320 MARCH 2, 1946 SINUS BAROTRAUMA AND AEROSINUSITIS BREITLSJOA than chemical formulae. The result is a book which is less dramatic instances the pain develops slowly on descent a mine of information about the effects of reproductive or after return to ground level. An explanation advanced hormones and related substances when administered to the by McGibbon' is that during ascent the relatively increas- animal, and a book which cannot fail to be much used for ing pressure within the sinus cavity causes an ischaemnia of the mucosa. On descent, with a relatively decreasing pres- reference purposes. In some ways, however, it is unsatis- sure of the sinus air, engorgement of the mucosal capillaries fying. To many workers the action of exogenous hormones results in oedema, effusion, and haemorrhage. In the is of interest mainly in so far as it throws light on the build- absence of any previous sinusitis x-ray evidence2 of opacity up of the normal animal. As it concerns the hormones or thickened lining membrane is suggestive of barotrauma. associated with reproduction, this approach demands a In a large number of patients, however, especially those in considerable knowledge of the changes occurring in the whom the only abnormal signs are radiological, it is almost normal reproductive processes. Mr. Burrows, however, impossible to differentiate cause from effects of baro- traumatic changes. gives little7 attention to the biological background of the A submucous haematoma of the frontal sinus was first reactions he describes, and the occurrence of oestrogen in described by Herman3 and later by P. A. Campbell.4 In the ovarian follicle is catalogued in the same non-committal a case of recurrent frontal sinus barotrauma an apparent way as its alleged presence in asphalt. Similarly, actions "polyp" removed by McGibbon was found to -be a of the gonadal hormone which in our present state of haematoma encapsulated in a densely collagenous fibrous knowledge seem trivial and incidental are not sharply tissue and undergoing organization. There was no inflam- matory infiltration to suggest infection. Experimentally the differentiated from functions essential for reproduction. picture has been reproduced by P. A. Campbell and his co- In general one wishes the author had taken more workers in a dog decompressed from 28,000 ft. (8,500 m.) trouble to indicate the probable relevance of the observa- after tight packing of the naso-frontal duct. Examination tions he records, even if this had meant more selection of disclosed a large haematoma extending upward from the his material. Interpretation is, of course, always dangerous, internal orifice of the duct. Multiple small mucosal haemor- and he may well have been dismayed by the incredible rhages were found to arise between the epithelium and the miscellany of observations recorded in the literature and periosteum in lightly vascularized areas of the mucosa. The mucosa of the unobstructed sinus was normal. Biopsy by the notorious propensity of reproductive endocrinology sections of antral mucosa have been examined in a few to confound its interpreters. Nevertheless, while all things cases of recurrent sinus barotrauma by C. Campbell5 in a are possible, some things are more likely than others even series of cases observed in the R.A.F. Subacute or chronic in this phantasmagorial field, and more expression of inflammatory changes, marked oedema, congestion, small opinion on the part of the author would have enlivened mucous or submucous haemorrhages, plasma cells, poly- the book. Its two-page glossary contains an excellent sum- morph and lymphocytic infiltration of the mucosa, and a moderate degree of fibroblastic hyperplasia were observed. mary of the definitions of international units of sex hor- But exactly similar changes may be found in the mucosa mones, but is otherwise so selective as to be of little value in subacute and chronic infective antritis in which there and there is a list of proprietary hormone preparations, use- has been no question of sinus barotrauma, so that in these ful but perhaps somewhat out of place in a scientific treatise. few barotraumatic cases the histological appearances are Mr. Burrows's book is one which all those interested in probably those of a complicating infective antritis. Age, the subject should have available for reference, and one amount of flying experience, nature of aircrew duties, and the author after a life as a type of aircraft flown are not predisposing factors, and the must congratulate who, busy aetiology of the syndrome is that of many contributory surgeon, not only has made important contributions to factors. These may be developmental, traumatic, allergic, research but has accomplished successfully a literary under- infective, neoplastic, or mixed. It is difficult to assess the taking of this magnitude. incidence. Figures are unreliable, as in many patients the contributory factor clinically overshadows the effects of barotrauma. P. A. Campbell gives an incidence of otitic barotrauma as 1 in 20. In a series of cases observed in the R.A.F. and reported by McGibbon the relationship SINUS BAROTRAUMA AND AEROSINUSITIS was approximately 1 case of sinus barotrauma to 4 of acute The war of 1939-45 has created conditions for high-altitude otitic barotrauma. In a series of experimental cases sub- flying. It gave the man on top great tactical advantage. jected to decompression the ratio was 1 to 5. It was further Thin air encountered at such altitudes increases air speed noted that the results of infection of the upper respiratory for any given power output and renders flying conmffortable tract are the most frequent contributory factors. At the under adverse weather conditions. Until high altitudes same time it must be stressed that many individuals suffer- became common few people were ever subjected to great ing from acute and chronic upper respiratory infections, changes in barometric pressure. The effects of these pres- established infective sinusitis, and polyposis fly without sure variations upon closed cavities containing gas and experiencing any ill effect. air were observed in the syndrome of sinus barotrauma or The diagnosis of sinus barotrauma is founded largely aerosinusitis, characterized by congestion and acute or on the patient's complaint of pain, and the syndrome lends chronic inflammation of the sinus membranes. Tem- itself to hysterical mimicry and perpetuation as a means porary or permanent changes in the sinus mucous of escape from duty. Observations extending over a long membrane, such as mucosal or submucosal haemorrhage, period and based on the examination of a large number of may result, depending on the amount of barotrauma. cases have led to this conclusion. The differentiation of Pain over one or more sinuses, usually the frontal, often true sinus barotrauma from neuropsychiatric symptoms described as a "sting over the eye" or "a blow by a 1 J. Laryngol. Otol., Nov., 1944, 59. crowbar," is commonly the onset of the syndrome. This 2 Schneider, M., Amner. J. Roentgenol.. June, 1945, 53. severe form is associated at times with stripping of the 3 Z 1-als. NWasen. Ohren., 1941, 48, 87. 4 Ar;. Otol. Rhinol. Laryng., June, 19/4. mucous membrane or submucosal haemorrhage, whilst in 6 J. Laryngol. Otol., Nov., 1944, 59. MARCH BRITISH 2, 1946 ISLET-CELL TUMOURS MEDICAL JOURNAL 321 which simulate the syndrome is aided by an experienced of obvious importance. Dizziness, nausea, pallor, and examiner's observations of the patient's reactions during a sweating may at first be mistaken for part of a psycho- standard decompression test. neurosis or even alcoholism; convulsions, clonic contrac- Prophylaxis can be summed up briefly. Flying should tions, and coma may, as in the case described by Maxeiner be avoided by anyone suffering from an acute or chronic and Bundy, lead to a diagnosis of epilepsy; while maniacal upper respiratory infection. Treatment is expectant, and seizures may produce serious consequences for which the any manifest contributory factor should be corrected. patient cannot be held responsible. Citing another case, Relief of symptoms occurring during descent from height M. S.-M. Rayner, C. H. Rogerson, and J. G. Jones5 point can be obtained by re-ascent, if in an aircraft, or decom- out that a diagnosis of hysterical or convulsive fits shou'ld pression in a chamber, followed by very gradual loss of never be made until hypoglycaemia has been excluded. height. Minor degrees of insulinogenic hypoglycaemia may not be uncommon, even when a firm diagnosis cannot be made, ISLET-CELL TUMOURS and it would seem justifiable to give glucose a clinical trial in any case of recurrent nervous manifestations of the type The literature on tumours of the islets of Langerhans and described, especially if they occur in fasting conditions the symptoms with which they are associated is piling up. (e.g., earfy morning) or after physical exertion. An admirable short historical survey and report of a case successfully treated by surgery have recently been given by Stanley R. Maxeiner and Harry E. Bundy.' These tumours were first recognized as long ago as 1902, but, probably THE OBLIGATION OF THE PHYSIOTHERAPIST because the first twenty reported were asymptomatic, were thought for many years to be of academic interest only. As a result of the war the science and practice of physio- The discovery of insulin and insulin shock led soon to therapy have gained wide publicity, and the chartered the realization that islet-cell growths may often cause physiotherapist is recognized as an essential member of symptoms due to hypoglycaemia: Whipple2 has collected the rehabilitation team. Nevertheless, far too little is still 149 cases of this type. known both of the standard of training and of ethical con- According to their size and malignancy the tumours may duct required of physiotherapists. A body for the training, be wholly without effect on function; may cause minor examination, and registration of physiotherapists has been disturbances amenable to medical treatment by glucose and in existence since 1894, the date of the foundation of the careful regime of life; may require surgical treatment; I.S.T.M.. A Royal Charter was granted to that Society in may cause fatal uncontrollable hypoglycaemia-for ex- 1920 when it took the name of the Chartered Society of ample, when metastases form in the liver. The diagnostic Massage and Medical Gymnastics, and in 1943 it became criteria are, according to Whipple, symptoms of insulin known as the Chartered Society of Physiotherapy, thus shock coming on in fasting or fatigued persons; a blood- denoting the increasing scope of a physiotherapist. Over sugar level of 50 mg. or less per 100 ml.; and prompt many years the standard of training laid down by the relief of symptoms by glucose. Maxeiner and Bundy, how- Chartered Society has been progressively raised, and the ever, stress that the diagnosis is difficult in many cases, and, length of the course has been increased from a few months as in hyperthyroidism, this must clearly be so in early and in 1894 to the present length of 2+ years. When the new mild phases of the disorder. Glucose-tolerance tests are curriculum is introduced the training will extend over unreliable, and administration of alloxan is not an effective 3 years. diagnostic measure. Other causes of hypoglycaemia must From the earliest days the Chartered Society has insisted be excluded. Usually the tumours are single, but in about on a strict ethical code for its members. Before being 10% of cases two or more have been found. In Maxeiner admitted to the Register a chartered physiotherapist must and Bundy's case eight inactive tumours and one active sign an undertaking "not to undertake any case except were found. Whether a condition analogous to primary under the direction of a registered medical practitioner," thyrotoxicosis affects the islet tissue, as suggested by Frantz,3 Attention is called to this by-law in a letter published in is tncertain. About two-thirds of all tumours are appar- our correspondence columns from Dr. W. S. C. Coppn1at, ently benign, one-tenth certainly malignant, and the Chairman of the Council of the' Chartered Society"of remainder doubtfully so. They are commonly found Physiotherapy. This ethical by-law affects not only 'the in the tail and body of the gland. (A paper by Louis P. chartered physiotherapist but also the patient and the medi- Good4 on the histopathology of the tumours suggests that cal practitioner. It safeguards the patient against loss of the tumour capsule is really compressed duct wall of the time and money and the consequences of unsuitable treat- pancreas, the presence or absence of a capsule depending ment, while the doctor knows that he will have the loyal on the site of origin of the growth.) co-operation of the physiotherapist and highly skilled treat- In describing the surgical approach Maxeiner and Bundy ment for his patient. emphasize that it may be very difficult to identify the tumour (or tumours) at operation; and several cases have been reported in which two or more operations were per- Dr. R. D. Lawrence will deliver the Oliver-Sharpey Lectures formed before a cure was obtained. When no growth can before the Royal College of Physicians of London on Tuesday, be found they advocate resection of the body and tail of March 19, and Thursday, March 21, at 5 p.m. at the College, Pall Mall East. His subject is " A Case of Lipodystrophy and the pancreas as being the most usual site of the tumours; Hepatomegaly with Diabetes, Lipaemia, and other Strange the alternative is to close the wound and wait until such Metabolic Disturbances suggesting a New Aspect of Insulin time as the tumour is big enough to be recognized af a Action." subsequent laparotomy. Both courses have obvious dis- advantages. By reason of the nervous manifestations which they Following the death of Sir Comyns Berkeley, the Central often cause the early recognition of islet-cell tumours is Midwives Board has elected Mr. Arnold Walker as chairhian and Mr. J. P. Hedley as vice-chairman for the rest of thie 1 1945, 18, 171. 2 Ibid.,Surgtery,1949, 8, 289. Board year until March, 31, 1946. 3 Ann Su'g, 1944, 119, 824. 4Surgery, 1945, 18, 159. 5 Lancet, 1943, 2, 476.