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again, and the posterior wall of the auditorymeatus sinks. Fluctuation over the mastoid is nolonger waited for to-day; but in young children,in whom the petro-squamous suture is still open,we are sometimes surprised by the appearance of aretro-auricular abscess. However, the develop-ment of an abscess in the mastoid process is not

always accompanied by such acute symptoms ;there may often be fairly extensive destructionof bone without high temperature or severe pains.Clinically, such a condition can be diagnosed whenan acute otitis is not completely cured in the courseof four or at the most five weeks. The secretion

may continue, if only very slightly, and when thereis still a pressure sensitiveness, no matter howslight, at the root or the tip of the mastoid process,abscess must be suspected; it may indeed be

present even in cases where there is no longerdischarge but the drum membrane is not entirelynormal and, which is very important, the hearingcapacity has not been satisfactorily restored. Thesevere intracranial complications may appear evenin the first few days in the so-called malignantform of acute otitis, and in such cases surgicalintervention is necessary at the very beginning.The indication for operation in acute otitis can

be supported by X ray examination of the bone,but it requires special practice and experience tomake correct pictures of the ear, and also to beable to interpret them. The following points arementioned by FREY : a veiling or shadowing ofthe mastoid cells does not mean that an abscessis present, for this may also be seen in cases ofuncomplicated otitis, since the mucous membraneof the cells is always involved in the inflammatoryprocess. It is an entirely different matter whenthe septa between the cells disappear or becomeindistinct, for a destructive process can then beassumed with certainty. It is always absolutelynecessary to prepare comparative pictures of thehealthy side, and in doubtful cases it is advisableto repeat the examination, for this is the best wayof recognising a progressive process. In any case,an X ray picture taken before operation givesinformation as to the extent and form of the

pneumatic system and the topography of the

adjacent cranial fossae.Dr. P. COTTENOT, of Brussels, recently described 2

the positions which he recommends for radiographyof the mastoid. He agrees with Prof. FREY thata comparison with the opposite side is essential,that a shadowing with diminution of the trans-parency of the mastoid cells is to be found in simpleacute otitis without clinical signs of mastoidinvolvement, but that a mastoid focus can bediagnosed when destruction of the intercellularsepta is seen. A skiagram of the mastoid is of no

diagnostic value unless it shows the details ofthese septa, which are very delicate and often onlyslightly visible ; such a picture should be sufficientlyclear and fine to be examined through a lens. Heremore than anywhere in the body the results ofradiography must only be interpreted in con-

junction with the clinical findings. Dr. R.

2 Paris Médical, Feb. 3rd, 1934, p. 95.

THINNFONT, of Antwerp, comes to similar con-clusions.3 In addition, he believes with WITTMAACKthat the course of an acute otitis is peculiarlyinfluenced by the form of pneumatisation of themastoid process, and that radiography, by showingthis, has its principal value in prognosis. Accord-

ing, to this theory, a normal or "

mesoplastic "

mucosa, with complete and regular pneumatisation,is rarely attacked by acute inflammation. Threedegrees of hyperplasia of the mucosa are distin-

guished : -. (a) a highly hyperplastic mucous mem-brane with complete arrest of pneumatisation islikewise rarely attacked ; (b) a moderate degree ofhyperplasia with partial arrest of pneumatisationis particularly predisposed to acute inflammation ;and (c) in the slightest degrees of hyperplasia thereis but very little tendency to inflammation. Acondition of hypoplasia can also influence the acuteinflammatory process ; thus, the most advanceddegrees of fibrosis, often the result of previousinflammation, are not easily infected, but the lessextreme hypoplasias do not always escape. Dr.TniENFONT holds that these various conditions

may be recognised by radiography, and thatvaluable aid to prognosis can thus be given ; butit cannot yet be said that his postulates havebeen proved.

HEALTH INSURANCE AS "SOCIALISEDMEDICINE"

THE American Medical Association at theirannual meeting in Cleveland, Ohio, on Junellth-15th will give special consideration to thequestion of introducing some form of compulsoryhealth insurance into the United States. Hithertothe Association have strongly opposed healthinsurance, regarding it as a form of "socialisedmedicine," even where insurance medical servicesare provided through the panel system, andtherefore repugnant to the rugged individualism ofthe American people; and any attempts to discussthe subject at the annual meetings have been, ifnot actually burked, at all events not encouraged.There are now unmistakable signs that the rankand file of the profession are dissatisfied with thisway of dealing with so important an issue, and alively discussion may be anticipated at the Cleve-land meeting. For the purposes of the discussionthe association’s bureau of medical economicshas prepared an elaborate report on

" The Insurance

Principle in the Practice of Medicine," whichpurports to set out the effects of health insuranceon medical practice in Europe. The report, thoughwritten with outstanding ability, is, on the whole, adisappointing document. One naturally expectsdocuments written by Americans for Americansto be before all things up to date ; and this report,admirable in many respects, is certainly not up todate ; it is almost wholly given up to criticisms ofthe oldest health insurance system in Europe-namely, the German-which from the insurancedoctor’s point of view is also the most unsatis-

factory.3 Bruxelles-Médical, March 18th, 1934, p. 641.

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The defects of the German system were wellknown to the medical profession of this country25 years ago, and it was to prevent the introduc-tion of those defects into the British insurance

system that the British Medical Association enteredupon their campaign of the " Six Cardinal Points."The points embodied certain basic principles ofinsurance medical practice for which the Germandoctors have for 50 years striven unsuccessfullyto secure : separation of medical services fromcash benefit administration, statutory right of

every doctor to undertake insurance practice, freechoice of doctor, selection by local doctors of thelocal method of medical remuneration, effective

participation of doctors in the central and localadministration of the system. Medical benefit inthe British system has been based on these prin-ciples since its inception 22 years ago, and withthe introduction of the system health insuranceentered upon a new phase ; in countries that havesince adopted compulsory insurance-France, forexample-the doctors have profited by the experi-ence of their British colleagues. At this time of

day it is unnecessary to concentrate attention onthe German system. It is by an open-mindedstudy of the British system that an inquirer maymost readily appreciate the issues involved in theintroduction of compulsory health insurance ; andit is surprising that the American Medical Associa-tion, in a document prepared to furnish the factsmost material to the forthcoming discussion, shouldhave dealt so inadequately with what the Britishdoctors have done to place insurance practice on asatisfactory basis. The statements that are madeare so brief that some are misleading or inaccurate ;it is said, for example, that " confinements " areamong the services provided, whereas attendanceon a confinement is expressly excluded from thepanel doctor’s duties-an important point to bearin mind when considering the amount of hisremuneration.We hope that the American Medical Association

will supplement their studies in German healthinsurance by giving some attention to what hasbeen done in this country to bring insurancepractice into harmony with the true traditions ofthe medical profession. After all the Briton is asfull of " rugged individualism

" as his American

cousin, and the spirit that took the Xayfloweracross the Atlantic still lives in the old country, tothe irritation of a certain reforming type. Ourinsurance system was not imposed upon us by adictator, but freely accepted as a valuable measureof social reform, and in developing the systemthere is no terror of " socialised medicine," whichmay mean anything or nothing according to whatis in the minds of those who use the phrase.X RAY DIAGNOSIS OF LOBAR PNEUMONIATHE importance of radiography in the diagnosis

of chronic thoracic disease is now generally recog-nised and a radiogram is rightly regarded as anessential part of every complete investigation ofthe chest. Its application to the diagnosis of acutedisease has been limited by the difficulty of adapting

apparatus suitable for chest work to use at thebedside. In some acute diseases, such as pulmonaryabscess or empyema, the slight risk involved inmoving the patient from ward to X ray departmentis so much less than those of a hesitating diagnosisthat the lesser of two evils has always been rightlypreferred. The portable X ray unit, which enablesthe physician to obtain a picture of the patient’schest with less strain to the sufferer than is entailedby a physical examination, should facilitate stillfurther the investigation of these types of disease,and even apply to conditions such as pneumoniain which the removal of the patient from his bedentails unjustifiable risks. The provision of a

portable set will ease the burden of responsibilityresting upon the physician who has had to dependupon physical signs alone to determine whetherthe patient is suffering from a simple pneumoniaor one complicated by sepsis within or without thelung parenchyma. The importance of such earlydiagnosis in pneumonia has become much moreevident since the introduction of Felton’s serum.

Radiography may also be expected to tell us

something of the manner in which pneumoniacommences, develops, and resolves. °

Interest thus attaches to a series of 40 casesof pneumonia which have been kept under

radiological observation at Chicago during thecourse of the disease. In reporting these 1 theauthors have endeavoured to correlate X rayfindings with deductions based on the results ofphysical examinations. Experience gained inrecent years from the radiographic study of chronicdisease prepares us to anticipate their first and,from the practical point of view, their most

important finding. None of the skiagrams takenlater than 24 hours after the onset of symptomsfailed to show abnormal shadows in the lungs,although at this early stage of the disease abnormalphysical signs might be lacking or so slight as tobe difficult of interpretation. Further, X raysproved to be more accurate than physical signsin determining the extent of disease until the stageof maximum consolidation was reached, when bothmethods proved equally trustworthy. The causefor this discrepancy is to be sought in the site ofthe original pneumonic focus which is generallydeeply situated. Lesions so placed may be entirelybeyond the reach of percussion and auscultation,as radiograms of tuberculous chests have abunedantly proved. A consideration of symptoms andthe result of X ray examination may thus enable a

diagnosis of pneumonia to be made with someconfidence at a stage when neither impairedpercussion note, bronchial breathing, nor hair

crepitation can be demonstrated.It must not, however, be supposed that a

radiogram of a pneumonic lung will provide acharacteristic picture diagnostic of the conditionwithout regard to symptoms or to the patient’sgeneral condition, in the way that a skiagram of achest may supply conclusive evidence of phthisiswithout reference to history or symptoms or

1 Graeser, J. B., Ching Wu, and Robertson, O. H.: ArchInternal Med., February, 1934, p. 249.