322

secondary deposits of carcinoma in the large intestine.They all have the character of diffuse thickenings of thewall with constriction of the lumen. The whole length ofthe rectum is affected, its wall thickened to an extent of in., and the lumen is greatly stenosed especially in itsupper part. The descending colon and sigmoid flexure areunaffected, except for marked dilatation. At the splenicflexure is a short stricture of moderate degree, with slightthickening of the wall. At or near the hepatic flexure isa diffuse thickening of about 2 in. of the length of thebowel, the thickness of the wall being about in. ; andthe lumen is reduced to about 1 in. in width. At aboutthe middle of the ascending colon is a stricture and

thickening similar to the last ; and at the junction of thecaeeum and ascending colon is a less-marked constrictionand thickening, which at its upper part is almost continuouswith the last-named constriction. The portion of bowelbetween the constrictions is enormously dilated and itswall thin and friable. In two situations enlarged, hard,and infiltrated mesenteric glands are present. All of the

deposits have similar microscopical characters, andconsist of intense infiltration of the tissues with spheroidalcarcinoma cells, partly isolated and partly united intosmall columns. The characters are identical with thoseof the tumour in the stomach.The colon and rectum measure 4 ft. in length.

MEDICAL SOCIETIES

ROYAL SOCIETY OF MEDICINE

SECTION OF LARYNGOLOGY

A MEETING of this section took place on Feb. 1st,Mr. LIONEL COLLEDGE being in the chair, whena discussion was held on the treatment of

Chronic Infection of the Nasal Accessory Sinuses

Dr. FERRIS SMITH (Michigan, U.S.A.) said that thetreatment of acute and subacute conditions of thesesinuses was generally agreed but that of the chroniccondition remained debatable, though most expertsfavoured more or less conservative measures. Hewould deal only with the upper group of sinuses-namely, frontal, ethmoid, sphenoid. In these chroniccases there were infected lining membranes, withchronic inflammation, cystic glandular degeneration,glandular hyperplasia, fibrosis, abscess formation,chronic periostitis, and’ other changes. The publiccould be forgiven for feeling that the efforts of theprofession to deal with chronic sinus disease werefor the most part failures. The recognition in recentyears of the importance of chronic sinus infection inrespiratory and systemic diseases had fortunatelyawakened a new interest in this problem. Theideal " cure " demanded the restoration of the normalcondition or function, a demand too great to besatisfied in the case of a long-standing infectiousprocess. But a clinical cure which removed the

pathological condition and preserved the normal

appearance of the patient could often be achieved.Non-success in treating chronic conditions of thesesinuses was largely attributable to the perpetualrecommendation of conservative measures and theremoval of only obviously diseased parts, perhaps inone sinus only, with a desire not to disturb the liningof another sinus, the danger of which disturbancehad been over-estimated. He had never failed tofind bacteria in these chronically diseased sinus

linings ; they were common in the subepithelial areasin the early chronic cases, and were always evidentabout the glands and vessels, and in the reticularspaces in the cases which were of longer standing.Periosteitis and osteitis were often seen to accountfor the recurrent symptoms after incomplete removalof the diseased tissue. It was seldom that purecultures were present. Hsemolytic and other strepto-cocci were almost invariably found, and the commonestaccompaniments were pneumococci and M. catarrhaliq.

Dr. Ferris Smith considered that the time hadcome for the rhinologist to cast aside his conservativepredilections and adopt more radical measures.

No operator, however skilful, using intranasal methodscould enter all the ethmoid cells, nor could he claimmore than increased drainage of a frontal sinus.He would not be able, with safety, to remove the

diseased linings of the superiorly placed ethmoidcells, or the diseased tissue about the cribriformplate. Failure to do this meant recurrence of symp-toms in most cases, disaster in some. To dealproperly with these conditions demanded a directapproach and a practically bloodless field. HerbertTilley years ago had declared the ethmoid to bethe key situation of the nasal sinuses, commandof that situation being the most important factor ina successful attack on any or all of them. The direct

operation on the sinus, in full view of the surgeon,produced, in skilled hands, nearly 100 per cent. of £successes ; it presented the minimum of risk andinconvenience, and the procedure was painless,practically bloodless, and the convalescence was

comfortable and brief.The technique was as follows :—On the evening prior to the operation the patient was

given pento-barbital sodium, and this was repeated anhour prior to operating. In the morning he had a hypo-dermic injection of morphine sulphate gr. and of scopo-lamine hydrochloride gr. 1/150. The face was cleansedwith soap and water, painted with 3 per cent. iodine, and,finaJly, sponged with alcohol. A black helmet, exposingonly the field of operation, was drawn over face andhead and fastened about the neck. The nose on the

operation side was packed with cotton pencils which hadbeen wrung out with a solution of epinephrine hydro-chloride 1 in 2000 containing 10 per cent. cocaine. Theincision area about the inner canthus of the eye wasinfiltrated with a 2 per cent. solution of procaine hydro-chloride containing 25 1Tl of epinephrine hydrochlorideto the ounce. The eyelids were closed by means of ahorsehair suture for the protection of the cornea. Theincision should begin immediately below the eyebrowand should be inch long. The superior palpebralvessels were incised between two forceps and ligatedwith 00 size plain catgut. The incision was continuedthrough periosteum to the bone. The ligaments aboutthe lacrymal sac were exposed and incised, and the sacwas turned outward and downward until the duct was

exposed in the floor of the fossa. The peri-orbital tissuewas freed with an elevator from the lamina papyraceaand the floor of the frontal sinus. The mesial orbitalwall was perforated through the lacrymal fossa with asharp perforator, and enough of the posterior marginof the nasal process of the maxilla was removed to permitof complete exenteration of the lining of the most anteriorcell and to afford a clear view. The lamina papyraceawas now removed with a Gruenwald punch forceps, leavinga wall 3/16th of an inch high along the orbital floor, whenthe condition of the bone permitted. The forceps intro-duced through the nostril removed most of the ethmoidcells and left the lateral wall of the middle turbinal clearlyexposed. With a Sluder ethmoid knife the turbinal wasslightly fractured. The remnants of the ethmoid cellswere completely removed with punch forceps, and thenasal roof completely freed from covering mEmbrane bythe use of small gauze balls. Every vestige of membranemust be cleared away and the bone left clean. The

sphenoid was dealt with by means of a Sluder knifeintroduced into the ostium ; very seldom indeed had heneeded to use a chisel to enter this sinus.

323

Dr. Ferris Smith said lie had used the method onmore than 500 patients. Most of them complainedof post-operative headache but never of actual

pain ; this headache persisted for from 3 to 30 days.A diplopia persisted for a similar time. In 5 casesthere was a recurrence of small polypi ; a few resistedall efforts to check the discharge of mucus. Afterabout two months the operation scar was scarcelyvisible. He used local anæsthesia, and there wereonly slight post-operative reactions.

DISCUSSION

Mr. A. LowNDES YATES said that if simple measurescould be made adequate, and especially if patientscame for treatment at an early stage, major operativemeasures on the sinuses would be very rare. Insuccessful operation cases the discharge consistedof muco-pus containing leucocytes but few epithelialcells, and in the latter the micro-organisms wereintracellular. When operation did not stop the dis-charge, the latter showed a few pus cells, manyepithelial cells, and quantities of micro-organismswhich were not dissolved by the bactericidal actionof the mucus. His experience led him to believethat when free micro-organisms were present in thedischarge, palliative measures gave better resultsthan operative ones. In obstructive sinusitis ciliawere active and were able to bring about a cure ifthe mucous membrane of the ostium was shrunkwith cocaine. In open sinusitis the ostia inflammationwas maintained by the ability of the micro-organismsto survive in the secretion, and the ostia was notobstructed. In many cases having abnormalities inthe nasal airway one channel did nearly all the workof removal of infection from the inspired air.Mr. T. B. LAYTON insisted on the dictum of Lister,

that an inflammation tended to get well of itselfif the cause of irritation was removed. He discussedthe question whether the new opening should be madeinto the middle or the inferior meatus, and, if the

latter, whether it should be approached by the intra-nasal or the sublabial route. If the procedure wereproperly carried out and the case was not complicated,chronic maxillary suppurative sinusitis would getwell. The problem in regard to the other sinuses wasmore complex. The chief cause of failure in the

past had been to consider mainly frontal sinusitis,whereas the key to all fronto-ethmoidal suppurationwas the maxillary sinus. Intermittent drainage of thelatter might cure a fronto-ethmoiditis ; if it did notdo so in a reasonable time, the products of inflamma-tion of the maxillary sinus should be diverted from themiddle meatus to the inferior. This would remove theirritation of the mucous membrane at the front endof the semilunar groove.

Mr. C. GILL-CAREY said that, technically, he agreedwith Dr. Ferris Smith. Several years ago he becamedissatisfied with the results of his intranasal opera-tions on the ethmoid, and therefore adopted theexternal method, since when his results in the ethmoidhad become very good. Results were also good infrontal sinus cases, but in some only for a limited time,as a year or two afterwards there was reinfection andthe sinus opening became stenosed. Skin-graftinghad not proved a successful remedy in his hands.A similar trouble was encountered in the sphenoid.He joined issue with Dr. Perris Smith as to the type ofcase in which the operation described was necessary.The speaker had operated upon a number of asth-matics, and the results were equally good but for ashorter time. His view was that there occurred anallergic change in the nose, which affected not onlythe linings but the septum and the turbinates. He

felt that if removal of mucous membrane were tobenefit asthmatics, all parts should be attended to.

Mr. WALTER HOWARTH said that the techniquedescribed by Dr. Perris Smith was almost identicalwith that which he himself had introduced in 1921and had carried out since then, but he had differentviews in regard to the treatment of the mucousmembrane. Dr. Ferris Smith said that he had neverfound a mucous membrane which was fit to be leftbehind ; moreover, he operated not only on theethmoid and frontal sinus but also on the sphenoid,implying that every case was a pan-sinusitis. Suchvirulent types of case were not usual in Britain.In many fronto-ethmoidal cases the sphenoid was notinvolved, and in many cases of fronto-ethmoidal

suppuration the frontal sinus mucosa was not full ofabscesses and underlying osteitis. In Mr. Howarth’sview the mucous membrane of the frontal sinusshould not always be removed unless it was grosslydiseased ; if it could be safely left behind, so much thebetter for the patient. His main difficulty in thesecases had been to maintain the patency of the newfronto-nasal duct ; but since using skin-grafting hisresults had been better.

Mr. H. G. BEDFORD RUSSELL said that he hadbeen trying out Dr. Ferris Smith’s methods, whichwere the outcome of 16 years of research, for a fewmonths and was able to confirm his statement that

patients were free from post-operative distress andfrom an obtrusive scar. With regard to the healingprocess, the possibilities lay between an obliterationof the cavity by sclerosis and the persistence of acavity lined with squamous epithelium. Whereaswhen the patient was suffering from septic absorp-tion from the sinuses the complete operation wasthe only logical course, it could be employed withadvantage in the treatment of anterior sinusitis

only when the essential trouble was mere mechanical

difficulty in ventilation or drainage of the frontalsinus. lIe had had excellent results in this way,though with delayed healing in one or twocases. Where the antrum and posterior group ofsinuses only were causing trouble he had been satis-fied with the results of Horgan’s transantral approach.

Mr. G. H. HowELLS explained that his contactwith sinus cases specially concerned those withorbital complications which he encountered atMoorfields. In these he followed Mr. Howarth’s

technique and had been satisfied with the results.He agreed that often it was unnecessary to denudethe fronto-nasal mucous membrane ; frequentlythe upper and back parts of the mucosa could beleft. In the antrum he favoured conservatism,trying first the intranasal procedure. As to stenosisof the fronto-nasal duct after operation, if a partof the nasal process of the maxilla was removed, theopening afterwards was less likely to stenose.

Mr. II. A. Kiscii felt satisfied that the only meansby which permanently satisfactory results could beachieved in frontal and other sinus cases was by theexternal approach. He had never used skin graftsto maintain opening into the frontal sinus. He

agreed it was important to remove the ascendingprocess of the maxilla to get a free opening into thefrontal sinus. He used general anaesthesia for hiscases.

Mr. E. WATS ON-WiLHAMS thought Dr. FerrisSmith’s outlook was unjustifiably gloomy. He foundthat, unless the condition was really desperate, mostpatients declined, on cosmetic grounds, to submit tothe external operation, whatever they,might be toldas to the insignificance of the scar. He had only

324

exceptionally found it necessary to do the externaloperation. It seemed unnecessary to sacrifice theturbinal in order to secure adequate drainage of thesinuses. The test of success of operative procedureswas whether the patient could, with a minimum ofinconvenience, get rid not only of his symptoms,but also of his irido-cyclitis and any rheumatictroubles. In only a small proportion of chronicsinus cases was it necessary to do more than provideadequate ventilation and drainage.

Mr. HERBERT TILLEY paid a tribute to the finetechnique and operative skill of Dr. Ferris Smith.

Sir JAMES DUNDAS-GRANT commented on theabsence from Dr. Ferris Smith’s armamentarium ofinstruments of the sharp-edged punch, which enabledportions of tissue to be brought away without tear-ing ; it had helped him in many cases of ethmoidalsuppuration. He had a leaning towards the Canfieldoperation.Mr. J. F. O’MALLEY understood that Dr. Ferris

Smith’s fundamental intention was the eradicationin these chronic cases of persistent osteitis, whichnearly always interfered with the efficiency of

drainage. When failure occurred he believed it wasfrom underdoing the operative procedure, ratherthan because a too extensive procedure had beencarried out.

Mr. W. STUART-Low considered that lavage wasthe worst thing for ethmoiditis as the micro-organismswanted water, and this also helped their dissemina-tion to other parts. He was an advocate ofsuction for the removal of the infection from thesinuses.

Mr. F. C. W. CAPPS said Dr. Ferris Smith confessedto him that the operation owed much of its successto the preparation of the patient beforehand, andthis he entrusted to those only whom he had himselftrained for many years. Many left the preparationin other hands, and often one felt that reliance couldnot be placed on it having been done thoroughly.Since he had done his own preparation his resultshad certainly improved.

ASSOCIATION OF CLINICAL

PATHOLOGISTS

THE seventh annual meeting of this associationwas held at the Royal Chest Hospital, London,on Jan. 26th. Dr. NORAH SCHUSTER, pathologistto the hospital, occupied the chair.

Dr. ROODHOUSE GLOYNE (London) delivered an

address on the

Clinical Pathology of the Pleural Fluid

He pointed out that cytological examination ofsuch fluid was difficult if it were allowed to clot andadvocated its collection in two tubes, one sterile forbacteriological examination and one containing a

little 1 per cent. sodium citrate. The appearanceof the fluid as collected offered valuable information ;the presence of blood suggested malignant growth ;the specific gravity and the total protein were ofimportance in distinguishing between a transudateand an exudate; fluids showing less than 1-5 percent. of total protein were probably transudates ;if the protein was above 3-0 per cent. they werepretty certainly exudates. For the examination ofthe cells Dr. Gloyne advocated Gordon’s modificationof Pappenheim’s stain. He was doubtful whetherthe cells usually described as lymphocytes actually

were such ; they were characteristic of establishedtuberculous effusions. In the earlier stages polymorphsmight predominate. Eosinophils might appear inthe exudate in large numbers in traumatic haemo-thorax, after artificial pneumothorax, in associationwith malignant disease and in the presence of anunresolved pneumonia. New growth cells were verydifticult to distinguish from pleural endothelialcells ; their cytoplasm was usually vacuolated andthe vacuoles contained a material staining yellowish-brown with osmic acid. In bacteriological examina-tion Dr. Gloyne stressed the necessity of anaerobicas well as aerobic culture. Anaerobic streptococciwhich gave rise to a particularly virulent form ofpleural infection might escape detection on simpleaerobic culture. Tubercle bacilli could often beidentified in films after careful examination, but wouldescape detection in many cases in which they mightbe found either by guinea-pig inoculation or by theuse of Loewenstein’s medium. Pleural puncturewas a safe procedure, but he had experience of onecase of severe haemorrhage and one of tuberculousinfection of the needle track following it. Dr.Gloyne stated that the number of new growths ofthe lung met with in post-mortems at the VictoriaPark Hospital showed a steady increase and was now15 per cent. of all performed there. He had seenone case in which a troublesome local tuberculousinfection was produced by the reinjection of tuberculouspleural fluid ; he deprecated the injection of pleuralfluid until it had been passed through a filter andshown to be sterile.

Dr. ARTHUR DAVIES (London) divided pneumo-coccal pleural effusions into the syn- and meta-

pneumonic. The appearance of the former coincidedwith the onset of pneumonic infection, the latter

appeared from seven to ten days after its establish-ment. The syn-pneumonic effusions were charac-terised by the presence of few pus cells and manyorganisms ; the meta-pneumonic by many pus cellsand fewer organisms. Dr. Davies pointed out thatat the time of appearance of the syn-pneumoniceffusions little reaction had occurred in the tissuesand that puncture at this stage might set up the

dangerous condition of " mediastinal flutter." Milky

fluids might be either chylous or pseudo-chylous;the former contained actual fat and were almost

invariably indicative of filarial infection ; the latterowed their opacity to material of a lipoid nature andmight occur in a number of conditions. He drewattention to the importance of infection below thediaphragm, as for instance the presence of an amoebicabscess in the liver as a cause of sterile purulenteffusion in the pleural sac.

Dr. JAMES MAXWELL (London) advocated theuse of the Rotanda syringe for the collection of

pleural fluid ; by means of it almost any amount offluid desired could be conveniently withdrawn atone puncture. Previous puncture he regarded as

the most common cause of the appearance of bloodin the pleural fluid. Speaking of the appearance ofpleural fluid, he cited one instance in which an

artificially induced oleothorax had been mistaken foran empyema ; one in which the instillation of

methylene-blue had led to a diagnosis of pyocyaneusinfection and one in which puncture had resulted inthe appearance of clear watery fluid; subsequentexamination of this fluid showed hooklets and scolicesand established a diagnosis of hydatid disease of thelung.

Dr. A. F. SLADDEN (Swansea) drew attention to theglobulin test as a means of distinguishing between