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283 severe winter without any large increase in their risk of heart-attack. The same seems not to be true of the less severe British winter. This indicates that at least one of the previously suspect factors-namely, the breathing of cold air-is unlikely to be important in explaining the British experience. It remains possible that in this country either our habits change differently in response to cold, or else we suffer greater body cooling. Those who have travelled both here and in North America will probably agree that they tend to feel a lot colder on this side of the Atlantic, whatever the thermometer may say. Similarly, it appears that chilblains are a British phenomenon: doctors from Northern Scandinavia or Canada are generally quite unfamiliar with the condition. To an epidemiologist the discovery of a difference in the disease experience of two populations is the starting-point of research to uncover an explanation. It is to be hoped that this report from Ontario will stimulate such an inquiry. If successful, it might help us to avoid the winter toll of fatal heart-attacks in Britain. ATTACK ON SMALLPOX NoBODY who has studied the statistical material put out by the World Health Organisation is likely to accept it as an exact image of the world as it is. Never- theless, these figures are welcome, for there are no comparable sources of information, and they can be both interesting and encouraging. In a report 1 on the incidence of smallpox, Brazil is the only country in South America which admits to the disease. This may be true, but Brazil shares its frontiers with nine other States and viruses require no visas. No-one ought to be too self-satisfied about the detection and reporting of smallpox: within the past twenty years alastrim has certainly escaped detection in this country. It is a matter for congratulation that so many impoverished States deliver credible reports to W.H.O. Three years ago it was decided to make an attempt to eradicate smallpox throughout the world. This campaign was to begin with mass vaccination in all the infected countries, followed by the detection and isola- tion of the individual victim. It was soon seen, how- ever, that, while smallpox was not reported as com- pletely as it might be, the estimated incidence was lower than had been expected. In 1968 the countries where the incidence of smallpox exceeded 5 cases per 100,000 were limited to India, Indonesia, and a few countries in west and central Africa; in only three of them was the incidence as high as 20 per 100,000. Vaccination scars were unexpectedly common. Another finding (which reference to the older literature might have disclosed) was that smallpox is seldom a pandemic but is usually concentrated in a few neighbouring villages. There were grounds for thinking that infection is usually acquired in the home or at school rather than in the world at large. These findings suggested that, while systematic vaccination must be given every encouragement, much might be done to control the disease by the detection and isolation of the individual cases. The diagnosis of 1. W.H.O. Chron. 1969, 23, 465. the isolated case is not always easy, even for the doctor who sees the disease often. As the incidence of the disease falls, the number of such doctors falls at least as fast. Certain diagnosis depends on the laboratory, and it has been an important part of this W.H.O. project to establish diagnostic laboratories in every country and to train the staff. As a part of this plan W.H.O. has published an admirable booklet of practical advice.2 Until a few years ago much of the vaccine in use was of low quality. A freeze-dried vaccine of high potency is now produced in several of the worst affected countries and is also supplied by some of the wealthier nations. Vaccination methods too have been improved so that 400-500 vaccinations by one operator each day are not unusual. It is too early to say whether these new (or revived) methods of smallpox control will eradicate the disease everywhere. The figures since 1967 show that in al- most every country reported cases have been well below those for 1962-66. Provisional estimates for 1969 indi- cate that more than 5 cases per 100,000 will be seen only in Indonesia and the Congolese Republic. The natural fluctuations of infectious disease must still any unquestioning optimism. Nevertheless, we must expect systematic vaccination to depress the level of susceptibles to a point where the virus will find it hard to discover a host. This campaign may well be a mile- stone in public health comparable to the introduction of diphtheria immunisation or dicophane (D.D.T.). Dr. Jenner would have been pleased, and the countries taking part might do worse than to erect a modest memorial in Berkeley, Glos., when the world’s last epidemic is concluded. OUTCOME OF ACUTE OTITIS MEDIA AT least a quarter of all children in the United Kingdom have acute otitis media at some time or other. The serious complications of mastoiditis and intracranial suppuration have become rare, but hearing does not always return to normal. Although the residual deafness tends to disappear over the years, it often persists long enough to cause difficulty in the child’s social and educational development. Fry and his colleagues 3 studied 403 children who had been seen with acute otitis media in a London middle-class general practice five to ten years earlier. The hearing was assessed by audiometry and the patients were examined by a specialist. The peak incidence of acute otitis media was in the pre-school and early school years, and discharge from the ear was a feature in 20% of attacks. Antibiotics were prescribed in 54% of patients and in 20% of attacks. In the follow-up period, 17% had a significant hearing loss, compared with 4-5% of matched controls. Deafness was com- moner in girls than in boys; in those children with siblings than in only children; in those who had had a discharge in any attack; and in those with a family history of ear disease. There was no correlation be- tween deafness and age at first attack, age at last attack, total number of attacks, or history of associated allergies. 2. Guide to the Laboratory Diagnosis of Smallpox. W.H.O., Geneva, 1969. See Lancet, 1969, i, 613. 3. Fry, J., Dillane, J. B., Jones, R. F. McN., Kalton, G., Andrew, E. Br. J. prev. soc. Med. 1969, 23, 205.

Transcript of OUTCOME OF ACUTE OTITIS MEDIA

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severe winter without any large increase in their risk ofheart-attack. The same seems not to be true of the lesssevere British winter. This indicates that at least one ofthe previously suspect factors-namely, the breathingof cold air-is unlikely to be important in explainingthe British experience.

It remains possible that in this country either ourhabits change differently in response to cold, or else wesuffer greater body cooling. Those who have travelledboth here and in North America will probably agreethat they tend to feel a lot colder on this side of theAtlantic, whatever the thermometer may say. Similarly,it appears that chilblains are a British phenomenon:doctors from Northern Scandinavia or Canada are

generally quite unfamiliar with the condition.To an epidemiologist the discovery of a difference in

the disease experience of two populations is the

starting-point of research to uncover an explanation.It is to be hoped that this report from Ontario willstimulate such an inquiry. If successful, it might helpus to avoid the winter toll of fatal heart-attacks inBritain.

ATTACK ON SMALLPOX

NoBODY who has studied the statistical material putout by the World Health Organisation is likely to

accept it as an exact image of the world as it is. Never-theless, these figures are welcome, for there are nocomparable sources of information, and they can beboth interesting and encouraging. In a report 1 on theincidence of smallpox, Brazil is the only country inSouth America which admits to the disease. This maybe true, but Brazil shares its frontiers with nine otherStates and viruses require no visas. No-one ought tobe too self-satisfied about the detection and reportingof smallpox: within the past twenty years alastrim hascertainly escaped detection in this country. It is amatter for congratulation that so many impoverishedStates deliver credible reports to W.H.O.Three years ago it was decided to make an attempt

to eradicate smallpox throughout the world. This

campaign was to begin with mass vaccination in all theinfected countries, followed by the detection and isola-tion of the individual victim. It was soon seen, how-ever, that, while smallpox was not reported as com-pletely as it might be, the estimated incidence was lowerthan had been expected. In 1968 the countries wherethe incidence of smallpox exceeded 5 cases per 100,000were limited to India, Indonesia, and a few countriesin west and central Africa; in only three of them wasthe incidence as high as 20 per 100,000. Vaccinationscars were unexpectedly common. Another finding(which reference to the older literature might havedisclosed) was that smallpox is seldom a pandemic butis usually concentrated in a few neighbouring villages.There were grounds for thinking that infection is

usually acquired in the home or at school rather than inthe world at large.These findings suggested that, while systematic

vaccination must be given every encouragement, muchmight be done to control the disease by the detectionand isolation of the individual cases. The diagnosis of

1. W.H.O. Chron. 1969, 23, 465.

the isolated case is not always easy, even for the doctorwho sees the disease often. As the incidence of thedisease falls, the number of such doctors falls at least asfast. Certain diagnosis depends on the laboratory, andit has been an important part of this W.H.O. projectto establish diagnostic laboratories in every countryand to train the staff. As a part of this plan W.H.O. haspublished an admirable booklet of practical advice.2Until a few years ago much of the vaccine in use wasof low quality. A freeze-dried vaccine of high potencyis now produced in several of the worst affectedcountries and is also supplied by some of the wealthiernations. Vaccination methods too have been improvedso that 400-500 vaccinations by one operator each dayare not unusual.

It is too early to say whether these new (or revived)methods of smallpox control will eradicate the diseaseeverywhere. The figures since 1967 show that in al-most every country reported cases have been well belowthose for 1962-66. Provisional estimates for 1969 indi-cate that more than 5 cases per 100,000 will be seenonly in Indonesia and the Congolese Republic. Thenatural fluctuations of infectious disease must still

any unquestioning optimism. Nevertheless, we mustexpect systematic vaccination to depress the level ofsusceptibles to a point where the virus will find it hardto discover a host. This campaign may well be a mile-stone in public health comparable to the introductionof diphtheria immunisation or dicophane (D.D.T.). Dr.Jenner would have been pleased, and the countriestaking part might do worse than to erect a modestmemorial in Berkeley, Glos., when the world’s last

epidemic is concluded.

OUTCOME OF ACUTE OTITIS MEDIA

AT least a quarter of all children in the UnitedKingdom have acute otitis media at some time orother. The serious complications of mastoiditis andintracranial suppuration have become rare, but hearingdoes not always return to normal. Although theresidual deafness tends to disappear over the years,it often persists long enough to cause difficulty in thechild’s social and educational development. Fry andhis colleagues 3 studied 403 children who had been seenwith acute otitis media in a London middle-class generalpractice five to ten years earlier. The hearing wasassessed by audiometry and the patients were examinedby a specialist. The peak incidence of acute otitismedia was in the pre-school and early school years,and discharge from the ear was a feature in 20% ofattacks. Antibiotics were prescribed in 54% of

patients and in 20% of attacks. In the follow-upperiod, 17% had a significant hearing loss, comparedwith 4-5% of matched controls. Deafness was com-moner in girls than in boys; in those children withsiblings than in only children; in those who had hada discharge in any attack; and in those with a familyhistory of ear disease. There was no correlation be-tween deafness and age at first attack, age at last attack,total number of attacks, or history of associated allergies.2. Guide to the Laboratory Diagnosis of Smallpox. W.H.O., Geneva,

1969. See Lancet, 1969, i, 613.3. Fry, J., Dillane, J. B., Jones, R. F. McN., Kalton, G., Andrew, E.

Br. J. prev. soc. Med. 1969, 23, 205.

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In acute otitis media the eustachian tube isobstructed and the air in the middle-ear spaces is

displaced by exudate. Hearing is inevitably reducedby these conditions, which resemble listening underwater. Sooner or later the patency of the eustachiantube is restored either by treatment or by Nature. Ifnatural resolution is delayed the viscosity of the fluidwithin the middle ear may increase to the consistencyof glue, which cannot drain down the tube. Theorigin of glue ear is as yet imperfectly understood;some cases may follow acute otitis, while manypresent as conductive deafness without a history ofearache. Treatment is aspiration of the fluid; and itmay often be necessary to provide ventilation and

drainage of the middle ear with a plastic tube orgrommet.4 4 Mucolytic agents have also been usedwith success.5The hardest task in the management of persistent

deafness after acute otitis media is to identify theaffected children. Surprisingly, the mothers are oftenunaware of their disability, and audiometry is oftenthe only reliable way of establishing the hearing loss.Effective follow-up of children after otitis mediatherefore entails audiometric examination, which is

normally available only in hospital departments and insome school medical services. The ideal supervisionfor the moderately deaf child is frequent and regularchecks at school or nursery by the peripatetic teacherof the deaf, who is regularly in touch with the localotologist. This arrangement works well in manycounties, serving to discover deafness, avoiding lossof schooling due to routine attendance at hospital,and rounding up defaulters from clinical follow-up.But that raises the questions of the supply of peri-patetic teachers, the resources for training them, andthe money to reward them adequately.

SOLAR RETINOPATHY

Now that winter is, it may be hoped, turning thecorner, the subject of solar retinopathy might not betoo remote. Like the effects of cigarette smoking, itis largely avoidable. Probably, through the centuries,each major solar eclipse has been followed by a smallepidemic of this condition. Many victims are school-children who have been marched out by their teachersto watch the solar display with little understanding ofthe dangers.6, 7The lesion caused by gazing at the sun for too long

is a simple and localised heat burn of the macular areaof the retina. The visual disability, which is permanentand lifelong, rarely amounts to a reduction of visualacuity of more than one or two lines of Snellens types.But the associated minute paracentral partial scotomamay cause much inconvenience. Fortunately, whenlooking at the sun through a filter, most people do sowith one eye only.

" Blindness ", a much misunder-stood and misapplied term, is as inappropriate to thiscondition as it is to the description of defects of colourperception.4. Harrison, K. Proc. R. Soc. Med. 1969, 62, 456.5. Bauer, F. J. Lar. Otol. 1968, 82, 717.6. Gilkes, M. J., Macpherson, D. G., Osmond, A. H., Thorne, B. T.,

Roberts, D. St. C. Br. med. J. 1959, ii, 1487.7. Gilkes, M. J., Roberts, D. St. C., Osmond, A. H. Thorne, B. T.

Lancet, 1961, i, 109.

Throughout the world eclipses are often allowed to ’

steal up on the population without warning: and laterthe harvest of solar retinopathy is counted. A roughestimate of as many as 500 cases per eclipse for Britainalone has been suggested.6 Recently the Departmentsof Health and Education have begun a programme towarn the public, similar to the one which, over theyears, reduced serious firework injuries of the eye.The customary methods of examining the sun

directly through filters are largely inadequate andinduce false security. They include dark photographicnegatives, sun glasses, instrument shades, or a narrowcleft between the fingers; and Socrates advised gazingat the reflection of the sun in water. All have proved tobe wanting at one time or another. The only safeadvice for the public is that under no circumstancesshould the sun be looked at directly using any form offilter whatsoever. Those wishing to examine solar

phenomena may use a pinhole projection method, suchas that described by Flynn.8 Where direct observationis essential " a filter density of 4-5 which does nottransmit more than 1:30,000 of the total solar radiationis effective and is achieved by the use of two appropriategelatin filters." 9

Eclipses apart, cases of solar retinopathy arise fromtime to time, even in temperate climates. Because ofthe paucity of symptoms, or the circumstances, thesecases may go unnoticed until the macular appearanceexcites an ophthalmologist’s interest during routinerefraction. It is clear that sunbathers are quite oftenaffected, 10 as well as members of certain religioussects,u,12 The mentally disturbed may also suffer

damage in this way, and Gilkes 13 described a schizo-phrenic patient whose macular changes were attributedto drug therapy, until it became apparent that this

patient’s delusions included a belief in his power tocontrol the sun and planets in their paths. A severelyretarded and deformed thalidomide child was foundto have abnormal macular appearances; and he likedto sit in a pram, rocking to and fro and gazing at the sun.

There may be an association between subliminalexposure of the macula to solar radiation and the later

development of macular degeneration. Although thework of Prof. Arnold Sorsby and others indicates thatmuch so-called " senile macular degeneration " has agenetic basis, exposure to the sun may play a part.Certainly, in some solar retinopathies the later macularappearances are not dissimilar to those of earlymacular degeneration.14The next total eclipse of the sun will be visible in

parts of this country, weather permitting, on Aug.11, 1999, but its remoteness should not discouragecontinuing efforts to ensure that not only the public atlarge but also parents and, most of all, teachers ap-preciate the almost entirely avoidable dangers oflooking directly at the sun. The next partial eclipse ison Feb. 25, 1971; but the warning is a worldwideone and not for these isles alone.

8. Flynn, J. A. F. Br. med. J. 1960, i, 563.9. MacFaul, P. A. Br. J. Ophthal. 1969, 53, 534.

10. Ridgway, A. E. A. Br. med. J. 1967, iii, 212.11. Das, T., Nirankari, M. S., Chaddah, M. R. Am. J. Ophthal. 1956,

41, 1048.12. Knudtzon, K. Acta ophthal., Kbh. 1948, 26, 469.13. Gilkes, M. J. Br. med. J. 1968, iii, 678.14. Duke-Elder, S. Text-book of Ophthalmology; vol. VI, p. 6496.

London, 1954.