F. and was ascribed to the scarletfever infection at first and later to a serum reaction.There was no earache, mastoidt enderness, or swelling ;yet the otorrhoea with a positive reservoir sign inten minutes incriminated the mastoid. Immediate

operation revealed the mastoid process to containa large abscess cavity with complete disintegrationof all the mastoid cells, and the temperature returnedto normal.

In acute otitis media the infection is limited to thetympanic cavity and rapidly subsides (as does everyother superficial abscess) when adequate drainage isestablished. Clinical experience leads me to believethat, in the majority of cases of acute otitis media,the tympanic cavity alone is involved. Mr. Watson-Williams’s description of a mastoid process with cells ... full of mucopus, the mucosa swollen, thebone inflamed " coincides with my view of one typeof an acute mastoiditis. Most of the 322 corticalmastoid operation cases mentioned in my paperwere admitted to the wards of a children’s hospital.

I admit and discharge without operation almost asmany cases as are operated upon. Of the latter, alarge number are kept under observation up to twoor three weeks before operation. The average casewas operated on from the fourteenth to the twenty-first day. About 1 in 15 of the cases of acute suppura-tive otitis media developed acute mastoiditis.

Is it prudent, once the diagnosis of acute mastoiditisis established, to permit the suppuration to smoulderon, to threaten life and hcaring—and perhaps developinto a chronic condition-when there is at our

disposal the cortical mastoid operation with itsgratifying results ?-I am, Sir, yours faithfully,

Harley-street, W., Jan. 25th. N. ASHERSON.

EARLY DIAGNOSIS OF RICKETS

To the Editor of THE LANCET

SIR,—In his article on rickets in your issue ofJan. 19th (p. 134) Dr. Sheldon states "that ricketsis fast becoming an uncommon condition, and themedical student of to-day may consider himselffortunate if he sees as many as half a dozen cases

during his period at hospital."This is undoubtedly true of the florid forms of

the disease which find their way to the hospitals,but in its early stages rickets is still the most commondisease of infancy. It is difficult to state its exactincidence, because this varies with the diagnosticstandards adopted by different observers. I believeit can be detected at some time during the first year,if the infants are examined at regular intervals, innot less than 50 per cent. of those who attend ourwelfare centres. Rickets is still the primary causeof much ill-health and a high infant mortality whichdoes not figure in the mortality-rates. The victimsare numbered among the deaths attributed to measles,whooping-cough, pneumonia, diarrhoea. &c. Dr.Sheldon himself reports two deaths in 11 cases. Aslong as our hospital teachers delay the identificationof rickets until unequivocal bony signs appear, suit-able preventive measures on a large scale will con-tinue to be delayed.The early signs are pallor, head sweating, restless-

ness, loss of muscle tone, enlargement of the abdomen,and serious reactions to minor infections. Of thesethe amyotonia is the most constant, and the first toyield to treatment by cod-liver oil and/or ultra-violet light. Moreover, this loss of muscle tone andthe accompanying laxity of ligaments is responsiblefor the great majority of the minor orthopaedicproblems of childhood, including the 50 per cent. ofchildren who develop a varying degree of genu-valgum.With our present knowledge it must be admitted

that the above signs do not make the diagnosiscertain, but for practical purposes these signs mustbe taken as diagnostic, because the vast majorityof the children showing them do develop the bonychanges if the signs go unheeded. When there is

beading of the ribs, bossing of the skull, or X rayevidence in addition, the disease is well established.Cranio-tabes is an unreliable sign, for it seems to

vary in different countries and in the hands ofdifferent observers (" Rickets in Vienna," p. 131).Much has been done in the infant welfare centres

to combat rickets-viz., the early administration ofcod-liver oil to both breast- and bottle-fed infants,free milk to those in need, attention to their diets,exposure to sun and air in the summer months, andto ultra-violet light in the winter. In spite of thesemeasures rickets is distressingly common, especiallyin the early months of life. Progress has been made,