- Email: [email protected]
ZYGOMATIC MASTOIDITIS
702 of anol
p-hydroxy-propenyl benzene appeared highly active: or
was
tested and
to be very
However, when attempts were made to repeat the work, some batches of anol were found to possess only very slight activity, and it was obvious that the activity in the first batch must have been due to a contaminant. The work was continued in collaboration with Sir Robert Robinson, and finally the compound 4 : 4’-dihy-
droxy-fx : &bgr;-diethyl stilbene, made and found to be very
or
stilbcestrol,
highly
I think the justifiable conclusion is to go into the laboratory and start work on something which interests you, refusing to be daunted by the great discoveries that have gone before. Success depends mainly on the amount of work that is done in the laboratory; and, though you may not succeed in discovering what you set out to find, you can see from the account I have given that you will always discover something. REFERENCES
was
active.
This compound and the two related compounds, hexoestrol and diencestrol, have found extensive use in the treatment of menopausal symptoms and other conditions for which formerly the naturally occurring
cestrogens were prescribed. Their great advantage lies in the fact that they are cheap to produce and that they are active by mouth, and thus patients are spared much inconvenience and expense. A further use has been found for these compounds in the treatment of carcinoma of the prostate gland. Huggins and Hodges (1941) showed that castration or the administration of cestrogens would bring symptomatic relief in a large proportion of cases and since then the compounds have been used extensively for this purpose. In about 95% of cases there is some response ; and, in a large number of cases responding, complete symptomatic relief is obtained in a short time. The treatment can in no sense be described as a cure, since if treatment is discontinued the symptoms return, and in many cases the relief obtained is not permanent. However, it is the first time that a substance active by mouth has been found of use in the treatment of any form of cancer, and it offers to the patient with carcinoma of the prostate a definite hope of freedom from pain and discomfort at least for a time, and the possibility of resuming his normal activities.
Addison, (1849) Lond. med. Gaz. 43, 517. (1855) On the Constitutional and Local Effects of Disease of the Suprarenal Capsules, London. Allen, E., Doisy, E. A. (1923) J. Amer. med. Ass. 81, 819. Aschheim, S., Zondek, B. (1927) Klin. Wschr. 6, 1322. Bachmann, W. E., Cole, W., Wilds, A. L. (1940) J. Amer. chem. Soc. T.
—
62, 824. Banting, F. G., Best, C. H. (1922) J. Lab. clin. Med. 7, 251. Brown-Séquard, E. (1856) Arch. gén. Méd. 8, 385, 572. (1858) J. Physiol. de l’Homme, 1, 160. Butenandt, A. (1929) Naturwissenschaften, 17, 879. -
—
(1931)
-
-
of the founders of this series of Addison lectures, of which I have had the honour of giving the first, is to stimulate young workers to enter research, particularly research into the endocrine system. It is impossible for me to know whether the picture that I have painted in this brief period will have the effect of beckoning new people into the laboratory, or the reverse effect of scaring them away. I shall feel satisfied if I have dispelled the current idea of how a successful research is conducted. It is practically impossible to convince students starting on research that such work is not for heaven-sent geniuses only. There is no doubt that successful research-workers tend to convey this impression to the outsider, because they follow the invariable scientific practice of writing their papers backwards, so to speak. When a research is finally published, it appears to the reader as an orderly series of steps carefully thought out ; and if the reader is not already in the trade, the - effect is to produce an acute inferiority complex in his mind and to persuade him that in no circumstances would he ever be able to
-
-
-
-
ZYGOMATIC MASTOIDITIS
object
conduct research. My object in this lecture has been to show that research is never done as it is written, and that the cold orderly paper is produced practically always by a series of blundering steps in which the research-worker is rather like someone in a dark room scrambling for the switch and tripping over the furniture. When he has once found the switch and turned on the light, he can arrange the furniture in an orderly manner.
44, 905.
-
A CALL FOR RESEARCH-WORKERS
The
Z. angew. Chem.
Cook, J. W., Dodds, E. C., Hewett, C. L., Lawson, W. (1934) Proc. roy. Soc., B, 114, 272. Doisy, E. A., Veler, C. D., Thayer, S. A. (1929) Amer. J. Physiol. 90, 329. Girard, A., Sandulesco, G., Fridenson, A., Gaudefroy, C., Rutgers, I. J. J. (1932a) C.R. Acad. Sci., Paris, 194, 1020. Rutgers, I. J. J. (1932b) Ibid, p. 909. Gull, W. (1873) Trans. clin. Soc. Lond. 7, 180. Guy’s Hospital Reports (1890) 32, 25. Harington, C. R. (1926) Biochem. J. 15, 293, 300. Barger, G. (1927) Ibid, 21, 169. Huggins, C., Hodges, C. V. (1941) Cancer Research, 1, 293. Kendall, E. C. (1915) Trans. Ass. Amer. Phys. 30, 420. Kocher, T. (1889) KorrespBl. schweiz. Ärz. 19, 1. (1895) Ibid, 25, 3. Laguesse, E. (1893) C.R. Soc. Biol. Paris, 5, 819. Lancet (1890) i, 324. Marrian, G. F. (1930) Biochem. J. 24, 435, 1021. Medical Times and Gazette (1860) 2, 20. Murray, G. R. (1891) Brit. med. J. ii, 796. Ord, W. (1878) Ibid, i, 671. Rosenheim, O., King, H. (1932) J. Soc. chem. Ind., Lond. 51, 464, 954. (1933) Ibid, 52, 299. Ruzicka, L., Goldberg, M. W., Meyer, J., Brungger, H., Eichenberger, E. (1934) Helv. chim. Acta, 17, 1395. Stockard, C. R., Papanicolaou, G. N. (1917) Amer. J. Anat. 22, 225. Swingle, W. W., Pfiffner, J. J. (1931) Amer. J. Physiol. 98, 144. Szent-Györgyi, A. (1928) Biochem. J. 22, 1387. von Mering, J., Minkowski, O. (1889) Zbl. klin. Med. 10, 393. Wieland, H., Dane, E. (1932) Hoppe-Seyl. Z. 210, 274. Wilks, S., Bettany, G. T. (1892) A Biographical History of Guy’s Hospital, London. Willis, T. (1681) The Remaining Medical Works of that Famous and Renowned Physician, London. Windaus, A. (1932) Hoppe-Seyl. Z. 213, 147.
PHILIP READING Lond., F.R.C.S.
M.S. SURGEON, THROAT
AND
EAR
DEPARTMENT, GUY’S HOSPITAL,
LONDON
ZYGOMATIC mastoiditis is not mentioned by Toynbee and Hinton, the pioneers of English otology. Only at the end of the second decade of this century did it gain general recognition, as the result of the publications of Mouret and Seigneurin (1920) and of Holmgren
(1921).
9.9
During the course of a suppurative otomastoiditis infection may reach air cells in the root of the zygomatic process and there produce an inflammatory swelling. The path of the infection from the mastoid to the zygoma is generally along a preformed track of cells (Holmgren 1921, Gadolin 1938), though sometimes there appears to be no direct communication between the two groups of cells. Heine (1908) suggested that infection might pass direct from the attic vault"to the diploe of the squama and so reach the temporal fossa. Horgan (1929) has suggested, as another possible route, the glaserian fissure, and Watson-Williams (1930) put forward the possibility that infection might track along a persistent petrosquamous sinus. Of the 29 cases of zygomatic mastoiditis under review, a cellular mastoid was found in all but one of the 27 cases of acute infection. A cellular track was demonstrable in most of these. In both the cases of zygomatitis due to chronic infection, one of which was caused by actino-
703
mycosis,
the pus had
apparently leaked through
the roof
of the meatus. CLINICAL PICTURE
All the
Thus 1 in every 4 cases of acute mastoiditis with had no perforation of the drumhead. Of those with no otorrhoea, 1 in every 4 had a swelling over the zygoma. Beta hsemolytic streptococcus was found in 10 of the cases with no otorrhoea and alpha haemolytic streptococcus in 3. Pneumococcus type 111 was not found in any. If the total number of cortical mastoidectomies, 602, is taken as the basis of computation, zygomatic mastoiditis without otorrhcea was present in 2-4%, and all forms of mastoiditis without otorrhoea in 9-8%. This compares with the 5% of mastoiditis without otorrhcoa reported by Watson-Williams (1929) in 300 simple mastoidectomies performed before the introduction of
superficial swelling
reported
cases
in this paper
presented
with thè
feature. Such swelling, preauricular swelling as aasprominent a after cortical
however, may appear
complication
mastoidectomy. Horgan(1929) reported two, Rosenwasser and Druss (1933) four instances, and attributed them
inadequate surgery.at the first operation. The greatest incidence is between the ages of 5 and 15 years. The swelling develops in the course of a suppurative otomastoiditis and is commonest when such infections are common-in the late winter and early spring. A firm tumour covers the root of the zygoma and often causes cedema of the lower eyelid. It is tender, but fluctuation and " pointing " of the abscess are signs long delayed in their appearance. Trismus is an inconstant symptom. Pain and difficulty in opening the jaws may be found in acute infection of the parotid gland and in inflammation of the skin of the anterior wall of the meatus. True zygomatic mastoiditis may be simulated by an abscess in the pterygomaxillary space. Greenfield (1934) described such an abscess, which is very rare, and showed that it presented below the zygoma and caused severe trismus. Mill (1932) showed an example of unusual zygomatic infection, which, from the printed description, was probably of the same nature. The differential diagnosis of acute zygomatic mastoiditis may be rendered difficult by the frequent absence of one of the classical signs of suppuration in the middle-ear cleftotorrhoea. to
ILLUSTRATIVE CASE-RECORD
sulphonamides. Sulphonamides had been given to 9 patients with zygomatic mastoiditis without otorrhcea, and to 6 with zygomatic mastoiditis and otorrhcea, before coming under observation. A study of the literature on zygomatitis will refute the suggestion that the absence of otorrhcea can be explained simply as a manifestation of " sulphonamide masking." Heine (1908), speaking of swellings above and in front of the ear, said :
.
"I have observed that these external signs were particularly well marked in cases in which the drum retained little or no sign of inflammatory change. The patients frequently state that, although they suffered from earache in the beginning, no discharge was noticed. This seems to suggest that the original trouble was a suppurative inflammation of the closed attic and that the pus found its way out directly without reaching the antrum or the mastoid cells."
More
.
succinctly, Mouret- and Seigneurin (1920) wrote : apprendra que 1’infection n’a fait que lecher la
" On
A girl, aged 6 years, was admitted to hospital with a caisse, l’antre, avant de se localiser dans la region swelling which had been growing in front of the ear for a temporale." The was and about firm, oval, fortnight. swelling 11/2 in. long, and its general direction coincided with that of the zygomatic A glance at the following table shows that otorrhoea. bone. When it had first appeared there had been slight earache,, is absent in a considerable number of cases and, also, but so young a child was not able clearly to distinguish that this absence is more frequent in the last two groups, between pain in the ear and pain in the adjacent swelling. which occurred within the sulphonamide era : Examination of the tympanic membrane showed no abnormality. Tenderness could be elicited on pressure only The solitary sign of aural disease over the zygomatic root. No pus was a slight impairment of the hearing on that side. escaped when the membrane was incised. A cortical mastoidectomy was performed. The mastoid Grey swollen muco-endosteum was process was cellular. "
found in all the cells, and pus in the mastoid antrum. A drachm of pus was liberated on opening the cells in the
zygomatic
root.
CONDITION OF TYMPANIC MEMBRANE
Since this experience careful note was taken of the condition of the tympanic membrane in all zygomatic and other mastoid swellings. Of the 27 patients with acute zygomatic mastoiditis, 13 had tympanic membranes scarcely distinguishable from normal. In 5 the membrane was injected and slightly bulging. In the remaining 9 otorrhoea was present, and a perforation could be demonstrated in the tympanic membrane. Impairment of hearing of varying degree was elicited in all. Those patients retained their hearing most who had apparently the most healthy membranes. This seemed to be an unusually high proportion of mastoiditis without otorrheea (66%). To obtain a control figure the records of other forms of acute mastoiditis were studied. In the five years ending Dec. 31, 1945, 602 primary cortical mastoidectomies were performed. Of these, 232 showed a superficial inflammatory swelling, caused by the underlying mastoiditis. Of these swellings 24 (10%) were centred over the zygoma, and 59, of which 15 (26%) were zygomatic, were not by otorrhoea. In 173 the mastoid swelling was associated with otorrhcea, and zygomatitis accounted for 9 (5%) of these.
accompanied
Single case-records are not included, such as those of Neville (1933), Watson-Williams (1930), and Watt (1932). All these described otorrhoea as a feature of zygomatitis. Breitstein (1926) described a, case without otorrhcea and drew attention to the lack of this symptom. One can infer that, though the absence of otorrhoea is common in zygomatic mastoiditis, it has become more common since the introduction of sulphonamides. No explanation of this absence of otorrhcea is apparent. Failing any other, we must accept the suggestion that, in a cellular mastoid with a cellular zygoma, early occlusion of the air cells and of the tympanum by swollen muco-endosteum allows the escape of pus by the only route left open, to the zygomatic root and the temporal fossa. At operation such thickening of the membrane could be demonstrated in the aditus of some but not all of the diseased mastoid bones. SUMMARY
A review of 27 is
cases
of acute
-
zygomatic
mastoiditis
presented.
Attention is drawn to the absence of otorrhcea in many zygomatic infections, and hence to the difficulties which may arise in diagnosis. acute
704 "
Sulphonamide masking," as an adequate explanation, be partly discounted. These patients were studied and treated at Selly Oak Hospital, Birmingham. To the medical superintendent of can
that hospital, Mr. R. P. S. Kelman, F.R.c.s., my thanks due for his kind permission to publish.
are
REFERENCES
Breitstein, M. L. (1926) Arch. Otolaryng., Chicago, 4, 300. Gadolin, H. R. (1938) Acta oto-laryng., Stockh. 26, 492. Greenfield, S. D. (1934) Laryngoscope, 44, 232. Heine, B. (1908) Operations on the Ear, London. Holmgren, G. (1921) Acta oto-laryng., Stockh. 3, 66. Horgan, J. B. (1929) J. Laryng. 44, 309. Mill, W. A. (1932) Proc. R. Soc. Med. 25, 489. Mollison, W. M. (1922) J. Laryng. 37, 545. Mouret, J., Seigneurin (1920) Rev. Laryng. 41, 33, 65. Neville, T. W. S. (1933) Lancet, i, 526. Rankin, N. L. (1923) J. Laryng. 38, 192. Rosenwasser, H., Druss, J. G. (1933) Arch. Otolaryng., Chicago, 17, 625. Watson-Williams, E. (1929) Brit. med. J. ii, 1099. (1930) Ibid, i, 1173. Watt, J. C. (1932) J. Laryng. 47, 712. —
RECOVERY OF STRETCH REFLEXES AFTER NERVE INJURY J. Z. YOUNG D. BARKER Oxfd, F.R.S. the and From Department of Zoology Oomparative Anatomy, Oxford, and the Department of Anatomy, University College, B.A. Oxfd
M.A.
London
.
IN spite of the large amount of published work on the regeneration of nerve very little is known of the recovery of proprioceptor function. Since the functions of the various receptors of muscle in normal life are still largely unknown, it is impossible to estimate the importance of their recovery after nerve lesions, but it seems likely that some of the imperfections of muscle function after
nerve
suture
are
due
to
incomplete
sensory
reinnervation. The only proprioceptor activities which it is easy to study experimentally or clinically are the stretch reflexes. The return of the ankle-jerk after nerve grafting has been described by Rezende (1942) in dogs and monkeys and by Davis et al. (1945) in cats ; a division of the rabbit’s crural nerve was made by Waller (1890) but seventeen months later the knee-jerk was still absent. Stopford (1930) reported the recovery of joint sense " after nerve injury in man, this being a subjective term for a sense of whose receptors little is known. Proprioceptor function is certainly not limited to response to stretching a muscle. The end-organs present in muscle include at least two chief types : muscle spindles and tendon organs. The stretch reflex is usually supposed to be mediated by the muscle spindles (Matthews 1933) ; but the evidence is incomplete, and it may well be that the excitatory afferent fibres belong to "
the tendon organs.
occasion that the reflex is elicited. The rods can slide through a series of numbered holes, and by subtracting the depth of the ankle from the total reading a measurement of the upward movement of the foot is obtained (fig. 1). As’in human subjects, the magnitude of the response is affected by the conditions prevailing at the time of testing, but tests made under conditions as standard as possible on successive days give reasonably consistent readings with a normally
distributed variation. It is thus possible to estimate the normal response and then watch its recovery after interruption of the crural nerve.
A complication is introduced by the fact that, because of the weight of the shank and foot, a considerable amount of reflex contraction tension has to be developed by the quadriceps before any upward movement is possible. The height of the jerk elicited does not there. fore give a linear measure of the force exerted by the muscles, even if the limb is placed in the same position at each test. The term " inertia factor " has been given to that force which the quadriceps must exert to lift the weight of the shank and foot and produce an upward movement which is just perceptible.
By transecting the quadriceps near its distal end and attaching the tendon to a spring balance it has been possible to determine the magnitude of this force in different positions of the limb and to assess approximately its proportion of the total reflex contraction tension required for the normal response. The tension required to elicit a slight movement in the usual testing position was 23-41 % of that required to effect mean normal responses of 17-11 test units. Moreover, plots of the tension required to lift the limb to various heights showed that more work must be done in the earlier than in the later phase of lifting the leg. The same relationship between quadriceps tension and leg extension was found by Haxton (1945), who measured the forces involved in experiments on cadaver limbs. The magnitude of the upward jerk cannot, therefore, be regarded as a linear index of the degree of recovery of the reflex after nerve injury ; the return of a small response may represent a degree of recovery as high as 60%, for the muscles will have to develop enough contraction tension to overcome the inertia factor and to produce a visible jerk in that part of the upward swing where the greatest lifting forces are required to raise the ankle. The smallest detectable responses are those giving an upward jerk of about 3 nun. and fall between 0 and 1 test unit on the scale used ; they ate both difficult to elicit with certainty and to measure with accuracy.
is desirable to devise some method of inertia factor. Testing the animal the other way up to that which has been described, or testing with the animal held vertically, proved impracticable. It might be possible to devise some method of testing the animal on its back and counterweighting the limb so that all the reflex contraction tension developed
Evidently it eliminating the
Histological investigation (Huber 1900, Tello 1907, Boeke 1916) has shown that there is some reinnervation of muscle spindles after nerve injury, but it remains uncertain whether the sensory and motor innervation are both restored. If all fibres become mingled at a point of nerve suture and no processes direct the regenerating fibres back into appropriate pathways, it is difficult to see how the normal pattern can be restored. MEASUREMENT OF KNEE-JERK
We have devised a means of measuring jerk in the unanaesthetised rabbit in order quantitatively its recovery after nerve injury.
the kneeto
assess
The rabbit is placed on its back on a testing-couch in such a way that movement is possible only in the hind legs. When the patellar ligament is struck, the foot jerks upwards from where it has been resting on a horizontal rod, the height which it reaches being recorded by adjusting an upper rod to the level at which it is hit by the foot on almost every
Fig. I-Apparatus used
to measure
knee-jerk in unangesthetised rabbit.
p-hydroxy-propenyl benzene appeared highly active: or
was
tested and
to be very
However, when attempts were made to repeat the work, some batches of anol were found to possess only very slight activity, and it was obvious that the activity in the first batch must have been due to a contaminant. The work was continued in collaboration with Sir Robert Robinson, and finally the compound 4 : 4’-dihy-
droxy-fx : &bgr;-diethyl stilbene, made and found to be very
or
stilbcestrol,
highly
I think the justifiable conclusion is to go into the laboratory and start work on something which interests you, refusing to be daunted by the great discoveries that have gone before. Success depends mainly on the amount of work that is done in the laboratory; and, though you may not succeed in discovering what you set out to find, you can see from the account I have given that you will always discover something. REFERENCES
was
active.
This compound and the two related compounds, hexoestrol and diencestrol, have found extensive use in the treatment of menopausal symptoms and other conditions for which formerly the naturally occurring
cestrogens were prescribed. Their great advantage lies in the fact that they are cheap to produce and that they are active by mouth, and thus patients are spared much inconvenience and expense. A further use has been found for these compounds in the treatment of carcinoma of the prostate gland. Huggins and Hodges (1941) showed that castration or the administration of cestrogens would bring symptomatic relief in a large proportion of cases and since then the compounds have been used extensively for this purpose. In about 95% of cases there is some response ; and, in a large number of cases responding, complete symptomatic relief is obtained in a short time. The treatment can in no sense be described as a cure, since if treatment is discontinued the symptoms return, and in many cases the relief obtained is not permanent. However, it is the first time that a substance active by mouth has been found of use in the treatment of any form of cancer, and it offers to the patient with carcinoma of the prostate a definite hope of freedom from pain and discomfort at least for a time, and the possibility of resuming his normal activities.
Addison, (1849) Lond. med. Gaz. 43, 517. (1855) On the Constitutional and Local Effects of Disease of the Suprarenal Capsules, London. Allen, E., Doisy, E. A. (1923) J. Amer. med. Ass. 81, 819. Aschheim, S., Zondek, B. (1927) Klin. Wschr. 6, 1322. Bachmann, W. E., Cole, W., Wilds, A. L. (1940) J. Amer. chem. Soc. T.
—
62, 824. Banting, F. G., Best, C. H. (1922) J. Lab. clin. Med. 7, 251. Brown-Séquard, E. (1856) Arch. gén. Méd. 8, 385, 572. (1858) J. Physiol. de l’Homme, 1, 160. Butenandt, A. (1929) Naturwissenschaften, 17, 879. -
—
(1931)
-
-
of the founders of this series of Addison lectures, of which I have had the honour of giving the first, is to stimulate young workers to enter research, particularly research into the endocrine system. It is impossible for me to know whether the picture that I have painted in this brief period will have the effect of beckoning new people into the laboratory, or the reverse effect of scaring them away. I shall feel satisfied if I have dispelled the current idea of how a successful research is conducted. It is practically impossible to convince students starting on research that such work is not for heaven-sent geniuses only. There is no doubt that successful research-workers tend to convey this impression to the outsider, because they follow the invariable scientific practice of writing their papers backwards, so to speak. When a research is finally published, it appears to the reader as an orderly series of steps carefully thought out ; and if the reader is not already in the trade, the - effect is to produce an acute inferiority complex in his mind and to persuade him that in no circumstances would he ever be able to
-
-
-
-
ZYGOMATIC MASTOIDITIS
object
conduct research. My object in this lecture has been to show that research is never done as it is written, and that the cold orderly paper is produced practically always by a series of blundering steps in which the research-worker is rather like someone in a dark room scrambling for the switch and tripping over the furniture. When he has once found the switch and turned on the light, he can arrange the furniture in an orderly manner.
44, 905.
-
A CALL FOR RESEARCH-WORKERS
The
Z. angew. Chem.
Cook, J. W., Dodds, E. C., Hewett, C. L., Lawson, W. (1934) Proc. roy. Soc., B, 114, 272. Doisy, E. A., Veler, C. D., Thayer, S. A. (1929) Amer. J. Physiol. 90, 329. Girard, A., Sandulesco, G., Fridenson, A., Gaudefroy, C., Rutgers, I. J. J. (1932a) C.R. Acad. Sci., Paris, 194, 1020. Rutgers, I. J. J. (1932b) Ibid, p. 909. Gull, W. (1873) Trans. clin. Soc. Lond. 7, 180. Guy’s Hospital Reports (1890) 32, 25. Harington, C. R. (1926) Biochem. J. 15, 293, 300. Barger, G. (1927) Ibid, 21, 169. Huggins, C., Hodges, C. V. (1941) Cancer Research, 1, 293. Kendall, E. C. (1915) Trans. Ass. Amer. Phys. 30, 420. Kocher, T. (1889) KorrespBl. schweiz. Ärz. 19, 1. (1895) Ibid, 25, 3. Laguesse, E. (1893) C.R. Soc. Biol. Paris, 5, 819. Lancet (1890) i, 324. Marrian, G. F. (1930) Biochem. J. 24, 435, 1021. Medical Times and Gazette (1860) 2, 20. Murray, G. R. (1891) Brit. med. J. ii, 796. Ord, W. (1878) Ibid, i, 671. Rosenheim, O., King, H. (1932) J. Soc. chem. Ind., Lond. 51, 464, 954. (1933) Ibid, 52, 299. Ruzicka, L., Goldberg, M. W., Meyer, J., Brungger, H., Eichenberger, E. (1934) Helv. chim. Acta, 17, 1395. Stockard, C. R., Papanicolaou, G. N. (1917) Amer. J. Anat. 22, 225. Swingle, W. W., Pfiffner, J. J. (1931) Amer. J. Physiol. 98, 144. Szent-Györgyi, A. (1928) Biochem. J. 22, 1387. von Mering, J., Minkowski, O. (1889) Zbl. klin. Med. 10, 393. Wieland, H., Dane, E. (1932) Hoppe-Seyl. Z. 210, 274. Wilks, S., Bettany, G. T. (1892) A Biographical History of Guy’s Hospital, London. Willis, T. (1681) The Remaining Medical Works of that Famous and Renowned Physician, London. Windaus, A. (1932) Hoppe-Seyl. Z. 213, 147.
PHILIP READING Lond., F.R.C.S.
M.S. SURGEON, THROAT
AND
EAR
DEPARTMENT, GUY’S HOSPITAL,
LONDON
ZYGOMATIC mastoiditis is not mentioned by Toynbee and Hinton, the pioneers of English otology. Only at the end of the second decade of this century did it gain general recognition, as the result of the publications of Mouret and Seigneurin (1920) and of Holmgren
(1921).
9.9
During the course of a suppurative otomastoiditis infection may reach air cells in the root of the zygomatic process and there produce an inflammatory swelling. The path of the infection from the mastoid to the zygoma is generally along a preformed track of cells (Holmgren 1921, Gadolin 1938), though sometimes there appears to be no direct communication between the two groups of cells. Heine (1908) suggested that infection might pass direct from the attic vault"to the diploe of the squama and so reach the temporal fossa. Horgan (1929) has suggested, as another possible route, the glaserian fissure, and Watson-Williams (1930) put forward the possibility that infection might track along a persistent petrosquamous sinus. Of the 29 cases of zygomatic mastoiditis under review, a cellular mastoid was found in all but one of the 27 cases of acute infection. A cellular track was demonstrable in most of these. In both the cases of zygomatitis due to chronic infection, one of which was caused by actino-
703
mycosis,
the pus had
apparently leaked through
the roof
of the meatus. CLINICAL PICTURE
All the
Thus 1 in every 4 cases of acute mastoiditis with had no perforation of the drumhead. Of those with no otorrhoea, 1 in every 4 had a swelling over the zygoma. Beta hsemolytic streptococcus was found in 10 of the cases with no otorrhoea and alpha haemolytic streptococcus in 3. Pneumococcus type 111 was not found in any. If the total number of cortical mastoidectomies, 602, is taken as the basis of computation, zygomatic mastoiditis without otorrhcea was present in 2-4%, and all forms of mastoiditis without otorrhoea in 9-8%. This compares with the 5% of mastoiditis without otorrhcoa reported by Watson-Williams (1929) in 300 simple mastoidectomies performed before the introduction of
superficial swelling
reported
cases
in this paper
presented
with thè
feature. Such swelling, preauricular swelling as aasprominent a after cortical
however, may appear
complication
mastoidectomy. Horgan(1929) reported two, Rosenwasser and Druss (1933) four instances, and attributed them
inadequate surgery.at the first operation. The greatest incidence is between the ages of 5 and 15 years. The swelling develops in the course of a suppurative otomastoiditis and is commonest when such infections are common-in the late winter and early spring. A firm tumour covers the root of the zygoma and often causes cedema of the lower eyelid. It is tender, but fluctuation and " pointing " of the abscess are signs long delayed in their appearance. Trismus is an inconstant symptom. Pain and difficulty in opening the jaws may be found in acute infection of the parotid gland and in inflammation of the skin of the anterior wall of the meatus. True zygomatic mastoiditis may be simulated by an abscess in the pterygomaxillary space. Greenfield (1934) described such an abscess, which is very rare, and showed that it presented below the zygoma and caused severe trismus. Mill (1932) showed an example of unusual zygomatic infection, which, from the printed description, was probably of the same nature. The differential diagnosis of acute zygomatic mastoiditis may be rendered difficult by the frequent absence of one of the classical signs of suppuration in the middle-ear cleftotorrhoea. to
ILLUSTRATIVE CASE-RECORD
sulphonamides. Sulphonamides had been given to 9 patients with zygomatic mastoiditis without otorrhcea, and to 6 with zygomatic mastoiditis and otorrhcea, before coming under observation. A study of the literature on zygomatitis will refute the suggestion that the absence of otorrhcea can be explained simply as a manifestation of " sulphonamide masking." Heine (1908), speaking of swellings above and in front of the ear, said :
.
"I have observed that these external signs were particularly well marked in cases in which the drum retained little or no sign of inflammatory change. The patients frequently state that, although they suffered from earache in the beginning, no discharge was noticed. This seems to suggest that the original trouble was a suppurative inflammation of the closed attic and that the pus found its way out directly without reaching the antrum or the mastoid cells."
More
.
succinctly, Mouret- and Seigneurin (1920) wrote : apprendra que 1’infection n’a fait que lecher la
" On
A girl, aged 6 years, was admitted to hospital with a caisse, l’antre, avant de se localiser dans la region swelling which had been growing in front of the ear for a temporale." The was and about firm, oval, fortnight. swelling 11/2 in. long, and its general direction coincided with that of the zygomatic A glance at the following table shows that otorrhoea. bone. When it had first appeared there had been slight earache,, is absent in a considerable number of cases and, also, but so young a child was not able clearly to distinguish that this absence is more frequent in the last two groups, between pain in the ear and pain in the adjacent swelling. which occurred within the sulphonamide era : Examination of the tympanic membrane showed no abnormality. Tenderness could be elicited on pressure only The solitary sign of aural disease over the zygomatic root. No pus was a slight impairment of the hearing on that side. escaped when the membrane was incised. A cortical mastoidectomy was performed. The mastoid Grey swollen muco-endosteum was process was cellular. "
found in all the cells, and pus in the mastoid antrum. A drachm of pus was liberated on opening the cells in the
zygomatic
root.
CONDITION OF TYMPANIC MEMBRANE
Since this experience careful note was taken of the condition of the tympanic membrane in all zygomatic and other mastoid swellings. Of the 27 patients with acute zygomatic mastoiditis, 13 had tympanic membranes scarcely distinguishable from normal. In 5 the membrane was injected and slightly bulging. In the remaining 9 otorrhoea was present, and a perforation could be demonstrated in the tympanic membrane. Impairment of hearing of varying degree was elicited in all. Those patients retained their hearing most who had apparently the most healthy membranes. This seemed to be an unusually high proportion of mastoiditis without otorrheea (66%). To obtain a control figure the records of other forms of acute mastoiditis were studied. In the five years ending Dec. 31, 1945, 602 primary cortical mastoidectomies were performed. Of these, 232 showed a superficial inflammatory swelling, caused by the underlying mastoiditis. Of these swellings 24 (10%) were centred over the zygoma, and 59, of which 15 (26%) were zygomatic, were not by otorrhoea. In 173 the mastoid swelling was associated with otorrhcea, and zygomatitis accounted for 9 (5%) of these.
accompanied
Single case-records are not included, such as those of Neville (1933), Watson-Williams (1930), and Watt (1932). All these described otorrhoea as a feature of zygomatitis. Breitstein (1926) described a, case without otorrhcea and drew attention to the lack of this symptom. One can infer that, though the absence of otorrhoea is common in zygomatic mastoiditis, it has become more common since the introduction of sulphonamides. No explanation of this absence of otorrhcea is apparent. Failing any other, we must accept the suggestion that, in a cellular mastoid with a cellular zygoma, early occlusion of the air cells and of the tympanum by swollen muco-endosteum allows the escape of pus by the only route left open, to the zygomatic root and the temporal fossa. At operation such thickening of the membrane could be demonstrated in the aditus of some but not all of the diseased mastoid bones. SUMMARY
A review of 27 is
cases
of acute
-
zygomatic
mastoiditis
presented.
Attention is drawn to the absence of otorrhcea in many zygomatic infections, and hence to the difficulties which may arise in diagnosis. acute
704 "
Sulphonamide masking," as an adequate explanation, be partly discounted. These patients were studied and treated at Selly Oak Hospital, Birmingham. To the medical superintendent of can
that hospital, Mr. R. P. S. Kelman, F.R.c.s., my thanks due for his kind permission to publish.
are
REFERENCES
Breitstein, M. L. (1926) Arch. Otolaryng., Chicago, 4, 300. Gadolin, H. R. (1938) Acta oto-laryng., Stockh. 26, 492. Greenfield, S. D. (1934) Laryngoscope, 44, 232. Heine, B. (1908) Operations on the Ear, London. Holmgren, G. (1921) Acta oto-laryng., Stockh. 3, 66. Horgan, J. B. (1929) J. Laryng. 44, 309. Mill, W. A. (1932) Proc. R. Soc. Med. 25, 489. Mollison, W. M. (1922) J. Laryng. 37, 545. Mouret, J., Seigneurin (1920) Rev. Laryng. 41, 33, 65. Neville, T. W. S. (1933) Lancet, i, 526. Rankin, N. L. (1923) J. Laryng. 38, 192. Rosenwasser, H., Druss, J. G. (1933) Arch. Otolaryng., Chicago, 17, 625. Watson-Williams, E. (1929) Brit. med. J. ii, 1099. (1930) Ibid, i, 1173. Watt, J. C. (1932) J. Laryng. 47, 712. —
RECOVERY OF STRETCH REFLEXES AFTER NERVE INJURY J. Z. YOUNG D. BARKER Oxfd, F.R.S. the and From Department of Zoology Oomparative Anatomy, Oxford, and the Department of Anatomy, University College, B.A. Oxfd
M.A.
London
.
IN spite of the large amount of published work on the regeneration of nerve very little is known of the recovery of proprioceptor function. Since the functions of the various receptors of muscle in normal life are still largely unknown, it is impossible to estimate the importance of their recovery after nerve lesions, but it seems likely that some of the imperfections of muscle function after
nerve
suture
are
due
to
incomplete
sensory
reinnervation. The only proprioceptor activities which it is easy to study experimentally or clinically are the stretch reflexes. The return of the ankle-jerk after nerve grafting has been described by Rezende (1942) in dogs and monkeys and by Davis et al. (1945) in cats ; a division of the rabbit’s crural nerve was made by Waller (1890) but seventeen months later the knee-jerk was still absent. Stopford (1930) reported the recovery of joint sense " after nerve injury in man, this being a subjective term for a sense of whose receptors little is known. Proprioceptor function is certainly not limited to response to stretching a muscle. The end-organs present in muscle include at least two chief types : muscle spindles and tendon organs. The stretch reflex is usually supposed to be mediated by the muscle spindles (Matthews 1933) ; but the evidence is incomplete, and it may well be that the excitatory afferent fibres belong to "
the tendon organs.
occasion that the reflex is elicited. The rods can slide through a series of numbered holes, and by subtracting the depth of the ankle from the total reading a measurement of the upward movement of the foot is obtained (fig. 1). As’in human subjects, the magnitude of the response is affected by the conditions prevailing at the time of testing, but tests made under conditions as standard as possible on successive days give reasonably consistent readings with a normally
distributed variation. It is thus possible to estimate the normal response and then watch its recovery after interruption of the crural nerve.
A complication is introduced by the fact that, because of the weight of the shank and foot, a considerable amount of reflex contraction tension has to be developed by the quadriceps before any upward movement is possible. The height of the jerk elicited does not there. fore give a linear measure of the force exerted by the muscles, even if the limb is placed in the same position at each test. The term " inertia factor " has been given to that force which the quadriceps must exert to lift the weight of the shank and foot and produce an upward movement which is just perceptible.
By transecting the quadriceps near its distal end and attaching the tendon to a spring balance it has been possible to determine the magnitude of this force in different positions of the limb and to assess approximately its proportion of the total reflex contraction tension required for the normal response. The tension required to elicit a slight movement in the usual testing position was 23-41 % of that required to effect mean normal responses of 17-11 test units. Moreover, plots of the tension required to lift the limb to various heights showed that more work must be done in the earlier than in the later phase of lifting the leg. The same relationship between quadriceps tension and leg extension was found by Haxton (1945), who measured the forces involved in experiments on cadaver limbs. The magnitude of the upward jerk cannot, therefore, be regarded as a linear index of the degree of recovery of the reflex after nerve injury ; the return of a small response may represent a degree of recovery as high as 60%, for the muscles will have to develop enough contraction tension to overcome the inertia factor and to produce a visible jerk in that part of the upward swing where the greatest lifting forces are required to raise the ankle. The smallest detectable responses are those giving an upward jerk of about 3 nun. and fall between 0 and 1 test unit on the scale used ; they ate both difficult to elicit with certainty and to measure with accuracy.
is desirable to devise some method of inertia factor. Testing the animal the other way up to that which has been described, or testing with the animal held vertically, proved impracticable. It might be possible to devise some method of testing the animal on its back and counterweighting the limb so that all the reflex contraction tension developed
Evidently it eliminating the
Histological investigation (Huber 1900, Tello 1907, Boeke 1916) has shown that there is some reinnervation of muscle spindles after nerve injury, but it remains uncertain whether the sensory and motor innervation are both restored. If all fibres become mingled at a point of nerve suture and no processes direct the regenerating fibres back into appropriate pathways, it is difficult to see how the normal pattern can be restored. MEASUREMENT OF KNEE-JERK
We have devised a means of measuring jerk in the unanaesthetised rabbit in order quantitatively its recovery after nerve injury.
the kneeto
assess
The rabbit is placed on its back on a testing-couch in such a way that movement is possible only in the hind legs. When the patellar ligament is struck, the foot jerks upwards from where it has been resting on a horizontal rod, the height which it reaches being recorded by adjusting an upper rod to the level at which it is hit by the foot on almost every
Fig. I-Apparatus used
to measure
knee-jerk in unangesthetised rabbit.