987

adsorption between antigen and antibody : (1) hydrogen-ionconcentration (oxidase-reducase system); (2) specific aminogroups. In the primary struggle the second factor cannotpossibly play a role, since it takes some time for the aminogroups in the lipoid-globulin molecules to be arranged in aspecific manner. Moreover, the primary struggle is a localaffair, a struggle between spore and cell, while the turningof the tide is a general affair-a struggle between the lipoid-globulin particles of the serum generally, of the plasma cellslocally, and those of the parasites.When a syphilitic spore enters the human body, in order

to develop it must enter a connective-tissue cell or an endo-thelial cell. To enter a cell it must alter the surface-tensionof that part of the cell where it is going to enter, and thiswill mean a local disturbance of the normal hydrogen-ionconcentration. It is absolutely certain that all cells requireand use oxygen, and probably certain that all cells (animal)in exchange for oxygen exhale carbon dioxide. Should a

spore be able to take some of the oxygen required by thecell it hopes to enter, the normal ratie between the oxygenand the carbon dioxide of that cell will cease to exist, withthe result that the normal hydrogen-ion concentration or theoxidase-reducase system will be locally deranged tempo-rarily, with the result that the spore wins, since the localsurface-tension of the cell will be such that the spore ispractically drawn into it.How this temporary derangement of the oxidase-reducase

system can be directly prevented is not at present clear, butfrom analogy to experiments I have undertaken in anotherdirection (anaphylaxis) the derangement can be preventedindirectly by increasing the stability of the permeability

(which can be done by intravenous injections of calcium Ichloride. ’The modits operandi of the turning of the tide is probably

as follows : Both the lipoid-globulin particles of the syphiliticphases and of the serum have an oxidase-reducase system.In the case of the former, the active oxygen is used by thenucleus for propagation purposes. In the case of the latter,there being no nucleus, the active oxygen will be used forthat purpose for which the particles exist-namely, for the

purpose of adsorption. Since the amino groups have the same

arrangement in the two kinds of lipoid-globulin, the necessariesfor the physical action of adsorption will be at their bestAs the active oxygen in the host’s lipoid-globulin will onlybe required for this physical action, it will follow that thehost’s lipoid-globulin has an advantage over that of the

parasite, with the result that the changes which the spore,in the primary struggle, caused the cell it was attaeking toundergo, will now be visited upon the parasites themselves.

If these views are correct, we should be able to forestallthe turning of the tide and to accelerate it by increasing theamount of active oxygen in the lipoid-globulin particles inthe serum of the host. This can be done (1) directly, bythe administration of strongly adsorbed metallic compounds,which act as peroxidases and produce active oxygen ;(2) indirectly, by the administration of a strongly adsorbednon-metallic compound, which acts as a disulphide andproduces peroxide and active hydrogen.This now brings me to discuss the rationale of chemo-

therapy in syphilis.

DOCTORS AND NOTIFICATION FEES.-At a meetingof the Executive Committee of the National Medical Union, iheld at 346, Strand, on May 4th, the following resolution was Ipassed :-That the Executive Committee of the National Medical Union express

their strong disapproval of the action of the Local Government Boardin attempting to effect any reduction in the notification fees. Theyurge that all local non-panel bodies should pass strong resolutions onthis matter and forward them direct to their local Members of Parlia-ment, and that each secretary be advised to circulate a petition amongthe local profession and forward these petitions when complete to the

secretary of the National Medical Union, 346. Strand. Such resolu-tions and petitions to be then referred to the Parliamentary Com-mittee of the Union, with the object of taking such further action asmay be necessary to place the matter before both Houses of Parliament

THE LATE DR. GEORGE EDWARD LANYON, J.P.-Dr. George Lanyon, medical officer of health of the Portof Falmouth, who died suddenly at his residence inFalmouth on April 17th, in his fiftieth year, was for 20 yearsin partnership with Dr. W. Banks, of Falmouth. Later hepractised in the town single-handed and had an extensiveconnexion. Besides being medical officer of health for thePort of Falmouth, he had recently been appointed a magis-trate for the town, where he was highly respected. He leaves Ja widow and five young children.

MALIGNANT DISEASE OF THE NOSE ORACCESSORY SINUSES.

ADVANTAGES OF OPERATION THROUGH THE FACE

(MOURE’S OPERATION OR LATERAL RHINOTOMY);RECORD OF TWO CASES WITH NO RECURRENCE

AFTER 5½ AND 3½ YEARS.BY SIR StCLAIR THOMSON, M.D. LOND.,

F.R.C.P. LOND., F.R.C.S. ENG.,SURGEON FOR DISEASES OF THE NOSE AND THROAT AND PROFESSOR OF

LARYNGOLOGY, KING’S COLLEGE HOSPITAL, LONDON.

Iratxodtcctory.THE recent progress of rhino-laryngology has been rapid.

The records of much of it-such as endoscopy of the air andfood passages, the removal of foreign bodies, and the exa-mination and treatment of diseases of the oesophagus-havespread beyond our special journals and societies and havebecome common knowledge through the articles in the

weekly medical press. But much of the advance of specialismis still unknown to the medical public, and this seems apity when a good deal of it might be done by the generalsurgeon who is willing to acquire some of the technique ofrhino-laryngology. Those who have not the taste or theopportunity for gaining dexterity in these modern methodsare doubtless glad to hear of the advances which have beenmade ; for just as the general surgeon has, in certain

directions, carried research and treatment beyond the linewhere physicians were able to take it, so the specialist hasbeen able to carry further perfection into the work of thegeneral surgeon.-

Historrical.In this article I propose to refer to some improvement in

the surgical treatment of malignant disease of the nose andits accessory sinuses. Before the days of rhinology patientswould rarely think of consulting anyone for such complaintsas nasal obstruction, catarrh, or epistaxis. Hence thesufferer from cancer of the nose seldom sought advice untilhe presented himself to a general surgeon with some

external manifestation of his dread disease. By the timeit had reached that stage it was perforce far advanced, andthe general surgeon had no alternative but to hazard someextensive and disfiguring operation from the outside of theface. This generally took the form of excision of the upperjaw, which was done for disease within the antrum itself, orin order to traverse that cavity so as to get at the ethmoidalor sphenoidal cavities. Sometimes, when the growthappeared to be limited to the nasal cavities, it was ap-proached either by turning the whole outer nose up on tothe forehead, or by the operation of Ollier in which the noseis reflected downwards from its root. It is common know-

ledge that in all these operations one certain consequencewas marked disfigurement, and rarely were there anyenduring benefits. The operation of Rouge (sublabialrhinotomy) was a decided step in advance. It avoids allexternal disfigurement, gives good access to growths in theanterior part of the nasal chambers, and is neither difficultnor dangerous.With the birth of rhinology cases of cancer of the nosecame under observation sooner, and some improvement

ensued from earlier diagnosis. Operative measures carriedon through the nostrils were certainly not mutilating, thoughit was only occasionally that they could claim lastingresults. This is readily realised when we recollect howvascular are these growths, how difficult it is in the narrow,bony cavity of the nose to manoeuvre round them, and howrapidly fungation takes place in a cancerous growth when itis only partly excised and is left exposed to the air. Theroute of approach via the nostril to these growths is difficultand oblique when they originate, as so many do, in theethmoidal region and the antro-nasal wall. Now, it is

precisely for malignant tumours originating in this region, aswell as for those starting in the roof of the nose, in theantrum, or in the sphenoid, that I would particularlyrecommend the following operation.

Lateral Rltinotoray or MOttre’ Operation.This operation was recommended as long ago as 1853 by

Michaux, but for my first knowledge of it I am indebted toMoure, of Bordeaux.l

1 Revue Hebd. de Laryngol., tome xxii., 1902, Oct. 4th, p. 401.U 2

988

Preparation. -The interior of the nose is prepared 30 to 60minutes before operation by coating the mucous surface withsmall pieces of one-inch ribbon gauze, saturated with equalparts of adrenalin and 5 per cent. solution of cocaine. Theseare tucked round the growth on the affected side, but it iswell to "paper" " the septum and even the nasal cavity onthe healthy side, as this helps in checking haemorrhage andcertainly aids in diminishing shock.When the patient has been placed under chloroform, two

tethered sponges are introduced into the postnasal space.Each of these is made of honeycomb sponge, compressed toabout the size of a walnut, attached to a piece of tape, intro-duced through the mouth into the nasopharynx, and tuckedin so as to fit the posterior choana snugly. A clip is passed

FIG. 1.through the tongue,which is drawnforward, so as toallow of the admin-istration of chloro-form through themouth. (Fig. 1.)If the operation is

being performed fora growth which

projects backwardsthrough the choanaor originates in the

’rongue cup

roof of the nasopharynx, or if the surgeon wishes to beable to introduce his left forefinger through the mouth intothe postnasal space to steady the growth from behind, thenit may be preferable to perform a preliminary laryngotomyand plug the entrance to the larynx with a tethered sponge,while the anaesthesia is continued through the laryngotomytube. In one or other of these ways the inconvenience anddread of haemorrhage is avoided, the anaesthesia can be quitesmooth and free from anxiety, and the surgeon can operatethoroughly and comfortably.

Operation.-Two incisions are started on the affected side,below the inner extremity of the eyebrow and halfwaybetween the inner canthus of the eye and the centre of theroot of the nose. (Fig. 2.) From this point one incisioncurves outwards below the lower eyelid to the prominence ofthe malar bone, and the other descends along the junctionof the nose and cheek to the nasal orifice. If the growthhas approached the nostril or is thought to be attached tothe floor of the nose, it is well to carry the incision rightinto the vestibule, so as to detach the lobe of the nostril on

Fic. 2.

Moure’s operation. Skin incisions.

that side, as in Fig. 2. But if the growth is in the higher ordeeper parts of the nose there is no necessity to carry thisdescending incision further than the furrow behind the alanaris. (Cf. Fir 10.)

Both these incisions should carefully follow the naturalcreases on the face, the upper one curving along the junctionof the lower eyelid with the face, and the vertical onelying in the wrinkle which is seen in many elderly facesalong the side of the nose.

FiG. 3. ’

Moure’s operation. Skin flaps have been retracted and thedotted lines show where the bones should be chiselledthrough.

These incisions are carried down to the bone and, withsuitable periosteum detachers and raspatories, a triangularflap of skin and soft tissues is turned downwards and out.wards. (Fig. 3.) The pyriform opening of the nose shouldbe defined, as well as the margin of the orbit, the ascendingprocess of the superior maxilla, and its junction with thefrontal and nasal bone. This latter bone is exposed right upto its junction with its fellow by reflecting the flap of skin,soft parts, and periosteum on the nasal side of the field ofoperation. With chisel and hammer the bone is nowdivided along three lines : (a) the first divides the nasalbone from its fellow, just external to the site of the nasalseptum ; (b) the second passes outwards from the upper partof this division into the orbit and follows the line of junc-tion of the frontal bone with the nasal and maxillary; and(e) the third passes from the lower and outer corner of thepyriform opening upwards and outwards into the orbit. Inthis last cut it is well to try and avoid the infra-orbital nervein its canal, but this cannot always be respected. The pieceof bone included in these lines is now seized with lionforceps and twisted out. Immediately below it we comedirectly on the ethmoid region, the antro-nasal partition, andthe upper part of the maxillary sinus. (Fig. 4.) The

lacrymal canal should be defined and carefully retractedunder the lacrymal bone, so as to avoid the risk of havingafterwards a lacrymal fistula. The ethmoid can now be dealtwith directly. On plucking it away with some instrumentlike Luc’s forceps (Fig. 5) we are able to see into the

maxillary sinus from above, like looking into an egg-cup.This same clearance of the ethmoid brings the front walland orifice of the sphenoidal sinus so well into thefield that it is now hardly 1 inch distant from the sur-face, instead of the 2i to 3i inches which is the averagedistance from the anterior nares. This dissection alsoexposes the roof of the nose. Diseased growth isattacked with Luc’s forceps, conchotomes, sharp spoons,or ring knives, and can readily be followed back intothe nasopharynx and sphenoid, outwards into the orbit,and downwards right on to the floor of the nose andthe maxillary sinus. If required, the whole of theorbital, nasal, and facial walls of the latter cavity can be

989

removed with bone forceps. If the growth is attacked boldlyand cleared away quickly I have not found the hemorrhagealarming. It can be controlled by pressure and packing with2-inch ribbon gauze, moistened with adrenalin or 5-volume

peroxide of hydrogen. Thanks to the two postnasal sponges,there is no trouble with blood descending into the air

passages.When the operation is completed and the bleeding arrested

the skin incisions are carefully brought together with silk-worm gut or horsehair sutures. Dressings on the face are notrequired ; the wound glazesover with its own serum andheals up by nrst intention likea shaving cut. It may be

protected with a pad of drygauze until the patient re-

covers consciousness. It isalso well to dispense with anydressing or plugging insidethe nose, and to leave the

cavity quite alone for four orfive days. If oozing of bloodshould persist at the end ofthe operation, a piece of 2-inchribbon gauze may be packedon to the spot and led outinto th nostril, through whichit is removed within 24 hoursand not replaced. The post-nasal plugs are, of course,removed before the patientleaves the table.Progress.-The wound on

the face heals up in a few

days, and the patient maybe about within a week (seeFig. 6). There will be someblood-stained discharge fromthe nostril for two or threeweeks. The patient shouldavoid blowing the nostrilcarelessly during this time,so he must be instructed tosuck the discharge backwards’into his throat, while he is’also relieved with nose lotions or sprays of some warmalkaline lotion (5 grains each of borax, soda, salt, andsugar to 4 oz. of warm water). If, when healing is completedat the end of from three to six weeks, there should be anycrusting in the nose, this toilette 12c nez may have to be keptup indefinitely, but it is very remarkable that these casesseldom complain of the symptoms of atrophic rhinitis,although most of the turbinal tissue may have beenremoved. In this respect these cases differ very markedlyfrom those in which the erectile tissue of the nose

has been destroyed by syphilis or some pyogenic process.R e s u I ts.- Externally

the scar within a fewmonths is so slight as

to be almost invisible.

(Figs. 6 and 9.) In someof my cases it can hardlybe discerned, even whencarefully searched for.There is certainly no

disfigurement and no

interference with themuscles of the face. Afew patients report a

little epiphora in windyweather,and some of themdraw attention to the formication or numbness of the upperlip and cheek on the affected side. But I have met with noneuralgia or similar trouble, even when the bone with theinfra-orbital canal in it has been removed.Internally there is a free thoroughfare through the nasal

chamber on the diseased side. This secretes sufficient mucusfor lubrication, and yet there is no crusting. Loss of smellis never complained of if the septum has been respected.In successful cases the enlarged nasal cavity presents aperfectly healthy surface, and in all its anfractuosities it isnow easy to keep a watchful eye for any appearances ofrecurrence.

Conaplementary Operations.My present purpose is only to call attention to this par-

ticular operation, but, of course, it can be extended to meetthe variable conditions met with, or combined with otheroperative steps. Thus, for instance, if it is found thatthe disease has deeply invaded the orbit this cavity can becleared out through the same incision, preserving the lowereyelid, while, if necessary, sacrificing the eye. The nasal

septum can be removed if the growth has attacked it. Theantrum might be further dealt with by an incision

tnrougn tne canine tossa,although I have always foundthat the access to the sinusobtained by a Moure’s opera-tion could not be improvedupon. This may also be com-bined with what is known asDenker’s operation. If thefloor of the nose is foundto be invaded the additionof a Rouge’s operation can

be made.

Ultimate Rewlts.

In all cases there is no

mutilation or disfigurement.Patients will readily consentto the operation. They areleft with an intact roof to themouth and require no trouble-some obturator, as in the oldoperation of excision of the

"

upper jaw. It is mucheasier after a Moure opera-tion to keep a direct look-outin the nose and its accessorycavities for any suspicion ofrecurrence. Recurrences aremore easily dealt with, eitherthrough the nasal orificeor by repeating the lateral

rhinotomy, and patients areless likely to object to thisthan to a further facial

disfigurement.

Moure’s operation. Exposure of the nasal and maxillarycavities through the side of the nose.

Comparison.When the upper jaw is removed for cancer of the maxillary

sinus, the antro-nasal wall, the ethmoid, the roof of thenose or the sphenoidal body, it is, in the words of Macbeth, a"most bloody piece of work." It is chiefly the front maxillarywall and alveolus which are then removed, and this bringsthe surgeon but little nearer the origin of the growth, forwhich he has to grope in the dark depths of a bleedingcavity, where haemorrhage is controlled with difficulty. Ifhe can arrive at the ethmoid region or posterior part of the

nasal chamber, it is diffi-cult for him to do morethan scrape away portionsof the growth, and it isnot therefore surprisingthat recurrence is almostthe invariable rule. 2

Recovery is tedious anddistressing, and, in anycase, the patient is dis-figured, and speech anddeglutition are rendereduncomfortable. The treat-ment of any recurrence

is almost impossible. -"

In Moure operation hasmorrhage can be well controlled,free access is obtained directly on to the point of origin ofthe neoplasm, and it can, in many cases, be widely removed.Recovery is rapid. There is no blemish, and no interferencewith speech or swallowing. Recurrences can be more easilyobserved, and their treatment is facilitated by this operation.I feel very confident that any surgeon who becomes acquaintedwith this operation will seldom, if ever, perform anotherexcision of the upper jaw for malignant disease in thisregion. The records of the two following cases will confirm

2 C. H. Fagge in Burghard’s System of Operative Surgery, vol. ii.,p. 181. London: Hodder and Stoughton. 1914.

990

this. In the first, an endo-thelioma, there has been norecurrence of growth after fiveyears ; in the second, an epi-thelioma, the patient remainsquite free at the end of threeyears.CASE 1. Rndotheliorna of the

ethmoid and antrum MoMre’soperation; no recurrence after5 years.-The patient, a ladyaged 60, consulted me inDecember, 1903, for polypi inthe right nostril. She re-

ported that she had undergonenumerous operations for thiscondition during the previousfour years, by means of thecold wire and electric snares.I removed, under cocaine, whatappeared to be simple polypiat three sittings in 1904. InMay, 1905, I found that theright maxillary antrum was

quite obscure to trans-illumina-tion, and advised the patient tolet me open and inspect it underchloroform, as there was littlehope of a radical cure of thenasal polypi if this sinus werediseased. This advice was de-clined. Removal of polypi,under cocaine, was carried outthree times in 1905, once in1906, twice in 1907, and threetimes in 1908. In August, 1909,the polypus looked so fleshy,and bled so freely on removal,that I had it examinedmicroscopically and receivedthe renort that it was "anenclothelioma, somewhat resembling the similar growthfound in the jaws. It is not encapsuled, and thereforehighly suggestive of having malignant character" " (T. G.Stevens). More extensive operation was recommended and

Fic. 7.

Exploratory puncture and lavage of the maxillary sinus from theinferior meatus.

declined. But in November the opinion of Mr. S. G.Shattock was taken as to the microscopical specimen. Heagreed that it was a typical specimen of lymphendothelioma,and this was further confirmed by the late Sir Henry Butlin,who pointed out that on our present knowledge prognosis inregard to this type of growth is almost impossible, somecases recurring rapidly, while others give excellent results.3On Nov. 10th, 1909, the patient was placed under chloroformand the right ethmoid well cleared. The removed growthagain showed the microscopical characters of endothelioma.The ethmoid remained free and clear of disease for seven

months, but in the summer of the following year (1910) theright nostril was found to be nearly blocked by a large,neshy, suspicious-looking polypus. After consultation SirHenry Butlin wrote to me as follows :-" If this lady were

3 Vide lecture by Henry T. Butlin, THE LANCET, Oct. 19th, 1901,1024.

FIG. 6. younger and more disposed tohave a free operation, I shouldrecommend that the interior ofthe nose should be exposed inthe manner we discussed andthat an attempt should be madeto remove all the parts fromwhich this disease is growing.There is no likelihood that youroperation will completely clearit out." The "manner dis-cussed" included excision of theupper jaw. The operation Ihad recommended was Moure’soperation of lateral rhinotomy.The patient declined the riskand mutilation involved in SirHenry Butlin’s advice, and, inspite of the opinion of mysenior and his high authorityon malignant disease, I deter-mined to make a trial of Moure’soperation.

Operation.-This was carriedout, with the assistance of Dr.Irwin Moore and Mr. H. L.Bates, at St. Albans, on J uly 4th,1910-nearly seven years afterthe patient first consulted meand 10 months after the firstmanifestation of malignancy.There was much haemorrhage,but it was under control. The

,

right maxillary sinus was foundto be filled with fleshy growth,which had eroded the floorabove the alveolus in two places,destroyed the ethmoid, andav+ani1.arl (]I lrB’t’B"" +:"hL’lo ....^^l AI th.,exvenueu along uDe rooi oi Me

Moure’s operation. Shows a patient, 7 days after operation. nose back to the sphenoid.F. F. Burghfird’s -as.) All was well cleared, although

I was a little afraid thst I hadbeen obliged to leave a suspicious point close up to thecribriform plate in the roof of the nose.Result.-Five and a half years have passed during which

the patient has led a full and energetic life, and she is nowhale and vigorous in spite of her 73 years. There has neverbeen any trace of recurrence and not even a single polypus.The interior of the nose is moist and healthy, there is noscabbing, there is a clear view into the ethmoidal andsphenoidal cavities, and a large opening from the nose intothe antrum. The patient has the full use of her alveolus,and, as she is well provided with sound teeth, she uses notooth plate.The patient was shown before the Clinical Section of the

Royal Society of Medicine three years ago (Feb. 14th, 1913)and at the Clinical Congress of American Surgeons onJuly 29th, 1914, when it was universally agreed that it was(lifficult to detect any scar. Her only complaint is of slightnumbness of the side of the face.

FIG. 8.

Moure’s operation. Temperature chart of cerebral irritation.

CASE 2. Epithelioma of left maxillary antrum; Moure’sopera.tion; no recurrence after three and a half years.-Thepatient, a lady aged 50, noticed a swelling of her leftcheek, with grumbling pain of a toothache character, in theearly part of August, 1912. In the country she was X rayed,

991

and the following report wassent : " X rays show a perfectlynormal condition of all thefacial bones. The swelling istherefore supraperiosteal. Shehas been taking 5 grains ofiodide. The disturbance seemsless localised in the bone nowand more diffused in the sub-cutaneous tissues. I think itis of a low inflammatory- character which should clearup under KI." (I quote thisto show the undesirability of,relying too much on X ray find-ings.) At the end of September,during my absence fromLondon, the patient was seenon my behalf by Dr. IrwinMoore, who found a large,tense, deep-seated swelling inthe left cheek over the caninefossa, not attached to bone andpossibly cystic. Transillumina-tion showed the left antrumto be absolutely opaque. Therewas some muco-pus in the leftmiddle meatus and the middleturbinal was polypoid. Theleft antrum was explored witha hollow needle from theinferior meatus and washedthrough ; no pus was expelled,but it was noted that therewas considerable bleeding onwitnarawing the needle. (Fig. V.) An exploratory opera-tion was carried out by Dr. Irwin Moore on Sept. 26th,1912. An incision was made under the left cheek over thecanine fossa, as in the first step of a Caldwell-Luc operation,and the cystic-like swelling was incised and curetted. Alarge amount of semi-gelatinous material was removed andthe free haemorrhage was checked by gauze plugging. Thebone appeared quite healthy. A microscopical examinationof the growth by Dr. d’Este Emery disclosed a glandularepithelioma.On Oct. 15th, 1912, I

’found the patient waspuffy all over the leftcheek, with loss of,definition of the upperjaw. The region of thecanine fossa was softand infiltrated. Trans-illumination showedcomplete obscurity ofthe-left antrum. A largepolypus was visible inthe left middle meatus.I recommended a

Moure’s operation, andthis advice was con-

firmed by Mr. F. F.Burghard, who saw thepatient with me.On Oct. 23rd, with

the help of Dr. IrwinMoore, I performed alateral rhinotomy. Theleft maxillary sinus wascrowded with malig-nant growth whichhad eaten through thecanine fossa and thenaso-antral wall. Itwas well cleared fromthe antrum and theethmoid, and I have abottle containing someounces of the removedgrowth. The infra-orbital nerve had to bedestroyed and the lac-rymal duct was exposedbut left intact. The facewas stitched up withhorsehair. Next day thepatient was markedlyand alarminglychanged. Instead ofbeing bright, vivacious,and chatty as usual, shewas dull, inattentive,silent, and restless.She could easily be

FIG. 9.

Moure’s operation. Shows the scar a few months after operationon the left maxillary sinus.

roused, but then her speechwas hesitating and indistinct.The temperature was 101.2° to103.6° F. and the pulse-rate was120 (see chart, Fig. 8). Shemade no complaint. Therewere no localising symptoms.Fearing that meningeal infec-tion had taken place throughthe sheaths of the olfactorynerve I asked Dr. H. Camp-bell Thomson to see the caseand he kindly sent me thefollowing report : " She isundoubtedly suffering fromcerebral irritation and I thinka little compression, but I don’tthink the signs at presentwarrant one making the dia-gnosis of septic meningitis.She strikes me rather as

probably having some exudation either serous or possibly

- mixed with some blood, andthis might have easily occurredas the result of the disturb-ance of the growth and mem-branes. If this is so the con-dition is more one of oedema,and, though very serious, isnot such a bad look-out asmeningitis. I should not there-fore at present regard thecase as hopeless, though Iam not very optimistic about

it." But, happily, within 24 hours there was an im-provement and the temperature was falling; at the endof 48 hours it had reached 100°, and the patient was brighterand her speech was again clear. On the third day thetemperature was 99° and, with re-awakened intelligence, shecomplained of severe headache on the left forehead. On theeighth day the temperature had become steadily normal andthe patient was out of bed. Her convalescence was uninter-rupted and she left the nursing home on the twelfth day.

The patient was givencalomel, bromide, andpolyvalent antistrepto-coccic serum, but Ido not claim any specialeffect from the latter.The microscopical re-

port of the removedgrowth was as follows:"The growth is in-filtrating the tissuesfreely and the latter aredensely crowded withsmall round cells.There are no cell nests,but the growth is un-doubtedly a carcinomaof a squamous - celltype. "Result. - For a few

months there was a

puffiness of the lowereyelid, similar to thecondition we some-

times see in the uppereyelid after an externalfrontal sinus opera-tion. I imagine it isconnected with trophicchanges or with thelymphatic circulation.This has quite dis-appeared. There hasbeen no neuralgia,although I had to ex-pose and destroy theinfra-orbital nerve on

the face. There is aslight amount of epi-phora on cold andwindy days. The lac-rymal canal was re-

cognised and leftuninjured at the opera-tion, so I think thislacrymation is dueto a little displace-ment of the cana-liculus by contractionof the scar.

FiG. 10.

Moure’s operation. Shows the single incision recently recommendedin this operation.

992 T

Three and a half years have passed ; the patient hashad no trace of recurrence; the left nostril is clear andmoist with a good view of the ethmoid, a large opening intothe antrum, and no suppuration or scabbing in the nose.She enjoys good health. She, also, was shown before theClinical Section of the Royal Society of Medicine on

Feb. 14th, 1913, and at the Clinical Congress of AmericanSurgeons in July, 1914. There is no disfigurement and thescar on the face is now hardly noticeable and is muchless perceptible than in the accompanying photograph,which was taken within a few months of the operation.(Fig. 9.)Both the above cases are recorded at some length for

the following reasons. They show that (a) both an endo-thelioma and a carcinoma in the nasal area are susceptibleof satisfactory treatment by this method of operation ;(b) a history of some standing (Case 1), or exteriorisationof the growth (Case 2), do not necessarily invalidate thegood results ; (0) dangerous, difficult, and disfiguringoperations which were formerly tried can be superseded bymodern methods which in the hands of experts are easier,safer, cause no disfigurement, and promise a lasting cure.By giving a detailed description of these two cases some

points of examination and diagnosis are suggested. An

early diagnosis, especially in cancer of the maxillaryantrum, is of great importance in securing a goodresult.Some cases I have operated on more recently suggest that

in most instances equally good results can be obtained by astill more limited incision. (Fig. 10.) A single cut is madefrom near the inner canthus of the eye, down the junction ofthe side of the nose with the face, to terminate in the alargroove just short of the nasal orifice. This cut is carrieddown to the bone, and the periosteum, with all the softtissues upon it, is raised and peeled back as far asthe line of the bridge of the nose internally, and externallyas far as may be necessary towards the malar prominence.The soft tissues of the face are so lax and pliablethat they can be raised and retracted outwards sufficientlyto expose nearly all the area illustrated in Fig. 3. Thissingle incision still further minimises the slight scar

on the face ; it does away with the puffiness of thelower eyelid which, otherwise, may persist for one or

two months ; there is much less tendency to epiphora ; andit should be the only incision to begin with and alsoin any exploratory operation. The second incision, curvinground below the eyelid (see Fig. 2), can be added if

required.Professor E. J. Moure writes to me (Dec. 18th, 1915) that

he has now abandoned the infra-orbital incision which hehad recommended in his earlier articles. He finds that the

single incision shown in Fig. 10 is quite sufficient to give freeaccess to the ethmoid region, the nasal chambers, and thesphenoid. It can be extended into the vestibule if it isfound necessary to detach and raise the lobule of the nose.Moure also recommends this single skin incision and thisroute through the side of the nose to gain access to naso-pharyngeal fibromata.4

Remarks by Mr. F. F. BURGHARD.

Having read over the MS. of the above article, I wouldlike to say that I have formed a high opinion of this opera-tion. Since it was first brought to my notice some six yearsago I have adopted it in all cases similar to those included inthis paper. Since realising the value of Moure’s operation Ihave not performed a single complete resection of the upperjaw, and I am in agreement with Sir StClair Thomson inthinking that I shall never perform this latter operation againfor malignant disease arising in the nose or its adjoiningsinuses ; it appears to me to possess many serious drawbackswithout a single advantage to counterbalance them. I wouldlay special stress upon the fact that patients who have had aMoure’s operation done and who are unlucky enough to getrecurrence, not only, as Sir StClair Thomson rightly observes,can have this dealt with without further mutilation, but alsothey can, even if the recurrence is so bad as to be ineradi-cable, go about free from those distressing deformities anddefects in speech and mastication that Fergusson’s operationentails.

4 Duverger : Thèse de Bordeaux. E. J. Moure et Georges Canuyt,Revue de Chirurgie, vol. xxxiv., 1914, 10 Juin, No. 6.

ON THE REMOVAL OF FOREIGN BODIESFROM THE ŒSOPHAGUS AND

BRONCHI:WITH A DESCRIPTION OF SOME NEW INSTRUMENTS.

BY IRWIN MOORE, M.B., C.M. EDIN.,SURGEON TO THE THROAT HOSPITAL, GOLDEN-SQUARE, LONDON, W.

THE direct method of examining the oesophagus andbronchi initiated by Killian, with the improvements byBriinings, Chevalier Jackson, Mosher, Guisez, Hill, andothers, has proved the immense value of the oesophagoscopeand bronchoscope in the surgery of foreign bodies in thefood and air passages, so that during the past few years ithas completely revolutionised our methods of treatment.

Improvements in instrumentarium and technique have notonly greatly minimised the dangers, but enormously reducedthe death-rate, in cases treated by this method. For example,in the case of foreign bodies in the bronchi, and left tothemselves, the mortality used to be 58 per cent. ; now,thanks to the direct method, if they are treated early, thedeath-rate is practically nil.l Cases, however, are still

reported where death has occurred from the accidentalswallowing of a tooth-plate or other foreign body, afterineffectual attempts at extraction through the mouth,followed in some instances by the external operation ofoesophagotomy or gastrotomy. The blind use of bougies orprobangs has also been the cause of many fatalities. The

operation of oesophagotomy is by no means free from danger,for the risk of opening the cellular planes in the neck cannotbe ignored. Statistics show that cesophagotomy for foreignbodies is followed by a mortality of from 12 to 20 per cent.-i.e., nearly 10 times as great as that following extractionby oesophagoscopy.

Killian has expressed the opinion that if a foreign bodyis large, has sharp edges or hooks-e.g., dental plates-allattempts at extraction are dangerous and may easily lead tofatal injuries of the gullet and adjoining parts. In suchcases oesophagotomy is indicated if the foreign body issituated no deeper than 24 to 26 cm. (10 inches) from theupper incisors ; if deeper, gastrotomy or posterior mediastin-otomy is called for (von Hacker). An exception may bemade in the case of vulcanite plates without large metallicparts." On the other hand, Mosher says that opening the *

oesophagus from the side of the neck. for the removal ofsmooth foreign bodies, is now obsolete surgery. ChevalierJackson holds that external surgery has no place in treat-ment, and is rarely if ever justifiable unless the foreign bodyhas already escaped through the oesophageal wall. In allother cases, no matter how large the foreign body, if it hasgone in by the natural passages it can be brought out by thesame route. When swallowed it assumes the position whichoffers the least resistance, and it remains for the endoscopistto assist its return journey under conditions which will giveleast resistance. In this opinion I am entirely in agree-ment. Judging by recent improvements in instruments andtechnique, there appears to be no reason why any swallowedforeign body, which has not passed into the stomach, shouldnot be retrieved per vias naturales. We may fairly hopethat-with suitable instruments in the hands of the skilled

endoscopist-the operation of oesophagotomy with its riskswill soon become obsolete in all cases of irregular foreignbodies, no matter their size or shape.With the object of further improving the technique and so

overcoming the many difficulties met with in the removalof foreign bodies I have designed the following newinstruments.

Non-slipping foroeps for removing foreign bodies of anydescription from the œsophagus, trache2, or bronehi-eg.,tonth-plates, ooins, buttons, nails, pins, fish or other bones, andfruit stones.-These forceps (Fig. 1) were originally designedby me to fit the dome-shaped portion of a tooth-plate whichhad been accidentally swallowed, and had remained undis-covered and impacted in the oesophagus for two and a halfyears. The blades are shaped on the principle of a crab’sclaw, the upper blade being curved and having at itsextremity a triangular tooth which fits between two similar

1 StClair Thomson : Diseases of the Nose and Throat, second edition,London, 1916, p. 744.