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TRANSACTIONS
OFTHE
SEVENTH SESSION
OF THE
INTERNATIONAL‘ MEDICAL CONGRESS
LONDON! PRINTED BY
BALLANTYNE, HANSON AND co., CHANDOS s'r.
AND PAUL'S WORK, EDINBURGH
TRANSACTIONS
INTERNATIONAL MEDICAL CONGRESS
London,August2dmk>9ﬂg1881
iﬁnparz‘u fut iBuﬁlicatinn 11mm the birzctinn of tha QExzsntihz Qtnmmittzz
BY
SIR WILLIAM MAC CORMAC
Honorary Secretary-General
ASSISTED BY
GEORGE HENRY MAKJNS ERCS
Under-Secretary
AND
THE SECRETARIES OF THE SECTIONS

IN FOUR VOLUMES
Vol. III.
LONDON
J.W.KOLCKMANN
1881
TABLE OF CONTENTS.
LIST or ILLUSTRATIONS . . . . . . .
PROCEEDINGS OF THE SECTION OF OPHTHAL-
MOLOGY . . . . .
Oﬂicers of the Section . . . . . . . .
Inaugural Address by the President, Mr. W. Bowman, ERS.
Appointment of Committee to deliberate concerning Tests of
Vision and Colour Sense . . . . . .
Die Antiseptische Chirurgie bei Augenkrankheiten. Prof.
Homer, Ziirich . . . . . . .
The Antiseptic Method in Cataract Extraction. Prof’. C.
Reymond, Turin . . . . . . .
Ueber die Wirkung von Fremdko'rpern im Inneren des Auges.
Prof. Th. Leber, Gottingen . . . . . .
Ueber die H'ziuﬁgkeit gewisser Krankheiten des Auges zu
verschiedenen Zeiten des Jahres. Dr. E. Emmert, Berne
Discussion on the employment of the Antiseptic Method in Eye
Surgery . . . . . . . . .
Speeches by : Dr. de Wecker—Dr. Warlomont—Dr. Gayet
~ ——Dr. Knapp—Dr. Galezowski—Dr. H. Pagenstecher
--Prof. Dor—Prof. Horner.
Des mouvements des yeux a l’état normal et a l’état pathologique.
Dr. Landolt, Paris . . . . . . .
Ténotomie partielle des muscles de l’oeil pour combattre l’insuf-
ﬁsance musculaire. Dr. Ch. Abadie, Paris . . .
Un Ophtalmomctre MM. J aval et Schiotz, Paris . . .
Sympathetic Ophthalmitis, the mode of its Transmission and its
Nature. Prof’. H. Snellen, Utrecht . . . .
On the Pathology of Sympathetic Ophthalmitis. Dr. W. A.
Brailey, London . . . . . . .
Comment l’ophtalmie sympathique peut-elle se produire
aprés l’enervation? Dr. Poncet, de Cluny
Discussion on Sympathetic Ophthalmitis . . . . .
Speeches by: Dr. Mooren—Prof'. Gruenhagen—Prof.
Pﬂiiger —— Dr. Samelsohn -— Prof. Leber —- Dr.
BOucheron—-—Prof. Panas—Dr. Snellen.
PART III.
PAGES
xix—xx.
1—129
1
1—7
'7
8-141
41- 151
15— 19
19-23
23-25
25- 29
29—30
30
3 1—35
35— -39
39-44
45-417
vi TABLE er CONTENTS.
Considérations pratiques sur l’examen des employés de Chemin
de fer, et de la marine an sujet de Daltonisme et de la
Vision. Dr. Libbrecht, Grhent . . . . .
A New Method of examining and numerically expressing the
Colour Perception. Dr. Ole Bull, Christiania . .
Primary Retinal Haemorrhage in young men (Abstract). Mr.
Henry Eales, Birmingham . . . . .
On the Connection between Optic Neuritis and Intra-eranial
Diseases. Prof. Theodore Leber, Göttingen . .
De la névrite optique dans ses rapports avec les maladies intra-
craniennes. Dr. Bouchut, Paris . . . .
Des thromboses vasculaires amenant des névrites optiques ou
des signes d’embolie. Dr. Galezowski, Paris . .
The Pathological changes in Retro-bulbar N euritis (Central
Amblyopia). Dr. Samelsohn, Cologne . . .
Discussion on the Connection between Optic N euritis and Intra-
cranial diseases . . . . . . . .
Speeches by: Prof. Dor-——Dr. Hughlings J ackson—Dr.
Parinaud———Dr. S. Mackenzie—Dr. Poncet—Prof.
Laqueur—Prof. Panas—Dr. Knapp—Dr. Pagenstech er
-——Prof. Leber—Dr. Brailey Prof. Leber.
Traitement des décollements de la rétine par les injections
souscutanées de pilocarpine. Dr. Dianoux, Nantes
Discussion . . . . . .
Speeches by: Dr. G. Martin—Dr. Martini.
Ueber Pathogenese und Ætiologie des Nystagmus der Bergleute
nach Untersuchungen von 7,500 Bergleute. Dr. N ieden,
Bochum . . . . . . . . .
Resolutions as to Tests of Sight suitable to be enforced in the
case of Signallers and look-out men and other persons,
by Land and Sea . . . . . . .
Ueber pathologische Veränderungen, Welche dem Glaucom
vorhergehen oder dasselbe verursachen. Dr. Adolf
Weber, Darmstadt . . . . . .
Increase of Refraction in Glaucoma. Dr. Laqueur, Strassburg .
The Pathology of Glaucoma. Mr. Priestley Smith, Birmingham
On the Etiology of Glaucoma. Dr. Angelucci, Rome .
Discussion on Glaucoma . . . . . . .
Speeches by: Dr. de Wecker—Dr. Osio—Prof. Leber—
Mr. G. E. Walker—Dr. Brailey—Dr. Galezowski—
Dr. Weber.
Extraction of Cataract by Peripheral Division of the Capsule.
Dr. H. Knapp, New York . . . . .
Discussion . . . . .
Speech by: Dr. Gayet, Lyons.
Des opérations contre le glaucome dans ses formes différentes.
Dr. L. de Wecker, Paris . . .
Sclerotomy in Glaucoma. Mr. C. Bader, London
Indications de la- sclérotomie. Dr. Ch. Abadie, Paris

PAGES
av-as
aa-so
51-52
52-57
58
58-60
60-61
60-65
65—_68
ce
69-72
72--75
75-83
83
84-86
so__s7
87 —89
89-95
es
95——98
98-99
99__100
TABLE OF CONTENTS .
vii
Zur Sclerotomie. Prof. H. Schoeler, Berlin
Discussion on Operations for Glaucoma . . . . .
Speeches by: Mr. Power - Prof. Panas -Dr. Argyll
' Robertson-Dr. Samelsohn-Dr. Knapp-Mr. G. E.
Walker-Dr. Cralezowski-Dr. dc Wecker.
Ein neues Operationsverfahren zur Heilung der Ptosis.
Hermann Pagenstecher, Wiesbaden . . . .
N ouvelles applications du fer rouge en chirurgie oculaire et de
quelques modiﬁcations apportées aux galvano-cauteres.
Dr. G. Martin, Bordeaux
Discussion . . .
Speech by: Dr. de Wecker.
Dr.
I On Oculo-Neural Reﬂex Irritation. Dr. Geo. T. Stevens, Albany,
New York . . . . . . .
Relation entre le kyste séreux sous~palpébral de l’orbite avec
microphtalmos et le coloboma de l’oeil. Dr. van Duyse,
Ghent . . . . . . . . .
Injuries to the Optic Nerve and Ophthalmic Artery from Fracture
of the Optic Canal. Dr. R. Berlin, Stuttgart . .
Transplantation des muqueuses sur l’oeil. Dr. Dufour, Lausaune
On Tuberculous Inﬁammations of the Eyeball. Prof. J. Hirsch-
berg, Berlin ‘ . . . . . . . .
Case of Aniriclia Congenita of both Eyes with Deﬁciency of the
Ciliary Bodies, and Anterior Part of the Choroid. Dr.
HiIario de Gouvéa, Rio de Janeiro . . . .
Observations on a ‘Peculiar Expression of the Eyes of the Colour-
blind. Dr. B. .Ioy Jeﬁ'ries, Boston, Mass. .
De l’énucléation de l’oeil clans la panophtalmie suppurative aign‘e'.
Dr. Daniel Molliere, Lyons
Description of a Registering Perimeter.
Albany, New York . . .
Histology of the Cornea. Dr. Eloui, Egypt . . .
Chromoptomctre pour l’cxamen des employés de chemin de fer
et des marins. Dr. Parinaud, Paris . . . .
U11 appareil pour l’appréciation de l’acuité chromatique dans un
examen sommaire du personnel de la marine et des che-
mins de fer. Dr. M aréchal, Brest . , . .
On a Method of Opening Closed Pupil after Operation for Cata-
ract. Dr. Lucien Howe, Buffalo, USA. . . .
Demonstrations . . . . . . . . .
Mr. C. Bader. Gonorrheal Ophthalinia; Conical Cornea
Dr. Crayet. Photographs of Specimens of Diseased Eyes .
Microscopical Specimens by: Dr. Hirschberg-Mr. Story-Dr.
Samelsohn-Mr. M. Gunn-Dr. Brailey-Mr. Nettleship
-Mr. Priestley Smith-Dr. Eloui . . . .
Apparatus and Instruments by: Dr. Parinaud-Dr. Ole Bull-
Dr Javal-Dr. Maréchal-Dr. Pagenstecher-Mr. M. M.
Hardy-Dr. L. Howe-Dr. Knapp-Dr. Nieden-Prof.
V011 Zehender-Dr. Stevens-Dr. Lopez Ocaﬁa-Dr.
Libbrecht-Dr. W. Thomson-Dr. J aesche .
Dr. George '1‘. Stevens,
PAGES
100-106
106-108
108-109
110-111
111
111-114:
114-115
115
116— 117
117-120
120-121
12 1-122
122-123
128-124
124
124-126
126-127
127-128
128
128
128
128-129
129
Z) 2
viii TABLE or CONTENTS.
PROCEEDINGS OF THE SECTION FOR DISEASES OF
THE SKIN . . . .
List of Oﬂicers . . . . . . . .
Inaugural Address by the President, Sir Erasmus \Vilson
Du pityriasis circiné et marginé, description de son mycoderme,
1e microsporon anomaeon (microsporon dispar). Dr.
Emile Vidal, Paris .
On Balano-posthomykosis.
Discussion . . . . . . . . .
Speeches by: Prof. Kaposi—Dr. Liveing—Mr. Malcolm
Morris—~Dr. Unua—Sir Erasmus \V ilson—M r. Bal-
manno Squire—Prof‘. Oscar Simon.
A Papillary Tumour of the Scalp, with a Short Account of its
Histology. Dr. Alfred Sangster, London . . .
Discussion . . . .' . . . . . .
Speeches by: Prof’. Kaposi--Dr.Thin-—M. Hillairet—Mr.
Gaskoiu—Dr. Sangster.
Un cas d’hydrosadénite diffuse produit par l’emploi de la pilo-
carpine. Dr. H. Rasori, Rome . . . . .
Discussion . . . . . . . . '. .
Speeches by: Prof’. Schwimmer—Prof. O. Simon—Dr.
Unna—Prof. Kaposi.
Sur l’étiologie de quelques maladies desquamatives de la peau.
Dr. Angelucci, Rome . . . . . . .
Discussion . . . . . . . . . .
Speeches by: Prof. O. Simon—Dr. Unna—Dr. Vidal-—
Prof‘. Kaposi—Dr. A. Jamieson—Dr. Thin—Dr.
Oavafy—Dr. Angelucci.
Ueber vaccinale Hauteruptionen.
Discussion . . . . . .
Speeches by : Dr. Von Hebra—Prof'. Hardy.
On the Causes of Alopecia Areata. Dr. R. Liveing, London
Discussion . . . . . . . . . .
Speeches by: Dr. Vidal—Prof. Hardy—Dr. von Hebra—
Prof. Kaposi—Dr. Unna—Prof'. Schwimmer—Dr. Thin
—-Prof. O. Simon—Dr. A. Jamieson—Mr. Gaskoin—
Prof’. Oscar Simon, Breslau .
Dr. Gustav Behrend, Berlin
Sir Erasmus Wilson.
Lupus Erythematosus. Prof. KaposiLVienna
’ Ditto Dr. Th. Veiel, Oanstatt
Discussion
Speeches by: Sir Erasmus Wilson—Dr. Vidal—Dr. Unna
-—Prof. SchWimmer—~Dr. Thin.
Ueber Leukoplakia buccalis. Prof. Ernst Schwimmer, Buda-
Pesth . . . . . . . .
Discussion . . . . . . . . . .
Speeches by: Dr. Hillairet--Prof. Kaposi—Dr. Vidal—
Mr. M. Baker—Mr. R. O. Lucas—Dr. Behrend—Dr.
L. Duncan Bulkley—Sir Erasmus Wilson ——Prof'.
Schwimmer.
PAGES
131——193
131
131——133
133——138
138——142
142——143
143——14&
144——145
146-—149
149
149——151
151—-l52
152——157
157——158
158——161
161——162
162——167
167-170
170——17l
171-173
173——175
TABLE OF CONTENTS.
1X
Lymphadénie cutauée. Dr. Vidal, Paris
Ditto M. Hillairet, Paris
Discussion . . . . . . . .
Speeches by : Prof. Kaposi—Prof. 0. Simon.
On Prurigo, or Eczematous Prurigo. W. Morrant Baker, London
Discussion . . . . . . . . .
Speeches by Prof. Kaposi—Dr. von Hebra—Mr. Malcolm
Morris—Dr. Liveing—Dr. Cavafy—Dr. \Valter Smith
--Sir Erasmus Wilson—Dr. Sangster—Dr. L. D.
Bnlkley—Dr. Unna—Prof'. O. Simon—Dr. A. Jamie-
son—Prof'. Kaposi—Mr. Morrant Baker.
On a Case of the Occurrence of Dipterous Larvae in the Human
Skin. Dr. Walter G. Smith, Dublin . . .
A Case of supposed Neurotic Excoriation. Dr. A. Sangster,
London . . . . . . . .
Discussion . . . . . . . . .
Speeches by: Sir Erasmus Wilson—Dr. R. Liveing—Dr.
Unna—Prof. O. Simon—Dr. Thin—Mr. Startin—Mr.
M. Baker—MnGaskoin—Dr. Sangster—-—Prof. Kaposi.
A Critical and Historical Essay on the Sweat Secretion.
Unna, Hamburgh' . . . .
Discussion . . . . . . . . . .
Speeches by: Prof’. O. Simon—Dr. von Hebra—Dr. Unna.
Sclerodermia diﬁ'nsa (scléreme des adultes—Thirial), sclerema
adultorum. Dr. J. H. Stowers, London . .
A Case of Congenital Abnormality in the Hair Production on the
Scalp. Dr. George Thin, London .
Discussion . . . . . . . . . .
Speeches by: Prof. Kaposi—Dr. Vidal—Dr. Unna—Dr.
Liveing—Dr. L. D. Bulkley—Dr. Thin.
Selected Notes on Dermato-Therapeia, illustrating the Author’s
Views and Methods of Treatment of some Cutaneous
Diseases. Sir Erasmus Wilson, London . .
International Committee to consider the questionof Nomenclature
in reference to Skin Diseases, and to report at a future
meeting of the Congress . . . . . .
PROCEEDINGS OF THE SUB-SECTION FOR DISEASES
OF THE THROAT . . . .
Officers of the Sub-section . . . . . . .
Inaugural Address by the Chairman. Dr. George Johnson,
London
On the Invention of the Laryngosoope. Sig. Manuel Garcia,
London . . . . . . . .
Dr.
A
PAGES
175—176
176-17 7
177--179
l79-—181
181——18l
18i-185
185——187
187——188
18s
189-190
190
191
191-_193
193
194_-335
195
195-—196
197-190
X TABLE OF CONTENTS.
On the Local Treatment of Diphtheria——
Papers by Dr. Morell Mackenzie, London
Dr. Tobold, Berlin . .
Mr. Lennox Brown, London . .
Discussion on the Local Treatment of Diphtheria . . .
Speeches by: Dr. Meyer—Prof. Burow—Dr. Becker—Dr.
Solis Cohen—D1213. Frankel—Dr. Bothe—Dr. Prosser
James—Dr. Johnson—Dr. Morell Mackenzie.
On the Pathology of Laryngeal Phthisis—
Papers by Prof. Krishaber, Paris
Prof. Bossbach, Wnrzburg . .
Discussion on the Pathology of Laryngeal Phthisis . . .
Speeches by: Dr. George Johnson—Dr. B.Frankel Prof.
Schnitzler—Prof. Voltolini—Prof. Cadier Dr. E.
Frankel—Prof. Gerhardt —- Prof. Krishaber ~— Prof.
Rossbach.
Laryngoscopic Signs in Connection with Injuries or Diseases of
the Motor Nerves of the Larynx—
Papers by Prof. Gerhardt, Wiirzburg .
Prof. G. M. Leﬁ‘erts, New York . .
Discussion on Laryngoscopic Signs in Connection with Injuries
or Diseases of the Motor Nerves of the Larynx . .


Speeches by: Dr. George Johnson—Dr. O. Bosenbach—Dr.
F. Semon--Prof. Schnitzler—Dr. Bosworth—Prof.
BuroW—Prof. Gerhardt—Prof. Leﬁ‘erts.
N euroses of Sensation of the Pharynx and Larynx—
Papers by Prof. Schnitzler, Vienna .
Prof. Elsberg, New York . .
Discussion on Neuroses of Sensation of the Pharynx and
Larynx . . . . . . . . .
Speeches by : Dr. B. Frankel--Dr. Tornwaldt-—Dr. Bayer
--Prof'. Schnitzler.
Indications for the Extra- or Intra-Laryngeal Treatment of
Polypi of the Larynx—
Papers by Dr. Ch. Fauvel, Paris . .
Prof. Burow, Ko'nigsberg . . . .
Discussion on the Indications for Extra- or Intra~Laryngeal
Treatment of Laryngeal Polypi . . . . .
Speeches by: Prof. Krishaber—Dr. HOPIDEIIIHMDI'. Booker
--—Dr. Solis Cohen Mr. Lennox Browne—Dr. Max
Schaﬂ'er — Prof. Schnitzler -- Dr. F. Senion-“I’rof.
LefFerts—Dr. C. Fauvel—Prof'. Burow.
The Results of Mechanical Treatment of Laryngeal Stenoses—

Papers by Dr. Koch, Luxeinburg .
Dr.‘J. Hering, \Varsaw. . . . .
Discussion of the Results of Mechanical Treatment of Laryngeal
Stenoses . . . . . . . . .
Speeches by: Dr. Tornwaldt—Dr. Grossmann-—-Dr. Max
Schaffer.
PAGES
199-203
203
204-205
205-208
208-210
210-212
212
214-215
215-221
221-223
223—-224
22a-_225
225
225-—227
227——233
233-237
237-—242
242-250
250-251
TABLE OF CONTENTS.
xi
Indications for the Complete or Partial Extirpation of the
Imrynx-
Papers by Dr. Foulis, Glasgow . .
r WM‘ 5- Dr. Philip Schech, Munich . .
Discussion on Total Extirpation of the Larynx . . .
Speeches by: Dr. Solis Cohen-Prof. Caselli-Dr. Morell
Mackenzie - Prof. Ozerny - Dr. F. Semon - Prof’.
Burow-Dr. Prosser James-Prof‘. Lefferts-Dr.
Johnson-Dr. Foulis.
The Galvano-caustic Method in Nose, Pharynx and Larynx-
Papers by Prof. Voltolini, Breslau . . . .
Dr. J. Solis Cohen, Philadelphia
Prof. Cadier, Paris . .
hdnlLennoxiBrowne,Lmndon .
Dr. Foulis, Glasgow . .
Dr. V. Lange, Copenhagen . . . .
Discussion on the Employment of the Galvano-caustic Method in
Nose, Pharynx and_Larynx . . . . . .
Speeches by: DrLowenherg—DrThudichum-Dr. Bosworth
-Dr. Rufus Lincoln-Dr. W. Meyer-Prof. Voltolini.
Adenoid Vegetations in the Vault of the Pharynx-
Papers by Dr. W. Meyer, Copenhagen
Dr. Lowenberg, Paris .
Dr. Guye, Amsterdam . . . . .
On Papillo-adenomatous Disease or Post>nasal Vegetations. Dr.
IE.YVoakea London . . . . . . .
Discussion on Adenoid Vegetations of the Pharynx . .
Speeches by: Dr. Michel-Dr. E. Frankel-Dr. Bo'cker
-Dr. Hopmann-Dr. Meyer-Dr. Lowenberg.
The Nature and Treatment of Ozaena-
Papers by Dr. B. Frankel, Berlin
Dr. E. Fournié, Paris . .
Mr. Spencer ‘Watson, London .
Discussion on the Nature and Treatment of Ozoena . . .
Speeches by: Dr. Krause-Dr. E. Frankel-Dr. Kendal
Franks-Dr. Hopmann-Dr. Bayer-Dr. Michel-
Dr. Gottstein-Prof. Jurasz-Dr. Lowenberg-Dr.
Prosser James-Dr. B. Frankel,I
A case of Web in the Larynx, probably Congenital. Dr. G.Vivian
Poore, London . . . . . . . .
Discussion on the Case . . . . . . .
Speeches by: Dr. Solis Cohen-Dr. Bocker-ProﬁSchnitzler.
The Spray Producer; the best means of making Applications to
the Superior Portion of the Respiratory Tracts. Dr. M.
F. Rumbold, St. Louis, U.S.A. . . . . .
Ueber die physiologische uud pathologische Schleimabsonderung
im Kehlkopf und der Luftrohre, sowie Beitiuige zur
Wirkung expectorirender und adstringirender bei
Schleimhautkatarrhen Angewendeten Arzneimittel.
Prof. Rossbach, Wurzburg .
PAGES
251——258
259——262
262——266
267——268
269——272
272-273
273——275
275——276
276
276——277
278——282
283——290
290——291
291—-300
300——301
302——303
303——809
309——311
311——316
316——317
317
317
317——320
xn TABLE OF coNTENTs.
lb
Discussion on the Paper . . . . .
Speeches by : Dr. B. Frankel—Prof. Rossbach.
Einﬁuss des weiblichen Geschlechtsapparats auf Stimmorgan und
Stimmbildung. Dr. Bayer, Brussels . . .
Discussion on the Paper . . . . .
Speeches by: Dr. E. Frankel-Dr. Felix Semon.
A Contribution to the Pathology of the NasalMucous Membrane.
Dr.f F. H. Bosworth, N ew York . . .
Discussion on the paper .
Speech by: Dr. Krause.
Du role de la portion libre de l’epiglotte et des fossettes glosso-
epiglottiques. Dr. Guinier, Cauterets . . . .
Clinical Demonstrations . . . . . . .
By Dr. Morell Mackenzie—Dr. G. Vivian Poore-Dr. F.
Semon-Dr. W. Me Neill Whistler-Dr. Foulis-
Dr. Michel-Dr. Cresswell Baber-Dr. Bosworth-
Dr. Foulis—Dr. B. Frankel-Dr. Prosser James-
Prof. Krishaber-Dr. Morell Mackenzie—Dr. Rum-
bold—Prof. Stork-Dr. Tornwaldt— Mr. Spencer
Watson—Prof‘. Cadier-Dr. Goodwillie-Prof. Vol-
tolini—Prof. Caselli-Dr. Meyer-Dr. Booker.
Resolution with regard to the abandonment of the scheme
of holding a Second Laryngological Congress .
Attendance at the Sub-sectional Meetings
PROCEEDINGS OF THE SECTION OF DISEASE OF
THE EAR . . . . . . . .
Oﬂicers of the Section . . . . . . . .
Inaugural Address by the President, WV. B. Dalby Esq , London
Note sur une modiﬁcation apportée a la myringodectomie clans
l’otite scléreuse. Dr. A. Paquet, Lille . .
Discussion on the Employment of Myringodectomy . .
Speeches by: Dr. Guye-Prof.Voltolini-Dr. Liiwenberg—
Dr. Gel]é—Prof.Paquet-Dr.Thomas Barr—Dr.Pierce
-Dr. U. Pritchard—Dr. Cassells— Dr. Lowenberg--
Prof. S. S. Jones.
On the Etiology of Aural Exostoses, and their Removal by a
New Operation. Dr. James Patterson Cassells, Glasgow
Morbid Growths of the Ear, and their Treatment, with illustrative
Cases. Dr. Laurence Turnbull, Philadelphia ,
Discussion on Aural Exostoses . . ' . . .
Speeches by: Dr. Méniere—Dr. Guye-Dr. Gellé-Dr.
Liiwenberg-DnGellé-Dr. Knapp—Dr.U. Pritchard
-Prof. Jones-Dr. Barr-Dr. Reeve-Dr.Sapolini-
Dr. Cassells.
PAGES
321
321——327
327
327-330
330
331-332
332-335
335
335
33 7-435
337
337--340
3410-3117
347-352
352-359
359-367
367 —- 37 0
TABLE or CONTENTS.
xiii
Les lesions nerveuses dans la surdité. Dr. Gellé, Paris
Zur-physikalischen diﬁ'erentiellen Diagnostik zwischen Erkran-
kung des schallleitenden Apparates, und N erventaubheit.
Mit Demonstrationen. Prof. A. Lucae, Berlin .
On certain conditions of the Eyes as a Cause of Loss of Hearing
by Reﬂex Irritation. Dr. George T. Stevens, New York
Remarks by: Dr. Knapp—Mr. C. Bader—Dr. Barr. .
Les Fonctions de la trompe d’Eustache. Dr. Edouard Fournié,
Paris . . . . -
Remarks by : Dr. T. F. Rumbold. .
The Cotton Pellet as an Artiﬁcial Drumhead.
York . . .
Discussion . . . . . . . . . .
Speeches by: Mr. Cumberbatcli--—Dr. Czarda---1\Ir. Keene
—Dr. Mac Millan—Dr. Cassells.
Objective Noises in the Ear. Dr. C. E. FitzGerald, Dublin
Discussion . . . . . . . .
Speech by: Dr. Lowenberg.
The Sense of Touch as a Standard of Comparison for Hearing
Power. Mr. A. Gardiner-Brown, London
Discussion . . . . . . . . . .
Speeches by: Mr. L. Purves—Dr.Knapp—Mr. L. Purves.
De l’accommodation dc l’oreille. Retard de la sensation. Etude
Physio-pathologiquo. Dr. Gellé, Paris .
Paretic Deafness. Dr. Edward \Voakes, London . . .
The Action of Syphilis on the Ear. Dr. F. M. Pierce, Manchester
Caseous Accum ulations in the Middle Ear regarded as a probable
cause of Miliary tubercle. Dr. Thos. Barr, Glasgow
Krankengeschichte und Sektions befund eines an Carcinoma aur.
med. et Labyrinth dest. verstorbenen 417 jahrigen Mannes.
Prof. Adam Politzer, Vienna . . . .
Some Difficulties in the Diagnosis, Prognosis, and Treatment of
Middle-Ear Deafness. Dr. P. McBride, Edinburgh
On the Prevention of Dumbness in those Cases Where it follows
Loss of Hearing. Mr. Arthur Kinsey, London .
Comment l’onde sonore arrive an centre acoustique.
. Dr. Knapp, New
Dr:
Sapolini, Milan . ..~ . . . . . .
Nouveau cas de Guérison de la Surdi-Mutité Infantile par
Otopiésis. Dr. Boucheron, Paris
The Acoustic Potentials of the Human Auricle. Mr. A. G.
Brown, London . . . . . . . ~ .
On Diﬁicult Cases of Introducing the Eustachian Catheter, and
a Method Facilitating the Operation in these Cases. Dr.
Loewenberg, Paris . . . . . . .
Ueber ein Kiinstliches ﬁiissiges Trommelfell. Dr. Michael,
Hamburg . . . . . . .
PAGES
370—37 2
372-37 4
374——-3 '76
3'7 6—37 7
377—37 9
379
380—383
383
383—391
391
392—393
393
393-395
395 ~398
399
400-406
406—408
408—4113
4:13—I18
418-428
428—430
430—432
432—i31i
434—435
xiv TABLE or CONTENTS.
PROCEEDINGS OF THE SECTION OF DISEASES Oh‘
THE TEETH . . . . . . .
List of Officers . . . . . . . .
Inaugural Address by the President, Mr. E. Saunders . .
On the Scientiﬁc Status of Medicine. Prof Owen, C.B., London
De l’état actuel de la greﬁ‘e dentaire par restitution appliquée a
la cure de la périostite alvéolaire chronique du sommet.
Dr. Magitot, Paris . . . . .
Replantation. Dr. W. Finlay Thompson, London
Discussion . . . . . . . . . .
Speeches by : Dr. Taft—Dr. J. Iszlai-~Mr. Coleman—Mr.
Spence Bate—Mr. Browne Mason—Mr. Balkwill—
Mr. Percy May—Mr. Atkinson.
Evidence of Reﬂex Action, in Relation to Constitutional Dis-
turbance induced by interrupted Secondary Dentition,
and coming under the personal observation of the author.
Mr. D. Corbett, Dublin . .
On Erosion. Mr. Alfred Coleman, London
Discussion . . . . . . . . . .
Speeches by: Mr. Gaddes—Dr. Taft—Mr. Magor—Dr.
Dentz——-Mr. C. S. Tomes—Mr. Coleman.
Experiments on the Action of some Agents used for the
Devitalization of the Tooth Pulp. Dr. Joseph Arkovy,
Buda-Pesth . . . . . . .
On the Reproduction of Bones, with special reference to the
Variable Portions of the Maxillze. Dr. W. H. Atkinson,
New York . . . . . . . .
The Study of Dental Surgery and the Means thereto. Mr.
John Tomes, London ' . . . . .
Restoration of Contour the only way to keep the Margins of
Enamel of the Proximal Surfaces of the Teeth
permanently separate and to prevent Recurrence of Decay.
Dr. Marshall I-I. wWebb, New York
Des limites de la Curabilité de la Caric Dentaire.
I?aris . . . . . . . .
An Investigation into the Eﬁ'ects of Organisms upon the Teeth,
and Alveolar Portions of the Jaws. Mr. A. S. Underwood
and Mr. 'W. T. Milles, London . . .
Discussion . . . . . . . . .
Speeches by: Dr. Taft—Dr. Dentz—-Mr. C. S. Tomes--
Mr. W. Coffin—Mr. Coleman—Mr. S. J. Hutchinson
--Y[r. A. S. Underwood.
Remarks on the Administration of Anaesthetics at the Dental
Dr. Magitot,
Hospital of London, from 1868 to the present time. Mr.
A. Coleman, London . . . . .
Alveolar Abscess. Dr. M. S. Dean', Chicago . . .
Civilization in its Relation to the Decay of the Teeth.
Norman Kingsley, New York . .
Dr:
PAGES
437——577
437
437——440
440——445
445——466
¢66——471
471—-474
474-476
A76——&S7
487-488
488——498
d98——501
502—-513
513-516
-516~—523
523——527
527—-529
529~—530
530—-533
533-539
TABLE or CONTENTS.
XV
Discussion . . . . .
Speeches by: Mr. Spence Bate
Magitot-Dr. G. M. Beard.
On the Causes of Dental Caries.
London . . . . . . . .
A generalized Treatment of Irregularities. Mr. Walter H.
Coﬁ‘in, London . . . . - -
Remarks by Dr. Rosenthal . . . . . . .
Causes of Irregularities of Position of the Teeth, Dr. T. Brian
Gunning, New York . . . . .
On the Origin and Treatment of certain Forms of Irregularities
of the Teeth. Mr. J. Oakley Coles, London .
Illustrative Skizzen zu Carabelli’s “ Mordex prorsus” und
desscn Verhaltniss zur sogen. “ Prognathia ethnologica ”
und Meyer’s “ Crania progenea.” Dr. Iszlai, Buda-
Pesth . . . . . . . .
Contour Restoration of the Superior Central Incisors. Dr. E.
Parmby Brown; New York . . ,
Dental Surgery in the Army. Mr. J. Gaddes, London .
Antrum of Highmore.-Diseases and Treatment. Dr. Taft,
Cincinnati . . . . . . .
Discussion 011 the Premature Loss of Teeth by Destruction of
their Alveoli . . . . . . . .
Speeches by: Dr. J. Walker-Dr. J. Arkovy-Dr. J.
Iszlai-Mr. Walter Coffin-Mr. Oakley Coles-Dr.
Atkinson-Mr. C. S. Tomes-Dr. Snow-Dr. Fried-
richs.
Mr. Oakley ‘Coles-Dr.

Mr. J. R. Mummery;
PROCEEDINGS OF
DISEASE
List of Officers . . . . . . . . .
Inaugural Address by the President, Dr. Lockhart Robertson.
Sur la mégalomanie. Dr. A. Foville, Paris . . .
Discussion . . . . . . .
Remarks by: Dr. Maudsley and Dr. Savage.
Physiologie pathologique des hallucinations.
Fournié, Paris . . . .
Discussion . . . . . . . . .
Remarks by: Dr. Ashe-Prof. Lasegue-Prof. de J ong.
Praparationsmethode zur Anlegen grosser Durchschnittsprii—
parate des Menschlichen Gehirns.
Vienna
Discussion . . . . . .
Remarks by: Prof. Benedikt-Dr. de J ong.
Certain Morbid Appearances produced by Methods of Hardening
Nervous Tissues. Dr. G. H. Savage, London
Remarks by: Prof. Benedikt . . . .
THE SECTION OF MENTAL
Dr. Edouard
Dr. Anton Holler, .
PAGES
539—-540
54l-542
542——547
547
548——552
552——555
555——569
569-—570
57I——573
573——575
575——577
579——660
579
579——592
593
593——594
594—-595
595
595——596
596
596
596
xvi TABLE or CONTENTS.
The Teaching of Psychiatric
burgh . . .
Discussion . . . . . . . . . .
Remarks by: Dr. Hack Tuke-Dr. Macdonald-Prot'.
Ball-Dr. Maudsley-Mr. Mould . .
On the Relations ofInsanity and Paralysis Agitans.
Paris . . . . . . .
Discussion . . . . . . . . . .
Remarks by : Dr. Savage-Dr. C. Mercier-Dr. Huggard.
Questions Médico—Légales: de l’explosion soudaine d’acces
d’alcoolisme aigu ou subaigu par choc moral. Dr. Motet,
Paris . . . . . . . . .
Discussion . . . . . . . . . .
Remarks by: Dr. Ashe-Dr. Bucknill-Dr. Clouston-
Dr. C. Mercier-Dr Maudsley-Dr. Motet.
Some of the Cranial Characteristics of Idiocy. Dr. Shuttlcworth,
Lancaster . . . . . . . . .
The Morphological and Histological Aspects of Microcephalic
and Cretinoid Idiocy. Dr. Fletcher Beach, Darenth
Discussion . . . . . . . . . .
Remarks by: Dr Huggard-Dr. Ireland —Dr. Dally-Dr.
C. Clapham-Dr. Shuttleworth-Dr. Beach. ’
Cerebral Localization and Hallucinations. Prof. Tamburini,
Reggio Emilia . . . . . . . . .
Discussion . . . . . .
Remarks by: Prof. Ferrier.
The Brains of Criminals. Prof. Benedikt, Vienna .
Discussion . . . . . . .
Remarks by: Dr. Crichton Browne-Dr. Dally.
On Unilateral Hallucinations and their relation to Cerebral
Localization. Dr. Alexander Robertson, Glasgow
Medicine. Dr. Clouston, Edin-
Prol'. Ball,
Mental Stupor. Dr. Hack Tuke, London . .
Discussion . . . . . . . . .
Remarks by : Dr. Foville-Dr. Crichton Browne-Dr.
Clouston.
An Experimental Study of Hypnotism. Prof‘. Tamburini, Reggio
Emilia . . . . . . . .
Gouty Insanity. Dr. Rayner, Hanwell .
Discussion .
Remarks by: Dr. Savage-Dr. Crichton Browne.
Epilepsie. Prof. Lasegue, Paris . . . .
Testamentary Incapacity. Dr. Bucknill, London
Discussion . . . .- . . . . . .
Remarks by: Dr. Macclonalcl-Dr. Maudsley-—Dr. ‘Vood
-Dr. Orange-Dr. Buckuill.
Treatment of the Prodromal Stages of Insanity. Dr. Otto
Muller, Blankenburg . . . . . . .
On the Race Relationships of General Paralysis. Dr. Ashe,
Dublin . . . . . .
PAGES
596~—602
602—-603
603——607
607
607—-609
609
609——614
615——630
630——631
631
631
631-—632
632
632——633
634——639
639
640
640——641
6A1
6¢I-643
643——649
649
650
650——656
TABLE or ooa'rnurs. _ xvii
, PAGES
Psychological Researches on the Rapidity of Perception in the
' Insane. Dr. Buccola, Reggio Emilia . . . . * 656
An Accidentally induced Hypnotism. Dr J. Mortimer
Granville, London . . . . . . . 656-657
On the Village Treatment of the Insane, particularly at Gheel.
Dr. Peeters, Gheel . . . . . . 657-658
On Exophthalmic Goitre and its Relations to Unsoundness of
Mind. Dr. G. H. Savage, London . . . . 658
On the Proposed Italian Lunacy Law. Prof. Tamburini, Reggie
:Enﬁﬁa . . . . . . . . . 658
On the Condition of the Blood in Pellagrous Insanity. Dr.
Seppilli . . . . . . . . . 659
Moral Insanity. Dr. C. H. Hughes, St. Louis, USA. . . 659—660
I
FIG.
1.
2.
‘. 3.
. Le champ de ﬁxation moyen.
LIST OF ILLUSTRATIONS.
Ce champ de ﬁxation binoculaire normale . .
{Le champ de ﬁxation normal minimum-Le champ de ﬁxa-
tion d’une insuﬁisance des muscles droits internes .
Le champs de ﬁxation des deux yeuX gauches. Parésic du droit
externe, avec strabisme convergent dc 15°. Strabisme con-
vergent non paralytiquc de 50° dai ant do In premiereeunesse;
oeil amblyope, individu agé de 50 ans . . . .
Le champ de ﬁxation des deux
yeux de la meme personne atteinte de parésie de presque tous
les muscles des yeux . .
5. Chromoptometre du Dr. Parinaud . . . . . .
6. Mycelium and spores observed in a case of balano-posthomykosis
7. Section of papillary tumour of scalp
8. Dipterous larva from beneath human skin ,
9. Section of polyp from the external auditory meatus . . .
10. Do. do. showing osseous deposit
11. Section of the surface of a polyp of the ear almost entirely
ossiﬁed . . . . . . .
12. Fibrous polyp from external auditory meatus . .
13. Aural exostosis . . . . . . . . \
14. _Fibroma of lobule of the ear .
15. Myxoﬁbroma of auricle . . .
16. Angioma springing from external auditory meatus
17. Do. do. . . .
18. External surface of auricle, indicating the positions of friction
sounds . . . . . . . .
19. Partial dissection of auricle, showing attachment of muscles
20. Dissection of posterior surface of auricle . .
20.* Effect of dcvitalizing agents on the soft tissues of
the dental
pulp . . . . . . . . .
A. Pulp acted on by pepsin showing demarcational line.
1. Blood-vessel from pulp treated with As,O.,.
with pepsine.
with A8203.
7’ 77 77
7,
. Enlarged connective tissue-pulp corpuscles treated with A920
' )7 ‘2 7’ 2,
. Blood-vessel from pulp treated with pepsine.
2
3
4
5. Nerve-ﬁbres from pulp treated with As,Os.
6
7
8. Dentinal ﬁbrils headed by action of A8203.
PAGE
26
27
28
126
139
144
182
355
356
356
357
357
360
361
362
363
431
431
431
494
\0
O
XX LIST OF ILLUSTRATIONS.
FIG.
21. Cranial Contours. Microcephalic .
22. Do. Mongol type . . . . ~.
23. Do. Hydrocephalic . .
24:. Do. Scaphocephalic
25. Microcephalic idiot . .
26.
27.
Brain of microcephalic idiot . . . . .
Cells from the third layer of cortex of frontal convolution of
Microcephalic idiot .
Cretinoid idiot . . . . . . . . .
Fatty tumours taken from the neck of cretin, with their relation
to the trachea and larynx .
28.
29.
30. Cells from the third layer of cortex of frontal convolution of.
cretinoid idiot . . . . .
PLATES.
Plate illustrative of Dr. Brailey’s paper on Sympathetic Oph-
thalmitis.
1. Meridional section through ciliary body and iris.
2. Section through choroid.
3. Section through optic disc in horizontal plane.
Instruments for employment in the removal of vegetations from the
pharynx
Illustrative of the effects of organisms on the teeth and the alveolar
portions of the jaws
/~
OPHTHALMOLOGY.
I-_+_
President.
WILLIAM BowMAN, LL.D., F.R.S.

Vice-Presidents.
GEORGE CRITCHETT, London. Dr. ARGYLL ROBERTSON, F.R.S.,
HENRY POWER, London. Edinburgh.
Dr. H. Rosisoaooen SWANZY, Dublin.
Council.
JAMES BANKAET, Exeter. DAVID LITTLE, Manchester. '
Dr. OLE BULL, Christiania. RIonAEn MIDDLEMORE, Birmingham.
Prof. BUSINELLI, Rome. Dr. Oslo, Madrid.
EDWIN CHESSHIRE, Birmingham. Dr. THOMAS REID, Glasgow.
W. WHITE OoorEa, London. Prof. REYIIoND, Turin.
JOHN CoUrEE, London. Prof. RossANDEE, Stockholm.
Prof. Don, Lyons. PEIEsTLEY SMITH, Birmingham. _
Prof. DOYEB, Leyden. Prof. WILLIAM TnoIIsoN, Philadelphia.
Dr. CnAELEs E. FITZGERALD, Dubhn. JonN TWEEDY, London.
Dr. GALEzowsKI, Paris. WILLIAM WALKER, Edinburgh.
Prof. HORNER, Zurich. T. SHADFoED WALKER, Liverpool.
Dr. ARCHIBALD H. J ACOB, Dublin. Dr. WAELoIIoNT, Brussels.
Dr. JAvAL, Paris. Dr. ADOLF WEBER, Darmstadt.
Dr. KNAPP, New York. Dr. DE WECKER, Paris.
Dr. LANDoLT, Paris. JoIIN CAwoon WoRDswoIiTH, London.
GEoneE LAwsoN, London. Prof. Von ZEHENDEE, Rostock.
Prof. LEBEE, Gottingen.
Secretaries.
Dr. BRAILEY. l EDWARD NETTLESHIP.
...._....¢._.._
INAUGURAL ADDRESS,
BY THE PRESIDENT,
WILLIAM BOWMAN, LL.D., F.R.S.
GENTLEMEN AND DEAR COLLEAGUES,—
Many of those whom I have the happiness and honour of now addressing will
be able to recall the proceedings of the fourth International Congress of Ophthal-
mology when it met in London nine years ago.
Our branch of practice on that occasion stood in a sort of isolation, separate
from the rest of the body medical, moving in an orbit of its own. In that isolation
it had during many years set an example, which was in due time to be followed by
the General International Medical Congresses, of which the seventh is now
PART III. B
2 OPHTHALMOLOGY.
being held in our Metropolis. To-day we are obviously one among many members
of the entire medical commonalty, and our work is admitted to be of the highest
value, not only for its own sake, but for the beneﬁcial inﬂuence which its aims and
methods exercise over the whole ﬁeld of Medicine.
In the brief interval since 1872, our President of that year, Professor Donders,
has been called upon to occupy the still more honourable post of President of this
General Congress, at Amsterdam. Let us greet him here once again, now in both
characters, with the respect and affection which are so much his due. We owe it
to him that our calling has been much advanced and elevated by the unfolding of
many new truths, and the free presentation of them to us in lucid array, so that all
men could turn them to account in the ordinary every-day round of practice, to the
great beneﬁt of ourselves and patients.
On the occasion to which allusion has been made, it was the College of
Physicians which oﬁered us accommodation, that ancient English Corporation of
the Sixteenth Century, which, at its original institution, comprised upon its rolls
almost all that was greatest among us in medical learning and practice, and. which
now, with characteristic liberality, is doing its utmost, with our other brethren, to
further the success of the present world-wide Convention.
It now happens, however, that our Ophthalmological Section of this Congress
is domiciled otherwise—viz., in the rooms of an illustrious Society, the time-honoured
representative among us of the whole range of natural knowledge, for the promo-
tion of which it was laboriously founded; largely, we may reﬂect with pleasure, by
the co-operation of men of our own profession.
The circumstance is quite accidental, but it may serve to remind us of the deep
and necessary connection of every Department of Medicine, our own in a marked
degree, with the principles and subject-matter of the Natural Sciences in general.
Man’s body and mind have relations with the whole universe, and thus far extend
also the aspects of those relations with which the healing art is concerned; which
we study in man’s interest, in order that we may understand how to modify or
control them for his individual or general advantage.
As to these great modern International Congresses of the private men of various
countries (of which it may perhaps be said that the present one is already
proving itself the largest and most remarkable of any), this room may remind us
how lofty, how noble have been the aims of some of the greatest intellects of the
past, of whose achievements we ﬁnd ourselves to be the fortunate inheritors. For it
is Science itself, and nothing less, in the persons of a series of its eminent culti-
vators in many countries, working in an unselﬁsh and open spirit, that has at length
made such Congresses possible, and, in fact, has brought them about.
The Royal Society was founded, we may remember, about the time of the
death of Harvey, and in the near radiance of that Baconian light, of which the
token was that it must be, not dry and barren, but fruitful and beneﬁcent for
the use of man’s estate. And above me, in your view, is the bodily presentment
of the greatest of the Society’s Presidents—of Newton, from whose genius and
character have radiated, for us and for all succeeding ages, the beams of a potent
and almost divine inﬂuence.
Let me, for a passing moment, strike a chord that will wake an echo in every
breast, and give expression to the trust, that in our deliberations we may be guided
by the simplicity of his pure love of truth, and of truth only: as well as by its
correlative, that modest self-estimate, that humility of mind, which in him was the
mark of a deep consciousness of his own individual littleness, and almost helpless-
OPHTHALMOLOGY. 3
uses, in presence of the dark problems of the unknown. “ I know not what I may
appear to the world,” he is reported to have said towards the close of his life, “ but
to myself I seem to have been only like a boy playing on the seashore, and diverting
myself in now and then ﬁnding a. smoother pebble, or a prettier shell, than ordinary,
whilst the great ocean of truth lay all undiscovered before me.”
Let us now proceed to what lies more immediately to our hand. Those who have
had the task of organizing the arrangements for the present Congress, have been
actuated chieﬂy by the desire that useful results should follow from it. With that
view they have endeavoured to apportion the very short time at our disposal to the
consideration of special subjects, carefully selected, such as seemed likely to be
elucidated by the mutual exchange of thought between men of weight and experi-
ence coming together from distant places. They think themselves fortunate in
having, in so many instances, secured the co-operation of distinguished masters,
who have, we have reason to believe, made special studies for their addresses, and
whose words will be received, I am sure, with the respect to which they will be so well
entitled.
In our own proper section of Ophthalmology, we shall have the advantage, on
successive days, of directing our minds to the several important questions set down
in our programme. The names of Homer, Snellen, Leber, Adolf Weber, and De
Wecker, assure us that the materials for deliberation will be ample, and com-
petently presented to us. There are also additional communications by able men,
bearing on the same matters, and these will be read in juxtaposition, previous to
opening the debates. The high reputation of so many of our members raises our
expectations as to the results.
As it is very desirable that a good record of our discussions should be preserved
in our Transactions, it is earnestly hoped that every member who may favour us
with his opinions should be as clear and as terse in the expression of them as may
be; and should, at latest, by the following morning, while the memory is still fresh,
give a copy of his remarks in writing to the Secretaries. As to this, facilities will
be afforded, and failing this, the Secretaries cannot be responsible for the publica-
tion, as we have no authorized reporters.
To-morrow the ﬁrst of the distinguished men whom I have just now named, will
place before us a. subject of great interest and importance, the Antiseptic Method
in Eye Surgery. I presume that no one nowadays will question the evils we are so
familiar with in our practice, and which have so often marred the intention of well-
devised operations skilfully performed, but where, as we hear it said, Nature has
failed to do her part, to second the effort of the surgeon by a due process of repair.
The study of the causes of such failures and of the means of obviating them, consti-
tutes far the most brilliant page in the history of Modern Surgery ; and in other
sections of this Congress, while the name of Lister will be applauded, the wide
questions he has raised, and in raising has so often cleared up, will receive the full
consideration they call for.
In the case of the organ of sight, specially constituted, and in some respects
screened from injury as it unquestionably is, there are reasons why the application
of precautionary antiseptic measures, though the principle of them must still assert
itself, should take a somewhat special form. Owing to the local structural conditions
they may apparently he often more simple, though the possible need of the more
elaborate of them should never be allowed to fall out of view.
The tears are a secretion as pure from extraneous particles as is the ﬁltered
air in the recesses of the lungs. They are poured out under cover, in the right
13 2
4 OPHTHALMOLOGY.
place, in quantity suitable to the need; while the lids diffuse them over the con-
junctival surface ere they escape by their proper channels. Their useful and
multiple office is performed in a way so simple and so perfect, that no art, how-
ever skilful, could pretend to equal it. We should ponder well the deep marvels
of adaptation of means to ends, and take heed that we do not hinder exquisite
Nature by meddlesome or needless interference, by the mimic. diligent/ta, Chirar-
go'ram, but only lend it tender and judicious help by our dressings and our
methods. We should always still be able to apply the words of our great poet,
“ The Art itself is Nature.”
Three papers, by Dr. Reymond, of Turin, Professor Leber, of Gottingen, and
Dr. Emmert, of Berne, relating to this same subject, of antiseptic surgery, will
be read before the discussion is proceeded with.
On Friday we propose to treat in our Section the deeply interesting, and I
must add the very sad, subject of Sympathetic Ophthalmitis, under the able
guidance of Professor Snellen. This in all its aspects and stages is an affection
peculiarly calculated to arrest attention. Though it has been extensively and very
accurately studied, it yet remains very obscure. Even its anatomical conditions
cannot be said to be fully explored; why it should occur is little understood. The
explanation of the very remarkable phenomena manifested lies hidden for the
present in unknown anatomical and physiological relations, and it is to experi-
ments on the lower animals that we may look with most probability for a clue to
the enigma. Humanity will have reason to rejoice when this too-frequent cause of
total blindness shall yield to a clearer insight into its nature, and to the consequent
hoped-for discovery of the means of prevention or cure; for at present it brings
lifelong misery to many homes. Meanwhile experience suggests some general
rules which may do something to ward 013’ this terrible malady, or help us, in
some instances, to control it, even now and then to check its progress temporarily,
and, perhaps, permanently. The difficulty lies in the application of such rules,
and to this point our discussions may, I think, very usefully be directed.
An important paper by Dr. Brailey, on “ Pathological Changes in Sympathetic
Ophthalmitis,” and another by Dr. Poncet, of Cluny, on the “ Histological Exami-
nation of an Eye Enucleated after Enervation,” will be read in this connection.
On Saturday,the main topic for us will be introduced by Professor Leber. It is
one of a class which has recently been shown to have much wider relations than
could have been imagined possible some few years ago, and which is certainly
destined to attract more and more attention, not only from ourselves, but prac-
titioners at large. The immortal invention of Helmholtz, by opening to the view
of all instructed men the marvellous background of the transparent chambers of
the eye, has gradually awakened inquiries on the part, ﬁrst, of oculists, and then
of physicians, which even in their infancy have yielded results of rare and unex-
pected value. The changes visible by the Ophthalmoscope will naturally be noted
down, and their varieties and sequences determined, before the precise interpreta-
tion of them by exact structural examination, and their true pathological import,
can be ascertained.
These only admit of being worked out slowly, as opportunities, often rare, give
occasion. Our knowledge of the relation of those aspects of the fundus of the
eyes to what is concurrently going on in the optic avenues, and in the several
associated portions of the wondrously complex double brain and spine, must in a
great measure lag behind. And we must be careful not to leave for a single
moment the safe ground of exact observation ; or suffer ourselves to bebeguiled bythe
OPHTHALMOLOGY. 5
wish to make the new knowledge ﬁt into the old, till all seems a delightfully com-
plete system. Such vain imaginations are not in the true spirit of Science. N ever-
theless, some broad and general facts already reward the clinical industry and
acumen of several physicians, whose names are a sufficient pledge of the reliable
character of their results. But I believe those who know the most, will be the
most ready to confess, how rudimentary, at present, is our insight into this very
important ﬁeld of inquiry. Indeed, the study of the brain function (employing
that term in its widest sense), and of the aberrations occurring in it that we call
disease, remains still in its very infancy. It advances, however, with rapid strides,
by the severalvparallel roads of Human and Comparative Anatomy, Experimental
Physiology and Pathology, and of Clinical observation, including Morbid Anatomy ;
and it cannot be long ere splendid conquests must be won for us in regions which
have been so long shrouded in darkness, and so dense, that in our ignorance we
have been hardly aware of their gloom. In connection with this discussion a com-
prehensive paper by Dr. Bouchut will be laid before you.
Glaucoma, the other great subject to be brought before us, is of even more
practical importance than Sympathetic Ophthalmitis, because of its far wider
prevalence, and its equally fatal consequences to sight when uncontrolled. We
shall consider it in two aspects. On Monday, on the initiative of Dr. Adolf
Weber, and after hearing papers by Professor Laqueur, of Strasbourg, by Mr.
Priestley Smith, of Birmingham, and by Dr. Angelucci, of Rome, all bearing on the
anatomical and pathological basis of the subject, we shall discuss its nature and
etiology: while on Tuesday the grand problem of its treatment, and chiefly its
operative treatment, will undergo critical examination at the hands of one fully
entitled to carry great weight with all of us, Dr. de Weaker, whose experience is
very extensive. His address will be followed, before the discussion, by communica-
tions from Mr. Bader and Dr. Abadie.
It was Albrecht von Graefe, as you well know, Gentlemen—that bright spirit,
whose too early death we have not yet ceased to mourn, for ourselves and for
Science—who, at the same moment that he announced to the world the discovery of
a remedy for Glaucoma, also drew for us, for the ﬁrst time, the grand outlines of the
clinical history of the disease. His treatise will endure as the model work of a most
fertile genius. In it he laid down the chief sub-divisions of the subject, and how
far his remedy was likely to be applicable in each. This single paper constituted
an epoch in our department of the medical art. It was read, but hardly discussed,
at Brussels, at the Second International Congress of Ophthalmology, September,
1857.
Several of those now present were there. The impression produced among
them was profound. But yet we are still, twenty-four years later, anxiously
inquiring what is the essential nature of the Glaucomatous process, and what is
the best remedy to employ.
It is, indeed, quite true that since that time our clinical knowledge of Glau-
coma has been greatly extended, and its varieties and complications recorded with
some approach to completeness. Extensive researches, anatomical, experimental,
and other, have also been undertaken to account for the remarkable train of phe-
nomena we observe. Attempts have also been repeatedly made to explain the
'mOOl’ttS opem'ndt of Von Graefe’s celebrated remedy, but as yet, it must be allowed,
without entire success. The treatment by Iridectomy, too, has been largely tried,
sometimes with modiﬁcations, and on the whole it has been admitted to be the
best and most reliable. The time, the method, the conditions of applying it to the
6 OPHTHALMOLOGY.
varieties of eye-tension have been in many particulars, though not with universal
concurrence, deﬁned and accepted.
But. as was perhaps inevitable, men asking themselves always how Iridectomy
arrested the Glaucomatous process, were now and then led to desire and to propose,
and then to inculcate, other methods, having the same end in view, proceeding too
often on some fancy or speculation, the validity of which experience has not sus-
tained. Some of these methods, after obtaining a certain currency, have fallen
into merited disfavour, while others remain more or less worthy of discussion, some
perhaps of general adoption, under limitations to be yet laid down.
It would be quite foreign to my present purpose to pass any opinion on parti-
cular modes of operating. We hope on Monday to hear the great problem, the
Pathology of Glaucoma, well handled by our distinguished colleague from Darm-
stadt, and. on Tuesday to learn, and debate upon, the latest conclusions on its
surgical treatment, announced by our eminent conﬁ'ere from Paris.
Many contributions are furnished on other subjects than those to which Ihave
hitherto adverted, and some of them bear upon a question of great and permanent
importance, to which I would now ask your attention for a few moments.
The precision of our modern methods of determining the accuracy of sight, and
of the sense of colour, has at length made it possible to urge with increasing
earnestness, on authorities responsible for the lives of travellers, whether by land
or sea, the necessity of enforcing adequate test-examinations, not only on candi-
dates before engagement, but subsequently, at stated intervals, on all persons
employed, where good sight is an essential qualiﬁcation.
If this be important in regard to railway drivers, guards, and signal-men, it is
even far more so in the maritime service. On land, each Government is in a very
direct manner held responsible to its own citizens, and accordingly much has been
done of late years in several countries, though eﬂ"ectually I fear in very few, to
institute strict periodical examinations under State authorization and control. As
to these, perhaps, a very close uniformity through diﬁerent countries is not so
very necessary, however desirable. But it is matter of common and urgent concern
to all nations, that on the open seas, on coasts, and in harbours, an uniform system
should prevail, as to the due and sufficient and periodical testing of the sight of
those who may be in the position either to give or to observe signals, on the prompt
discrimination of which a multitude of precious lives may at any moment depend.
And I trust it may not be very long ere such an uniform system of tests as
Science can now supply, and also the obligation to put them in force among their
own subjects, will be willingly accepted by all civilized States.
The present seems a favourable opportunity for coming to some conclusions, and
for laying down some deﬁnite rules, which by their clear and practical character
may be likely to meet with general acceptance, and for pressing these with some
urgency on Governments throughout the world.
It is for your consideration, Gentlemen, whether a Committee of this Section,
the composition of which might be International, may not with advantage be
appointed to deliberate on this grave subject, and to report to us before the Congress
closes.
I entertain the conﬁdent hope that any recommendations emanating from such
a source, hearing, as they would probably do, the impress of moderation and good
sense, as well as of exact knowledge of the subject-matter, would everywhere meet
with the most favourable attention of statesmen, and be admitted by them as
carrying great weight.
' OPHTHALMOLOGY. 7
I would suggest such a Committee, with Prof. Donders as Chairman, if he
would be so good as to undertake that ofﬁce. '
Gentlemen, we anticipate hard work, within the narrow limits of our sittings. ‘I
trust we shall be able to assemble punctually, so as not to waste moments which
can never be recalled.
One more remark—There will be, I fear, the unavoidable difficulty and source of
(confusion in our converse, arising through the want in some of us of familiar
acquaintance with one or more of the languages in which others are giving
‘expression to their views. It is but too certain that we have not yet a common
tongue, however probable it may be that mankind are tending in that direction.
Misapprehension of each others’ meaning is not unlikely to occur, and, at any rate,
both the expression and the recognition of ideas will be impeded.
To lessen as far as possible this drawback, great pains have been taken to
prepare, in the three official languages of the Congress, a suitable abstract of
every paper, and to place these abstracts in the hands of every member who may
wish to acquaint himself beforehand with the Authors’ propositions.
Besides the volume of Abstracts, comprising those of all the Sections, a few
separate copies of those proper to our own will be in our meeting-room, for the use
of those who may not happen to have the volume at hand. These copies remain
.in the room.
The Executive of .the Section have reason to thank the Authors for the
promptitude with which in most cases the abstracts have been furnished to our inde-
fatigable and able Secretaries, who have been at the pains of collating them. If
any faults of translation or of printing should be discovered, they will doubtless
be attributable to the pressure under which the laborious task has had to be
accomplished.
And now, my dear Friends and Colleagues, let me say, that if some difﬁculties of
the kind just mentioned await many or most of you, how much must you ﬁnd them
enhanced by the circumstance, unfortunate for himself also, that your President is
to a great extent ignorant of the languages, French or German, in which many of the
most valuable communications will be addressed to you, and the speeches delivered.
All my life long I have regretted the slightness of my acquaintance with those
foreign tongues, which in the past, as in the present, have been and are the channels
-by which priceless discoveries have been announced to the world, as well perhaps
as the media of keen, even burning, controversies, when men encounter each other
in their search after truth. Thus, and from other causes appreciable enough to most
of us as .life advances, we are apt to fall relatively into the background, and to have
to rest content in ﬁnding our pleasure rather in learning at second hand, and after
some interval of time, what others have been happily accomplishing, than in hoping
to establish for ourselves, or to maintain, a forward place. But never till the
present moment have I had so much cause to lament my many deﬁciencies, since
now they must of necessity aﬁect others even more than myself. I rely, however,
with full conﬁdence, on your kindness and indulgence, otherwise I could never at
all have ‘ventured to undertake the honourable office of being your President at this
great Congress.
It was proposed by Mr. Critchett, seconded by Dr. Argyll Robertson, and
carried unanimously, that “ A Committee be appointed by the Section to deliberate
concerning the Tests of Vision and Colour Sense most applicable to persons
‘employed in Working or Observing Signals by Land or Sea, where the lives of
-others were involved ;—and to :report thereon to the Section,”
8 OPHTHALMOLOGY.
It was proposed by the President, and carried unanimously, that the following
members of the Section constitute the Committee :—
>)"Chairman: Professor Donders, LL.D., F.R.S., Utrecht, Consulting Oculist of
State Railways; for the Netherlands.
*Wm. Bowman, LL.D., F.R.S., London, President of the Ophthalmological
Section of the Congress ; for Great Britain.
Dr. Dufour, Lausanne; for Switzerland.
Dr. Gama Lobo; for Brazil.
‘Dr. Samuel T. Knaggs, Member of the Medical Board of New South Wales
Government Railways; for N. S. Wales.
*Professor Leber, Gottingen; for Germany.
Dr. Libbrecht, Ghent, delegate from the Belgian Minister of Public Works;
for Belgium.
>X‘Dr. L. Maréchal, Brest, Médecin Principal de la Marine, delegate from the
French Government; for France.
Dr. Ole Bull, Christiania; for Norway.
Dr. Osio, Madrid; for Spain.
Dr. Reymond, Turin; for Italy.
J. T. Rudall, F.R.C.S.E., Melbourne; for Victoria.
>Y-‘Professor W. Thomson, Philadelphia, Examiner to the Pennsylvania Railroad;
for United States.
Dr. \Varlomont, Brussels, delegate from the Belgian Government; for Belgium’.
*Secretary : DnBrailey, London, one of the Secretaries of the Ophthalmological
Section of the Congress.
Die A m‘z'sepz‘z'sc/ze C kirw’gz'e éez' A zggmz/ermz/éﬁez'z‘m.
Professor HORNER, Zurich.
Hocnvnnnnn'rnn HERE Pnlsrnnur, HOCIIGEEHRTE HERREN CoLLneEN,——An diesem
Platze, in diesem Lande iiber Antisepsis zu sprechen, konnte kiihn genannt werden,
wenn mich nicht die ehrenvolle Einladung des Comités berechtigte und wenn ich
nicht gerne laut aussprache, was auch wir Augenarzte dem Manne verdanken,
der den machtigen Umschwung der modernen Wundbehandlung hauptsachlich
bewirkt hat.
Das Thema : “Antiseptic Methods in Eye-Surgery,” darf ich wohl einschranken
und nur specieller erortern: “ the employment of antiseptic methods in cataract
extraction.” Einerseits fallt die Anwendung der antiseptischen Methoden bei
Operationen an den Lidern, den Thréinenorganen, in der Orbita ganz in das Gebiet
der chirurgischen Wundbehandlung iiberhaupt; anderseits ist Alles, was fl'ir die
wichtigste Bulbusoperation—die Staarextraction—als erprobt erkannt wird, auch
fiir alle andern Operationen am Auge selbst giiltig. Dazu kommt, dass sich
difEerente Ansichten wesentlich nur bei der Lehre von der Staarextraction geltend
gemacht haben.
Wenn wir die Frage der Amwvendung der antiseptischen Methode bei der Staar-
extraction inductiv behandeln wollen, so thun wir wohl am besten, zuerst die

* Those marked with an asterisk were named as a working Sub-Committee.
OPHTHALMOLOGY. 9
Ursachen der Verluste, besonders der primären Wundeiterungen kritisch zu
beleuchten, eventuell die Gründe der glänzendsten Statistiken anzudeuten und auf
die Resultate dieser Untersuchung unsere Ansicht aufzubauen. Es scheint mir
dass dieser Weg besonders geeignet sei, uns vor blosser theoretischer Deduction
und unbedingter Annahme eines Dogma’s zu bewahren.
Wenn ich die sämmtlichen primären Verluste, welche ich unter 1,090 Extrac-
tionen nach von Gräfe’s Methode beobachten konnte, zusammenstelle, so scheiden
sie sich ursächlich in folgende Rubriken :
I.—Directe Infection von aussen.
(a) von der Umgebung des Auges aus : Krankheiten der Lider, des
Thranensacks, der Oonjuncttoa.
Hiezu müssen auch z. Theil die Fälle plötzlich sich entwickelnder
Eiterungen gerechnet werden, welche noch am fünften, ja achten
Tage durch gewaltsames Aufdrücken der Wunde entstehen.
(b) von Operaftonsmaterialten aus : Schwämmen, Instrumenten, Verband-
material.
(c) durch pathogene Bacterten, welche vom Patienten und seiner Umgebung
durch eiternde W'unden (Beingeschwüre, &c.) geliefert ‘oder durch das
Operations- odcr Wartpersonal eingebracht werden. (In grossen
Spitälern mit sehr gemischter Bevölkerung und in grosser Nähe von
Fäulnissproducten, sowie bei Beschäftigung der Assistenten, &c.‚ mit
septischen Substanzen, kann diese Rubrik an Bedeutung gewinnen.)
IL—Infectton durch besonders günstigen Nährboden für Ooccen-Entw’icklung.
Trotz Mangel einer nach Qualität oder Quantität besonders aggressiven
Infection haftet sie wegen der günstigen Localbedingungen. Dies
wird begünstigt:
(a) durch Alles, was den Wundbezirle in seiner vitalen Energie herabsetzt .-
schlechtes ‘Nasser, rohe Wundsetzung und Quetschung, zu starke und
\ unreine Antiseptica, welche ätzend wirken und locale Gewebenecrose
bedingen.
(b) durch Allgemeinzustände, welche erfahrungsgemäss den Widerstand
der Gewebe gegen locale Infection herabsetzen: Alcoholismus (cfr.
Ulcus serpens). Diabetes, &c. (Hohes Alter allein kommt nicht in
Betracht; jeder Operateur weiss, dass gerade frühzeitige Cataract-
bildung schlechtere Prognose giebt.)
Die secundären Verluste durch Iritiden und Iridocycliten schleichenden Ver-
laufs fallen ebenfalls in die 2. Gruppe, sei es, dass der Operationsverlauf zu
ungünstigen 'Wundverhältnissen führte, sei es, dass der Allgemeinzustand sehr
bedenklicher Natur war, sei es endlich, dass besonders günstiger Nährboden zur
Fertilisirung von Ooccen gegeben wurde—trotzdem diese weder in grosser Zahl
noch von pathogener Herkunft vermuthet werden konnten. Als ein solcher be-
sonders günstiger Nährboden ist zu betrachten: reichliche Oorticalsubstanz im
Pupillargebiet und Glaskörper in der W‘unde.
Es ist wohl am Platze, die so eben gegebene Eintheilung der Ursachen primärer
und secundärer Verluste noch etwas näher zu beleuchten durch Hervorheben der
wesentlichen Aenderungen, welche dadurch ganz verbreitete Ansichten erfahren,
wie schon von de W'ecker hervorgehoben wurde.
Wie Sie wissen, dreht sich der Hauptkampf in der Lehre von der Staar-
extraction um Schnz'ttgrösse, Schntttjbrm und Schnittlage. Die Lösung gestaltet
I O OPHTHALMOLOGY.
sich äusserst einfach, wenn man die Erfahrungen der Klinik zu Hülfe zieht. Die
Schnittgrösse hat, sobald man überhaupt innerhalb der Gränzen physicalischer
Nothwendigkeit verbleibt, keine grosse Bedeutung; wir sehen einerseits die
glänzende Statistik Jacobson’s und anderseits die allseitige Bestätigung, dass
Iridectomie-Schnitte fast nie zur Eiterung führen. (Ich habe seit 1862 auf viele
Tausende von Iridectomieen keine Wundsuppuration gesehen.) Die untere Grenze
der Schnittgrösse ist gegeben durch die Gefahr der Quetschung resp. der Ver-
minderung der vitalen Energie der Wundränder; die obere durch die Maximal-
grösse der Linse selbst.
Die Schnittform darf weder die locale Disposition zu Gewebsinfection durch
Erschwerung der Passage (Quetschung, Einführung von Instrumenten, &c.)
steigern, noch auch dadurch die unbedeutendste Infection gefährlich machen, dass
die demarkirende Arbeit der Gewebezellen durch allzu grosse Entfernung vom
Ernährungsgebiet erschwert wird.
Die Sehnvlttlage endlich ist, abgesehen von den zwingenden physicalischen
Bedingungen, durch unsere ganze klinische Erfahrung über die Unterschiede
zwischen dem Verlaufe centraler und peripherer Hornhautentzündungen noth-
wendig eine periphere.
Treten so die Anschauungen über die Wichtigkeit kleinster Unterschiede in
Schnittgrösse, Schnittform und Periphericität für den Erfolg wesentlich in den
Hintergrund, vorausgesetzt, dass man sich vor Extremen hütet, welche physica-
lischen Gesetzen und klinischen Erfahrungen gleich sehr widerstreiten, so gewinnt
unsere Rubricirung der Verlustursachen noch mehr Bedeutung, wenn man sich
gegenwärtig hält: dass die grosse Mehrzahl der rapidesten Eiterungen gerade bei
hergestellter vorderer Kammer erfolgt, während der länger dauernde Abﬂuss des
Humor aqueus günstig wirkt. Die Irrigation der Wundränder durch das stetig
abﬂiessende Kammerwasser verhütet die Festsetzung einer Wundinfection. Diese
Erfahrung zusammen mit der Richtung der perlmutterfarbenen Streifen (streiﬁge
Keratitis), sowohl bei Randwunden, als bei infectiösem traumatischem Geschwür
(Ulcus serpens) lehrt deutlich die Abhängigkeit der Wundentzündung von äusserer
Infection.
Der Schilderung der primären Verluste müsste nun die Kritik der Umstände
folgen, welche besonders glänzende Erfolge bewirkt haben. Es wäre leicht zu
zeigen, wie bald die sorgfältigste Antisepsis, bald die günstigsten Aussenver-
hältnisse, dann die ausgesuchteste Delicatesse in der Ausführung der Operation
oder die Vermeidung jeder Gefährdung der Wundränder die Nachtheile des Opera-
tionsmaterials oder der Umgebung beherrscht haben. Doch vermeide ich lieber
diesen in’s persönliche Gebiet eindringenden Excurs und resumire die Thatsachen
kurz dahin:
Die unglücklichen Ausgänge der Staarextraction sind unter Voraussetzung
vernünftiger Schnittform, Schnittlage und Schnittgrösse am sichersten zu
beschränken.
1.—-Vor der Operation, durch die präventive Antisepsis des Operationsterrains
im weitesten Sinne des Worts, sowie aller mit dem Patienten in nähere Berührung
kommenden Individuen und Objecte.
2.—- Während der Operation, durch Bewahrung des Wundbezirks vor Schwächung
seiner vitalen Energie und Schutz der Gewebe gegen infectiöse Einﬂüsse.
3.—Nach der Operation, durch Desinfection des Operationsgebietes und genü-
genden Schutz vor secundären Infectionen.
Diese Ueberlegungen müssen der Technik der Antisepsis zu Grunde gelegt
OPHTHALMOLOGY. I I
werden, stets gleichzeitig berücksichtigend die Verhütung der Infection und die
Kräftigung des Widerstands der Gewebe.
1.—-Die präventive Antisepsz's hat sich zuerst auf den Patienten selbst zu
beziehen, der womöglich gebadet und in reiner Kleidung zur Operation kommen soll.
Eiternde Wunden werden aseptisch, Ozaena ebenfalls durch Nasendouche mit
desinﬁcirender Flüssigkeit wenigstens temporär unschädlich gemacht, u. s. w.
Der Allgemeinznstand bedarf bei ausgeprägtem'Alcoholismus einer Vorbereitung
durch allmählige Entwöhnung, bei Diabetes durch physiologisch richtige Nahrung.
Eminent wichtig ist der Zustand der Lidränder, der Bindehaut und vor Allem
des Tlw'änensacks. Bei Catarrhen und Blennorhöen des letztern operire ich
unbedenklich, sowie nach Spaltung des obern Thränenkanälchens der N asengang
mit Hülfe der hohlen Sonde energisch ausgespritzt und desinﬁcirt werden konnte.
Eine Inundation des Operationsgebiets mit einem Antisepticum vor und nach der
Extraction und ein antiseptischer Verband sind unumgänglich nöthig.
Von Operateur, Assistenten und Wartpersonal könnte man dieselbe Gewissen-
haftigkeit fordern, wie sie jeder Chirurg bei der Ovariotomie als selbstverständlich
verlangt. In dieser Hinsicht wird nicht selten gefehlt. Nicht allein schreitet man
sofort zur Operation nachdem man sich stundenlang in der sehr zweifelhaften
Atmosphäre des angefüllten Ambulatoriums befand, ohne eine genügende Des-
infection vorausgehen zu lassen, sondern auch, nachdem man sich im Bereiche von
Productionsﬁächen pathogener Bacterieen aufhielt (Anatomie, Sectionen, &c.).
Die zur Operation nöthigen Utensilien bedürfen besonderer Rücksicht. Ich
habe eine Reihe Stoffe in wirksamen Concentrationen (4 per Cent) darauf geprüft,
ob sie die Messer und damit die Reinheit der Wunde bei längerer Einwirkung
schädigen. Bor- und Salicylsäure sind nicht zu gebrauchen, da sie die Schneide
sofort schädigen; besser ist reine Carbolsäure, ganz unschädlich benzoesaures
Natron; Resorcin (und wohl auch Hydrochinon) geben bei langem Liegen einen
schmierigen Belag, verletzen aber die Schneide nicht.
Absoluter Alcohol ist theuer, und darf nicht an die Wunde gebracht werden.
Verwerflich sind Schwämme, wenn sie nicht aus 5 per Cent Carbolsäurelösung
entnommen, mit reinstem, abgekühltem Wasser oder in dünner Carbollösung
(1 per Cent) angewandt werden. Sie sind leicht zu ersetzen durch eine gutbereitete
5 per Cent Salicylwatte.
Zum Operationsterrain im weitesten Sinne müssen wir auch das Zimmer zählen,
in welchem operirt wird.
Gewiss ist es ein wesentlicher Unterschied, ob man in Räumen operirt, welche
äusserster Reinhaltung zugänglich sind, oder in Zimmern, welche klein, nach keiner
Richtung frei, inmitten grosser Krankheitsheerde fast nothwendig mit pathogenen
Bacterien gefüllt sein müssen. Ich selbst mache meine Operationsräume nur
durch die ergiebigste Lüftung und Reinigung aseptisch, und kann mit nicht völlig
1,6 per Cent Totalverlust während zehn Jahren zufrieden sein. Allein in grossen
Spitälern, inmitten enger schmutziger Strassen, fern von einem ausgedehnten
Luftraum würde ich eine regelmässige Desinfection der Zimmer durch andauernden
Dampfspray, &c., namentlich vor Operationszeiten für nöthig halten. In diesem
Sinne, dass die ganze Luftmenge des Operationsraums sorgfältig desinﬁcirt werde,
möchte ich von einem Luftspray sprechen.
2.——Nun wäre Alles zur Operation bereit: Zimmer, Instrumente, Operateur und
Assistent, der Patient ebenfalls, und es fragt sich bloss, ob die Operation selbst
unter Spray zu geschehen hat oder eine Inundation des Operationsgebiets
genügt.
I 2 OPHTHALMOLOGY.
Ich habe den Spray nach einigen Versuchen ganz aufgegeben, da mir die
minutiöse Genauigkeit der Operation darunter zu leiden schien, und das Bedürfniss
in meiner Statistik nicht vorlag. Die glänzenden Resultate einiger Operateure,
die stets unter Spray operiren, sind bekannt und beweisen die Ausführbarkeit.
Ich meine natürlich nicht jene illusorischen Sprühregen sehr verdünnter (1 per
Gent und darunter) Oarbolsäurelösungen, welche auf dem Operationsfelde in einer
Verdünnung ankommen, die keine Sicherheit gewähren kann.
Unter den Chirurgen macht sich gegenwärtig eine allgemeine Reaction gegen
den Spray geltend, und die glänzendsten Statistiken aseptischer Operationen ohne
Spray erregen unsere Bewunderung. Bedenken wir, dass durch zu concentrirte
oder an sich ätzende Antiseptica der Spray zu oberﬂächlicher Wundnecrose und
damit zu Eiterungen führen kann; dass durch den Spray die Luftkeime geradezu
auf die Wunde niedergerissen werden, und seine Wirkung einzig darin bestehen
kann, “ durch Aufschlagen einer geringen Menge des Antisepticums den Nährboden
(die Wunde) für die Keimung ungünstig zu gestalten.” Diesen Zweck können wir
auf viel einfachere, und weniger störende ‘Veise erreichen, indem eine Flocke
5 per Gent Salicylwatte in kalt gesättigter Salicyllösung benetzt und sachte über
Lider und geöffnetes Auge ausgedrückt wird. Die Uebergangsfalten werden so
besser gereinigt als mit dem Spray, und die Procedur ist viel weniger reizend als
die Anwendung eines Oarbolspray von genügender Concentration bei nicht narco-
tisiitem Patienten.
Man mag über die Sprayfrage noch verschiedener Ansicht sein; man kann
die Anwendung des Spray eclectisch empfehlen in Fällen wo voraussichtlich
durch Glaskörperverfall oder Belassen von Oorticalsubstanz ein besonders
günstiger Nährboden für Keimung von Bacterien bereitet wird; gewöhnlich
ist er unnöthig und durch eine leichte Inundation des Operationsgebiets zu
ersetzen.
Die delicateste Ausführung der Operation selbst ist eines der wichtigsten
Schutzmittel des Auges. Je besser die Instrumente sind, je zarter sie geführt
werden, je mehr jede Erschütterung des Bulbus vermieden wird, desto resistenter
bleibt das Gewebe des Wundbezirks, desto weniger günstig ist es für septische
Vorgänge. Ich stehe nicht an zu erklären, dass nach meiner Beobachtung bei gleich
geübten Operateuren und annähernd gleichem Material der Unterschied in der
Zartheit der Ausführung der Operation das Resultat der Statistik wesentlich
beeinﬂussen wird.
3.——-Die Operation rist beencligt, der Wundrand coaptirt, der Oonjunctivallappen,
diese wichtige Deckung der erst später sich schliessenden Hornhautwunde, aus-
gebreitet, eine nochmalige Inundation des Oonjunctivalsacks in der angegebenen
Weise ist leicht und rasch auszuführen.
Nun folgt der Verband. Haben wir jede Infection aus dem Oohjunctivalsack
und dem Thränensack unmöglich gemacht und die Operation möglichst aseptisch
ausgeführt, so müsste ein Verband mit reinster Watte genügen, sowohl die Lider
in Ruhe zu halten, als eine Luftinfection zu vermeiden. Vergessen wir nicht, dass
wir in der Mehrzahl der Fälle nach sechs Stunden die Wunde coaptirt ﬁnden, und
ausserdem durch ihre Lage nach oben fast die Bedingungen einer subcutaneu
Wunde haben. l/Virklich habe ich mich früher wegen dieser speciellen Verhältnisse
gewöhnlich dieses Verbandes und nur ausnahmsweise des von circa vier Jahren
beschriebenen nassen Salicylverbandes bedient. Anstatt letztern nur eclectisch
bei Blepharitis, Oonj. Oatarrhen, Thränensackleiden zu gebrauchen, verwende ich
ihn aber nun immer allgemeiner nach der Staarextraction, wie schon lange bei
OPHTHALMOLOGY. ‚ I 3
allen Plastiken, Enucleationen, &c. Ist er doch auch in mehreren chirurgischen
Kliniken, besonders bei Gesichtsoperationen, als vorzüglich erprobt.
Die Kritiken, welche dieser Salicylverband erfahren hat, beweisen, dass ich ihn
ungenügend beschrieb. Er besteht aus 5 per Cent Salicylwatte, welche in einzelnen
Flocken, durch Salicylwasser benetzt, aufgelegt wird, und zwar in genügender
Menge um einen Abschluss nach aussen zu sichern. Eine leichte Calicot-Binde
halt die Watte, welche circa alle 41—5 Stunden von Neuem mit Salicylwasser
benetzt wird. So erhält man einen sichern, gut anschliessenden, kühlen Verband
der von der Haut der Lider ertragen wird. Seine Entfernung und Wiederholung
ist nicht zu mühsam. Dies ist nöthig! Keine 'I‘emperaturerhöhung verrath uns
die ersten ‚Anfange eines abnormen Verlaufs; nur das geübte Auge sieht die Zeichen
einer beginnenden Wundeiterung. In jedem Falle, wo Operationsverlauf, All-
gemeinzustand, grössere Empﬁndlichkeit Verdacht erregen, soll nachgesehen
werden; denn es gelingt selbst eine ausgebrochene Wundeiterung völlig zum Still-
stand zu bringen und zu beherrschen. Um dies zu erreichen, muss man die Regeln
der Chirurgie über das “ Aseptisch-Machen eiternder Wunden, Höhlen, &c.” im
vollen Umfange befolgen.
Der Conjunctivalsack wird mit 2 per Cent Carbolsäurelösung ausgespült, die
Hornhautwunde mit einem in antiseptische Flüssigkeit getauchten Spatel eröffnet.
Mit diesem, immer von Neuem befeuchtet, wird die Vord. Kammer und das
Pupillargebiet allseitig aseptisch gemacht, und inﬁltrirte Corticalis entfernt. Diese
Procedur soll, wie bei Spaltung eines septischen Hornhautgeschwürs, von 6—12
Stunden wiederholt und jedesmal der nasse Salicylverband aufgelegt werden.
Die Beherrschung wird unterstützt durch Chinin und Wein innerlich, sowie durch
Befolgen des vortrefflichen Raths von Snellen solche Patienten an möglichst
frischer Luft spazieren zu führen.
Bei Patienten, welche schon nach achtzehn Stunden massenhafte eiterige
Conjunctivalsecretion, Chemosis, purulente Iritis mit Ausfüllung des Pupillargebiets
zeigten, wurde so die Eiterung sistirt, der Bulbus erhalten und sogar ein Seh-
vermögen von einem Drittel erreicht.
Entschieden einfacher wäre es, anstatt die Wunde aufzusprengen, sich eines
Drain-Röhrchens zu bedienen, das sehr wahrscheinlich auch präventiv angewendet
werden könnte; allein ich habe die technischen Schwierigkeiten noch nicht
überwunden.
Die Grundsätze erlauben eine Anpassung an die Verhältnisse jeden Operations-
terrains, und sind geeignet die Leistung der Staaroperation noch zu erhöhen.
Acceptiren wir die Zahlen der Statistik von H. Noyes mit der arithmetischen
Berichtigung von A. Geissler, so haben wir :
Bei der Lappenextraction . . . . Verluste 10‘4 per Cent
„ „ Linearextraction . ,, 58 Per Cent
Ich habe schon bemerkt, dass ich die Wiederbelebung der alten Lappen-
extraction nicht für berechtigt halte. Die Lebensbedingungen des Wundrandes
bei einer Proportion von Wundbasis zu Lappenhöhe wie 2 z l (anstatt mindestens
4 : 1) sind zu ungünstig, und die Gefahren secundarer Infection durch Aufsprengen
der Wunde zu gross. Es beschäftigt uns nur die Linearextraction in der Modiﬁ-
cation, welche allgemein zu Gunsten einer weniger peripheren Lage der Wunde
und damit einer grössern Lappenhöhe eingeführt wurde.
Die Resultate dieser Linearextraction werden nun—das zu behaupten erlauben
die vorhandenen Zahlen—erhöht durch eine dem Auge angepasste Antisepsis.
I 4 _ OPHTHALMOLOGY.
Es werden nicht nur die geiibtesten Operateure, nicht nur diejenigen, welche, wie
ich, in den besten Aussenverhaltnissen operiren, sehr gute Resultate erringen,
sondern die Antisepsis gewahrt auch dem weniger Geiibten bessere Erfolge, weil
die Schadigung der vitalen Energie des Wundgebiets nicht so gefahrvoll wird, eine
Schadigung, die eben nur die Delicatesse des geiibten Operateurs regelmassig zu
vermeiden Weiss.
Hochgeehrter Herr Prasident ! Hochgeehrte Herren Oollegen!
In der mir zugemessenen Zeit konnte ich die Frage der Antisepsis bei der
Staarextraction nicht ersch'o'pfencl behandeln. Es schien mir ausreichend, die
Grundsatze, welche uns leiten miissen, zu discutiren, und an der Hand meiner
Erfahrungen meine Ansicht klar zu legen.
Hoﬁen wir, dass bald grossere Zahlen den Beweis liefern werden: dass wir
wieder einen Schritt 'vo'rwdn‘ts gethan haben, zugleich zur Ehre der W'issenschaft
und zum Heile unserer Mitmenschen.
T/ze Am‘z'sepz‘z'a Met/20a’ 2'12 Cami/act Exz‘mcz‘z'om.
Prof. O. REYMoND, Turin.
The present paper is in continuation of what I said at the last International,
Ophthalmological Congress on Lister’s Antiseptic Method in Cataract Extraction.
My object then was to show :—(1) that a solution of 1'75 0/0 of absolute phenol was
well borne by the eye ; (2) that Lister’s method strictly carried out (with one
exception only that hydrophile gauze was used, which had previously been soaked for
some days in the same solution, and was kept moist during the whole treatment)
had reduced to a triﬂing number the primary corneal sloughings till then so common
in my hospital practice.
The present paper contains statistics of all my cataract extractions from
January 1, 1880, to July 1, 1881, a total of 346. During part of the present year
I have used, instead of the moist dressings above referred to, Lister’s carbolized
gauze prepared according to his instructions. These statistics seem to support
the conclusion that Lister’s method, if strictly observed, almost entirely prevents
corneal sloughing, and, that inflammation of the lacrymal sac is no longer a source
of danger, since the discharge ceases during the dressing.
As a general rule the dressing is not opened till the sixth day, when it is replaced
by boric lint. I think it necessary to continue the dressing with boric lint for some
days so as to prevent partial inﬁltrations of the wound, which may occur even after
the cessation of the carbolic dressings; but these yield to the use of chlorine water and
boric acid dressings. Several hours before operating, the beard and lower part of
the forehead are shaved, the conjunctival sac washed out with the carbolic water,
and the eye tied up with gauze and cotton-wool soaked in the same solution, to be
removed only at the moment of operating. The spray causes no inconvenience, and
is probably indispensable; it is certainly very useful, for, by making the eye anaes-
thetic, it materially aids us in dispensing with chloroform. The antiseptic method
does not quicken the healing of the wound, if we judge by the frequency, under its
use, of slow healing with perfect transparency. The method has of course no
inﬂuence on the direct consequences of an imperfect operation. The commonest
imperfections in the healing of the wound are :—(1) Greyish inﬁltration of the
edge of the ﬂap, the scar remaining afterwards whitish; the sclcral part of the
wound is rarely affected. (2) Lines of inﬁltration parallel with each other and
perpendicular to the edge of the wound. (8) After the cessation of the carbolic
OPHTHALMOLOGY. I 5
dressing, a form of keratitis, beginning as whitish points in some part of the corneal
ﬂap, sometimes rather severe, and slowly proceeding to sclerosis of the affected
parts of the cornea; this form occurs chieﬂy in old or weakly patients. The above
results are not peculiar to the antiseptic method, being well known with other
kinds of dressings. (4) In the wound, a greyish, felt-like substance forms, and
increasing downwards towards the pupil, sometimes obliterates it. The microscope
shows that it is not caused by pieces of the capsule (like those described by
Dr. Knapp). It is only seen where the antiseptic dressing is applied, or borne,
badly. The morbid changes just described are nearly always associated with slight
fever and frequent changes of general body temperature.
In 346 extractions, made with antiseptic precautions, between January 1, 1880,
and July, 1, 1881, under ordinary conditions (including 3 cases complicated by
detachment of the retina, and 6 with inﬂammation of the lacrymal sac), the operative
results were as follows :—
Ordinary cataracts . . . . . . . . . 346
Immediate success . . . . . . . 326
Successful, after secondary operation for closed pupil . 9
Pupil closed, but case suitable for secondary operation 4
Loss by sclerosing keratitis (No. 3 of the above-
described varieties) . . . . . . . 1
Loss by suppuration of cornea (5 too unruly to keep
the dressing well applied; 1 had paralysis of facial
nerve on operated side and anaesthesia of opposite
side of face) . . . . . . . . 6
Traumatic cataracts . . . . . . . . . . 9
Successful . . . . . . . . . 5
Closed pupil, result uncertain (traumatic cataract in
glaucomatous eye) . . . . . . . 1
Failure (shrinking without suppuration, 2; suppuration
under carbolic dressing, with foreign body in eye, 1). 3
Extractions in specially bad conditions (irido-choroiditis) &o. . . 4
Successful . . . 3
Failure (case of sympathetic iritis) . . 1
Extraction of false membranes (antiseptically), all successful. . . 5
Errors in healing retard recovery, without deﬁnitely compromising it. They
are always accompanied by a peculiar form of catarrh of the conjunctiva, in which
the discharge is viscous, greyish, or rather bluish, stringy, or ﬂaky, and showing many
.little white dots. There is uniform conjunctival injection, with slight inﬁltration
and thickening. The discharge is sometimes more solid, gelatinous, and adherent
to some ulcerated point of the wound, or it may penetrate into the anterior
chamber in the ﬁbrillar form already described (No. 4). It may ﬁnally even form
a greyish membrane adherent to the wound, and extending more or less over the
conjunctiva. This membrane has an amyloid reaction.

Ueéer die W z'rémzg 2101c Fremd/éo'rpewz 2972 [727267672 des Auger.
Prof. TH. LEBER, Gottingen.
Seitdem die iiberraschenden Erfolge der antiseptischen Wun dbehandlung den
Beweis gelicfert haben, dass die traumatischen Entziindungen im Allgemeinne
I 6 OPHTHALMOLOGY.
durch eine septische Infection hervorgebracht werden, ist es nothwendig geworden,
die Wirkung von fremden Körpern, welche in das Innere des Auges eingedrungen
und darin zurückgeblieben sind, mit Rücksicht auf die Frage einer genaueren
Untersuchung zu unterziehen, wie viel von den Folgezustanden, welche man nach
solchen Verletzungen auftreten sieht, der Wirkung des fremden Körpers selbst
und wie viel der häuﬁg damit verbundenen Verunreinigung mit septischen Stoffen
zuzuschreiben ist. Ich habe es mir zur Aufgabe gesetzt, diese Frage durch Ver-
suche an 'I‘hieren zu entscheiden, und bin durch zahlreiche, im Lauf der letzten
Jahre angestellte Versuche zu den folgenden Ergebnissen gelangt, welche auch mit
fremden und eigenen Beobachtungen am menschlichen Auge sehr gut überein-
stimmen. _
Die blosse Gegenwart eines reinen d. h. nicht mit entwickelungsfähigen Keimen
von Mikrobien behafteten und chemisch indifferenten Fremdkörpers im Inneren
des Auges ruft keinerlei Entzündung hervor. Man konnte dieses Ergebniss von
vornherein mit Bestimmtheit erwarten nach den Erfahrungen, welche die Chirurgie
mit Suturen aus Gold-und Silberdraht gemacht hat und nach der darauf gegrün-
deten Methode NVecker’s, der sogenannten Drainage des Auges, bei welcher feine
Golddrahte WVochen lang im Auge vertragen werden. Doch ist es immerhin von
Interesse, dass ich durch Versuche, welche sich über Jahre hinziehen, die absolute
Unschadlichkeit des Verweilens grosser Stücke von Golddraht oder anderer indiffe-
renter Substanzen in der vorderen Augenkammer oder im Glaskörper von Thieren
feststellen konnte.
Es ist ein überraschendes Bild, ein Stückchen Golddraht vollkommen frei in
der vorderen Kammer zu sehen, das auf den Boden derselben hinuntergefallen ist,
oder mit dem Augenspiegel einen im Glaskörper suspendirten Golddraht prachtvoll
metallisch glänzend, ohne jede entzündliche Veränderung zu beobachten. Auch
Glassplitter verhalten sich ganz ähnlich; so habe ich ein Kaninchen noch jetzt
am Leben, welches seit 1g Jahren einen langen, schmalen Glassplitter im voll-
kommen klaren Glaskörper erkennen lasst. Nur an den Stellen, wo der frei
bewegliche Splitter kleine Stichverletzungen der Retina gemacht hatte, waren
zarte umschriebene 'I‘rübungen im Augengrund entstanden. In der vorderen
Augenkammer verweilte ein Glassplitter über 6 Monate lang ohne jede Trübung
und wurde dann allmälig von einer sehr zarten Bindegewebsschicht eingekapselt.
Dass auch beim Menschen Glassplitter im Auge ebenso gut vertragen werden,
lehrt eine Beobachtung von Gritchett, wo ein solcher Fremdkörper 16 Jahre lang
ohne nennenswerthe Folgen in der vorderen Augenkammer verweilt hatte.
Wenn es nun auch von grossem theoretischäm Interesse ist, zu erfahren, dass
ein so zartes und empﬁndliches Organ wie das Auge in Bezug auf sein Verhalten
gegen chemisch indifferente Fremdkörper keine Ausnahme von den übrigen
Organen und Geweben des Körpers macht, so ist doch die praktische Bedeu-
tung dieser Erfahrung sehr gering, weil die grösste Mehrzahl der in das Auge
eindringenden fremden Körper nicht als vollkommen indifferent in chemischer
Hinsicht zu betrachten sind. Uebrigens sind doch einzelne hierher gehörige Falle
beobachtet; abgesehen von den schon erwähnten Glassplittern hat man beim
Menschen kleine Steinfragmente, Oilien, Dornen, &c.‚ unbestimmt lange ohne
jeden Reizzustand oder wenigstens ohne eigentliche Entzündung im Auge zurück-
bleiben sehen.
Bei weitem häuﬁger sehen wir aber beim Menschen Verletzungen durch Splitter
von Eisen, Stahl, Kupfer, Messing, kurz durch Metalle, welche oxydationsfähig
sind. Die heftige, eitrige Entzündung, welche gewöhnlich auf diese Verletzungen
OPHTHALMOLOGY. I 7
tfolgt, hat man bisher stillsehweigend der Wirknng des Fremdkérpers zngesehrieben,
Iohne zn untersnchen, ob sie nicht vielmehr dnreh eine gleiehzeitige septische
Infection entstehe. Diese Miigh'ehkeit muss um so mehr beriieksiehtigt werden,
weil Falle beobachtet sind, wo naeh solchen Verletznngen jede acute Entziindnng,
namentlich jede Eiterbildung ansgeblieben ist, wenn aneh der Fremdkdrper dnreh
andere Folgeznstande sieh nieht als indifferent ﬁir das Ange erwies.
Es ist nieht schwierig, bei Thieren ein friseh gegliihtes Stiick einer Nahnadel
oder einen spitzen Knpferdraht in die vordere Kammer oder in den Glaskérper
einznfiihren, so dass die kleine Stiehwnnde sich dahinter vollkommen schliesst nnd
der fremde Kérper nicht mehr damit in Beriihrnng ist. Anch diese Verletznng
rnft nun durehaus keine aente Entziindnng nnd keine Eiterbildnng hervor, kann
aber andere sehwere Folgen fiir das Ange, namentlich ﬁir die Retina, naeh sich
ziehen.
Bei den Verandernngen, welehe das Ange dabei erfahrt, hat man die rein
<ehemisehen Wirknngen des fremden Kérpers, welehe am todten Ange ebenfalls zn
beobaehten sind, Von den Erseheinnngen zn trennen, welche den vitalen Eigen-
sehaften dieses Organes ihre Entstehnng verdanken. Die chemischen Wirknngen
beobaehtet man am dentliehsten am Glaskiirper, in welehen ein Stiiek Stahldraht
eingefiihrt ist. In der Umgebnng des Fremdkérpers bildet sich eine rostbranne
Verdichtung des Glasknrpers, deren Farbe von feinen Kérnehen von Eisenoxyd-
hydrat heln‘iihrt. Die Kiirnchen ﬁnden sieh in znnehmender Feinheit noch ziemlieh
weit Von dem Metallstiiek entfernt. Die in den Angenﬂiissigkeiten absorbirte
Kohlensanre 16st ein Wenig von dem Metall als doppelt-kohlensanres Salz anf,
dieses verbreitet sieh dnreh Diffusion im Glaskérper, Wird aber bald in nnldsliches
Eisenoxydhydrat nmgewandelt nnd in Gestalt von feinen Kérnehen ansgeschieden,
wobei es sich anch wohl mit den vorhandenen Eiweisskéirpern verbindet. In dersel-
ben Weise entsteht aneh die eigenthiinﬂiche rostgelbe Farbe gewisser tranmatiseher
Oataraeten, Welche man schon lange als Z eiehen der Anwesenheit eines Metallstiiek-
ehens im Ange kennt.
In der vorderen Angenkammer Von Thieren bewirkt die Anwesenheit soleher
Fremdkiirper keine erhebliehen Stiirnngen. Ieh habe Stiieke V011 ITahnadeln bei
Kaninchen Monate oder Jahre 1ang in der vorderen Kammer ohne Sehaden ver-
weilen sehen. Sie incrustirten sich mit einer Oxydschieht nnd ragten zuweilen
naeh langerer Zeit wieder an der Einstichsstelle hervor, so dass ich einmal den
Fremdkérper mit der Pineette fassen nnd extrahiren konnte, n'aehdem er fast
1%; Jahre im Ange gewesen war.
In Bezng anf die Krystallinse ist aueh vom Mensehen bekannt, dass darin
verweilende Metallsplitter, abgesehen von der Oataract,1ange Zeit ohne Sehaden
fiir das Ange vertragen werden.
Dagegen stellen sich im Glaskdrper nnd in der Retina nm so schwerere Veran-
dernngen ein, Welehe man in den Versnehen mit dem Angenspiegel in ihrer ganzen
Entwickelnng verfolgen kann, weil dabei keine anssel'e Entziindungerscheinnngen
anftreten nnd die Dnrehsiehtigkeit der Medien griisstentheils erhalten bleibt.
Naehdem der im Glaskérper frei snspendirte, oder nach nnten gesenkte Fremd~
kérper sieh mit der sehon erwéihnten oxydhaltigen Verdichtnng der Glaskijrper-
snbstanz nmgeben hat, welche bei ophthalmoscopischer Untersnehnng ein hellgl'zin-
zendes Anssehen darbietet, sieht man schon naeh wenigen 'I‘agen die N etzhant
weit abgeliist, nnd zwar znnaehst in ihrem markhaltigen Theil (es handelt sich nm
Versnche an Kaninehen), dann anch in ihrem gefasslosen, nicht markhaltigen
Abschnitt; zugleich erseheint sie stellenweise eingerissen nnd zerfetzt, was aber
PART III. 0
I 8 OPHTHALMOLOGY.
durchaus nicht von der Verletzung herrührt, sondern die Folge theils einer hoch-
gradigen Erweichung und Atrophie, theils einer Zerrung durch Schrumpfung des
Glaskörpers zu sein scheint.
Die mikroscopische Untersuchung zeigt eine acute Atrophie der Netzhaut, in
deren Gewebe zahlreiche grosse oxydhaltige Körnchenzellen eingelagert sind;
letztere ﬁnden sich auch im Glaskörper in reichlicher Menge, ebenso in der Linse,
wenn diese bei Einführung des Fremdkörpers an ihrer hinteren Fläche verletzt
wurde. Dabei bietet die Netzhaut im ersten Stadium noch folgende höchst merk-
würdige Veränderungen dar : Die Stäbchen sind zum Theil bedeutend verlängert;
sie wachsen in die Zellen des Pigmentepithels hinein, so dass sie bis zur Glas-
lamelle der Aderhaut reichen. Die Zellen des Pigmentepithels sind stark ver-
grössert und zeigen von der Fläche her zahlreiche N etzhautstäbchen, kreuz und
quer durch einander gelagert, in ihr Inneres eingeschlossen. Die äussere Körner-
schicht ist stellenweise hügelig verdickt, die Zahl der Körner daselbst vermehrt,
und die Körner selbst in Gestalt und Aussehen verändert.
Ich bin der Ansicht, dass die genannten Veränderungen auf die chemische
Wirkung zurückzuführen sind, welche die geringen Mengen in den Augenﬁüssig-
keiten gelöster Metallsalze auf die Netzhaut ausüben, und welche in den Gewebs-
elementen derselben gewisse vitale Vorgänge anregen. Einige Beobachtungen
sprechen dafür, dass beim Menschen ähnliche Folgen auftreten, wenn der fremde
Körper, was gewöhnlich nicht geschieht, zufällig rein, aseptisch ins Auge einge-
drungen ist. So habe ich ein Auge enucleirt, wo sieben Jahre zuvor ein Eisenstück-
chen durch Hornhaut und Linse in die Ciliargegend eingedrungen war. Die anfäng-
liche Reizung war bald vorübergegangen und zwei Jahre nachher fand sich trau-
matische Oataract bei vollkommen gutem Lichtschein. Erst im weiteren Verlauf
trat zuweilen Röthung des Auges, später auch vorübergehende Schmerzen ein, und
nach einigen Jahren war der Lichtschein völlig erloschen. Es kam zu Blutungen
in die vordere Kammer, diffuser Trübung und eigenthümlicher brauner Färbung der
Hornhaut, das Auge wurde sieben Jahre nach der Verletzung entfernt. Die Linse
war vollständig resorbirt, der Eisensplitter sass in der Zonula ciliaris; die Netz-
haut war vollständig abgelöst und atrophirt, der Glaskörper verschwunden und
die beiden Blätter der abgelösten Netzhaut dicht an einander gelegt; keine Spur
von plastischer Exsudation. Die braune Farbe der Hornhaut war durch dichte
Vascularisation und haematogene Pigmentirung verursacht.
WVerden bei den Versuchen an Thieren die nöthigen antiseptischen Vorsichts-
massregeln versäumt, so tritt auch hier, wie bei zufälligen Verletzungen beim
Menschen die Regel ist, leicht eitrige Entzündung im Innern des Auges auf.
Wenn ich in solchen Fällen den Glaskörper frisch untersuchte, so fand ich ihn von
zahllosen, feinsten, beweglichen Mikrobien durchsetzt; auch beim Menschen habe
ich mich von dem Vorkommen niederer Organismen bei traumatischer Glaskörper-
eiterung überzeugt.
Ueber die ‘Wirkung dieser niederen Organismen und von entzündungserregenden
Schädlichkeiten überhaupt habe ich noch verschiedene Versuchsreihen angestellt,
von deren Ergebnissen ich hier der Kürze wegen nur das Folgende mittheilen
kann.
Da die blosse Gegenwart indifferenter Fremdkörper im Auge nicht entzün-
dungserregend wirkt, so können wir uns die Wirkung der Mikrobien nur als eine
chemische denken. Wir müssen annehmen, dass diese Organismen durch ihren
Lebensprocess gewisse Substanzen erzeugen, welche als Entzündungsreiz auf die
davon betroffenen Theile wirken. Die Wirkung dieser Substanzen muss eine
OPHTHALMOLOGY. I 9
ähnliche sein, wie die von gewissen chemischen Stoffen, von welchen bekannt ist,
dass sie heftig entzündungserregend wirken, wie, z. B. Crotonöl, Oanthariden,
Arsenik, Quecksilberoxyd &c. Die Wirkung dieser zuletzt genannten Stoffe ist ganz
unabhängig von der Betheiligung niederer Organismen, und ich habe mich durch
besondere Versuche überzeugt, dass die Folgen dieselben sind, wenn diese Stoffe
vollkommen rein, aseptisch in’s Innere des Auges eingeführt werden.
Die eben aufgestellte Vermuthung über die Wirkung der Mikrobien wird nun
dadurch bestätigt, dass es mir gelungen ist, eitrige Entzündungen in Auge zu
erzeugen durch Injection von Extracten fauliger Flüssigkeiten, deren Mikroorga-
nismen durch Kochen oder auf anderem Wege zerstört waren. Wie zu erwarten,
geht diese Entzündung nach einiger Zeit wieder zurück, da die lebendigen
allmahlig durch Resorption aus dem Auge verschwinden, und da die lebendigen
Keime fehlen, durch welche sonst diese Stoffe fortwährend anf’s Neue gebildet
werden.
Die angeführten Versuchsergebnisse werfen auch ein neues Licht auf die schäd-
liche Wirkung gewisser im Inneren des thierischen Körpers, speciell des Auges,
lebender Parasiten, insbesondere des Oysticercus cellulosae. Es ist bekannt, und
ich kann dies bestätigen, dass diese’ Entozoen eitrige Entzündung in ihrer
Umgebung hervorrufen können. Da die blosse mechanische Wirkung keine
Entzündung hervorruft und da hier an eine Betheiligung von Mikrobien nicht zu
denken ist, so muss wohl die Annahme gemacht werden, dass diese Parasiten
eine entzündungserregende Substanz absondern, wofür ja auch die Analogie mit
dem Verhalten mancher anderer parasitär lebender Organismen angeführt werden
kann.
U e561’ die Häuﬁgkeit‘ gewisser Krank/teilen des A ages zu
verschiedenen Z ez'z‘en des ja/zres.
Dr. E. EMMERT, Bern.
Unter dem 15. April dieses Jahres sandte ich an eine grössere Zalh von
Augenärzten ein Oircular, welches seitdem auch im Oentmlblatt für praktische
Augenheilkunde von Herrn Hirschberg durch dessen Güte abgedruckt worden ist.
In diesem Oirculare nahm ich mir die Freiheit darum zu bitten, zum Zwecke einer
Statistik über die Häuﬁgkeit der Ophthalmia neonatorum, der Oonjuntivitis
diphtheretica und der Hopopyon-Keratitis in den verschiedenen Monaten des
Jahres, die Zahl der in den Jahren 1870-1880 beobachteten Falle dieser Krankheiten
in die verschiedenen Abtheilungen desselben einzutragen, wobei es selbstver-
stündlich Jedem überlassen werden musste so viele Jahrgänge zu dieser Statistik
zu verwenden als er konnte und wollte.
Da der Versuch zu einer solchen Statistik durchaus nicht nur localer N atul‘
sein, sondern im Gegentheil möglichst weitverbreiteten Verhältnissen Rechnung
tragen sollte, waren Circulare in alle Länder versandt worden. Die erhaltenen
Resultate sind dadurch internationale geworden. Es dürfte daher gerade hier, wo
so verschiedene Nationen vertreten sind, der Ort sein, über das Gewonnene
Bericht zu erstatten.
Von 24 Oollegen erhielt ich auf den gewünschten Termin, d. h. auf 1. Juli d. J.
die Oirculare ausgefüllt wieder zurück. Ich spreche denjenigen unter ihnen
2 O OPHTHALMOLOGY.
welche dieses gethan und hier anwesend sind, meinen verbindlichsten Dank aus.
Diese 24 Collegen sind: In Deutschland: Alexander (Aachen), Bäuerlein (Würz-
burg), Betke (Bremen), Haase (Hamburg),Hänel (Dresden)‚Höring (Ludwigsburg),
Landsberg (Görlitz), Michel (Wiirzburg), Mooren (Düsseldorf), Rheindorf (Neuss),
Sattler (Erlangen), Seggel (München), Stoer (Regensburg); in Oesterreich: Brettauer
(Triest), Schenkl (Prag), Stellwag (Wien); in der Schweiz: Pﬂüger (Bern); in
Frankreich: Gayet (Lyon); in Italien: Ponti (Parma); in Spaniern: Oarreras-
Aragö (Barcelona); in Russland; von Becker (Helsingfors), Hirschmann (Charkow),
Schmid (Odessa).
Sie vertreten, mich selbst inbegriﬁ'en, zusammen 182 Jahre. Acht von fünf und
zwanzig gaben auch die Zahl der Kranken an, auf welche sich ihre Mittheilungen
bezogen; so Bäuerlein 30,000, Betke 19,017, Hänel 5668, Landsberg 3607, Mooren
56,969, Stcllwag 17,000, Ponti 4520, v. Becker 6286, zusammen 143,067, so
dass wohl angenommen werden darf, dass die Gesammtzahl aller Kranken auf
welche meine Statistik sich stützen soll, sich auf wenigstens 300,000 belaufen
wird. Unter diesen wurden 2932 Fälle von Ophthalmia neonatorum, 189 von
Oonjunctivitis diphtheritica und 3431 von Hypopyon-Keratitis beobachtet.
Indem man die Gesammtresultate in Curven überträgt, lässt sich Folgendes
aus ihnen herauslesen:
1.—Die Ophthalmia neonatorum hat ihr Maximum, 270 Fälle, im Monat Mai,
ihr Minimum, 190 Fälle, im Monat December. In die Monate Januar 258, Juli
263, und September 261 Fälle fallen geringere Ansteigungen und vom Monat
September hinweg ﬁndet eine fortwährende Abnahme statt.
2.-——Die Oonj unctivitis diphtheritica erreicht ihr Maximum, 24 Fälle, im Januar,
Minimum, 12 Fälle, im August und hat im Juni 29 und November 19 Fälle.
Man kann schlechtweg sagen, dass von Monat August an die Zahl der Fälle
von Conj. diphth. unter Schwankungen stets wächst bis Januar, und von da hinweg,
unter einmaliger bedeutender Ansteigung im Juni, abnimmt bis August.
3.-—Die Hypopyon-Keratitis zeigt ihr Maximum, von 411 Fällen im August,
ihr Minimum, 191 Fälle, im December, verhält sich daher, was gewiss sehr
interessant, gerade umgekehrt zur Conj. diphtheritica.
Dass die Zahl der Fälle von Hypopyon-Keratitis in den Monaten Juni, Juli
und August am grössten, ist, für Deutschland wenigstens, schon lange bekannt,
nicht so für andere Länder, ebensowenig, dass vom Monat December hinweg
die Zahl der Fälle beharrlich zunimmt, von Monat August an dagegen mit
kurzer Wiederansteigung im October ebenso beharrlich abnimmt.
Es schien mir nun nicht uninteressant zu untersuchen, wie sich die Häuﬁgkeit
genannter drei Krankheiten in den einzelnen Ländern verhalte, aus welchen
ausgefüllte Circulare mir zugegangen waren ; konnte man doch von vornherein an
die Möglichkeit denken, dass die verschiedenen Länder, kältere und wärmere,
nördlichere und südlichere, Verschiedenheiten in der Häuﬁgkeit dieser Krankheiten
in den einzelnen Monaten darbieten würden. Und in der That lassen die betref-
fenden Länder, Deutschland, Schweiz, Russland, Frankreich, Italien, Spanien,
besonders bei Umwandlung der für sie gefundenen Zahlen in Curven, einige
Eigenthümlichkeiten in unzweideutiger Weise hervortreten. Bei der folgenden
Zusammenstellung sei mir gestattet Triest zu Italien zu zählen.
OPHTHALMOLOGY. 2 I
Der K 'ärze und Uebersichtl'ickkeit wegen bezeichne ich die 0plzth. necmat. mit I. , die Oonj. dip/1th‘
mit II.‚ und die Hypop-Kemtit. mit III. Es fanden sich die

MAXIMA man
I II III
in Russland im Januar 60, Mai 58, Sept. 59 Fälle Feb. 4, März 4 Fälle. Juni 38 Fälle
„ Spanien „ März 22, November 22 Fälle April 3, Juli 3 ,, Feb. 38 ,,
,, Italien „ Mai 14,4, Fälle Juni 1 ,, Juni 14.4 ,,
,, Frankreich Zu wenige Fälle. Juli 16 „
,, Schweiz „ Juni 24‚ Fälle Juni 6 „ Juli 14 „
,, Deutschland „ Juli 158 Fälle Jan. 16 „ Aug. 184 „
(Deutsch. Reich und Oesterrcich)
MIN IMA DEB
I n In:
in Russland im Juli 22 Fälle Juli 0 Fälle. Nov. 18 Fälle
„ Spanien „ Juni 11 „ Feb.‚ März, Mai, Juni, Oct, 0 Fälle Sept. 20 ,,
,, Italien „ Dec. 61 ,, Alle ubrigen Monate 0 Fälle Dec. 61 ,,
,, Frankreich Zu wenige Falle. Oct. 2 ,,
,, Schweiz im Dec. 11 Fälle April 1 Fall März 4 ,,
,, Deutschland im Dec. 93 ,, August 5 Fälle Nov. 76 ,,
(Deutsch. Reich und Oesterreich)
Sehr bemerkenswerth ist bei diesen Resultaten die Vertheilung der Maxima
und Minima auf verschiedene Monate in den einzelnen Ländern. Ich mache
besonders darauf aufmerksam, wie die Ophth. neonat, welche durch eine ziemliche
Zahl von Fallen vertreten ist, ihre Maxima in jedem Lande in einem andern
Monat zeigt, und wie in eben der Reihenfolge, in welcher wir die verschiedenen
Staaten geordnet haben, das Maximum in immer spätere Monate fällt,
dass ferner Russland und Deutschland sich sowohl hinsichtlich der Maxima,
als der Minima umgekehrt verhalten, Russland nämlich sein Maximum von
Fallen im Januar, Deutschland im Juli, Russland dagegen sein Minimum
im Juli, Deutschland im December hat; dass ebenfalls bezüglich der Ophth.
neonat. Russland und Spanien weit mehr Aehnlichkeit miteinander, als mit
den anderen Staaten haben, so, dass bei ersteren beiden die Maxima ganz in
den Anfang des Jahres, die Minima in die Mitte, bei letzteren die Maxima in die
Mitte des Jahres, die Minima an’s Ende fallen; dass dagegen für die Conj. diphth.
Russland und Deutschland sich sehr nahe stehen, und bei der Hypopyon-Keratitis
Spanien sein Maximum bereits im Februar erreicht, Russland und Italien es im
Juni, Frankreich und die Schweiz es im Juli haben, während es für Deutschland
erst in den August fällt.
Schmid in Odessa verdanke ich Mittheilungen über die, von ihm während der
Jahre 1877-80 beobachtete, Conjunctivitis epidemica. Diese Erkrankung scheint
einen fast zweijährigen Typus zu haben.
Im Jahre 1877 war sie am stärksten, im April 13, August 13, und September 13
Falle und war ganz verschwunden während der Monate November und December.
Im Jahre 1878 traten nur wenige sporadische Fälle auf im April, Juli und
September.
Im Jahre 1879 erlangte die Epidemie im Monat September mit ‘241 und beson-
ders October mit 32 Fällen, eine nie erreichte Höhe, nachdem in den Monaten März,
Mai, Juni, Juli, August gar keine Falle vorgekommen waren.
Im Jahre 1880 trat eine kleine Epidemie im Februar (7 F alle) auf, während in
den übrigen Monaten keine oder nur sehr wenige Fälle zu verzeichnen waren.
Interessant sind auch die Mittheilungen, welche wir von Horner durch die
Diss. des verstorbenen Medicin studirenden Kendall aus Boston über die Häuﬁg-
keit des Herpes corneae catarrhalis in den verschiedenen Monaten der Jahre 1874-‘
2 2 OPHTHALMOLOGY.
1879 und der Neuralgia supraorbitalis intermittens aus den Jahren 1860-1879
(lurch die Diss. des Herrn v. Mandaoh erhalten.
Aus diesen geht hervor, (lass der Herpes corn. catarrh. unter bedeutenden
Schwankungen von Januar bis November an Hauﬁgkeit abnimmt, sein absolutes
Maximum, 14 Falle, im Juli, (laneben aber im Januar und October noehmals fast
gleiche Belle, 13 Falle, erreicht.
Ungleioh eharakteristischer dureh die Zeit ilires Auftretens ist die Neuralgia
supraorbitalis intermittens, welolle ein absolutes Maximum, 15 Falle, im Februar
zeigt uncl allm'zihlig bis October auf ihr fiinfzehn Mal geringeres Minimum, 1 Fall,
herabsinkt.
Diese Zusammenstellung von seohs verschiedenen Erkrankungen cles Auges,
(1e1' Ophthalmia neonatorum, der Conjunctivitis diphtheritioa, der Hypopyon—
Keratitis, der Oonjunotivit. epidemica, des Herpes oorneze oatarrhalis und der
Neuralgia supraorbitalis intermittens, beweist auf das Unzweifelhafteste, dass
jede dlESGl‘ Krankheitsformen ihre so zu sagen oharacteristisehen Zeiten ihres
liauptsaehliohen Auftretens und Verschwindens hat. Die Einen fallen mehr in die
Sommer—clie anderen mehr in die Wintermonate; es spielen somit hoohst wahr-
scheinlioh meteorologisohe Einﬂiisse eine grosse Rolle. Als ebenso sichei' festge—
stellt darf betraohtet Werden, dass, gerade in Folge des so wahrscheinliehen Ein-
ﬁusses meteorologischer Verh'elltnisse, die versohiedenen Lander, je nach ihrer
geographisclien Lage uncl geologisohen Bodenbeschaffenheit, Versohiedenheiten in.
Bezug auf hauﬁgeres oder selteneres Auftreten einer Krankheit iiberhaupt, sowie
auoh ihrer Zu-und Alonahme zu verschiedenen ‘Jahreszeiten darbieten. Ferner ist
anzunehmen und fiir einzelne bewiesen (vgl. die Oonj. epidemioa), dass, wahr-
soheinlioh aus den namliohen Griinden an ein 11nd demselbem Orte in versohiedenen
Jahren, ein und dieselbe Krankheit bedeutenclen Schwankungen in Bezug auf
Hauﬁgkeit ihres Auftretens, Intensitat und Zahl der Falle unterworfen ist. End—
lieh ist es auch in hohem Grade wahrsoheinlich, dass nooh viele Augenlzrankheiten
als von meteorologisohen Einﬂiissen abhangig zu ﬁnden sein Wei-den.
Sind Wir sohon jetzt so weit zu wissen, dass manohe Erkrankungen cles Auges
mit der Bildung Von Mikroorganismen einhergehen, welohe Wahrscheinlich nicht
Folge, sondern Ursaohe der betreﬁ’enden Krankheiten sind, so ist es einer vielleioht
nioht zu fernen Zeit vorloehalten clie speoiﬁschen Krankheitserreger kennen zu
lernen, Welche entwecler besondere Arten oder nur versohiedene Entwioklungsstufen
ein 11nd desselben Organismus sincl.
Diese noch mangelnde Kenntniss cler speoiﬁsohen Krankh eitserreger kann uns
jeclooh nioht abhalten darnaeh zu forschen, welohe Krankheiten meteorologischen
Einﬁiissen, und welohen meteorologisohen Einﬂiissen sie unterworfen sind. Es
Wird im Gegentheil das eventuelle Auﬂinden von Mikroorganismen und ihrer
speciﬁsohen Eigenthiimliohkeiten erleiehtern, wenn bereits bekannt ist, unter was
fiir ausseren Einﬂiissen sie am hauﬁgsten vorkommen. Wiirclen alle Diejenigen,
welche Jahresberiohte sohreiben, statt die ziemlioh werthlose Gesammtzahl jeder
einzelnen Krankheit zu bereohnen, sioh die kleine Miihe nehmen anzugeben, wie
viele Falle jeder Krankheitsform in jeclem Monat (les Jahres beobaohtet wurden,
so konnte daduroh schon eine reoht niitzliohe Statistik erzielt werclen, welohe
nooh bBLlGlltGHd an Werth gewinnen wiirde, wenn Operationen und Operations-
erfolge, ganz besonclers die Staaroperation, in derselben WVeise beriioksiohtigt
Wiirden.
Allerdings muss zugestanden werclen, dass damit noch nicht Alles erreioht und
namentlich cler Meteorologie nioht hinreichend Rechnung getragen Ware ; sollte
OPHTHALMOLOGY. 2 3
dieses der Fall sein, so miissten die bestehenden Barometerstande, 'I'emperatur»
verhaltnisse, Windrichtungen u. A. mit angemerkt werden.
Die Gelegenheit Solches zu thun ist allerdings gegenwartig beinahe iiberall
gegeben durch die fiir viele Orte tiiglich ausgegebenen Witterungsbiilletins, aber es
wilrde hier wohl gehen wie iiberall—wo zu viel gefordert wird, wird nichts erreicht.
Es geniigt vorlauﬁg eine Statistik in der angegebenen W'eise zu erhalten.
Hieriiber Kenntniss zu erlangen, das ist die Hoffnung, welche ich zum Besten
unserer in allem Uebrigen so weit vorgeschrittenen Wissenschaft an die gemachten
Mittheilungen kniipfe.
DISCUSSION.
Dr. DE WECKE a, Paris, who opened the discussion at the request of the President,
said :—I cordially agree with the weighty and very practical advice given us by
Prof. Horner, and I especially admire his caution as to the results which statistics
afford us. I am a thorough partisan of the antiseptic method, but would call
attention to the contradictory evidence which my own statistics aﬁord, if I
conﬁne myself to the results for the last 18 months. During last year I extracted
250 cataracts under strict antiseptic precautions, and I had only one single suppura—
tion. I thought that I had succeeded in abolishing this, the opprobrium of all
operations for cataract. But, unhappily, in the ﬁrst six months of the present
year, under precisely the same conditions and methods of antisepsis, I have
had 7 suppurations in 150 cases, a result almost as bad as any before the days
of antiseptics. If the numbers were differently manipulated a still more
striking difference might be shown; thus, I performed 200 extractions between
the month of August, 1880, and the end of the year, without a single suppura-
tion, an apparent triumph for the antiseptic method; and yet, as above
stated, '7 suppurations have occurred in 150 cases during the present year. Again,
if all the cases in the 18 months be added together (1880, 250; ﬁrst 6 months
of 1881, 150), we have a total of 4:00 with 8 suppurations, giving 2 °/O, or exactly the
same proportion as with the old dressings. An exact estimation of the antiseptic
method can be arrived at only by examining the returns for a number of years.
Whenever the antiseptic method fails to give us the results of which it is clearly
capable, we must, however disagreeable it mayr be, blame the imperfect execution
of the method. I think that the sincere thanks of the meeting will be due to Prof.
Horner, if by his valuable indications he has simpliﬁed the details of the method.
Dr. IVARLOMONT, Brussels, thought that the antiseptic method ought not to be
applied as a rule in cataract operations. It seemed to him not yet proved that
the prevention of suppuration by this method is not. more than counterbalanced
by the irritating properties of the agents used. ' It would perhaps be different if a
non-irritating antiseptic substance were discovered... At present he thought that
the method should be reserved for cases where unfavourable conditions are present
either in the patient or in his surroundings.
Dr. G'AYET (Lyons) :--I am a strong adherent, of the antiseptic method, but
althoughI have employed it with care in operations on the eye, I have had no
marked success. I attribute this want of success to the agent (carbolic acid) used,
which, even in weak solution, is hurtful to the conjunctiva. Some other substances
must be found in its stead, for the method mustcon. no account be given up.
24 OPHTHALMOLOGY.
Dr. KNAPP, New York :—Watching very closely, for years, the reactive pro-
oesses after extraction, I have been able to account for almost all of them by a phy-
sical injury done to the parts involved. In the vast majority of instances I have
seen the inﬂammation arise from the corners of the wound, which suffer most from
the pressure of the knife and of the emerging lens, and where particles of cataract are
stripped off and remain in the Wound, often together with shreds of capsule and
iris. Scarcely twice in a hundred cases have I been able to trace the origin of the
inﬂammation to the centre of the wound. These observations have prevented me
from being a ready convert to the current views of sepsis in eye surgery. If the
centre of the ﬂap, the broad avenue for admission of disease germs, is so rarely the
seat of origin of inﬂammation, whereas the narrow corners almost always prove
the starting point of all kinds of reactive processes, infection from outside cannot
be considered as their cause. Moreover, if you attack with a needle, never so
scrupulously cleaned, an old tough pupillary pseudo-membrane, you may see
plastic and suppurative irido-cyclitis ensue: nobody will make infection respon-
sible for this result. I have performed the most extensive operations in the orbit,
removal of exostosis where several of the neighbouring cavities were implicated,
extirpation of sarcomata and other growths where the malar antrum, the nasal pas-
sages, the frontal sinuses, the ethmoid and even the sphenoid cells were opened and
portions of the roof of the orbit removed, so that the pulsations of the brain were
visible across the room, and yet the recovery was free from fever, from swelling of
the neighbouring parts, and from suppuration. I will not cite any further examples,
but I desire to say that for 2% years I did not see one case of suppuration in
any operations performed on the eye at the Institution which is under my charge,
and over 1,000 operations, of course not all extractions, were made during the period,
all without antisepsis ; then, after that, three cases of suppuration occurred. I am
far from denying the existence of infection, the cases of dacryo-cysto-blennorrhoea,
for instance, prove it clearly enough ; I only cannot share the views of those who
believe that infection is the most powerful, if not the only, cause of severe inﬂam-
mation and suppuration in the eye, and who consequently ascribe to antiseptic
treatment such a paramount importance in ophthalmic surgery.
Dr. GALEzowsKI, Paris :—I agree completely with the statements of Prof.
Horner, even though the results are sometimes but little encouraging. Referring
to Dr. de Wecker’s unsatisfactory results in the present year, I state as my own
experience, that, whilst during the two years before this, I had only 2 0/o or 3 0/o of
suppurations, this year I have had 5 suppurations in 98 cases. The existence of an
epidemic influence is all the more reason for the strictest employment of antisepsis.
The following fact appears to me signiﬁcant :—-I used the same knife for two extrac-
tions of cataract and one iridectomy in irido-choroiditis, and all three cases went
into suppuration. I think, then, that the same knife ought not to be used for-
more than one patient. I think that statistics have practical value only when care-
is taken to separate soft cataracts, congenital cataracts, &c., from senile cataracts.
Dr. HEBMANN PAGENSTECIIER, Wiesbaden:--I am a strong advocate of anti-
septic dressings in eye surgery. Two points, mentioned by Prof. Horner as
especially predisposing to septic suppuration, are particularly interesting;
viz., the inﬂuence of fragments of lens matter left behind and loss of vitreous.
Having had a very long experience of extraction of the lens in its capsule for-
many years without, and for many years with, antiseptic precautions, I have not
OPHTHALMOLOGY. 2 5
the least hesitation in asserting that the losses have decreased very much under-
the latter method. Loss of vitreous, as is well known, is not uncommon in
extraction with the capsule, yet I can aﬁirm that, since the adoption of full anti-
septic precautions, I have never seen so-called primary suppuration of the vitreous,
lie, yellowness- of its anterior part leading to panophthalmitis, a result often seen
before antisepsis was known. Iritis has also diminished in the same marked
manner. I use carbolic spray of 2 to 2-é-o o, and proportionately strong carbolic
water for the dressings. It is essential that the purest and best acid be used.
Cleanliness is an essential point. I have seen no cases in which I felt sure that
the antiseptics had any bad inﬂuence on the healing of the wound, on the iris, or
on the vitreous ; but sometimes conjunctival irritation occurs. I feel no doubt that
the adoption of this method will spread in ophthalmic surgery, though, doubtless,
some time will elapse before the antiseptic best suited for the eye is found and
generally recognized. ’
Prof. Don, Lyons :—The employment of antisepsis is absolutely necessary
in certain special cases—e.g., when there is dacryocystitis or during epidemics of
erysipelas, &c. It is important not to keep the dressing on if it prevents inspec-
tion of the wound. On the other hand, it is advisable to examine the parts often.
Antiseptic precautions are always favourable, but the spray may be omitted.
Prof. HORNER, Zurich, in reply, said :——I am quite in accord that statistics have
signiﬁcance only when they extend over a considerable time. Mine reach from
1867-1881, and they show, through antisepsis, a gradual improvement of results
from 6'6 0/0 to 1'1 0/0. Therefore I put it prominently forward, once again, that I
operate under much more favourable circumstances of late than previously. Like
Dr. Gayet, I attach great importance to the quality of the antiseptics employed;
I do not ﬁnd the use of good carbolic acid to be attended with danger. Though
a skilled operator may obtain brilliant results in a good atmosphere without the use
of antiseptics, yet he, and still less anyone of slight experience, can never attain
them in large hospitals and under unfavourable circumstances.
-_-—__
Des Mouvemeuts des Yew: 62 Z’e’tazf normal at a‘; Z’éz’azf
pat/tologz'gue.
Dr. LANDOLT, Paris.
Les mouvements des yeux sont des rotations autour d’un centre immobile.
Tout mouvement de l’oeil et tout défaut de mouvement, ou de direction de l’oeil
(stmb'is'me) trouve donc son expression dans un arc, dont le centre est le centre de
rotation, et comme tel, il est mesuré par des degrés.
L’auteur mesure les excursions des yeux a 1’aide de son périmetre, au centre
duquel i1 place l’oeil observe (autant que possible, son centre de rotation). La téte
est immobilisée par une plaque en bois tendre, dans laquelle 1e patient mord. On
lui fait suivre un objet de ﬁxation, visible seulement par la fosse centrale, qu’on
promene le long de 1’arc dans tous les méridiens. Les points limites sont marques
sur un schema, comme 1e champ visuel. Par leur réunion on circonscrit le champ
des excursions des yeux, pour lequel l’auteur a adopté le nom de “ champ de ﬁxa-
tion” (Field of ﬁmation, Flimiofeld) au lieu de “ champs de regard ” (Blz'ckfeld).
Le champ d'e ﬁxation s’étend, a l’état normal, au minimum a. 45° dans toutes les
26 OPHTHALMOLOGY.
directions, à l’exception de la direction inféro-interne, où il est restreint par le nez,
et quelquefois en haut, où le bord orbitaire supérieur le limite. La grandeur et
la forme de l’oeil relativement à celles de l’orbite peuvent avoir une inﬂuence sur
l’étendue et la forme du champ de ﬁxation. C’est ainsi que Donders et Schuur-
mann ont trouvé le champ des myopes moins étendu que celui des emmétropes et
surtout des hypermétropes. L’auteur a constaté des différences analogues, et en
démontre des spécimens. Mais les exceptions sont très fréquentes, attendu que la
grandeur du globe n’est pas le seul facteur capable de modiﬁer les mouvements d’un
œil. L’insertion et la force des muscles doivent y contribuer beaucoup.
(Les courves pointillées de la ﬁgure 2 donnent des spécimens des champs de
ﬁxation moyens pour les deux yeux.)
Le champ de ﬁxation binoculaire est mesuré à. grande distance à l’aide de la
division en tangentes d’une paroi et du plancher de la salle de consultations. Les
yeux peuvent être considérés comme réunis au centre de cette sphère. L’un est
couvert d’un verre coloré bombé. Une ﬂamme est promenée le long des diﬁ'érents
méridiens de la division. La personne examinée indique jusqu’a quelle limite elle
voit les deux ﬂammes réunies (Fig. 1).

Ce champ de ﬁxation binoculaire n’est pas schématique.
Il appartient a un cas donné.
L’auteur a étudié ‘a l’aide de ces méthodes toutes les formes de troubles de la
motilité des yeux :
1. Inszqiﬁscmces des droits internes etzeætea'nea—Les champs de ﬁxation monocu-
laires peuvent être normaux, et le champ binoculaire seul est restreint. Dans
l’insufﬁsance interne, il se manifeste à droite et à, gauche une diplopie croisée, dans
l’insufﬁsance externe, une diplopie homonyme. Dans d’autres cas, les champs
monoculaires sont limités en dedans dans l’insufﬁsance des internes (Fig-.2), en dehors
dans l’insuﬁisance des externes. (Démonstrations de plusieurs champs de ﬁxation
monoculaires et binoculaires cl’insufﬁsance des droits internes et externes avec myopie
et hypéropie.)
2. Strabisme non-pamlytvlqua—Û’est a tort qu’on veut expliquer tout Strabisme
par un vice de réfraction. Il faut chercher la cause ailleurs, et commencer par
OPHTHALMOLOGY. 27
l’étude de la motilité des yeux. Ici encore, on rencontre des différences considé-
rables entre des cas en apparence semblables.
Il existe des strabismes alternants, convergents et divergents, avec des champs
de ﬁxation monoculaires normaux. (Démonstration)
Fig. 2.
, \/
I60‘\\|8_0—-/I60
Œil gauche. Œil droit.

. . . Champ de ﬁxation normal minimum.
—-————- Champ de ﬁxation d’une insuﬁisance des mm. droits internes.
Dans d’autres cas de Strabisme alternant, les champs des deux yeux sont restreints
dans le sens du Strabisme. (Démonstration)
Dans le Strabisme monoculaire non paralytique, les deux champs de ﬁxation
peuvent être intactes. D’autres fois on rencontre dans ce cas un rétrécissement

Champs de ﬁxation de deux yeux gauches.
. . . Parésie du droit externe avec Strabisme convergent de 15°.
--——— Strabisme convergent non paralytique de 50° datant de la première jeunesse.
Œil amblyope. Individu âgé de 50 ans.
2 8 OPHTHALMOLOGY.
opposé à la direction du Strabisme dans les deux champs monoculaires. (Démons-
tration.)
Il arrive même que le champ de l’œil dévié est limité dans toutes les directions.
, (D émonstration.)
Lorsque le Strabisme a existé longtemps sur le même œil, on trouve générale-
ment un rétrécissement très-marqué du champ de ﬁxation. Ce rétrécissement
diﬁère de celui produit par une paralysie musculaire. (Fig. 3.)
3. Strabisme paralyttque—Ici le champ de ﬁxation est des plus caractéristiques.
Un regard jeté sur le schema sufﬁt pour savoir quel est le muscle atteint, et jusqu’à.
quel degré il est parésié. Dans le cas de paralyse totale, la comparaison du champ
de ﬁxation altéré avec le champ normal, donne les indications les plus précieuses
sur le mode d’action du ou des muscles paralysés. (Démonstrations de champs de
ﬁxation de parésies et paralysies‘ du droit externe (Fic. 3); de l’oblique supérieur,
du moteur oculaire commun.)
L’auteur insiste sur la fréquence avec laquelle on rencontre simultanément la
paralysie du moteur oculaire commun avec la parésie de l'abducens et de l’oblique
supérieur.
De plus, il observe, que très-souvent la paralysie totale de la troisième paire
d’un œil est accompagnée de troubles dans le domaine du même nerf de l’autre côté.
(Fig. 44.)
Fig. 4.

Œil gauche. Œil droit.
. . . Champ de ﬁxation moyen.
Champs de ﬁxation des deux yeux de la même personne atteinte de parésie de
presque tous les muscles des yeux.
The’mpeutiqaa—Dans le traitement des troubles de motilité des yeux, il faut.
toujours avoir en vue le but suprême, qui n’est pas seulement de redresser un oeil
au point de vue cosmétique, mais de rétablir la vision binoculaire.
Ce but serait atteint inﬁniment plus souvent, si, basé sur un examen appro-
fondi du cas (mensuration de l’angle du strabisme et des champs de ﬁxation, 820.),
on faisait coopérer tous les moyens de traitement dont nous disposons. _
Pour favoriser la vision binoculaire, on égalisera la réfraction ‘des deux‘ yeux
pour la distance à. laquelle elle sera le plus facilement obtenue. Un augmentera la.
OPHTHALMOLOGY. 29
vue de l’œil dévié par la, correction de “son astigmatisme et par des exercices avec
exclusion de l’autre œil.
S'il le faut, on corrigera le Strabisme par l’opération: ténotomie ou ténotomie
avec avancement, ou ténotomie sur les deux yeux, &c. Seulement il faut se rendre
compte de l’effet que ces opérations peuvent donner.
L’auteur a constaté que, dans les meilleures conditions, une ténotomie‘ ne donne
pas plus de 15° de correction. Il a étudié l’eﬁ’et des opérations des muscles de
l’œil à. l’aide du champ de ﬁxation et il fait voir des spécimens des plus curieux, de
champs de ﬁxation avant et après ténotomie, avant et après avancement musculaire.
Après 1’opération on aura recours aux exercices gymnastiques. Ils peuvent être
inﬁniment variés.
Lorsqu’il n’y a pas de diplopie, on la provoquera à l’aide des méthodes con-
nues; puis on se servira des exercices stéréoscopiques dans le genre de ceux que
M. J aval a indiqués.
L’autenr se sert d’un stéréoscope ordinaire, dont le couvercle peut être muni
de verres de nos boîtes d’essai. Il n’emploit généralement pas de prismes, mais il
munit ch’aque œil du verre nécessaire pour voir a la distance des objets.
Ces derniers consistent en deux lignes verticales, dont l’une coupe la moitié infé-
rieure, l’autre, la moitié supérieure du champ présenté à chaque œil. Par leur
réunion stéréoscopique elles ne forment qu’une seule ligne. Ce résultat est obtenu
par l’écartement ou le rapprochement dans le stéréoscope des cartons qui portent
les lignes. Le stéréoscope ainsi employé vient puissamment en aide à l’opération
dont il peut augmenter ou diminuer l’eﬁ‘et.
Enﬁn l’anteur cite des cas de rétablissement de la vision binoculaire, par la-
combinaison de l’opération avec la correction de l’amétropie, les exercices visuels et
stéréoscopiques, où on ne l’aurait jamais obtenu avec un des procédés seulement, à
cause de l’ancienneté et du haut degré du Strabisme, et de la différence considérable
de réfraction et d’acuité visuelle qui existe entre les deux yeux.
TZmz‘omz'eparz‘ieZZe des Muscles de Z’Œz'lpom’ comôaz‘z‘m
Z’fmuﬁmme musculaire.
Dr. CH. ABADIE, Paris.
L’insuﬁîsancedes droits internes est fréquente chez les myopes; elle est ordinaire-
ment associée é, la progression de la myopie et précède 1’apparition de lésions
profondes de l’œil, choroïdite atrophique diﬁuse, choriorétinite de la région de la
macula, décollement de la rétine. Cette insuﬁisance oue probablement un certain
rôle dans le développement des altérations qui frappent le segment postérieur de
l’oeil, aussi, il y a un intérêt majeur à la combattre aussitôt que possible.
Lorsque l’insuﬂisance des droits internes commence à. se manifester et a se tra-
duire simplement par les symptômes de l’asthénopie musculaire, on n’a d’autres
ressources que de donner des verres prismatiques à. base intense. Ce moyen est
d'ordinaire insuﬁisant; si l’on opère la ténotomie complète des droits externes, même
en suturant énergiquement la conjonctive, on risque de dépasser la mesure et
d’avoir un Strabisme convergent. C’est dans ces cas que la ténotomie partielle m’a
rendu de grands services. '
Chez les emmétropes et même les hypermétropes, on peut rencontrer de l’insuf—
ﬁsance des droits internes assez accusée pour provoquer de l’asthénopie musculaire
30 OPHTHALMOLOGY.
(j’en ai observé plusieurs exemples) ;‘ dans ces cas-là. encore la ténotomie partielle
des droits externes est indiquée et donne de bons résultats.
Le manuel opératoire est le même que pour la ténotomie complète sauf qu’on
respecte quelques ﬁbres tendineuses médianes. On peut, si on le désire, affaiblir
considérablement le muscle en ébarbant avec les oiseaux les parties supérieures et
inférieures qui ont été détachées. Dans les cas de myopie progressive avec ten-
dance au strabisme divergent, si le lendemain de l’opération on reconnaît que la
correction est insufﬁsante, il est facile de la compléter en achevant de sectionner
les ﬁbres qu’on avait ménag ées.
Un Op/zz‘almome‘h/e.
Présenté par MM. JAVAL et SCHIôTz, Paris.
Qui leur sert à. mesurer l’astigmatisme cornéen avec une précision et une
rapidité extrêmes. Partant de l’ophtalmomètre de Helmholtz, les auteurs ont
voulu :
, l.—Supprimer l’erreur de collimation, ce qui est obtenu en ramplaçant les
plaques héliométriques par un cristal bi-réfrigent;
2.-—Supprimer tous les calculs et permettre de lire immédiatement en dioptries
la réfraction de chaque méridien;
3. Diminuer le nombre des lectures pour chaque position, en augmentant assez
la précision de l’instrument pour qu’on ait toute sécurité en se bornant à une seule
lecture;
Lit—Quand on recherche seulement l’astigmatisme, permettre de trouver immé-
diatement les méridiens de courbure maxima et minima, ce qui réduit dans une
mesure énorme le travail à faire dans ce cas particulier, qui est le cas ordinaire;
5.-Rendre inutile l’emploi d’une chambre spéciale, en disposant les choses de
manière à pouvoir travailler en plein jour;
6.———Diminuer suﬁisamment les dimensions de l’instrument pour qu’il soit facile
de le poser, tout prêt à. fonctionner, sur une table quelconque;
7.-Réduire d’au moins moitié son prix, condition tout-a-fait nécessaire pour
vulgariser l’emploi de cet indispensable instrument.
Au cours de leurs recherches, MM. J aval et Schiôtz ont trouvé que dans un
grand nombre de cas, l’astigmatisme cornéen diffère peu de l’astigmatisme total;
ils ont démontré l’existence d’un astigmatisme latent, devenant peu à peu manifeste
avec les années.
Pour plus de details, voir Annales d’OcuÎ/ist'igue, numéro de juillet-août [1881,
et suivants.

Dans la séance du 8 aout, M. J aval a donné des explications complémentaires
plus spécialement destinées aux confrères qui avaient fait acquisition de l’instru-
ment. Ces détails sur l’emploi du nouvel ophthalmomètre sont répétés dans la
brochure qui est adressée à toute personne qui en fait la demande à M. Laurent,
opticien, 21, rue de l’Odéon (Paris).
OPHTHALMOLOGY. 3 r
Sympathetic Opel/admins, Me Mode of 22s Transmission, and
22% N aim/e.
Prof. H. SNELLEN, Utrecht.
Sympathetic ophthalmitis belongs to the most serious diseases; the physio-
logical explanation of its nature has been an open problem ever since it was ﬁrst
observed.
Our knowledge of this disease is of recent date. We ﬁnd it mentioned in 1830,
by Mackenzie, in the ﬁrst edition of his “ Practical Treatise on the Diseases of the
Eye,” p. 4180. He says :——“ We sometimes meet with severe sympathetic inﬂam-
mation in the eye which has not received the injury.” In the second edition of the
same book, 1844, Mackenzie relates a couple of cases, which he describes with an
accuracy and completeness, to which, from a clinical point of view, the knowledge
of our present day has but little to add. Later literature yields an abundance of
clinical observations proving that this disease is relatively not uncommon. Dr.
Joseph Schneiderfx‘ in gathering together all published observations, compiled, up to
1880, 758 cases, of which 69 were caused by operative treatment.
With regard to the physiological interpretation of the nature of sympathetic
ophthalmia, Mackenzie suggested that the transmission of inﬂammation from the
one eye to the other is to be sought either by reﬂective nervous action through the
ciliary nerves, or, propagated per continuitatcm through the optic nerves along the
chiasma.
The hypothesis of transmission by reﬂective nervous action has been till lately
the most generally adopted. The phenomena here observed were even utilized as
a proof of the direct trophic action of the nervous system on the nutrition of the
tissues. Sympathetic ophthalmia on this hypothesis was regarded as an analogue
of the neuro—paralytic sloughing of the cornea after division of the trigeminus, and
also as analogous to the keratitis, consecutive to herpes zoster of the frontal nerve.
Both of these analogical types have lost their value as proofs of the trophic inﬂuence
of nervous action. I succeeded, 24 years agoﬁ in proving that ophthalmitis after
division of the trigeminus is not a neuro-paralytic phenomenon, but the result of
injury of the anaesthetic eye. After cutting the trigeminus of a rabbit and closing
the eye and fastening the sensitive ear before the anaesthetic face, I prevented
traumatic inﬂuence, and hereby annihilated neuro-paralytic inﬂammation. In the
same Way herpetic keratitis has ceased to stand as a proof of nervous nutritive
action; the pathologico-anatomical researches by Wyss,I in Zurich, having
shown convincingly that herpes zoster consists in continuous inﬂammation of the
nervous ﬁbres, propagating itself to the ﬁnal ramiﬁcations of nervous tissue in
the epidermis of the skin and the epithelium of the cornea.
After withdrawing these interpretations of analogical processes, to attribute
sympathetic cyclitis to reﬂective nervous action makes of it an isolated fact,
and as such it is apparently not beyond distrust. The origin of nervous
irritation was sought in incarceration of ciliary ﬁbres in the cicatrix of the sclerotic ;
but in many cases such compression is not to be seen. That sometimes symmetrical
parts of both eyes are affected has been accepted as another proof of nervous action,

* Inaug. Dissert., Wurtzburg. Hirsclzberg’s Centralbl. 1880. P. 136.
t H. Suellen, “De invloed der zenuwen op. de ontsteking.” Utrecht. 1857.
i Wyss, Beitrage zur Keuntniss des Herpes zoster: Wayner’s Archie, xii. p. 261.
3 2 OPHTHALMOLOGY.
but this also is not without many exceptions, and may be assigned to accidental
occurrence. Reﬂective and irradiant nervous action can undoubtedly produce
sympathetic irritation of other parts, and sympathetic neurosis of the eye may be
ascribed to nervous irritation.it Neurosis is not sympathetic inﬂammation: both
may coincide, but the one need not be the sequel of the other. Sympathetic neu-
rosis, manifesting itself by watering of the eye, photophobia, irritation, and even
temporary anopsia,'ﬁnally disappears after extirpation of the injured eye,* and
may be attributed to reﬂected ciliary action. It seems probable that, for sympa—
thetic inﬂammation, a diﬁerent path of transmission is to be sought.
Sympathetic inﬂammation never occurs before a characteristic process has
developed itself in the eye ﬁrst injured. It never appears earlier than two or
three weeks after the injury; and mostly later, sometimes only after years. The
sight of the eye ﬁrst injured is always considerably lessened. We constantly
observe iritis, cyclitis, choroiditis, with obscuration of the pupil and of the vitreous
humour-l- In the beginning the tension is lessened, but it constantly increases
before the second eye is affected. The increase of tension proceeds from the
posterior part of the eye. The iris is drawn forwards, and on anatomical investigation
of the extirpated eye, we ﬁnd the iris impregnated and covered by solid exudation.
The vitreous humour, and with it, partly or totally, the retina, is often drawn
forward into a funnel shapefi the apex of the funnel, remaining attached to the
optic nerve, seems to pull forward its tissue. WVe may conclude that the lymphatics
through the iris and the anterior parts of the eye are closed, whilst those of the
posterior part of the eye are becoming dilated. The pathological changes in the
uveal tissue are characteristic. In all cases of extirpation of the globe, where sym-
pathetic inﬂammation has already arisen, and in many cases where apparently it
was imminent, we ﬁnd the uveal tissue thickened, impregnated and covered with
lymphoid cells and granular masses. These lymphoid cells and granules are spread
through all the tissues of the posterior part of the globe.
The anatomical changes that we observe may be grouped into two series :—(1),
The dilatation of the posterior lymphatic spaces; and (2), an infective plastic inﬂam-
mation of the uveal tissue. I suggest that both factors must coincide to produce
the secondary affection of the other eye. This may explain the great differences
of time occupied in the extension of the process in different cases. The lymphatic
vessels are the most probable paths along which the affection can be transmitted
from the ﬁrst eye to the other. The perichoroidal spaces are constantly partly
dilated.§ The tissues around the optic disc are found impregnated with lymphoid
cells. Professor MacGillavry,“ of Leyden, was the ﬁrst to show, as has been lately
repeatedly stated, that the same lymphoid cells are to be found in the subdural
lymph space of the optic nerve. Max Knies‘ﬂ found lymphoid cells inﬁltrated in
the arachnoid layer over the whole length of both optic nerves in a case of serous
iritis, not however of traumatic origin. In a case of real sympathetic ophthalmitis,

'* F. O’. Donders, Klin. Jlfonatsbh, i. p. 448. Th. Leber, Arch. f. 0phth., xxvi. 2, p. 249.
+ A. von Graefe, Klin. MonatsbL, i. p. 447. ‘
i Th. 'I‘rcitel, Arch. Ophth, xxvi. 3, p. 83.
§ B. Steinheim, Knapp’s Arch. Ophth, ix. 1). 51.
I] “ Oompte rendu, 6me Session du Oongres internat., Amsterdam, 1879,” ii. p. 284.
‘TI Max Knies, “Bericht Ophth. Ges.” Heidelberg: 1879. P. 52. Idem, Knapp’s
Arch. Qphth, ix. p. l.
OPHTHALMOLOGY. 3 3
where extirpation was succeeded by fatal meningitis, Pagenstecherii found in the
sympathising eye, as well as in the injured one, inﬁltration of the optic disc and
surrounding tissue, and of the uvea and vitreous humour with lymphoid cells.
The repeated observations of meningitis after extirpation of eyes with purulent
inﬂammation makes it probable that propagation along the optic nerve into the
intracranial cavity may take place. I have observed a case of acute meningitis
with acute otitis arising and proceeding simultaneously with, sympathetic ophthal-
mitis after injury of one eye—Mr. N., aged 27 years, came to me the 17th
of October, 1876, with purulent inﬁltration of cornea and lens; he had wounded
the eye three weeks before, while opening a champagne bottle. On the
8th of November I incised the cornea and let out the lens, as the eye had
got hard and painful. We had decided not to extirpate on account of the
purulent state of the eye; moreover, we were inﬂuenced by the fact that the injury
had not affected the ciliary body. A few days afterwards the second eye was
injected, and showed decided sympathetic cyclitis. The patient lost his hearing,
complained of severe headaches, and grew delirious. On the 23rd of November I
enucleated the injured eye. The cerebral functions were slowly restored, but the
patient remained totally deaf and totally blind. The remaining eye was painful for
some time and became shrunk and atrophic. In this condition the patient con-
tinues now, being otherwise in good health. The extirpated eye was given to
Professor MacG‘rillavry, of Leyden, who was occupied with his researches on sympa-
thetic ophthalmia, the results of which he gave at the last International Congress
at Amsterdam. The retina and the vitreous humour were drawn forward in a
funnel-shape; the nvea was considerably thickened and inﬁltrated with lymphoid
cells. Lymphoid cells were abundant in the tissue surrounding the optic disc and
in the subdural space of the optic nerve.
Pagenstecher‘l' has published a case of injury where the optic nerve had been
torn off, and still sympathetic affection followed. He concludes therefrom against
the transmission of the inﬂammation along the optic nerve. But it seems to me
that the suggestion is admissible that the lymphatic communications may be restored
through the connective tissues after division of the nerve. The same question
arises in those cases where sympathetic inﬂammation follows optic neurotomyl
the Operation recommended to replace excision, but of which lately so many dis-
couraging instances have been recorded.
All nerves seem to be surrounded by lymphatic sheaths, and in cases of
inﬂammation one may well expect to find on the ciliary nerves a corresponding
impregnation. N ettleship§ conﬁrmed this lately in his communication to the
Clinical Society of London. “In the sections of ciliary nerves a considerable
space was often present between the nerve and its ﬁbrous sheath. . . . . In many
parts there was a considerable collection or inﬁltration of cells in the tissue external
to the nerves.” He reminds us at the same time that Hermann Schmidtll (of Mar-

* Hermann Pafgenstecher, Klin. rI'ZOnatsbL, xi., p. 123.
't H. Pagenstecher, Knapp’s Arch. f. Ophth. viii, p. 65.
I “Klinische Beobachtungen iiber die sympathische Ophthalmic. Ans der Graefe’-
schen Augen-Anstalt zu Halle.” Von Dr. Bunge. Dessau, 1880. T11. Leber, Arch. f.
Oyahtla, xxvii. T, p. 331.
§ E. Nettleship, Three cases of Symp. Ophtlr: Transact. of the Olin. Soc. of London,
vol. xiii. 1880.
|| Klin. ilfonatsbL, xii. p. 182. 1874.
PART In‘. 1)
34 OPHTHALMOLOGY.
burg) had stated, in 1874, that of several parts of ciliary nerves which he ex-
amined, the nervous ﬁbres were not apparently altered, but when compared with‘
normal ciliary nerves, they seemed to contain a greater quantity of cells, between
the ﬁbres.
If it is admitted that transmission of the inﬂammatory process may occur to the
brain and to the other eye through the lymphatic spaces, the question arises what
may be regarded as the substantial constituent of the transmitted principle?
Leber* suggested last year that meningitis, such as is sometimes observed
after the extirpation of suppurating or inﬂamed eyes, might be caused by parasitic
infection. “ Als Ursache solcher Vorfalle muss wohl eine Infection der Orbitalwunde
angenommen werden, welche in loco nur zu einer unbedeutenden, der Beobachtung
sich entziehenden infccz‘aosen Entziinclang con propagatorischen Character fiihrt, die
oermuthlich (larch Vcneabahncn in die Schadelhohle weiterkrieoht. . . .Wo ein
Zusammenhang existiren kann, der durch inncrhalb der Vane/n, fortgepﬂanzte
unmerkliche W'ucherungen parasitarer Organismen bedingt ist.” It. Berlini“ was
the ﬁrst to argue the hypothesis that the inﬂammation which leads to sympa-
thetic affection may also be of parasitic nature; and, following the representations
of Leber,jj he-sought the route of the propagation of the infection through the
bloodvessels. Presently Leber§ embraced the suggestion of Berlin, so far as regards
the parasitic character of sympathetic inﬂammation, but he pleads for the lymphatic
system as the route of transmission :—“ Es steht deshalb fiir niich fest wenn die
sympathische Entziindung eine infectuose ist, so kann die Fortleitung mm‘ durch
den Sehnerven erfolgen.”
In many wounded eyes, which had led to sympathetic affection, there have been
observed, besides copious lymphoid cells, granular masses, which might be taken for
accumulations of parasitic microphytes. Commonly the necropsy of such eyes is
not undertaken without hardening the tissues in chromic acid. Will these granular
masses show motion, if examined fresh, immediately after extirpation of the eye P
Leberll is inclined to state this in the afﬁrmative, from an experience of this year.
In a wounded eye, which had produced sympathetic Ophthalmitis, he saw in the
optic nerve, as well as in different parts of the globe, the motion of molecules of
different sizes z—“Ihre Grosse ist verschieden und geht bis an die Grenze der Sicht-
barkeit; auch die Form ist ungleich; die Gebilde sind theils isolirt, theils zu zwei
Oder mehrere an einander hangend; iiberall erhalt man aber, durch lebhafte,
drehende, kreisende Bewegungen und Formveranderungen. den Eindruck des
Lebendigen.” I repeatedly have had the chance of observing the same phenomenon,
and may mention the following observation‘ﬂ :—G. Iirons, a girl of fourteen years,
had wounded the right eye by a weaver’s shuttle, twenty-one days previously;
large black cicatrix in the ciliary region; total loss of vision; eye painful to the
touch; other eye normal. I extirpated the globe and removed a sufficient piece
of the optic nerve. Immediately afterwards I dissected the eye, cutting through
the cicatrix, and by the side of the optic nerve, but leaving this untouched. Care
was taken to use none but well-cleaned instruments and only newly boiled salt

* Leber, Arch. f. Ophth, xxvi. 3, p. 210.
+ R. Berlin, Volkmann’s Sammlang Klin. Vortréigc, N o. 185. 1880.
I Th. Leber, Zoc. cit.
§ Leber, Arch. Ophth, Xxvii. l, p. 331. II Ibid. p. 341.
‘H These observations are being piu'sued, and will shortly be published.
OPHTHALMOLOGY. ' 3 5
solution. The ﬁrst microscopicalspecimen was taken by scraping the edge of the
cut through the cicatrix; the sight of all the moving molecules was striking. All
the ﬁeld of vision was a living mass. Soon we recognized that most of these were
pigment molecules of the prolapsed uveal tissue. In the mean time several some-
what larger bodies showed by their ampler movements all the characteristics of
microcoeci. The same was found all over the choroid. The sheath of the nerve,
carefully split, showed moving bodies—~apparently microcoeci.
What connection the microcoeci may have with septic processes—whether they
are to be regarded as cause or consequence—is a question that here may be left
for the present. However, we may expect that an increase of our knowledge of
septic microphytes may lead to the recognition of the paths that inﬂammation will
follow. Next to the vascular changes and to the inﬁltrations of lymphoid cells we,
at all events, shall have to watch the increase and accumulation of microphytic
organisms. The process of traumatic ehoroiditis shows all the marks of a
slow septic inﬂammation; a vascular tissue—made to be well sheltered by a solid,
impermeable sclerotic—becomes lacerated, and exposed to the air, and is brought
into contact with the decomposable mucus of the conjunctiva. If ever there be an
opportunity for septic infection of a wound, here we ﬁnd all the conditions for it;
and it cannot surprise us if septic infection becomes transmitted through the
connective lymphatic system.
The results of my considerations may be brieﬂy summarized as follows :—
1.—The hypothesis that sympathetic ophthalmia is explained by reﬂex action
through the ciliary nerves is devoid of all convincing proofs.
2.—-Sympathetic ophthalmitis may be looked upon as proceeding from a septic
choroiditis of deﬁnite type, not improbably resulting from an abnormal continuity
between the external tissues and the uvea.
3.—The morbid changes of the vessels, the increase of lymphoid cells, and
perhaps also, the accumulation of microphytal organisms, are the guiding signs
that may indicate the direction in which the morbid process is propagated.
‘la—The path of the transmission is most probably along the lymphatic spaces
of the optic nerve.
_—
012 Z/ze Paz‘fzoiogy 0f Sympathetic Op/zf/zalmz'iz's.
Dr. W. A. BRAILEY, London.
‘ Can the uveitis which forms so prominent a feature of sympathetic disease be distin'
guished anatomically from inﬂammations of the uveal tract produced in other ways?
Clinically two forms of sympathetic inﬂammation are recognizable in the iris : either
there is an iritis, with increased depth of aqueous chamber, and dots on the posterior
surface of the cornea, or the iris is thick and velvety, with large tortuous blood-vessels
and diminished secretion.
The ﬁrst condition prevails at the onset of the disease. The iritis appears to be
hypersecretive, the synechiae are neither ﬁrm nor extensive; indeed, they may be
altogether absent. The general characters, both clinical and pathological, are like
those sometimes found in secondary syphilis, being there known as iritis serosa with
keratitis punctata, or as aquo-capsulitis. In this communication the general title of
uveitis serosa will be applied to this condition, however produced.
The second may, on account of its severity and intractability, well be called a
n 2
36 OPHTHALMOLOGY.
malignant inﬂammation, and it will be herein designated by the familiar title, uveitis
maligna. This form of inﬂammation has certain deﬁnite anatomical characters by
which it can be distinguished from the uveitis of syphilis, myopia, 810. An inﬂam-
mation with similar characters may be the result of a wound. Indeed, the eye which
is exciting the sympathetic inﬂammation is always the subject of a uveitis maligna. It
does not follow, however, that this condition necessarily produces sympathetic inﬂam-
mation in the fellow-eye. For this purpose it must be of considerable extent and
severity. Serous and malignant uveitis are closely related, anatomically as Well as
clinically. Indeed, it would appear that all traumatic non-suppurative inﬂammations
belong to one type or the other. A traumatic uveitis maligna is, as above said, exactly
like sympathetic uveitis maligna. But traumatic uveitis serosa, though in other
respects somewhat like the uveitis serosa of sympathetic or syphilitic disease, is not,
according to my observation, accompanied by dotted deposits on the cornea. I am
informed, however, that these have been observed at Moorﬁelds Hospital, in certain very
rare cases of traumatic iritis.
In uveitis maligna, pathologically examined, the thickened iris is closely inﬁltrated
by round lymphoid bodies, capable of being stained deeply by colouring reagents.
They make their appearance in clusters, the middle strata being those earliest affected.
The clusters increase and coalesce, so that the entire iris is a mass of lymphoid cells.
Many of its blood—vessels, especially those near its anterior surface, have very thick
and pellucid walls, while their lumen is obliterated by proliferated endothelial cells.
A thick stratum of lymphoid cells next makes its appearance on the posterior surface ‘
of the iris, behind its pigmented epithelial layer, the pigment of which is scattered and
somewhat diminished, so that an irregular zig-zag line is all that represents it. The
lymphoid cells are very little prone to changes, whether of degeneration or organization.
Those behind the iris become earliest converted into ﬁbrous tissue. There is no change
in the cells of the lens capsule, or of Descemet’s membrane. The ligamentum pectina-
tum, and canal of Schlemm, are very little affected.
In the ciliary body the changes are very similar. Clusters of lymphoid cells
make their appearance in the midst of the connective tissue on the inner surface of
the ciliary muscle, between the latter and the basement membrane of the pigment
epithelium. They increase and coalesce till they occupy the entire thickness of this
connective tissue layer. Then, similar cells are seen on the internal aspect of the base-
ment membrane, between it and the elongated elements of the pars ciliaris retinas.
The pigment epithelium found normally in this situation disappears as a continuous layer,
and its scattered granules form merely an irregular zig-zag line in the midst of the
lymphoid cells, as in the iris. The elements of the pars ciliaris retinae, though they may
be widely separated from the basement membrane, are comparatively but little
affected till a very late stage, when they may be destroyed by pressure. The ﬁbres
of the ciliary muscle are also comparatively little involved.
In the choroid, the clusters of lymphoid cells appear ﬁrst in the middle layers, the
outermost and the chorio-capillaris being, in the earlier stages, perfectly free. The
clusters enlarge, encroaching upon the adjacent healthy tissue, and coalescing, ﬁnally
occupy entirely the much thickened choroid. They do not make their appearance in
any special relation to the blood-vessels. They are separated from the arteries by
the lymphatic sheath-spaces, though their cells touch the veins more closely. Each
cell is about (in. in diameter, and has a small clear nucleus. Hitherto I have not been
able to detect giant cells among them. '
The blood-vessels are gradually invaded and destroyed by the increasing number of
cells. There is no proliferation of the pigment epithelium internal to the choroid, and
no exudation on either of its surfaces.
There is inﬂammation in and around the walls of the retinal blood-vessels, especially
upon the papilla. Some optic neuritis is present, and also inflammation, which may
be considerable or extremely slight, in the intervaginal space of the optic nerve.
OPHTHALMOLOGY. 3 7
In severe cases there are cells on the exterior of the sclera, in the ciliary nerves,
and also around them and the long ciliary arteries. The vitreous cells are increased
in number, especially in the neighbourhood of the ciliary body and optic disc. In the
latter position many are caudate.
In the later stages of the disease the globe shrinks; the ﬁrm ﬁbrous tissue deve-
loped in the exudation behind the iris and on the ciliary body, contracting, draws
away the latter from the sclerotic, and a sparsely-nucleated, tough, not dense ﬁbrous
tissue occupies the gap. Similar ﬁbrous tissue is also developed in the choroid, espe-
cially in its outer layers. The vitreous lamina bounding the choroid internally becomes
ewrinkled, and its pigment epithelium disappears. The tough and much-thickened
choroidnow appears to the naked eye greyish, translucent and avascular.
Uveitis serosa has been made the subject of many inquiries, none better than the
recent one of Knies on “Iritis Serosa.” Brieﬂy speaking, it consists in an uniform,
not dense, inﬁltration of the thickened iris, choroid, and connective tissue layer of
the ciliary body, or parts of them, with lymphoid cells, which can be stained only feebly
with reagents. A few similar cells are scattered on the anterior surface of the iris, on
Descemet’s membrane—where they form little rounded masses—and among the ﬁbres of
the zonula. There is also considerable inﬂammation—more than in uveitis maligna—in
and around the walls of the arteries of retina and papilla, extending for some distance
along the course of the central vessels of the optic nerve. There is swelling of the papilla,
with some inflammation of the optic nerve trunk. -
The characters of serous and malignant uveitis, whether of sympathetic origin or
not, pass into each other ; for in the four cases of well-marked clinical non-sympathetic
uveitis serosa which I have had the opportunity of examining, I have found in the
uveal tract some of the characteristic cell clusters of uveitis maligna. These are most
common in the peripheral parts of the iris, and next in the connective tissue layer of
the ciliary body. Here also small globular aggregations of unpigmented cells, in or
upon the pigment epithelial layer, are not uncommon, by means of which small tracts
of the overlying ciliary retina may be raised in an arch-like manner. And I have
seen an area of choroiditis serosa, and a typical patch of choroiditis maligna, existing
side by side in one of these eyes, the subject of a well-marked clinical iritis serosa
with keratitis punctata, the cause of which, however, remained obscure.
The uveitis serosa in which sympathetic disease usually begins may remain as
suOh throughout the whole course of the disease, or it may take on the characters, both
clinical and anatomical, of uveitis maligna.
In this last case, the deposits on the cornea get less, so that they are often un—
recognizable by the naked eye, while the posterior synechiae become very extensive
and very ﬁrm. The change is usually accelerated by operative interference with the
uveal tract.
The clinical characters of uveitis maligna will therefore he usually apparent where
the sympathetic disease is of long standing. But I suspect that there always remains
in the sympathizing eye some histological evidence that the disease began as uveitis
serosa, however well expressed are the clinical characters of uveitis maligna at the time
of excision. At least, in the ﬁve cases where I have had the opportunity of making
such examinations, there were distinct, though slight evidences of dotted deposits on
the cornea, though the clinical characters were those of severe uveitis maligna. And I
should expect to ﬁnd similar indications, even where the disease was observed to have
had these characters from its very onset. From the above-described conditions, I
gather that the two forms of inﬂammation in sympathetic disease are essentiallythe
same, uveitis serosa being the milder, and uveitis maligna the more severe type. The
ﬁrst appears to be hypersecretive, and the’ lymphoid cells set free cause pathological
changes on Descemet’s membrane, in the ligamentum pectinatum, and round the canal
of Schlemm. The second is attended with extensive exudations on iris and ciliary
body, while the ﬂuid secretion tends to diminish.
3 8 OPHTHALMOLOGY.
The uveitis maligna of the ﬁrst affected, or causing eye, is usually due to a perfora-
ting wound; in rare cases it is caused by a traumatic dislocation of the lens under the
unruptured conjunctiva; in very rare cases it arises spontaneously in eyes shrinking
in consequence of other long-standing inﬂammations. I have never seen it arise thus
in an eye previously healthy.
Both forms of sympathetic uveitis differ from those inﬂammations in which clusters
of lymphoid cells make their ﬁrst appearance close to the vitreous lamina of the choroid,
or close to the pigment epithelial layer of the iris, leading in each case to proliferation
of the pigment epithelium. In this way little heaps of pigment, colloid masses, or
inﬂammatory exudations, are produced on the internal surface of the choroidal
vitreous lamina, or tough pigmented membranes on the ciliary body, or point-, or
ring-like posterior synechiae. The uveitis of syphilis is of this nature, and also the
cyclitis sometimes following perforated corneal ulcers. The anatomical characters of
purulent uveitis and of the uveitis of primary glaucoma are also different. But a still
more striking clinical difference is that none of these forms are ever concerned in
sympathetic inﬂammations. My inquiries have not been directed to the presence
and inﬂuence of micro-organisms.
Generally speaking, we may say that eyes containing hone, though usually exciting
sympathetic irritation very strongly, very rarely give rise to sympathetic inﬂammation
of the uveal tract. This may mean only that by the time bone is developed, the stage
of active inﬂammation is passed. But I think that it implies more; for inﬂamma-
tions which produce exudations on the internal surface of the choroid—the most common
position in which bone is found—are not those which excite sympathetic uveitis. Still,
bone is occasionally found within the choroid, and I cannot say positively that it may
not be developed in this position as a sequel of choroiditis maligna. Hitherto, it has
been diﬂicult in England to study anatomically the results of uveitis maligna, for in
former years the practice was to excise the ﬁrst affected eye directly on the outbreak
of the sympathetic disease.
Is sympathetic inﬂammation due to direct physical transmission, or to reﬂex nerve
action P The similarity of the conditions in the two eyes, and the period required for trans-
mission, point to the former conclusion. But nerve irritation has some inﬂuence on the
disease, though probably only an indirect one; for statistics, taken from the museum re-
cords of Moorﬁelds Hospital, comprising ﬁfty-nine cases, show that a wound occurring in
the summer months is more liable than one in winter to be followed by sympathetic disease
(twenty-nine wounds in the six summer months being thus followed, as against ﬁfteen in
the other six) ; and also, that sympathetic inﬂammation is more likely to break out in
summer irrespective of the time when the ﬁrst eye was injured. (There were thirty-
nine outbreaks in summer as against thirteen in winter. In the remaining cases it was
impossible to ﬁx the date with any precision. The total number of excisions was
approximately equal in the two seasons of the year.) And it happens quite commonly that
sympathetic disease appears very shortly after exposure of the second eye to light; for
example, soon after a patient has quitted the hospital. Probably the irritation of light
stimulates into activity a slight inﬂammation of the serous type, a condition which
might otherwise have escaped notice, or have been passed over as sympathetic irritation.
Though uveitis maligna is accompanied by some optic neuritis, yet it is worthy of
note that the nerve is more inﬂamed in many diseases which are not known to affect the
fellow—eye sympathetically—0.9., glaucoma and uveitis serosa.
The physical condition of the ciliary nerves and blood-vessels will not afford the
necessary explanation, nor will that of the sclerotic or episcleral tissue. It is not im—
probable that the inﬂammation may travel along the loose tissue between dural and pial
optic nerve-sheaths ; but it is to be remembered that the inﬂammation of this is usually
extremely slight, compared with that of the uveal tract itself, and that sympathetic
inﬂammation may occur without any implication of the choroid in the neighbourhood
of the papilla of either eye.


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OPHTHALMOLOGY. I 39
Occasional cases point towards the existence of sympathetic inﬂammatory affections
of cornea and optic nerve, independent of any sympathetic uveitis; but at present the
evidence does not appear conclusive. .
The well-known sympathetic irritation which causes pain, photophobia, sluggish
iris, feeble accommodation, injection of conjunctiva, and, indeed, all the morbid con—
ditions consequent on impaired nutrition, inclusive probably of corneal ulcer, and, after
long duration, even of cataract, is entirely different from true sympathetic inﬂammation,
Shrunken eyes, and especially those containing bone, are its most prominent causes,
though such are rarely productive of sympathetic uveitis. Though mostly relieved by
excision of the ﬁrst-affected eye, sympathetic irritation may be kept up by an irritable
condition of the socket. It usually bears a direct relation to the amount of pain in the
ﬁrst eye, and is doubtless due to a reﬂex irritation of the ciliary nerves.
If I might venture to draw from pathology an inference as to treatment, it would
be that, as long as sympathetic irritation is absent, enucleation of the ﬁrst-affected eye is
only justiﬁable where it is absolutely sightless, or where it is painful.
The case is different where sympathetic irritation is superadded to a sympathetic
uveitis; for, in my opinion, the former, though incapable of producing, yet can aggra-
vate the latter. Here, as in the cases where sympathetic irritation alone is present, we
must be guided in the question of enucleation by the degree of this, and by the condi-
tion of the inﬂamed eye.
I should judge, lastly, from a consideration of the statistics I have quoted, that the
exclusion of light is an important factor in the treatment of sympathetic disease, and
that cataract operations are less likely to be followed by this dire calamity in the duller
season of the year.
DESCRIPTION OF PLATE.
FIG. l.—Meridional section through ciliary body and iris—The iris is much thickened by
an inﬁltration of lymphoid cells. A stratum of similar cells behind the scattered
remains of its pigment epithelium layer unites it ﬁrmly with the lens-capsule.
Near its anterior surface numerous blood-vessels are seen. Each has thickened
pellucid walls and lumen obliterated by endothelial proliferation. The part of the
ciliary body internal to the ﬁbres of the ciliary muscle is in a similar condition, except
that the peculiar blood-vessels are not seen.
FIG. 2.—-Section through choroid—Clusters of similar lymphoid cells are seen in its middle
strata. The chorio-capillaris is free from them.
FIG. Int—Section through optic disc in horizontal plane—The papilla is somewhat swollen,
and there is an increase of nuclei round its blood-vessels. There is slight neuritis,
as well as some nuclear increase in the space between the dural and pial nerve-
sheaths ; a characteristic cluster of lymphoid bodies is seen in the middle stratum
of the choroid.
Comment‘ Z’Op/zz‘a/mz'e sympaZ/zz'gue pezci-cilc se pv/oa’uz'rc
aprc‘s Z ’Em1/vaz‘z'0n ?
Médecin Principal Dr. PONCET de Oluiry.
Si l’anatomie pathologique n’a pu formuler d’une facon certaine quelle était 1a
voie suivie par l’irritationtse portant d’un oeil sur un autre dans les conditions
ordinaires, i1 paraitrait plus difﬁcile encore de savoir comment se développent les
accidents sympathiques quand 1e chirurgien a sectionné les nerfs qui mettent en
rapport les deux organes.
L’ophtalmie sympathique se produisant apres 1’énervation n’est malheureuse-
40 OPHTHALMOLOGY.
ment pas un fait rare, et nous en possédons aujourd’hui un assez grand nombre
d’exemples: mais les commentaires qui expliquent ces irradiations douloureuses
varient avec les auteurs.
Pﬁüger, portant surtout son attention sur les conséquences de l’hémorrhagie,
estime que le caillot rétro-bulbaire s’organisant, est capable d’exercer une inﬂuence
funeste sur les voies de communication de 1’œil sain. Derby a soutenu aussi cette
opinion devant la société médicale de Boston. Wadsworth énucléant un œil énervé
insensible, mais restant la cause de douleurs profondes dans l’orbite, accepte
l’hypothèse d’une affection rhumatismale.
Un fait de ce genre s’étant produit cette année à. la clinique de notre collabora-
teur et ami M. le Dr. Landolt, il nous a semblé utile de faire un examen approfondi
de l’oeil énervé, puis énucléé, qu’il a bien voulu nous remettre.
Voici les renseignements cliniques qui nous ont été fournis à. ce sujet :
M. Jacq, âgé de 67 ans, a perdu complètement la vision de l’œil gauche, d’une
façon brusque, et, d’après les renseignements fournis, par un décollement de la
rétine, il y a près de 20 ans. Il est atteint à l’œil droit d’une myopie=20 D.
ACÜItéZ-l-g'ô.
En Avril, 1880, des douleurs atroces se déclarent dans l’œil gauche. Iris
décolorée, augmentation de la tension. De plus, à. droite la. vue diminue et des
troubles du corps vitré se produisent.
Le malade refuse l’énucléation qui lui est proposée, et demande l’énervation
dont il a entendu parler.
Le 20 Avril, 1880, cette dernière opération est pratiquée par M. le Dr.
Landolt, qui résèque une portion du nerf optique, et sectionne largement les tissus
autour du pôle. Hémorrhagie. Peu de réaction. L’oeil énervé est immédiatement
insensible; toutefois la sensibilité de la cornée reparaît quatre jours après, et en
même temps l’acuité visuelle diminue rapidement à droite; des douleurs se pro«
duisent dans cet œil.
En Mars, 1881, la cornée gauche est tout-à—fait insensible; l’œil droit est le siège
de douleurs profondes, la conjonctive est injectée, chémosis général ; l’acuité baisse
rapidement.
L’énucléation fut proposée à. nouveau et pratiquée le 2 Mars; l’opération fut
suivie de la cessation des douleurs à. droite, et l’acuité remonta d’une façon notable ;
à. la ﬁn d’Avril le malade pouvait se conduire, tandis que deux mois avant il ne
distinguait pas les doigts à. deux mètres.
L’œil extrait, plongé pendant un mois dans une solution d’acide chromique
légère, était, au moment où l’examen fut pratiqué, d’une consistance dure, donnant
à. la pression cette résistance générale particulière aux bulbes dont les humeurs
mélangées d’exsudat, se coagulent sous l’inﬁuence de la solution chromique. C’est
un moignon phtisique, quadrangulaire, avec dépressions équatoriales ; il mesure
23 millimètres transversalement, 19 verticalement, et 18 d’avant en arrière.
La cornée est rétrécie en tout sens, mais surtout verticalement; elle est ovalaire
et recouverte en quelques points par un exsudat blanchâtre.
Au pôle postérieur, nou recherchons en vain des traces du nerf optique. Il a été
abrasé dans la première énervation, et même réséqué sur une petite longueur. Toute
cette région pôlalre est englobée dans un tissu cicatriciel induré, formant une
cupule épaisse. o
Une section verticale équatoriale pratiquée au niveau de la partie postérieure du
cristallin, nous a montré que toutes les humeurs de l’œil étaient, comme nous
1’avions pensé, coagulées, l’œil se coupant comme un morceau de gélatine.
OPHTHALMOLOGY. 4 I
La disposition des parties était la suivante : En dedans de la sclérotique, à. 2 ou
3 millimètres, existe un ﬁlet noirâtre circulaire; c’est la choroïde épaissie, et dont
il est déjà permis de noter la purulence; en dedans de cette membrane, un cercle
d’exsudat irrégulier, de 3 ou 4 millimètres, la sépare d’une masse plissée au centre,
c’est-‘a-dire de la rétine. Enﬁn, au milieu de l’organe, se voit la cupule du
cristallin dont la face postérieure est enclavée dans un exsudat qui réunit la lentille
au convolvulus rétinien.
Cette simple coupe macroscopique démontre donc déjà. un décollement complet
de la rétine, avec suppuration de la choroïde et altération profonde des humeurs.
L’examenrhistologique a été pratiqué sur les deux segments antérieur et pos-
térieur; et nous en résumerons les données aussi brièvement que possible en
zn’insistant que sur les points spéciaux à cet œil.
Segment antérieur. ———Les coupes micrographiques comprennent la cornée, l’iris,
et une partie du cristallin. Elles ont été faites suivant les procédés ordinaires
gomme et alcool, et la section pratiquée du cristallin à la cornée, c’est-a-dire,
d’arrière en avant; ce détail a quelque intérêt.
Toutes les parties constituantes de ce segment sont coulées pour ainsi dire dans
une gangue de ﬁbrine; exsudat coagulé qui permet d’avoir des préparations d'une
exactitude topographique précieuse.
Notons que la face antérieure de la cornée à son limbe, présente une chemose
ﬁbrineuse, hémorrhagique, qu’il estassez rare d’avoir à. examiner. La membrane
de Bowman à son extrémité, est séparée de l’épithelium. On reconnaît son
ﬁlet anhiste isolé du revêtement cellulaire par une cavité hémorrhagique et un
épanchement ﬁbrineux mêlé de leucocytes. Cet exsudat s’est produit à. la limite du
tissu lymphatique conjonctival. Les faits les plus graves se rapportent à l’état
de la chambre antérieure, soit au centre, soit vers la région ciliaire.
Centra—La solution de picro-carminate permet de constater ici des détails de
majeure importance. La cornée elle-même n’est pas en voie de suppuration; ses
faisceaux sont épaissis, disjoints, le protoplasma des cellules ﬁxes est hypertrophié,
et il existe ça et là. quelques vaisseaux de nouvelle formation; toute cette partie
est colorée en rose par le carmin. En arrière de ce tissu cornéen se trouve
une bandelette d’exsudat, d’une structure absolument différente de la cornée,
mélange de leucocytes et de ﬁnes ﬁbrilles d’une couleur jaunâtre séparant la
cornée de la membrane de Descemet. Celle-ci, vivement colorée par le carmin, forme
un ﬁlet replié, sinueux, adhérent en quelques points a cet exsudat rétro-cornéen,
mais le plus souvent a un exsudat placé en avant de l’iris. Les replis de cette
membrane de Descemet sont comblés par un mélange de globules sanguins et de
ﬁbrine.
L’iris, transformée en un tissu complètement purulent, embyronnaire, ne
contenant plus de vaisseaux normaux, est enclavée dans deux couches d’exsudat
ﬁbrineux, l’une antérieure soude ce voile aux replis de la membrane de
Descemet: l’autre postérieure la réunit non moins solidement a la capsule
antérieure du cristallin. Cette disposition existe sur toute la surface postérieure
de l’iris ; les synéchies étaient complètes et l’espace postérieur n’existait plus.
Le cristallin était complètement graisseux. Nous avons retrouvé la cristalloïde
antérieure sans épithélium ; cette couche cellulaire était remplacée par un exsudat
ﬁbrin eux, avec globules blancs en voie d’organisation.
Région céliai'ra—Les désordres sont encoree plus grands. A la périphérie de
la cornée, le canal de Schlemm et les vaisseaux voisins sont remplis de pus et de-
pigment. Le ligament pectiné n’est qu’un reticulum purulent se rendant à. la
I.
4 2 OPHTHALMOLOGY.
région ciliaire et a l’iris, dont toutes les parties sont aussi gorgées de globules
blancs, au point que l’organisation primitive a disparu. Dans le sinus terminal de
la chambre antérieure, sur un grand nombre de préparations, nous avons pu suivre
la mode du rupture de la membrane de Descemet: de petits fragments restent
adhérents près du ligament pectiné, tandis que la membrane entière est en synéchie
antérieure avec des exsudats de l’iris.
Les faisceaux du muscle ciliaire sont eux-mêmes dissociés par le pus.
Enﬁn—fait sur lequel nous avons insisté déjà. en 1874, dans nos premières
recherches sur les décollements de la rétine—entre la sclérotique et le muscle
ciliaire existe un exsudat séreux purulent très-abondant qui n’est séparé de la
chambre antérieure que par la zone pectinée.
Qu’il nous soit permis de dire incidemment, qu’il faudrait, dans des conditions
semblables pratiquer une communication entre la chambre antérieure et la région
postérieure, en détachant cette barrière pectinée. Il sufﬁt de jeter un coup
d’œil sur la ﬁgure représentant la disposition de ces parties pour comprendre qu’une
section de la cornée et le détachement de la zone pectinée constituaient un véri-
table débridement des régions postérieures de l’œil.
Segment postériezwu—Nous ne voulons nous arrêter qu’aux faits principaux, et
il nous sufﬁra de dire que toute la choroïde depuis la zone ciliaire usqu’au point
d’entrée du nerf optique n’était qu’une nappe purulente. Dans les points les moins
altérés, la purulence était remplacée par un mélange de leucocytes et de sane‘.
La rétine adhérente par la zone ciliaire formait un entonnoir plissé. Ce tissu
n’oﬁ‘rait plus trace de l'organisation première; tous les éléments propres avaient
disparu, et il ne restait que des mailles allongées formées par la substance de
soutien (fulchrum, mélangé de pus). Cette disposition est bien connue en anatomie
pathologique.
Mais ce que nous n’avions jamais rencontré sur aucun bulbe phthisique, c’est
la séparation du pédicule de la rétine a l’entrée du nerf optique. Nous avons dit
que tout ce segment postérieur était englobé, coulé pour ainsi dire, dans un exsudat
gélatineux; les parties avaient en outre été gommées et traitées par l’alcool; elles
étaient donc bien en place. Or, sur toutes les coupes, le pédicule terminal
de la rétine, qui devait s’appuyer sur la lame criblée, était reporté latérale-
ment à 3 ou 4 millimètres et soudé à la choroîde par un tissu ﬁbreux
nouveau. Cette disposition était d’autant plus aisée à vériﬁer, que le tissu rétinien,
même dégénéré, reste coloré en aune au picro-carminate, tandis que le tissu
conjonctif même est vivement rosé. La différence des couches est facile à.
constater.
Ce tissu conjonctif nouveau partait de l’oriﬁce du nerf optique, pénétrait dans
le globe et se terminait dans l’exsudat situé entre la choroïde et la rétine déplacée.
Quant a trouver un vestige du nerf optique continuant la rétine, il n’en existait
pas, et tout le canal ancien était comblé par un tissu ﬁbreux occupant la gaine
même du nerf. Nous avons constaté que les faisceaux connectifs de la gaine
vaginale, a revêtement endothélial si caracteristique, limitaient précisément
ce tractus ﬁbreux. Il se confondait en arrière de la sclérotique avec un magma
cicatriciel formant cupule au globe énucléé.
Le tissu cicatriciel formé au lieu de la première section optico-ciliare, était
très—dense et composé de gros faisceaux solidement unis à. la sclérotique. O’est au
milieu de ce tissu et immédiatement adjacentes a la sclérotique que nous avons ren-
contré presque toutes les extrémités centrales des nerfs ciliaires sectionnés, éparses
dans cette cicatrice aux environs de l’ancienne ouverture optique. Sur des coupes
OPHTHALMOLOGY. 4 3
où la section avait été perpendiculaire, il nous a été facile de reconnaître que ces
ﬁlets ciliaires étaient le siège d’une grave altération. Comprimés dans la gangue
cicatricielle, ils ne contenaient plus que de rares tubes intacts, c’est-à-dire à myéline
et a cylindre axe. Un grand nombre de ces ﬁlets avaient complètement disparu :
les uns étaient réduits à l’état de ﬁbres de Remack, d’autres ne contenaient pas de
cylindres axes et se présentaient a la coupe comme une goutelette graisseuse. La
plus grande surface de la section était occupée par du tissu conjonctif fasciculé,
émanant de la gaine générale du tronc nerveux.
La lésion très-évidente de ces nerfs ciliaires était donc une sclérose avec
dégénérescence atrophique des tubes nerveux.
Sur des coupes longitudinales, outre la sclérose, également très-nette, nous
avons constaté une vascularisation anormale de ces nerfs ciliaires, et, en certains
points, de véritables hémorrhagies.
Dans cette même région cicatricielle existaient aussi des vaisseaux ciJiaires en
pleine voie de suppuration (phlébite et artérite), traversant la sclérotique pour
s’aboucher dans la choroïde. La suppuration, en un mot, pouvait être suivie
depuis le lieu de la section optico-ciliaire jusque dans les membranes et les milieux
oculaires.
Enﬁn en séparant la choroïde purulente, nous avons retrouvé contre la scléro-
-tique des débris des nerfs ciliaires intra-bulbaires. Ces ﬁlets sectionnés depuis un an
étaient frappés d’une dégénérescence absolue; en les dissociant avec le plus grand
soin, après teinture au picro-carminate, il ne nous a pas été possible de retrouver
un seul tube ressemblant de loin à une ﬁbre normale: plus de myéline, quelques
ﬁbres mélangées à du tissu conjonctif et diﬁiciles à distinguer de ce dernier,
reliquats de cylindres d’axes entourés de leucocytes ; voila ce qu’il en restait.
Loin de rencontrer ici, comme dans certaines expériences sur les animaux, une
régénération des nerfs ciliares, c’est la dégénérescence absolue que nous avons con-
statée. Au plexus ciliaire, vers les procès, la suppuration était encore plus
accentuée.
Les conclusions à tirer de ces recherches histologiques relativement à la pro-
pagation de l’ophtalmie sympathique nous paraissent graves.
Il est certain en effet que l’énervation n’a pas arrêté la marche des accidents.
Cette opération pratiquée un mois après l’invasion des premières douleurs n’a
pas été suivie d’apaisement, malgré les soins pris pour arrêter tout courant ner-
veux. Il faut même reconnaître que les délabrements constatés sur cet œil énervé
dépassent ceux qu’on rencontre d’habitude dans les bulbes en voie d’atrophie. Le
décollement de la membrane de Descemet, la suppuration généralisée de tout le
tractus irido-choro‘idien, les hémorrhagies, la séparation totale de la rétine d’avec
son pédicule optique sont des faits rares, indiquant une intensité inﬂammatoire,
une abondance d‘exsuclat purulent peu ordinaire. L’origine de cette suppuration
est clairement indiquée par la purulence des vaisseaux ciliaires; le mal est parti du
lieu primitif de la section optico-ciliaire. Cette opération a été un coup de fouet
donné a la suppuration du bulbe. '
Nous avons donc dans ce cas une conﬁrmation malheureusement trop précise
des dangers de cette méthode, dangers que nous avons déjà signalés par des
recherches expérimentales’)?
Dans plusieurs cas d’énervation la sensibilité s’est rétablie, a persisté et amené
des irradiations sympathiques, puis ﬁnalement l’énucléation. La physiologie a

* Archives d’ Ophtalmologie, No. 2, 1881.
44. OPHTHALMOLOGY.
démontré en effet que les branches nerveuses de la cinquième paire pouvaient
aisément se régénérer et rétablir le courant nerveux au bout de quelques mois. La
voie que pourrait suivre dans ces conditions l’ophtalmie sympathique serait toujours
la même. Mais ici tel n’est pas le fait. Notre confrère M. Landolt, connaissant
bien la possibilité de retour de la sensibilité, avait pris soin de réséquer une
portion des tissus nerveux; de plus, nous avons constaté la dégénérescence absolue
des ﬁlets ciliaires intra-bulbaires.
Ce n’est donc point par suite des accidents de ce phtisie oculaire, très-violents
il est vrai, que les phénomènes sympathiques (douleurs, diminution de l’acuité,
troubles du corps vitré) ont pu continuer leur marche ascendante et force nous est
de chercher une autre cause en dehors des parties contenues dans la sclérotique.
Des faits semblables, nous ne l’ignorons pas, se produisent après l’énucléation ;
et les recherches de Lawson, pour ne citer que les plus récentes, démontrent bien
que l’ophtalmie sympathique peut continuer après une énucléation pratiquée même
de bonne heure. Notons cependant que les faits contraires à la thèse de Lawson,
sont fréquents, et le malade même dont nous rapportons l’observation a vu son
état s’améliorer notablement, les accidents céder de suite et par l’extraction du globe
malade; il est dès lors permis de penser, d’après ce résultat, que si l’énucléation
avait été pratiquée de suite, l’œil congénère eût été exempté des phénomènes qui
ont suivi l’énervation. Mais, quoiqu’il en soit, et en acceptant encore toutes les
remarques judicieuses et cliniques de Lawson, la question n’en reste pas moins
posée: Quelle est l’origine de l’irritation sympathique après l’énervation? et, si l’on
veut transporter plus loin la question, pourquoi l‘énucleation n’arrête-t-elle pas
toujours ces accidents?
Nous pensons que dans notre observation l’état de la cicatrice au pôle postérieur,
la sclérose irritative des nerfs ciliaires fortement injectés, comprimés dans le tissu
connectif, la suppuration même des vaisseaux de la région, sont des motifs
suﬂisants pour admettre une névrite localisée sur les extrémités du bout central
des nerfs. Il ne nous a pas été donné jusqu’ici d’examiner l’état d’un moignon
du nerf optique, mais le travail cicatriciel qui s’y produit est analogue à celui des
ﬁlets ciliaires, il agit même sur des éléments nerveux plus délicats, plus sensibles.
Nous croyons en un mot qu’il peut se former, après la section optico-ciliaire
un magma cicatriciel, avec névrite des ﬁlets sectionnés, comme les névromes dans
une amputation de la jambe : d‘où permanence des douleurs sympathiques.
Ces conditions se réalisent-elles dans l’énucléation? Û’est aux examens histo-
logiques a le démontrer, et peut être les échecs de l’énucléation, mis en lumière
par Lawson, trouveront-ils la une explication anatomique.
Mais il faut bien reconnaître que les conditions ne sont pas les mêmes dans
l’extirpation pure et dans l’énervation. Dans le premier cas la cicatrice s’établit
simplement sur la muqueuse, derrière laquelle, dans une énucléation bien faite, la
capsule de 'I‘enon n’a pas subi de désordre important; l’hémorrhagie est extérieure;
il n’existe pas d’induration du moignon. Avec l’énervation, au contraire, quand
celle-ci s’accompagne d’une large dénudation du pôle, de la résection .du nerf
optique, la capsule est fatalement ouverte. Le malade de M. Landolt n’a pas
eu de ﬁèvre, mais l’hémorrhagie a été abondante derrière le globe; le tissu
cicatriciel que nous avons trouvé au pôle était épais, induré, pénétrant
jusque dans les milieux oculaires; la suppuration des vaisseaux de la région
était manifeste et s’étendait la clioro'ide. La section optico-ciliaire avait
créé un foyer d’irritation dont le premier effet a été la, névrite ciliaire permanente
et la propagation de l’ophtalmie sympathique.
O PHTHALMOLO GY. 4 5
DISCUSSION.
Dr. Moonnx, Diisseldorf : I believe that the extension of sympathetic inﬂam-
mation takes place through the optic and ciliary nerves. Clinical observations are
more in favour of the optic nerve. This has been found pathologically by Brailey,
Hirschberg, and Alt. Extension of every neuritis depends on a reﬂex dilatation of
the vessels. The inﬂuence of the vascular system explains the rapid development
of sympathetic disturbances in the other hitherto intact eye. Cohn’s observations
explain the complete absence of painful sensations in the ciliary body, for the area
of the inﬂammation may have been localized in some more distant part of the
ciliary nerves. After enucleation, we can often see the phenomena of neuritis in
the naso-ciliary and optic nerves. In every inﬂammation the lymph acts as a
decomposing inﬂuence on the axis cylinder and leads to its swelling. In this
sense the lymph favours the development of inﬂammation. But the latter is only
produced as the eﬁect of reﬂex dilatation of the vessels; for cauterizations of the
cornea with nitrate of silver show immediately afterwards an excess of ﬁbrine and
albumen, not only in the anterior chamber of the affected eye, but likewise of the
other.
Professor Gnunnnxenx, Konigsbergz I am strongly of opinion that, in the
question as to how sympathetic ophthalmitis is set up, the nerves which dilate the
vessels of the eye deserve more consideration than has hitherto been their share.
In experiments on curarized animals (rabbits, cats) it results that irritation of the
cornea of the one eye causes the secretion of albuminous and ﬁbrinous material,
together with a migration of white blood-cells, not only into the aqueous of the
irritated, but also into that of the unirritated eye. The explanation of this fact I
believe to be that irritation of the sentient corneal nerves leads reﬂectively to an
excitement of the nerves which dilate the blood-vessels, and that in consequence
of the relaxation of the vascular walls an increased separation of albumen and
ﬁbrine results.
Professor PrLiiGEn, Berne: About two years ago I observed a case analogous
to that of Poncet. It was published in the reports of the Ophthalmic Hospital
of Berne, in 1878. The eye was quite painless after the neurotomia optico-ciliaris,
but the patient complained of a feeling of pressure behind the eye, and said he felt
as if a wall were there. At enucleation, on account of sympathetic irritation, a
mass consisting of new-formed connective tissue was found behind the eye,
pressing on the peripheral ends of the ciliary nerves. Although I myself have
experienced no such evil results, yet it is always possible that they may occur,
and the risk of this is, in my opinion, a very great drawback to the operation.
Though, indeed, the same thing may occur after enucleation, yet, this is extremely
rare in proportion to the great number of enucleations performed.
Dr. SAMELSOIIN, Cologne: There is another way of propagation of the inﬂam-
mation producing sympathetic disease, as I can prove by an anatomical specimen
-1-viz., the way through the suprachoroid and the sclera, along the sheaths of the
vessels and the ciliary nerves into the supra-vaginal space, itself a lymphspace
in connection with the lymphatic spaces of the brain.
Professor LEBER, Gottingen: I have lately made a great number of experiments on
rabbits. I irritated one eye invarious ways. The corn ea, iris, or ciliarybody was exposed
46 OPHTHALMOLOGY.
to chemical or mechanical irritation; or foreign bodies of the most various nature were
introduced into the anterior chamber. I have never observed the least hyperaemia
in the fellow eye. My observation was especially directed to this point, for it was
of the greatest interest to me to observe the mode of origin of sympathetic inﬂam-
mation. I cannot at all explain the observations that Professor Gruenhagen has
communicated, but I think that they have no value in relation to the origin of
sympathetic disease. I think that his hyperaemia of the vessels in the second eye
must have been inferred only, for I could scarcely have passed it over in my long-
continued observations.
Dr. BOUCHERON, Paris, in connection with Dr. Poncet’s case, thought that it was
not altogether unfavourable to the operation of enervation. Indeed, the very
changes resulting from that operation would probably so alter the condition of
things that sympathetic disease could not now reproduce itself. Poncet had found
the ciliary nerves as far as the scar completely degenerated, and hence they could
not transmit sympathetic ophthalmitis even if the conditions favourable to it had
existed in the ﬁrst eye. The persistence of corneal sensibility was not, in the speaker’s
opinion, as it had been considered, a powerful argument against enervation. He
interpreted it by the existence of recurrent ﬁlaments supplying the cornea from
the supra- and infra-orbital nerves, which escaped division, however completely the
posterior part of the eye had been denuded. He compared this sensibility with the
recurrent sensibility of the hand observed by Arloing and Tripier after division of the
median, and in the eyelids after division of the supra- and infra-orbital nerves. The
recurrent nerves of the cornea, not supplying any other part of the eye, could not,
in the speaker’s opinion, transmit sympathetic disease. He accounted for the occur-
rence of sympathetic disease in Poncet’s case by the presence 'Of neuritis in the
ciliary nerves outside the eye. He thought enervation the proper remedy for
painful stumps.
Professor PANAS, Paris, called attention to the dangers of enervation, and men-
tioned one case in which the eye was lost, and another of death from basilar
suppurative meningitis in a child of fourteen years, coming on on the third day
after the operation. He insisted on the importance of complete antiseptic pre-
cautions, with iced carbolized compresses. He considered enervation a more
formidable operation than enucleation, which he had never known followed by
dangerous results, even in cases of suppurative panophthalmitis.
In the course of the discussion, Dr. H. SNELLEN asked Dr. Gruenhagen what
animals were used for his experiments, for he himself had been trying in vain to
get sympathetic ophthalmitis in animals, notwithstanding that he had used different
sorts of animals, and inﬂicted different kinds of injury.
Dr. LEBER, Gottingen, stated that he always got the same negative results.
Dr. HORNER, Zurich, asked Dr. Gruenhagen whether he had taken the aqueous
humour during life or after the death of the animal.
Dr. GRUENIIAGEN, Konigsberg, answered that he had used rabbits, and that 'he
had taken theaqueous humour after killing the rabbit, by means of a ﬁne‘ puncture
through the cornea.
OPHTHALMOLOGY. 4 7
Dr. SNELLEN, replying to the discussion, said that all speakers seemed to agree
that sympathetic irritation is to be distinguished from sympathetic inﬂammation.
Sympathetic irritation may be the result of reﬂective nervous action. The hypo-
thesis of sympathetic inﬂammation by reﬂective action from the ciliary nerves has
met here with no defender. Only Dr. Gruenhagen has communicated that he got
increase of ﬁbrine and of cells in the anterior chamber in both eyes after wounding
one eye, which he ascribes to the action of vaso-dilator nerves. As Gruenhagen
took the aqueous humour after death, he may be reminded that Deutschmann has
lately stated that after death the aqueous humour can be restored, and then always
shows an increase of ﬂbrine. The highly-interesting researches of Dr. Brailey
show that the inﬂammation of the uvea is of a typical character. Besides7 in almost
every case of sympathetic ophthalmitis more or less neuritis has been found in both
eyes. Much evidence has been brought forward, proving that the inﬂammation
may be traced along the optic nerve. However, this inﬂammation does not seem
continuous and equal over the whole nerve. The different observations put on
record seem to prove that not a continuous but more a metastatic inﬂammation
may be accepted. As the neuritis is in some cases slight, it is probable that the
transmission goes through lymphatic spaces. \Vhether the extra-dural (as Dr.
Samelsohn suggests), or the sub-dural or the sub-pial lymphatics here predominate,
or whether all together may have a share in the transmission, will have to be
determined by future researches.
_____
Considérations pmz‘z'gues 52H’ Z’Examm des Employés du C Æemzäz
de F6?’ ez‘ de la Man/2'726 au sujet du Dalz‘mzz'sme ez‘ de la Vision.
Dr. LIBBRECHT, Gand.
Le Daltonisme—Pour l’observateur superﬁciel, l’examen de première main à
l’aide des laines colorées semble élémentaire. C'est la, sans contredit, une erreur
ﬂagrante. Le savant Professeur Holmgren propose, dans son ouvrage, de faire subir
un double examen aux ouvriers des chemins de fer. Le premier serait provisoire,
et pourrait être pratiqué par tous les médecins des administrations; le second
servirait de contrôle, et rentrerait dans les attributions d’un ophthalmologiste.
Sans doute notre éminent confrère est d’une compétence que nul ne contes-
tera. Permettez-moi cependant de dire qu'il me paraît nécessaire que le premier
examen, comme le second, soit exercé par un spécialiste.
Plus d’une raison milite en faveur de cette opinion. Qu’il me sufﬂse de vous faire
remarquer, que dans mes recherches, j’ai rencontré un nombre relativement consi-
dérable de sujets atteints de Daltonisme ou ne possédant pas l’acuité visuelle
normale; et cependant, entrés récemment dans l’administration, ils avaient subi,
avant leur admission, devant le médecin agréé, l’examen rigoureux que prescrivent
les réglements.
Nos confrères—ai—je besoin de le dire P—s’acquittent de leurs fonctions avec zèle
et dévouement, et les erreurs qu’ils commettent ne sauraient être imputées qu’à leur
inexpérience.
Acuité visuelle—Sur les 8,000 sujets soumis a mon examen, il s’en est trouvé
7'18 sur cent.* qui ne possédaient pas l’aeuité visuelle normale; alors que les

* Impossible de le dire exactement, attendu que je n’ai trouvé la défectuosité des
échelles qu’après avoir fait la statistique.
48 OPHTHALMOLOGY.
Daltoniens ne se rencontraient qu’au nombre de 260 sur cent. Quant à. la
défectuosité du champ visuel, elle n’est guère fréquente (% sur cent), et générale-
ment elle n’affecte qu’un œil. _
J ’ai examiné 300 femmes, et deux seulement d’entr’elles étaient viciées'pour le
vert: aucune ne l’était pour le rouge. Les diﬁérentes théories que l’on a émises
pour expliquer la rareté du Daltonisme chez le sexe ne me paraissent pas con-
cluantes.
J’ai peine à admettre que chez la femme se livrant aux travaux des champs, à
des travaux que ne réclament aucun effort d’intelligence, le sens chromatique se
développe outre mesure.
Et si la faculté de distinguer les couleurs se perfectionne chez l’adulte par
l'éducation, je vois surgir de nouveau la diﬁiculté lorsque j’examine les enfants;
car, comme je l’ai constaté, sur 2,215 enfants, le Daltonisme se rencontre rarement
chez les petites ﬁlles.
Le Professeur Horner a produit des travaux remarquables à ce sujet; mais
néanmoins la question me semble rester ouverte.
Le Daltonisme est peu fréquent chez les personnes du sexe ; c’est incontestable.
Mais, dans l’état actuel de la science, il serait téméraire, je crois, d’assigner une
cause exacte a cette immunité.
Parmi les sujets que j’ai examinés s’en rencontraient un grand nombre privés de
toute instruction.
Cette circonstance m’a permis de constater que le Daltonisme affecte indis-
tinctement et dans les mêmes proportions les personnes lettrées et les illettrées;
mais sous le rapport de l’acuité visuelle, ces derniers soumises à l’examen des
échelles atteignent en si grand nombre la vision normale, alors qu’il n’en est
pas ainsi pour les premières. Il semblerait donc que les ouvriers illettrés pré-
sentent sur les lettrés une véritable supériorité.
Or cette supériorité n’est pas réelle.
Elle n’est qu’apparente, et la cause de la différence résulte de ce que les lettres
sont plus difficilement reconnues que les signes.
Et en effet des employés, c’est-à-dire des personnes sachant lire, n’atteignent
que deux tiers sur l’c’chelle des lettrés, et arrivent au contraire a la vision normale
sur l’échelle des illettrés’)?
Dans nos divers congrès nous avons ‘été unanimes a décider qu’il est urgent
d‘instituer une commission internationale a l’eﬁ‘et d’établir un mode uniforme
d'examen au point de vue du Daltonisme.
Nous avons décidé aussi que, pour rendre cette mesure féconde en résultats,
il est indispensable que les gouvernements et les administrations admettent au
préalable les mêmes signaux affectant des couleurs identiques.
Les circonstances sont du reste favorables à leur réalisation: nous nous trou-
vons en effet au sein de ce peuple britannique qui jamais ne reste indifférent aux
idées de progrès, et peut—être le gouvernement de Sa Majesté daignera-t-il prendre
l’initiative d’une réunion internationale.

* Donc un tiers de différence pour toutes ces statistiques.
OPHTHALMOLOGY. 49
A N ew Mei/tow’ 0f Examining and NZHWéViCLZZZJ/
Expressing z‘ke C 0102” Pea/cepz‘z'mz.
Dr. OLE BULL, Christiania.
The method is based on producing the four principal colours of an equal shade
and intensity.
As there are different opinions about which hues of the four principal colours
ought to be considered as the purest, it is necessary to make a choice between
them. I have tried to ﬁnd out which are the purest, in a physiological sense, in
the following manner :
For the blue I have chosen that hue which, mixed up with any amount of un-
coloured light, has appeared either as blue or colourless. The complementary
yellow is then produced of such an intensity as to give, when mixed on the rotating
disc with blue in equal parts, an uncoloured (grey) light.
In selecting the red and green I had to seek some other method. As the colour-
ing of the yellow-spot in different individuals is not the same, either in intensity
or in hue, the perception of these colours is modiﬁed in accordance therewith.
Therefore the purity of these colours can better be controlled by examining them
with the peripheral parts of the retina. It is a well-known fact that hues of red
and green, which on the central part of the retina are estimated as the purest, if
presented suﬂiciently far out on the periphery, appear as yellow, and that the
complementary colours, blue-green and rose, appear as blue. But there must
exist hues of red and green which, with all parts of the retina, are perceived in their
real colours, if perceived as coloured at all. Such hues of these colours, which I
would call physiological red and green, are not difficult to produce. Mixed with
each other in equal parts they, too, like the blue and yellow, will, if they be of the
same intensity, give an indifferent grey.
Having produced the four principal colours in such a way that each pair of the
coniplemental colours, when mixed in equal parts on the rotating disc, gives a
colourless grey of the same shade, I can be sure that the intensity of each colour
in the two pairs is alike. This, however, gives no assurance that the red may not
be more intense than the blue, or the green more intense than the yellow. In order
to examine the intensity of the non-complementary colours I have determined the
magnitude of the sector sufﬁcient to give on the rotating disc an impression of
each colour. By altering the intensity up to a point where the same average
magnitude of the sector (deduced from a number of observations) gives a per-
ceptible impression of the colour, I have succeeded in producing four colours of
like intensity.
From each of those four colours, of the same intensity and shade, a series of
six different tints is made, by mixing up on the disc of Maxwell the single colour
with uncoloured (grey) light of the same shade as that given by each pair of the
complcmental colours mixed together. These six tints of each colour I have ﬁxed
by imitating them with pigment. To try the correctness of the imitation I have
painted the pigment on small round plates, which, on the disc of Maxwell, can be
put over the coloured and grey plate. In this manner it is not difficult to compare
the tint given by the pigment and that given by the coloured and grey sector
mixed together. When a correct harmony is obtained, so that, for instance, a tint
of yellow, corresponding to yellow 160° and grey 200° on the rotating disc, is
produced by pigment (this was shown by experiment), then the relative intensity
PART III. E
5o OPHTHALMOLOGY.
of the colour given by the pigments can be expressed simply by indicating the
degrees of the coloured sectors—via, 40°, 60°, 80°, 120°, 160°, 240°. With the
same pigments, I have painted on ablack plate squaresl cm. in length, and the
same distance apart. These squares I have arranged in such a manner, that one or
more coloured squares of the same intensity, but of different hues, are put together
in one line with one or more grey squares. On the cardboard, we consequently
have seven different tints of each colour—namely, the unmixed colour and six
fainter tints derived from it.
Now, if we want to make an examination of a patient’s colour-sense, this may be
done by simply pointing out any coloured or uncoloured square, and then asking
the patient to indicate that square which to him appears most like it. If he is
colour-blind, he will make mistakes, and sometimes point out as alike complemental
coloured squares. If his colour-sense is diminished by disease of the nervous ap-
paratus, not only the kind of his commencing colour-blindness may be detected, but
also the grade. I have found from examining a great number of individuals, that a
healthy eye at a distance of one metre from the plate can just discern the faintest
tint (corresponding to 40° of the coloured sector and 320° of grey). Therefore, when
I ﬁnd that a patient can do this, I say his colour-sense is normal. But if, for in-
stance, he can discern green only up to 120°, red to 80°, blue and yellow to 440°, I judge
that he is beginning to turn red-green blindjland his perception of these colours
may be expressed for the green by T429, and for the red by $3. If he is' suffering
from any disease by which his perception of light is lowered, he will be in the
same plight as the normal eye by diminished illumination, and consequently confuse
faint tints of yellow with red and green with blue. The plate may therefore serve
not only to detect and numerically express aberrations in the colour-sense, but
also as a means of diagnosis between diseases of the nervous apparatus and
those of the external layers of retina.
In order to examine the peripheral colour-perception, I have painted upon
a small round disc the four principal colours in squares measuring 2 cm. By
putting the discs under a second black plate with a central pin, around which they
can be turned, any of the four colours may be brought before a quadrangular open-
ing in this plate, and so be singled out to view.
Owing to the yellow pigment in the central part of our retina, our perception
of blue and yellow cannot be in this region so sharp as for the red and green. If
we therefore examine the periphery with a blue and yellow, which, for the centre
is as intense as the red and green, the same blue and yellow must appear compara-
tively more intense colours. Consequently, we should expect to ﬁnd a wider ﬁeld
for these colours than for the red and green, and such is the fact. The difference
in favour of the blue and yellow is especially large in highly pigmented individuals,
as in them the yellow pigment is more intense. As to the red and green, these
colours are perceived at the same distance from the centre. So we only need to use
alternately one of these colours, and in this_way time may be saved in mapping
out the ﬁelds for the four principal colours. ‘
OPHTHALMOLOGY. 5 I
A ﬁshnet of Paper me “Primary Retina! Hzmowfkage in
Young Men.”
Mr. HENRY EALEs, Birmingham.
Under the above title it is proposed to deal exclusively with a rare form of
retinal haemorrhage, which is believed to be peculiar to young men between the
ages of puberty and adolescence, is usually profuse, constantly recurring, and
most common in the left eye.
Characters of the Retinal Aﬁ'ecttom—The haemorrhages are usually multiple,
often cause complete opacity of the vitreous, and when quite recent are of a venous
colour.
Though occurring at all parts of the fundus, they are most common at the
extreme periphery of the retina. They are not associated with any other evidences
of retinal disease, and are roundish, diffused, and not ﬂame-shaped. They con-
stantly recur, they are generally found in close proximity to the branches of the
retinal vein, which are often lost in them, or a venous trunk is directly continuous
with an opacity in the vitreous caused by the haemorrhages. Vision often appears
to be impaired only in proportion to the opacity of the vitreous. In some cases,
the recovery is so complete that between the attacks no trace of the previous
disease is found.
In all of my own cases the haemorrhages occurred most profusely in the left eye,
but in two cases haemorrhages were found in the right eye also. In all of my own
cases the calibre of the retinal vessels was unusually large in both eyes, the veins
especially being dark, large, and tortuous.
In two of my cases the retinal veins at the periphery were found to present
remarkable corkscrew-like tortuosities, while surrounding these were evidences
of previous retinal haemorrhages. In one case, sight was permanently lost by the
occurrence of glaucoma.
Gene/ml Condition of the Patients—All were young males, the youngest being
aged 14, and the eldest aged 20. All were previously, and while under treatment,
troubled constantly with constipation, and occasionally with epistaxis, especially
during the summer months. Two were very subject to headaches, three were
habitually lethargic and indolent, and complained of depressing feelings and want
of energy.
In one case, there was evidence of mitral incompetence. In the others, the
heart presented no anomaly. The pulse in each case was below 60 at the time
they ﬁrst came under observation. The aortic second sound was accentuated in
only one case. Pulse-tracings in three cases showed low tension, but they were
taken some months after the heemorrhages occurred; the condition of pulse-tension
at the time of the haemorrhage is therefore still undetermined.
In two cases only, there was the faintest shadow of albumen in the urine, and
in no case were any casts found.
There was no indication of anaemia in any case; the blood of one case examined‘
.by the haemo-cytometer was quite normal.
Among the exciting causes were coughing, laughing, and stooping.
The family histories were destitute of any decided facts in favour of Mr.
Jonathan Hutchinson’s view of the gouty origin of this condition, but it is interesting
to note that in two cases the fathers had been subject to epistaxis for many years
in early life.
E 2
5 2 OPHTHALMOLOGY. I
The characters and the position of the haemorrhages point to their origin from
the turgescent venous system. This venous turgescence is regarded as the conse-
quence of a neurosis affecting the whole splanchnic area, leading to vasomotor
constriction,and muscular inhibition within that area, and compensating hyperaemia
of the parts outside, especially of the vessels of the head and neck.
072 17% Cormeaz’z'm éez‘wm Opz‘z'c N eurz'z‘z's and [mm-Mania!
Diseases.
Professor THEODORE LEBER, G‘ottingen.
Mn. PRESIDENT AND GENrLEMEN,——In complying with the kind invitation I have
received to read a paper before you on the Connection between Optic Neuritis and
Intra—cranial Diseases, I desire, at the outset, to bespeak your indulgence for the
somewhat hypothetical character of my paper. I propose to present to you the
different theories which have been put forward upon the subject, and to give you
at the same time my own views, which I have tried to strengthen, so far as possible,
by new investigations. I would have preferred to hold back my opinions until I
could have supported them with decisive proofs; but I hope now, at least, to bring
forward some points which may serve to excite discussion, and to stimulate to
further research. -
The most important question which here awaits our decision is admittedly
the following :——-How does inﬂammation of both optic papillae arise in disease of
the brain, although the optic nerve itself, the connecting link between brain and
eye, presents no sign of inﬂammation to the naked eye? Especially how are we to
explain the occurrence of papillitis in coarse disease, particularly in tumours of the
brain, when, as post-mortem examination shows, these diseases are unaccompanied
by meningitis, and need not stand in any direct communication either with the
optic centres or with the nerve trunk? How are We to explain it, further, in
cases of basilar meningitis, when the autopsy discovers no extension of the inﬂam-
mation to the nerve trunk?
Hitherto these phenomena have been mostly explained by the aid of mechanical
causes, especially as the result of some obstacle to the free escape of venous blood ,
from the eye, supposed to be due, it may be, to compression of the cavernous
sinus from increased pressure within the cranium, or it may be to pressure upon
the optic nerve from a dropsy of its sheath. I shall try to show that these theories,
which attempt to explain in a mechanical way the connection of which I am treat-
ing, are insufﬁcient and unsatisfactory, and that a cause directly exciting to
inﬂammation must be adopted as the explanation, and I shall attempt to indicate-
a way in which this may come about.
To begin with the changes in the eye. It is now universally admitted that the
distinction formerly made in the ophthalmoscopic appearances between so-called
congestion-papilla, or choked disc, and descending neuritis cannot any longer be
maintained. No doubt the ophthalmoscopic appearances, apart from the different
stages of the process, present great varieties in the individual cases; at one time
a very considerable and very steep swelling of the papilla, with great congestion
of the veins will be found, again a more moderate prominence gradually shelving
into the surrounding retina. with considerable participation of the latter in the
OPHTHALMOLOGY. 5 3
inﬂammation. These, and other, differences in the ophthalmoscopic appearances
do not, however, depend upon the nature of the fundamental disease, nor upon the
presence of meningitis, and they are accordingly of no importance for the question
as to the development of the optic-nerve process. Moreover, the separation into
two distinct processes is disproved by the post-mortem examination, according to
which a descending neuritis apparent to the naked eye rarely occurs, and is just as
seldom found in meningitis, where one would most expect it, as in cases of cerebral
tumour. '
It seems, therefore, that with the exception of simple atrophy, we have to deal
with but a single kind of disease of the optic nerve in cerebral diseases, and this
may be described indiiferently by the terms papillo-retinitis, or papillitis encephalo-
pathica.
New this papillitis is a true inﬂammation, and not merely an oedema caused by
passive venous congestion. The tissue changes produced by it are the same as
those which occur in the different kinds of haemorrhagic retinitis, as it is found in
certain general diseases, such as nephritis, diabetes mellitus, leucaemia, pernicious
anaemia, cardiac disease, &c., and is equivalent to the red softening of the brain, or
encephalitis. These changes consist in inﬂammatory oedema with exudation of
ﬁbrin into the interstices of the tissues, inﬁltration of lymph-corpuscles, hypertrophy
and proliferation of the radial ﬁbres of Miiller, heemorrhages, masses of granular
cells, thickening of the nerve-ﬁbres, &c. In all the above-mentioned diseases we
ﬁnd always these same changes, no doubt in very diﬁerent degrees of development,
and varying in their distribution over the retina, sometimes one alteration, some-
\ times another being more prominent, while again, others are less apparent or com-
pletely wanting. Upon this variation depends the characteristic ophthalmoscopic
picture from which We can often diagnose the nature of the fundamental disorder,
while the details of the histological alterations in the retina have nothing pathogno'
monic in any of the diseases referred to. Moreover, as you know, even the ophthal-
moscopic pictures pass over into each other, so that the differential diagnosis is often
uncertain. In some rare cases of Bright’s disease, for example, the typical picture
of the so-called congestion-papilla is seen, and, on the other hand, with cerebral
tumour one occasionally ﬁnds a form of papillo-retinitis, which in no particular can
be distinguished from the most marked retinitis albuminurica. “To learn here
that the so-called choked disc can develop itself without any cause of venous
obstruction; this is also proved by the anatomical examination of some cases of
phthisis bulbi following upon injuries, in which the highest degree of swelling of
the optic disc, much more extreme than is usually found with cerebral tumour, and
with quite the same histological alterations, may be observed under conditions where
the cause is only to be sought in transmitted inﬂammation, and not in an ob-
stacle to the escape of venous blood from the eye.
It is also an error to believe that a stage precedes the appearance of the actual
papillitis, in which only oedema and passive venous congestion are present. In the
ﬁrst stage, apart from the hyperaemia, the swelling of the papilla is chieﬂy due to
the well-known thickening of the nerve ﬁbres of the retina, in addition to which
there is a slight increase in the nuclei, and an inﬁltration of small round cells
especially along the vessels, alterations of which the last one at least is undoubtedly
to be considered as inﬂammatory. I have found this in two cases in which, with
the ophthalmoscope, I saw the process developing, and in which I was enabled.
to obtain a post-mortem examination of the eye a few days afterwards. Occasionally,
too, there is a remarkable increase in the number of the small vessels and capil-
5 4 OPHTHALMOLOGY.
laries; in rare cases an almost teleangieotatic condition of the disc, which I
believe to be equally of inﬂammatory origin. I cannot enter here into the details of
post-mortem examinations published by different authors, but as far as I know, no
case has been described in which the alteration consisted merely in passive venous
hyperaemia and pure passive oedema.
A principal reason for the assumption that the encephalopathic papillitis is
caused by passive venous congestion has always been found in the peculiar form of
the hyperaemia, marked as it is by extreme dilatation and tortuosity of the veins, while
the arteries retain their normal dimensions, or are even contracted. It was thought
that the same cause which prevented the outﬂow of blood through the veins
diminished also the inﬂux through the arteries. But there are strong arguments
against this reasoning. Even ﬁve years ago,E. Jager had already very properly raised
objection to it. The same condition of these vessels is found in general in the most
different kinds of retinitis} and it cannot therefore be employed as a proof that
in this form a mechanical cause for the inﬂammation exists. I leave undecided
what the cause of the deﬁcient dilatation of the arteries may be, and I will also not
reject the opinion that the swelling of the tissues may act as an impedi—
ment to the circulation; but this factor would act only in a secondary way, or
equally as in the other forms of retinitis, and cannot be regarded as the actual cause
of the process. Further, the assumption of a venous obstruction should involve
the equal dilatation of the veins over the entire retina, while, as we know, it
culminates at the papilla and its immediate neighbourhood, and at but a short
distance diminishes in a marked degree. One would also expect that the tissue
changes would extend similarly over the whole retina, as it occurs—ray, in throm-
bosis of the central retinal vein. Even in complete thrombosis of this vein, however,
Michel of Wurzburg found no swelling of the papilla, but the whole retina closely
packed with small heemorrhages, a picture widely diﬁering from that of the
so-called choked disc.
It must be doubted all the more that the papillitis in cerebral disease depends
upon passive hypereemia, inasmuch as, under other circumstances, obstruction to
the return of the venous blood gives rise to no genuine inﬂammatory process. Even
if we were to admit this possibility for very high degrees of venous congestion, it
would not materially affect the position here, because the obstruction to circulation
can be but a moderate one, as may be concluded from the fact that normal vision
is so frequently retained.
Finally, the mechanical theory affords us no explanation as to why, notwith-
standing the continuance of the cause of the hyperaemia, yet the latter diminishes
after a time, and the condition passes over into that of atrophy, a succession of
events which may be observed in every intense papillitis or retinitis.
The investigation of the changes in the eye shows us, therefore, an inﬂammatory
process, which has its point of greatest development at the papilla, and loses
itself gradually in the retina, an appearance which admits of the supposition of an
inﬂammatory irritation transmitted from the brain, and operating only on the
portion of the retina nearest the central organ.
If this is admitted, we need not delay long in examining the two different
theories on which a mechanical explanation is adopted. We have at ﬁrst the theory
of Von Graefe, based upon the compression of the cavernous sinus from increased
intracranial pressure. This view was given up when we became acquainted with
the wide anastomoses of the veins of the orbit with those of the face and temporal
region, which, should an impediment to the ﬂow through the cavernous sinus occur,
OPHTHALMOLOGY. 5 5
would open up collateral outlets for the venous ﬂow from the retina. I must not
omit to mention here, that even the most extreme congestions in the great veins
of the body react but little, or not at all, upon the vessels of the interior of the eye,
as is shown by clinical observations, and by experiments upon animals. A case
which occurred in one of Professor Ebstein’s wards, at Gottingen, was, for me, very
instructive from this point of view. It was a case of sarcoma in the anterior
mediastinum, in which the autopsy showed that the tumour had obliterated the
left innominate vein, and had grown far into the superior vena cava, in conse-
quence of which the lumen of the latter was very much contracted. During
life the most extreme congestion of all the veins of the upper part of the body
existed, and also of the orbit, as the presence of double exophthalmos showed.
Nevertheless, the ophthalmoscopic examination discovered not only no choked
disc, but not even any marked dilatation of the retinal veins.
The other theory in question is that of H. Schmidt and Manz, according to which
dropsy of the sheath of the optic nerve gives rise to the papillitis, by the ﬂuid con-
tained in the distended sheath exercising pressure on the optic nerve at its entrance
into the eye. There are also important objections against this theory. Apart
from the fact that the tension of the ﬂuid is usually but slight, so that it
probably never can give rise to any great pressure upon the central vein or the optic
disc, there are several cases on record in which at the autopsy, although performed
with the greatest care, no dropsy of the sheath of the optic nerve was found; so
that in any case only a very slight quantity of ﬂuid could have been present,
although during life well-marked papillitis existed. The theory of a lymphatic con-
gestion in the optic nerve, in which also refuge has been taken, is wanting in
anatomical support, for the lymph-spaces in the lamina cribrosa, supposed to be in
direct communication with the inter-vaginal space, and into which the ﬂuid from
the dropsy of the sheath is supposed to be driven, have not again been found on
repetition of the injection experiments, and this I can corroborate from injections
I have myself made.
A very important objection to this theory lies in the observation that the choroid
immediately around the optic disc takes part in the hyperaemia and inﬁltration with
lymph-corpuscles. I had formerly noticed this condition of the choroid in several
cases which I examined, some of them cases of cerebral tumour, others of
tubercular meningitis (without tubercle in the choroid), and since I have paid
attention to it, I have found it more or less developed in every case; and quite
lately, in four cases of cerebral tumour, which Dr. Deutschmann examined for me.
Formerly, when compression of the cavernous sinus was believed in, this condition of
the choroid was not taken much notice of, because there did not seem anything
remarkable in the fact of the choroid taking part in the congestion; and it was
wholly disregarded in connection with the theory of dropsy of the sheath of the
optic nerve, which affords no explanation for it, inasmuch as, owing to the indepen-
dence of the vascular systems of the retina and choroid, the effect of compression of
the central vein of the retina cannot be transmitted to the choroidal veins. As
the inﬂammatory changes in the choroid, like those in the retina, are conﬁned to
the immediate neighbourhood of the optic disc, this circumstance corroborates
once more the supposition of an inﬂammatory excitation transmitted to the eye
through the optic nerve.
I have to mention one more theory, which refers papillitis encephalopathica to
the intermediation of the vaso-motor nerves. This view has but lately obtained the
support of so important an authority as Dr. Hughlings Jackson, although he has
5 6 OPHTHALMOLOGY.
not omitted to mention the objections which may be raised against it. As yet no
one has demonstrated these nerves, and it is diﬂicult even to imagine what course
they may take, because, as we know, tumours occupying every position within the
cranium give rise to papillitis ; and yet, nerves which would produce a reﬂex effect
upon the vessels in the eye, cannot have their origin in every part of the brain; and,
moreover, it is difficult to understand why the vaso-motor effect should be conﬁned
to the eye. Finally, the belief that true inﬂammation can be caused either
by irritation or paralysis of vaso-motor nerves, has almost completely lost its
former position in pathology ; and even one of the last of the examples which seemed
to support the theory—namely, sympathetic ophthalmia, is now more correctly
explained as depending upon a neuritis migrans. If, notwithstanding these con-
siderations, the vaso-motor theory still has its supporters, the reason may be that
a purely mechanical theory has not afforded satisfaction, and that the existence of
an inﬂammatory irritation has been assumed. I thoroughly sympathize with this
feeling, but I believe it may be satisﬁed in another way. In order to do so, we
have still to investigate whether the anatomico-pathological conditions are really
irreconcileable with the theory that the optic nerve effects the transmission of an
inﬂammatory process from the brain to the eye. If we conﬁne ourselves to an exami-
nation with the naked eye, we ﬁnd, as a rule, no sign of inﬂammation, but the
microscopical examination very often shows inﬂammatory changes in the optic
nerve. We ﬁnd perineuritis, neuritis interstitialis and medullaris; and, in short, a
normal naked eye appearance of the optic nerve does not exclude even an advanced
degree of degeneration in it. And here the microscopical examination is decisive-
What should we know to-day about the so-called choked disc, were we without the
ophthalmoscopical appearances, and had we to depend upon the naked eye appear-
ances of the optic disc after death P When in such cases practised observers
often enough cannot trust themselves to say that they see any diseased condition
in the optic disc, we cannot expect to have changes in the optic nerve which would
be more visible to the naked eye. But yet there are cases in which, owing to
hypertrophy of the inter-vaginal tissue, the inﬂammation can be recognized with the
naked eye. In order to be quite sure of its condition, the optic nerve must be
examined in its entire length, and no value can be attached to autopsies where this
point has been neglected. By this means Ihave been enabled, as a rule, to discover
inﬂammatory changes of a more or less marked kind. In but one case which I
examined did I not succeed, although softening and atrophy of some of the nerve-
ﬁbre bundles was present. This latter condition, I think, we may fairly refer to a
former inﬂammatory process, for we know that, as regards the optic disc, inﬂam-
mation results in atrophy after a certain time. It would seem, indeed, that the
optic disc suffers in a higher degree than the nerve itself; and this may, perhaps,
depend on the greater delicacy of the retinal structure, or perhaps it shows that the
cause of inﬂammation acts more severely on the optic disc.
So far we have relied upon anatomical facts, which have given evidence of an
inﬂammatory process transmitted from the brain to the optic nerve trunk and
disc. As to the cause of the inﬂammation I propose the following theory. I
would seek the cause in the ﬂuid which is driven into the optic sheath by the
increased intra-cranial pressure—the so-called hydrops vaginee—and which is
found both in cases of cerebral tumour and in meningitis, when papillitis is pro-
duced. If we ascribe the property of setting up inﬂammation to this ﬂuid, then
the development of the papillitis, the restriction of the inﬂammation to the imme-
diate neighbourhood of the optic disc, and the participation of the choroid, are
OPHTHALMOLOGY. 5 7
completely explained, as well as the more active affection of the optic disc, as com-
pared with that of the optic nerve; for the ﬂuid is collected in greatest quantity in
its neighbourhood, and must there give rise to its greatest effect. Even the
absence of a distinct dropsy need cause no difficulty in the acceptance of this theory,
for it depends, not so much on the quantity as on the quality of the ﬂuid.
A very important conﬁrmation of this theory is supplied by experiments on
animals, which Dr. Deutschmann, of Gottingen, has just published, on the conse-
quences of the inoculation of tubercle in the interior of the cranium. He has
succeeded in keeping young rabbits, into the cavities of whose crania he had injected
tubercular pus, alive for weeks and months, and in observing the consequences
of the injection with the ophthalmoscope. In these experiments, two kinds of
alteration were developed in the optic nerve : at ﬁrst, a simple inﬂammation, quite
similar in ophthalmoscopic appearance, and in the anatomical alterations, to optic
neuritis in meningitis tuberculosa of man; and afterwards, an eruption of miliary
tubercules in the sheath of the optic nerve, in the optic disc, and even in the
vitreous humour. The development of speciﬁc tubercular productions proves that
some tubercular substance or virus passed from the cranium into the inter-
vaginal space, where it must have acted at ﬁrst as a simple irritant. In a similar
way, we have to picture to ourselves the effect of certain coarse diseases, especially
of cerebral tumours, concerning which Dr. Hughlings Jackson has emphatically
insisted that they play the part of foreign bodies. We can hardly regard this
action, which may make itself felt at considerable distances, as other than a chemical
one. If we could substitute for the tumour a bit of glass or disinfected wood, we
should ﬁnd just as little inﬂammatory action to follow, as after a cerebral haemor-
rhage, where the extravasation is also to be regarded as a foreign substance, or,
as I have ascertained by numerous experiments, after the introduction of chemically
indifferent foreign bodies into the anterior chamber of the eye, or into the vitreous
humour.
The power of cerebral tumours and of tuberculosis to excite inﬂammation is
likewise the cause of the internal hydrocephalus which regularly occurs with them.
The high pressure under which this ﬂuid is secreted, the great ﬂattening of the
cerebral convolutions, and the diminution of space within the cranium, point to
the inﬂammatory nature of this exudation, just as is the case in sub-retinal
exudations with choroidal tumours, which, with a great increase of the intra-ocular
pressure, gradually produce complete absorption of the vitreous humour. When
tumours occur on the surface of the body—~among other places, on the eye—we see
often to what great distances the inﬂammatory congestion of the surrounding
vessels extends, and we can then readily picture to ourselves the processes within the
cranium.
In order to sum up my views, I would put forward the following propositions :—
Intra-cranial tumours, as also tuberculosis, give rise to congestion of the vessels,
secretory inﬂammation, hydrops ventriculorum, and increased pressure. The
products of tissue-change of those neoplasms which become mingled with the
inﬂammatory transudations, act as an inﬂammatory stimulus, and, passing with
the cerebro-spinal ﬂuid into the inter-vaginal space of the optic nerve as far as the
eye, give rise there to neuritis and papillitis.
5 3 OPHTHALMOLOGY.
De la Net/rite Opz‘z'gae dams ses rapports avec les
maladies z'm‘m-cwi‘m'ennes.
DR. BoUcHUr, Paris.
D’après une étude poursuivie pendant vingt ans, et après avoir recueilli plus de
1200 observations ou résultats d’autopsie, je crois pouvoir dire que toutes les mala-
dies importantes du cerveau ou de la moëlle épinière, et que les diathèses graves se
reconnaissent au fond de l’œil par des altérations du nerf optique, de la rétine ou
de la choroïde. C’est ce que j’ai appelé “Cérébroscopie.” En effet, dans les
troubles fonctionnels du système nerveux, l’hypérémie et le gonﬂement du nerf
optique annoncent la congestion cérébrale ou méningée, la compression du cerveau,
ou le début d’une maladie spinale. L’œdème de la papille et de la rétine avoi-
sinante annonce l’œdème des méninges et l’obstacle a la circulation des sinus et
des veines méningées dans la méningite tuberculeuse, dans l’hydrocéphalie aiguë,
dans l’hydrocéphalie chronique, l’hémorrhagie cérébrale, certaines tumeurs céré-
brales accompagnées d’encéphalite, &c.
L’anémie névro-rétinienne absolue annonce l’arrêt de la circulation cardiaque et
cérébrale. C’est la mort, qu’il est très-facile de constater par l’ophthalmoscope.
Les varices et les thromboses rétiniennes annoncent thromboses des sinus et des
veines méningées.
Les anévrismes miliares des artères de la rétine annoncent les anévrismes des
artères du cerveau.
Dans les ﬁèvres et les maladies du système nerveux, des hémorrhagies de la ré-
tine indiquent la compression du cerveau par un fort épanchement, la diathèse
hémorrhagique, un obstacle à la circulation cérébrale provenant du cœur, ou les
altérations des vaisseaux du cerveau et de la rétine par l’albuminurie chronique, la
glycosurie, la syphilis ou la leucémie.
Les granulations tuberculeuses de la rétine et de la choroïde annoncent la
tuberculose du cerveau ou des méninges.
Enﬁn, dans les aﬁcctions nerveuses, l’atrophie papillaire ou sclérose du nerf
optique indique toujours une sclérose disséminée du cerveau ou des cordons
antérieurs de la moelle.
Des Tamméoses vasculaires amenant a’es eee’m/z'z‘es optiques
ou des signes d’emâolz'e.
Dr. GALEZOWSKI, Paris.
lV_[essieurs,——L’anatomie pathologique nous a démontré, que dans les névrites
optiques cérébrales, les vaisseaux du nerf optique subissent une oblitération, et qu’il
existe des signes évidents d’endoartérites ou de périartérites dans le nerf atrophié.
D’autre part nous savons qu’il existe des dépôts calcaires, des dégénérescences
grasseuses, des scléroses, des parois, comme Liber, Manz, Muller l’ont démontré,
soit dans les branches principales de l’artère centrale, soit dans les artères périphé-
riques de la rétine.
Ce qui existe dans les vaisseaux rétiniens, a été observé aussi dans les vaisseaux
cérébraux. Charcot a démontré qu’il existe des endartérites oblitérantes, et Lan-
OPHTHALMOLOGY, 5 9
ceraux a trouvé des périartérites et des artérites syphilitiques. Dans les névrites
optiques cérébrales on trouve des oblitérations vasculaires et des thromboses.
Mais, quels sont les phénomènes que présentera un œil atteint de ces altéra-
tions, et sous quelle forme ophthalmoscopique et fonctionnelle reconnaîtra-
t-on la maladie? Tels sont les problèmes que je me suis proposé de résoudre, et
j’apporte ici les résultats de ces recherches, qui me paraissent présenter à plus d’un
titre un intérêt pratique. '
Les altérations artérielles qui s’observent dans les vaisseaux rétiniens sont de
deux sortes :—les unes qui amènent des troubles visuels lents, progressifs, comme
ceux, par exemple, que nous observons dans la névrite optique cérébrale ou dans
la rétinite albuminurique; les autres, au contraire, amènent des phénomènes instan-
tanés foudroyants, a tel point que les malades perdent la vue d’une manière subite,
comme dans l’embolie de l’artère centrale.
L’analogie entre ces endartérites oblitérantes et l’embolie est tellement grande,
que jusqu’à présent tous les auteurs ont confondu ces deux maladies. Aussi, on
voit un individu atteint d’une amaurose subite d’un œil, avec rétrécissement des
artères rétiennes et inﬁltration ou suﬁ‘usion périvasculaire, et on déclare qu’il s’agit
d’une embolie.
Depuis plusieurs années, j’étais déjà frappé de ce fait que chez un certain
nombre des malades atteints d’embolies rétiniennes, je ne trouvais pas la moindre
trace d’afEection cardiaque. J e ne voulait pas me ﬁer à mes propres investigations
du cœur, et j’ai adressé mes malades les uns au Professeur Lasègue, d’autres au
Professeur Peter, a mon regretté ami le Docteur Maurice Raynaud, d’autres à
Charcot et à. Patain.
Il résulte de ces examens contrôlés par les praticiens les plus éminents de Paris,
que sur 99 cas d’embolies, il y a eu dans 13 cas absence complète de toute altération
du cœur. Des tracés sphygmographiques ont été faits à. la clinique du Professeur
Patain chez quelques—uns de ces malades, et qui ont démontré l’état normal de la
circulation artérielle.
Mais, si on recherche les causes probables de ces différents cas d’oblitération
artérielle, on trouve des indications très-intéressantes a cet égard. C’est ainsi que
j’ai observé dans trois cas une relation entre les accès de ﬁèvre intermittente perni-
cieuse et l’oblitération de l’artère rétinienne; trois fois la maladie était due a la
syphilis; une fois elle a suivi de très-près une chute sur la tête; deux fois je l’ai
vue survenir à la suite d’un fort accès de colère ; chez une malade il y a eu une
aortite, comme Potain, avait constaté, ce qui pouvait à. la rigueur amener soit
embolies soit thromboses; enﬁn, dans deux cas on ne pouvait pas rattacher l’oblité-
ration des vaisseaux rétiniens à. aucune autre cause qu’a la migraine ophthalmique.
Le tableau statistique pourra, du reste, renseigner sur plus d’un fait étiologique
important de l’embolie et de la thrombose rétiniennes.
D’autre part, en analysant attentivement tous les symptômes qu’accusent les
malades atteints de l’une et de l’autre de ces affections, on trouvera quelques
signes distinctifs.
60 OPHTHALMOLOGY.
Tableau statistique de 46 Cas cl’E'mbolies et de 13 Cas de Tlw'omboses rétùztennes.


10-20 1 20-30 3040 40-50 50-60 60-70 70-80 80-90
AGE
4 11 12 13 27 25 9 2
, Hommes . . . . 15 -
SEXE Femmes . . . . 414J Embolie . . . . 29
ÆË âÿÿähe I I I 1 ‘fl, Thrombose artérielle . . 13
Fièvre intermittante
Syphilis .
Chute sur la tête .
Emotion vive ou colère .
Aortite . . .
Migraine ophthalmique
Goutte .. . . . . . . .
Accidents cérébraux accompagnant l’embolie
\IHNJHNI-JOQOU
Il y a dans ce tableau 13 cas, dans lesquels on pouvait rapporter les accidents
oculaires a toute autre cause qu’à. une aﬁ’ection cardiaque. Mais sur les 46 autres
cas, il est probable qu’il se trouve un certain nombre des malades tout les acci-
dents emboliques devaient se rapporter aussi à une thrombose, mais a ce moment
mon attention n’était pas attirée de ce côté, et j’ai pu confondre les deux maladies,
en ne me basant que sur un seul fait des symptômes ophthalmoscopiques qui se
ressemblent entre eux.
Il serait donc important de rechercher dans la symptomatologie ainsi que dans
les indications étiologiques, des signes caractéristiques qui permettent d’établir un
diagnostic diﬂ’érentiel entre les deux affections.
C’est ainsi, que la perte de la vue, quoique subite, est précédée, le plus souvent,
de quelques symptômes prodromiques. Un de mes malades voyait, pendant quatre
mois consécutifs, constamment des bluettes devant l’œil malade; un autre, pen-
dant les trois jours qui ont précédé l’attaque, voyait de plus en plus mal; chez
un autre, des douleurs périorbitaires venaient par crises pendant un mois, et ne
cessaient complètement qu’avec la perte de la vue. Les thromboses donnent aussi
lieu bien plus souvent que les embolies aux hémorrhagies rétiniennes qui accom-
pagnent l’inﬁltration séreuse périvasculaire ainsi que les autres signes d’embolie.
T/ze Pat/zologz'cal Changes in ReWo-éuléar Nearz'z‘z's
(Centra! Amôlyqtz'a).
Dr. SAMELSOHN, Cologne.
The specimen on which this communication was based has already been
described in its relation to the anatomy of the optic nerve (Oentralblatt f. d. m.
Wtssensch. Berl. 1880); and the author proposes to publish it, with plates, in
further detail elsewhere.
The following is an abstract of the paper presented to the Congress. The
microscopical specimens and drawings were demonstrated by the author :—
OPHTHALMOLOGY. 6 I
1.-—The anatomical condition of the disease described as central amblyopia is. a
true retro-bulbar neuritis.
2.-—This neuritis is essentially a primary inﬂammation, which results in con-
traction and a consequent descending pressure-atrophy.
3.-—-This interstitial neuritis appears to be localized at the canalis opticus.
4.1.-—In typical cases this neuritis affects only the bundles of ﬁbres which supply
the macula lutea.
5.——These bundles do not run a straight course in the intra-orbital part of the
nerve, but they decussate with other ﬁbres in order to appear ﬁnally on the lateral
aspect of the nerve. ‘
6.——The inﬂammatory nature of the disease demands an energetic resolvent
treatment.
DISOUS SION.
Professor Don, Lyons, stated that in his experience true colour-blindness did
not occur in any diseases limited to the eye itself, nor even in papillitic atrophy of
the disc; the defect for colours in all these cases corresponding in degree with the
defective acuteness of vision. But defective colour-sense—qla, defect greater than
the loss of acuteness of vision—was always present in toxic amblyopia, and in atrophy
whether from sclerosis of optic nerve, or from central disease. He concluded from
these facts that the seat of colour-perception is in the brain, and not either in the
eye or the peripheral parts of the optic nerve.
Dr. HUGIILINGS JACKSON, London: In advertiug to Dr. Leber’s mention of my
acceptance of the vase—motor hypothesis, I must remark that I hold this hypothesis
very loosely. In a paper read this year at the Ophthalmological Society, I only
said that the vase-motor was “the most plausible” of the three hypotheses I then
knew of; there is now a fourth, that of Leber. I would state some of the facts
which I think ought to be considered in relation to any hypothesis. The most im-
portant is that optic neuritis may exist with good sight, and may, under
treatment, pass off, leaving sight good. I would urge that headache and vomit-
ing, so often occurring with optic neuritis, ought to be considered as equally
requiring investigation and explanation.
Dr. PARINAUD, Paris: I would refer to an article which I published in 1879
(Ann. d’Ocal/ist), in which I arrived, though by a different way, at conclusions
nearly the same as those of Professor Leber—viz., that optic neuritis in intra-
cranial disease was the result neither of venous stasis nor of vase-motor irritation ;
that increased intra-cranial pressure alone, however produced, could not cause it;
and that eﬁ'usion into the optic nerve-sheath was only of secondary importance,
and could not, by compression, cause changes at the disc. I consider that optic
neuritis in cerebral diseases is primarily a lymphatic oedema connected with
hypersecretion of the cerebro-spinal ﬂuid. This oedema occurs in the same way
as that of the brain-substance under the same conditions, and is the starting-point
of the inﬂammatory process. Though it may be of passive nature. it seems more
prone to cause inﬂammatory lesions than oedema by venous stasis. Though the
histological changes (in the nerve) were those of true inﬂammation, this was not,
in my opinion, the result of direct connection with intra-cranial lesion. The optic
eneuritis was, even in acute meningitis, I aﬂirmed, related to hypcrsecretion of liquid,
and not either to the intensity, quantity, or position of the meningeal exudation.
62 OPHTHALMOLOGY.
Optic neuritis in intra-cranial diseases indicated cerebral oedema. As this oedema
nearly always occurs in cerebral tumour, as well as in meningitis with hydro-
cephalus, neuritis is to be taken as an almost certain sign of ventricular dropsy,
although this dropsy is not indispensable for the production of the optic nerve
disease.
Dr. STEPHEN MACKENZIE, London: I concur with Professor Leber in rejecting
the theories of venous stasis due to diminished intra-cranial space, and of irritation
of vasO-motor nerve, as the usual causes of optic neuritis in connection with coarse
intra-cranial disease. I think that the theory of Professor Leber would explain
many cases. But we meet with cases where there is no evidence of serous effusion
(internal hydrocephalus), and in which this theory, to me, fails to explain the
neuritis. I have published a case of neuritis without naked eye appearance of
disease, but in which microscopy revealed general diffused cerebritis. There was
no evidence of meningitis,and no distension of the sheath of the optic nerve. I believe
thatin such cases the neuritis is explained byadirect extension processfrom the brain.
This view is supported by microscopic examinations of the trunk of the optic nerve,
by Dr. Growers, Dr. Walter Edmunds, and others, who have found, like myself,
increase of nuclei throughout its length, chieﬂy in the course of the blood-vessels.
Further, in some published cases of unilateral neuritis from cerebral tumour, with
post-mortem examinations, it is remarkable that the neuritis was on the side
opposite to the tumour. It seems to me that such cases are unexplained by
increased intra-cranial pressure, or by a vaso-motor theory, or on Professor Leber’s
theory; but that they are explained by a direct extension process. The same
explanation would apply to other cases where there is no evidence of meningeal
effusion. There may be, I think, one of two processes which are usually in
action in causing the optic changes—via, either (1) direct extension of the central
change, inﬂammation, atrophy, &c., to the optic nerve; or (2) like tissues being
affected in a like way by one inﬂuence, as in Bright’s disease, diabetes, ague,
anaemia, leucocythaemia, 860. Still, Dr. Leber’s theory may explain cases where
serous meningeal effusion occurs.
Dr. PONOET, Oluny: Optic neuritis from meningitis is chieﬂy situated in the
tissue of the neuroglia; it consists in an accumulation of nuclear elements with
oedema; but the interstitial vascular connective tissue is free. It is the
neuroglia that is chieﬂy implicated in the degeneration of the nerve. Optic
neuritis is not produced in animals by irritation either of the sympathetic or ﬁfth
nerves.
Professor LAQUEUR, Strasbourg, agreed with Dr. Galezowski and others as
to the absence of evidence of heart-disease in many of the cases of so-called
embolism; in seventeen such cases he had found cardiac disease in scarcely eight.
The symptoms might be due to true embolism, or to thrombosis, or to haemorrhage
into the optic nerve. True embolism was probably the explanation of the cases
where the permanent symptoms were preceded by a passing attack of blindness_
Professor PANAS, Paris: My experience of papillary stasis (stauungs-papilla)
points to the following conclusions in traumatic lesions of the brain (commotion,
concussion, contusion, fractures, and gun-shot injuries). The presence or absence
of swollen disc does not help us either in the diagnosis or prognosis of the lesion;
OPHTHALMOLOGY. 6 3,
patients showing this condition may recover, though the swelling continues during
their convalescence. Post-mortem examinations have shown that when there had
been swelling of the disc, the sub-vaginal space was always distended by serous or
bloody ﬂuid; whilst this distension was entirely wanting in cases where no
stauungs-papilla had existed during life.
Dr. KNAPP, New York: In support of the theory of Professor Leber, I would like
to mentionthat orbitaltumoursfrequently cause the highest degree of exopththalmos,
but no choked disc. Only when they encroach upon the sheath of the optic nerve,
especially the non-capsulated malignant tumours of the periosteum, do they cause
neuro-retinitis. As to the curability of choked disc, of which ‘Dr. Hughlings
Jackson has spoken, I beg to state that I have seen a few marked cases combined
with headache and vomiting, in persons of tuberculous families, recover not only
their full sight, but also a normal aspect of the optic nerves. Moreover, I desire to
mention those cases to which Dr. Kipp, of Newark, N.J., ﬁrst drew the atten-
tion of the profession (in the Archives of Otology), and of which Ihave also seen a
few instances; I mean choked disc caused by purulent meningitis from suppurative
otitis media. They get completely well when, with the ear disease, the consecutive
meningitis is also cured.
Dr. PAGENSTECHER, Wiesbaden: I ask Professor Leber whether, in the experie
ments to which he has alluded, where tubercular material was injected into the
brain, any deposits of tubercle were found in other organs than the optic nerve and
retina? The reply to this question appears to me to bear in an important manner
on the conclusions which can be drawn from the experiments.
Professor LEBER, Gottingen : The experiments I alluded to were not made by
me, but by Dr. Deutschmann, assistant at the Ophth. Clinic of Gottingen. Tuber-
cular pus was injected into the cranial cavity of young rabbits, and the animals sur-
vived this operation for weeks and months. Some of them died spontaneously, others
werekilled at different times after the inoculation. In all cases post-mortem examina-
tions were made, and the different organs examined, aided, if necessary, by micro-
scopic research. In the ﬁrst stage, there were found quite the same alterations as
in tubercular meningitis of man; the optic nerve in its intra-cranial portion being
normal, while in the region of the orbit a dropsy of the sheath was present, accom-
panied with some perineuritis and neuritis interstitialis, which increased as the
eye was approached. Sometimes this process during life went back into atrophy,
which could be observed by the aid of the opthalmoscope. In the further course of
the disease, miliary tubercles became developed in the sheath of the optic nerve,
in the papilla, and even in the vitreous humour. The result of the examination
showed evidently that the inﬂammatory process was propagated in some way from
the intra-cranial cavity, and the greater development of the changes at the anterior
end of the optic nerve seemed to be attributable to the entrance of some irritating
matter into the inter-vaginal space of the optic nerve.
Dr. BRAILEY, London : Speaking from memory alone, I am strongly of impres-
sion that tumours of the orbit can, by simple pressure on the optic nerve, produce neu-
ritis. I have examined carefully the specimens of Dr. Edmunds, alluded to by Dr.
64 OPHTHALMOLOGY.
Mackenzie, and I agree that inﬂammation can be traced along the optic nerve itself
as far as the brain. This is, of course, consistent with its having spread along, and
from, the meninges, entering the nerve from its pial sheath. The increase of nuclei is
best seen in the walls of the small blood vessels, and in the ﬁbrous stroma of the
nerve, though the neuroglial corpuscles are also increased in size. If actual inﬂam-
mation can be traced along the nerve-sheath it seems unnecessary to assume the
existence of a phlogogenic ﬂuid.
Prof. LEBER: In resuming the result of our discussion on the connection
between optic neuritis and intra-cranial diseases I can be short, because on most
points there has been no divergence of opinion. It seems to be generally admitted that
optic neuritis in intra-cranial diseases is a true inﬂammation, which cannot be pro-
duced by purely mechanical causes, and that the theories which try to explain this
connection by compression, either of the cavernous sinus by increased intra-cranial
pressure, or by compression of the optic nerve by dropsy of its sheath, ought to be
abandoned. There remain, then, only two theories: that of reﬂex-motor action, and
that of propagated inﬂammation, a special modiﬁcation of which I have tried to
defend before you. I shall not enter here any more into the arguments against the
reﬂex theory, which has lost to-day, as I believe, much of its former credit; and I
allude only to the analogy of sympathetic ophthalmia, for which this theory is
about to be abandoned also, as our discussion of yesterday has proved. On the
contrary, the anatomical facts are quite in favour of the supposition that the in-
ﬂammation is in some way propagated from the intra-cranial cavity to the eye. As
to the origin of this inﬂammation, I agree with the views of Dr. Parinaud so far
that the serous exudation in the ventricles—which is found as well in cerebral
tumours as in meningitis, when they give rise to papillitis—is produced by some
inﬂammatory process, by a kind of encephalitis. Serous exudation also passes into
the intervaginal space, and seems to act here, as I believe, as an irritant to the
optic nerve and disc. We may explain, in this way, how the inﬂammation is not
always found to be quite continuous, and how it can increase with the distance from
the central organ. Dr. Stephen Mackenzie seems to prefer for certain cases, where
the inﬂammatory process is continuous from the brain to the eye, the explana-
tion by a direct extension process. But I believe that here there is no real diﬁer-
ence of opinion ; if we admit that the inﬂammation is propagated from one point to
another, we have to admit also that the inﬂammatory irritant, the cause of this
process, must propagate. The cases Dr. Mackenzie has alluded to make, from this
point of view, no great diﬂiculty in the explanation. Dr. Hughlings Jackson
has hinted at the clinical symptoms, and has very judiciously remarked that a
theory must explain not a single symptom only, but all symptoms. I believe that
our theory is able to do that, as far as our knowledge goes to-day. It will account
as well for the papillitis as for the other clinical symptoms, such as headache, spasm,
&c., which may easily be explained by an inﬂammatory condition within the cranial
cavity. The transitory attacks of severe cerebral symptoms seem to depend on
periodic inﬂammatory congestions, with increased serous transudation, such as
commonly occur in these neoplasms. But we can go still farther trying to follow
the theory in its consequences, and to state if it will prove suﬂicient. If really the
ﬂuid driven into the optic sheath is liable to set up an inﬂammatory state, we
should expect the same consequence in those parts of the brain which come into
contact with this ﬂuid, especially the walls of the ventricles. In hydrocephalus,
and in cerebral tumours, doubtless always a considerable softening of the walls of
OPHTHALMOLOGY. 6 5
the ventricles does exist, but this usually is regarded as a post-mortem appearance,
although, perhaps, certain changes may exist during life. With regard, however,
to hydrocephalus internus in tubercular meningitis, Professor Orth, of Gottingen,
has informed me that changes similar to those in the retina really do occur, and that
he has frequently observed numerous small heemorrhages, some on the grey and some
on the white substance of the walls of the ventricles. Lastly, I have to mention
the papillitis in orbital tumours, in regard to which Professor Knapp has made a
remark in favour of the inﬂammation theory. There is a striking analogy between
optic neuritis occurring in diseases of the brain, with increased intra-cranial pres-
sure, and in orbital tumours which exercise a pressure on the eye ; and if we ought
to refer the development of neuritis in the last case to mechanical pressure, we
would be inclined to admit the same explanation for cases of cerebral tumour also.
But against this reasoning, we can state at ﬁrst what Professor Knapp has already
mentioned, that papillitis in orbital affections is not constant, and, even in a high
degree of pressure on the globe, it does not always occur. Further, this reasoning
is in contradiction to anatomical facts. By the kindness of Professor Horner, I
have had an opportunity of making the anatomical examination of a case of orbital
tumour, in which, as far as I remember, the tumour was not in the immediate
vicinity of the optic nerve. I found an enormous swelling of the papilla, just as
in cerebral tumours, with a very great distension of the small vessels of the
choroid, and inﬁltration with lymph-corpuscles, which, however, was conﬁned to the
immediate neighbourhood of the papilla, whilst the principal branches of the venee
vorticosae and the other vessels of the choroid were but moderately distended. I
cannot account for this condition by mere venous congestion, and I must
suppose that by some, as yet unknown, channel, inﬂammation passed from the
tumour to the eye. Accordingly, papillitis, occurring with orbital affections,
furnishes still another argument for the inﬂammatory development of papillitis
encephalopathica.

T raz'z‘ewem‘ des Décollemem‘s de [a Re’tz'rze par les z'njecz‘z'mzs
sozrscutane’es a’e Pz'locarpz'rze.
Dr. DIANOUX, Nantes.
Dans un premier travail inséré dans les Archives d’Ophthalmologie, je publiais
an mois de N ovembre dernier les résultats que j’avais obtenus contre le décollement
de la rétine par les injections souscutanées de pilocarpine. Oette publication, un
peu hative peut-étre, me paraissait justiﬁée et par l’importance des résultats et par
le désir d’attirer sur ce point l’attention du public medical. Depuis cette époque
j ’ai pu non seulement aj outer de nouvelles observations, mais encore suivre et
control'er les anciennes de maniere a me former une opinion plus solidement assise
sur la valeur réelle de la medication.
Oas traités 16
Guérisons absolues . . . . . ‘i
Guérisons presque absolues 3
Améliorations . . . . . . . - 8
l
Insucces absolu
Voila ma statistique. Elle exclut toute idée de série fortuitement heureuse.
PART III. F
66 OPHTHALMOLOGY.
Pour ne pas abuser des moments si précieux d’un congrès, je me bornerai à.
donner le résumé de mes récentes observations qui seront publiées en détail dans
la thèse de mon chef de clinique.
Qu’il me suffise d’ajouter qu’aucun des malades qui avait bénéﬁcié de la
médication et dont les observations ont été déjà 'publiées, n’a subi de rechute ou
d’aggravation depuis le mois de Novembre.
Observation I.——Le 5 Novembre, l1880. Sœur St. B. , hospitalière à. la
Maternité de l’Hôtel Dieu; 50 ans, est d’une santé chêtive, asthmatique, sujette à.
des constipations opiniâtres, très-myope, n’a jamais porté de lunettes. La vision a
commencé à baisser en Janvier, 1880, puis est tombée brusquement tout récemment.
O.D. V. = ë. O.G‘r. V. = 515. M. = 10 D.
Décollement de la rétine gauche très-tendue, corps vitré troublé, 15 injections
de pilocarpine, puis repos de huit ours.
V = 515; lit No. 9 de Wecker; extension du champ visuel, scléro-choroidite
postérieure très-avancée intéressant la région de la macula. Malgré une poussée
d’iritis l’amélioration continue, mais vers le 20 Octobre, sous l’inﬁuence de maux
de tête consécutifs dus eux-mêmes à une constipation opiniâtre, une rechute survient.
De nouvelles injections ramènent une amélioration, qui ne s’est pas démentie depuis
Novembre. Elle lit le No 8.
Le 21 Janvier le décollement n’a plus qu’une épaisseur insigniﬁante, il siège en
bas dans la région équatoriale. Le 15 février on ne trouve plus à cette place qu’une
coloration louche. La guérison se maintient.
Observation II.—Land, 32 ans, teinturier, assez maigre, gastralgique, néuropathe,
a été considéré comme tabétique. Abaissement progressif, puis brusque, de la
vision de l’œil droit à. la suite de fatigue extrême après une journée de foire.
Est venu consulter un médecin qui le soigna par les ventouses et les injections
de strychnine.
Vers la ﬁn de Juillet, 1880, la vue commence à baisser de l’œil gauche. Il
vient me consulter à cette époque. Je constate O.Gr. M —-10 diopt. ‘v.= Fr. O. D.
Compte diﬁicilement les doigts.
De ce côté décollement de la rétine occupant le pôle postérieur de l’œil; le
décollement est peu saillant.
Sur mon avis le médecin de la localité qu’habite M. L. lui pratique 9 injections
de pilocarpine. Les trois premières, par erreur dans la dose injectée, produisent
un effet excessif. Le 11 Septembre :——0. G. V.= —â—. O. D. V.= Îïî.
Le malade peut lire le No. 41 de Wecker facilement avec l’œil malade. Il persiste
un scotome irrégulier, mais seulement relatif. Teinte grisâtre, à ce niveau nom-
breuses plaques de scléro-choroïdite.
Nouvelle série de 12 injections a la suite desquelles je ne constate plus trace
du décollement.
Le scotome relatif qui persistait encore a disparu ultérieurement. La guérison
se maintient.
Observation IIL-Rondeau, 32 ans, Vannier, scrofuleux et alcoolique, souffre
d’une affection du foie.
Myope (9 diopt). La rétine décollée vient de ce côté masquer tout le champ de
la pupille sauf à la partie interne.
Après 15 injections amélioration considérable; le malade peut lire quelques mots
du N o. 10 de Wecker.
Observation IV.—Le 4: Février, 1880. Madame V., 60 ans, exerce la profession
fatigante de femme de ménage; elle est anémique et se nourrit irès-insuﬁisamment.

OPHTHALMOLOGY. 67
Huit jours avant de venir consulter, abaissement subit sans cause appréciable de la
vision de l’œil gauche. O.D. M.= 2'25. ‘7.2%.
Madame V. n’a jamais porté de verres.
Œil gauche ne peut compter les doigts.
De ce côté légère cataracte étoilée. Décollement étendu de la rétine, tension
diminuée.
Après 15 injections de pilocarpine, agrandissement du champ visuel et éclair-
cissement notable du corps vitré, malgré une poussée d’iritis vite enrayée par un
traitement approprié. .zälg sans verre.
Le 29 Mars V.='glî. La malade peut se conduire seule avec l’œil malade dans un
milieu bien éclairé. Etat stationnaire jusqu’au mois de Mai; à cette époque à la
suite de chagrins de famille et de mauvais traitement, augmentation rapide du
décollement, l’œil devient phtisique et tend à s’atrophier; je fais cesser la compres-
sion employée depuis quelques jours.
La malade, découragée et en butte à. des reproches continuels, de la part de son
mari qui l’accuse de perdre son temps, cesse tout traitement.
Observation V.——Le 18 Décembre, 1880, entre Eula. clinique ophtalmologique de
l’Hôtel Dieu la nommée Marie Blaie, lingèrc, âgée de 23 ans. Elle porte depuis
longtemps des verres concaves; malgré cela sa vue a toujours été mauvaise. J e
constate sur les deux'yeux un décollement étendu de la partie inférieure des rétines,
avec trouble considérable du corps vitré. La myopie est de 10 diopt. V.=-ÉU. -
Après 15 injections et 10 jours de repos V=Î1Î avec un verre approprié et la
lecture du No. 43 de Wecker est possible, quoique diﬁicilement.
Après 15 nouvelles injections la lecture de ce même numéro est facile. La
rétine s’est réappliquée, mais elle conserve une coloration grisâtre qui est due à
l’interposition entre la membrane nerveuse et la choroïde, dont on aperçoit la
coloration rosée, d’un tissu de nouvelle formation, l’analogue des plaques laiteuses
du péricarde ou des fausses membranes de la pleurésie.
Le 10 Mai le champ visuel de l’œil gauche est redevenu normal à. son tour,
et la malade peut lire le No. 3. Le corps vitré contient encore de nombreux
ﬂocons.
En présence de semblables résultats je crois pouvoir dire sans risquer d’être
contredit par personne, qu’aucune médication n’a jamais rien produit, à. beaucoup
près, d’aussi satisfaisant.
Oo'nclusio'na—Les injections de pilocarpine méthodiquement pratiquées doivent
constituer le traitement principal des décollements de la rétine. Elles sont seules
applicables dans les décollements très-limités ou inaccessibles à. la ponction.
Ces injections modiﬁent avantageusement dans presque tous les cas, la lésion
oculaire.
Cette lésion doit être assimilée aux épanchements des séreuses de cause irrita-
tive; le pilocarpine agit comme un révulsif et un dérivatif spécial, qui excite
la secrétion des glandes salivaires innervées par la même paire nerveuse qui
préside à. la secrétion des liquides oculaires, et a un plus haut degré en amenant
une déperdition d’eau considérable dont un des premiers effets est la résorption des
liquides de nature inﬂammatoire, suivant les lois de la pathologie générale.
Les résultats produits sont passagers ou déﬁnitifs suivant des conditions qu’il
est actuellement impossible de ﬁxer absolument. ’
Les conditions favorables sont la jeunesse du sujet et des conditions sociales et
hygiéniques satisfaisantes ; le peu de temps écoulé depuis le début de l'affection,
l’intégrité, du moins relative, du corps vitré, la conservation de la tension normale
‘z
F 2
68 ' OPHTHALMOLOGY.
intra-oculaire, le traumatisme ou le froid comme causes, l’absence de ponction
antérieure.
Les contre-indications: état de phtisie manifeste du globe ou diminution
accusée de la tension, détachement complet de la rétine.
Très-grande ancienneté de la lésion (plus de deux ans).
Etat cachectique du sujet ou lésion cardiaque grave. Les injections devront
être pratiquées d’après les règles suivantes.
La solution est aussi formulée:
Nitrate de pilocarpine, vingt centigrammes.
Eau distillée, quatre grammesﬁ“
La dose variera suivant les sujets de 5 a 10 et l5 gouttes. L’eiÏet obtenu devra
être une salivation de deux heures de durée au moins.
Chez les sujets jeunes et vigoureux, les quatre ou cinq premières injections pour-
ront être faites à. dose suffisante pour amener une abondante-transpiration.
Ces injections seront faites a la partie postérieure de l’avant bras.
Elles devront être continuées pendant dix ou quinze jours consécutifs suivant
la force de résistance des malades.
Elles seront reprises après 10 jours de repos, et pourront être continuées ainsi
pendant plusieurs mois. L’insuccès dans la première série ou un état stationnaire
après une amélioration au début ne devront pas décourager.
Les injections devront être reprises à la moindre menace de rechute.
L’eniploi simultané du collyre d’atropine peut neutraliser chez certaines per-
sonnes mêmes de fortes injections de pilocarpine; elles ne devront donc être employées
qu’en cas d’absolue nécessité.
Il va de soi que toutes les précautions hygiéniques appropriées seront prises.
La compression, au début, peut être un utile adjuvant, elle doit être cessée s’il
y a menace de diminution de la tension intra-Oculaire.
DISCUSSION.
' Dr. G. MARTIN, Bordeaux: I have not been so successful in eight cases of reti-
nal detachment, seven of which were spontaneous, and one traumatic. Pilocarpine
was used before operating by puncture, or galvano-caustic, in ﬁve, and after Opera-
ting in six. Each patient had twenty injections of 2 0. gr. The duration of the
detachment varied from ﬁve days to three months. In ﬁve cases the detachment was
local, in three it was nearly complete.
Dr. MARTINI, Rome: I have treated, since 1879, twelve cases of detached retina
by pilocarpine injections ; complete cure was obtained in 5, decided beneﬁt in 2, tem-
porary beneﬁt in 2, failure in 3. The prognosis is best when the detachment is small
and recent; doubtful when it is limited and old; hopeless, when old and very ex-
tensive. I prefer nitrate of pilocarpine to hydrochlorate. I begin with 1'5 to 2 0. gr.
Salivation and sweating always in my cases lasted 2 to 2% hours.

* En France la pilocarpine de Dusquesnel est la seule a laquelle on puisse se ﬁer.
OPHTHALMOLOGY. 6 o
Ueöer PaZ/wgenese zum’ Aez‘z'ologz'e des N ysz‘agmus der Bergleute
nach Uzzz‘erszee/zzmgen 7/012 7 500 Bergleufeﬂ.
Dr. NIEDEN, Bochum.
Gehe ich in Kürze auf das Wesen dieser Ihnen allen gewiss bekannten
Erkrankung des Muskelapparates der Augen ein, so besteht der Nystagmus der
Bergleute ja eben in einer im spätem Leben erst acquirirten, periodisch auftre-
tenden Augenmuskelaifection bei denjenigen Bergleuten, die in der Dunkelheit
des Grubenschachtes ihre Arbeit als sogenannte Hauer zu verrichten haben.
Dieselbe äussert sich darin, dass bei herabgesetzter Beleuchtung bei den leichteren
Fällen, bei gewöhnlichem 'I‘ageslichte bei den schwereren und zwar bei dem
Versuche, das Auge nach oben zu drehen, die bulbi der betreffenden Individuen in
unendlich rasch erfolgende Drehungen und Rollungen um ihre Vertical resp.
Diagonalaxe gerathen, und nicht eher wi'eder zum Stillstand kommen, als die
Augäpfel kräftig nach unten gewendet werden oder die Patienten die Augen
schliessen. In Folge dieser unwillkiihrlichen Augenbewegungen wird bei den
betreffenden Patienten Scheinbewegung der gesehenen Cbjecte vorgetäuscht und
werden Schwindelzustände dadurch hervorgerufen.
Bei den höheren Graden dieses Leidens pﬂegen sich diese Nystagmus-Bewe-
gungen der Augen auch schon bei horizontaler Lage der Blickebenen einzustellen,
so dass die Patienten gezwungen sind, schon im gewöhnlichen mit stark zurückge-
legtem und streng ﬁxirtem Kopfe einherzugehen, um nicht durch die Schwindel-
zustände zu sehr gestört zu werden. Zuweilen gesellen sich in diesem Zustande
blepharospastische Zuckungen des Orbicularis hinzu, die je stärker werden, je mehr
der Patient seinen Blick nach oben richtet und dadurch also stärkeren Nystagmus
hervorruft. Bei noch ausgeprägterer Form des Leidens betheiligen sich auch die
Musculatur des Halses und N ackens an diesem Tremuliren.
Gewöhnlich sind die Nystagmus—Bewegungen der Augen rein associirte auf
beiden Seiten. Nur viermal habe ich unter 299 Fällen dissociirten Nystagmus
beobachten können. Einmal fand sich nämlich auf dem einen Auge rein oscil-
lirender Nystagmus, zweimal gab sich auf dem einen Auge eine sehr beträchtliche
Aﬁection kund, während das andere Auge nur bei stärkeren Eixationsbestrebungen
in leise Zuckungen gerieth und nur einmal konnte ich einseitigen oscillirenden
Nystagmus constatiren. Ungleichmässig starke Entwickelung, abwechselnd je
nach der Drehung der Blickebene nach oben, innen oder aussen, lässt sich indess
in zahlreichen Fällen nachweisen. Die rein rotirende Form wurde in 72 per Cent
aller Fälle, die oscillirende in 12'5 per Cent und die gemischte Form in 15‘5 PP
Cent gefunden ; horizontaler Nystagmus kam nicht zur Beobachtung. ‘
Bei dem Mangel aller Daten gerade über das procentarische Verhältniss und
andererseits die Unwahrscheinlichkeit der bezüglichen Mittheilungen z. B. von
Romiäe, der in 20 per Cent Nystagrnus unter den Bergleuten constatirt haben
will, veranlasste mich, Massenuntersuchungen in loco auf den einzelnen Zechen zu
veranstalten. Ich liess zu dem Zwecke vor der Früh resp. Mittagsschicht die
Bergleute an einem etwas dunklen Orte je einzeln vertreten, ﬁxirte den Schädel
mit der Hand in der mittleren Ruhelage, liess dann meinen ausgestreckten Finger
der anderen Hand ﬁxiren und hob denselben nach oben hin, wendete ihn
links und rechts, machte einige rasche Hin-und Herbewegungen bei stets
nach oben gerichteter Blickrichtung des Untersuchten und war damit nach
7 O OPHTHALMOLOGY.
stattgehabter Notirung des Alters, Art der Beschitftigung, Art des Gruben-
liohtes 850. die Untersuchung beendet. Es wurden hiebei folgende Zahlen
gefunden: Von 7416 untersuohten Bergleuten fand sioh aoquirirter Nystagmus
deutlich augesprochen in 299 Féillen oder 403 per Gent der Gesammtsumme. Von
grosserem Interesse War es, festzustellen, ob die Ermiidung durch die Arbeit von
so grossem Einﬁusse auf das augenbliokliohe Hervortreten des Leidens sei, wie
Romiée behauptet. Ioh untersuohte deshalb auf den einzelnen Gruben separat
2003 Mann, die von der Arbeit zu Tage gefordert Wamen und fand bei diesen vier
und seohsig mal oder in 3.2 per Gent Nystagmus-Bewegungen der Augen, wiihrend
von den 1913 zur Arbeit einfahrenden Mannschaften sioh dieselben bei 55 Féillen— ‘
2'9 per Gent zeigten. Der Untersohied in beiden Zahlen ist ein relativ geringer zu
Ungunsten der von der aohtstiindigen Arbeit zuriiokkehrenden, und oorrespondirt
wieder nicht mit den hohen von Romiée in diesem Falle gefundenen Zahlen.
Wiihrend bei diesen Zahlenangaben die Bergleute in toto genommen sind betr.
des Vorhandenseins der Nystagmuskranken unter ihnen, und sioh hier die Ziﬁ'er von
‘1'03 per Gent herausstellt, ergiebt sioh, Wenn wir naoh dem Auftreten des Leidens
nur unter den augenkranken Bergleuten forsohen, dass sich bei 3017 in sieben
Jahren wegen Augenleidens in Behandlung getretenen Bergleuten, Nystagmus
1'72 mal verzeiohnet ﬁndet oder in 5'6 per Gent, Wéihrend sioh das prooentamische
Verhétltniss bei den in diesem Zei’oraum behandelten 29,640 Augenleidenden meiner
Praxis nur 211 054 per Gent stellt. Gewiss sind also die erstaunlich hohen Zahlen
von 20 per Gent, &0., selbst bei derAnnahme des Vorhandenseins aller moglichen,
besonderen Sohéidlichkeiten viel zu hoch gegriﬂ‘en, und hat sioh der Beobaohter
Vielleicht duroh kurze Zuckungen der Augen, die bei vielen Individuen bei rasoher
Drehung der bulbi naoh oben ausgelost werden, zu der irrigen Annahme bewegen
lassen, in allen diesen Fallen N ystagmuskranke vor sich zu sehen.
Hoohst auﬁallend war mir indess bei meinen Untersuohungen von einigen zwolf
Bergwerken, dass sioh die Erkankung, zwaa' fast nur bei Bergleuten einerlei
Gattung, néimlich den Hauern, die die Kohlen nus ihren engen Lagern loszulosen
und auszuhauen haben, zeigte, sioh indess nur auf bestimmte Gruben des meiner
Beobachtung zustehenden Gebietes von Steinkohlenzechen besohréinkte. Soheinbar
lag hier ein Zusammenhang mit der geographisohen Lage der Bergwerke vor,
indem die naoh Nord und Nordost von meinem Wohnorte gelegene Zechen die
Erkrankung in exquisiter Weise und zwar e weiter naoh Nord um so betréichtlioher
zeigten, wéihrend die naoh Siid und Siidwest gelegenen fast frei von der Aﬁection
waren. So oonstatirte ich Z. B. auf den am weitesten naoh N 0rd gelegenen Gruben
das Vorkommen von '7 per Gent aller 0a,. 2000 Mannsehaften, Wéihrend die nnoh
Siid gelegenen bei gleicher Anzahl kaum 0'25 per Cent des Vorkommens zeigten.
Anféinglioh glaubte ioh hiefiir vielleieht die grossere Tiefe der naoh Nord
gelegenen Gruben und damit die grossern Sohéldlichkeiten des hoheren Luftdruokes
fiir diese eigenthiimliohe Erscheinung des localisirten Auftretens als urs'etohliches
Moment ansehn zu miissen. Allein als sioh Weiter herausstellte, dass grade eine
jener durch den Nystagmus beriichtigten Zeehe néichst gelegene und mit ihr con-
solidirte Grube von nahezu gleioher Tiefe fast vollstéindig frei von Nystagmus-
kranken WELT, musste die Annahme des sch'zidigenden Einﬁusses der Tiefe der
einzelnen Gruben als nich’oig hinfallen. Naohdem ioh weiter meine Beobaohtungen
zur Eruirung der Pathogenese dieses Leidens auf die Zeit des etwa zu consta-
tirenden héiuﬁgeren Auftretens geriohtet, indess keinen wesentliohen Untersohied
zwischen den einzelnen Jahreszeiten hatte constatiren konnen ebensowenig Wie die
Art und chemische Beschaﬁ‘enheit der Kohlen der einzelnen Gruben Veranlassung
OPHTHALMOLOGY. 7 I
gab, in dieser das besonders schädigende Moment zu suchen, noch auch die Lage
des Arbeitsfeldes, ob die Kohlen aus horizontal liegenden, oder in steilen Winkel hang-
enden Lagern entfernt werden müssen, wodurch natürlich stärkere Anstrengung
der nach oben oder unten arbeitenden Muskelgruppen des Auges die Folge ist, ergab
sich schliesslich auch meine alte Beobachtung wieder als richtig, dass die Wetterein-
flüsse der einzelnen Zechen von gar keiner directen Bedeutung seien. Allein der
Umstand, dass sich herausstellte, dass alle diejenigen Zechen, auf denen die Berg-
leute der ungünstigen Luft und Wetterverhältnisse halber mit geschlossener,
sogenannter Sicherheitslampe arbeiteten, die zahlreichsten Fälle dieser Erkrankung
aufwiesen, während die Mannschaften der nach Süd gelegenen Gruben zumeist mit
offneu Lampen arbeiteten, legte mir die Frage nach der Beleuchtungs-Qualitat und
Quantität des Arbeitsfeldes nahe.
Nicht die schlechten Luftverhaltnisse als solche, wie sie von einigen Autoren
angegeben werden, sind die schädigenden, die Entstehung der Krankheit begün-
stigenden Momente, sondern der Mangel der Beleuchtung, wie sie durch jene
Sicherheits—(Davy’sohe) Lampen gesetzt werden. Eine quantitative Licht-
untersuohuug der einzelnen Beleuchtungsapparate hat mir denn auch gezeigt, dass
sich nach dem Bunsen’schen Photometer gemessen das Lichtquantum der offenen
Lampe zu der frisch entzündeten und zu einer acht Stunden in einer von Kohlen-
staub angefüllten Luft im Gebrauch gewesenen Sicherheitslampe verhalt wie 10.0 =
41-0: 3.0, so dass also der bei der Sicherheitslampe einige Stunden arbeitende Berg-
mann nur ein Drittel der Lichtmenge erhält, wie der bei offener Lampe beschäftigte
Arbeiter. Mein in den letzten zwei Jahren auf diesen Punkt gerichtetes Augen-
merk hat denn auch ergeben, dass von den 117 in diesem Zeitraum wegen Nystag-
mus in Behandlung getretenen Bergleuten 107—91‘4 per Cent ihre Arbeit mit
Sicherheitslampen-Beleuchtung verrichten musste, während auf zwei Zechen, die
nur offene Lampe führen, unter 772 Mannschaften nur 0'35 per Cent Nystagmus-
kranke gefunden wurden. Nicht allein die mangelnde Lichtmenge dieser Lampen,
sondern auch die für die Arbeit der Hauer specielle ungünstige Construction
derselben, hatte die Leute selbst bald darauf geführt, die Ursache der Entstehung
ihres Leidens in die Lichtquelle zu verlegen. Dafür, dass also die Beleuchtung
von wesentlichstem Einﬂuss für die Pathogenese des Nystagmus ist, liefern unsere
Daten den stricten Beweis.
Indess nicht die mangelnde Beleuchtung des Arbeitsfeldes allein, sondern auch
das mangelnde Perceptionsvermögen von Seiten der Augen ist es, was besonders
die Entstehung des Nystagmus begünstigt. So ergiebt sich aus der Statistik der
letzten Jahre, dass von den in specielle Behandlung getretenen Nystagmuskranken
37 per Cent resp. 39'41 per Cent an anderweitigen Augenaffectionen litten, als :
Trachom, Trübung der Cornea, Iritis chronica, Irido-chorioiditis, Atrophie des
Opticus, &c. &c., wodurch also ein erschwerter Gebrauch des Sehorganes bei der
Arbeit bedingt war, und die ungewöhnliche dadurch nothwendige starke Anstren-
gung der Augen leicht zu einer Üeberanstrengung Veranlassung gab, von der die
Uebermüdung die natürliche Folge war.
Weiter kommen noch als begünstigende Momente allgemeine Constitutions-
anomalien hinzu, wie sie sich in fast 4,5 per Cent aller meiner Beobachtungen als
anamische, catarrhalische, gastrische, nervöse Zustände verzeichnet ﬁnden, um das
Leiden entweder indirect durch Schwächung des allgemeinen Systemes hervor-
zurufen oder sein Auftreten zu verstärken.
Fassen wir kurz zusammen, so lässt sich der Nystagmus der Bergleute hinstellen,
als ein in dem Procentsatz 4-5 per Cent unter Kohlen-Grubenarbeitern vorkom—
7 2 OPHTHALMOLOGY.
mendes neuropathisches Leiden derjenigen Nervenbahnen, die die Drehung des
bulbus nach oben vermitteln, denen sich in schwereren Fallen gleiche Affection der
die andern Muskelgruppen des Auges versorgenden Nerven anschliessen. Der
Affection 1iegt nicht, wie allgemein fast angenommen wird, ein Krampfzustand in
den Muskelgruppen zu Grunde, sondern sie besteht in einem Schwachezustand,
einer Atonie des Innervationsstromes, wodurch dieser nicht in oontinuitate wie
gewöhnlich, sondern stossweise nach Analogie des “Tremors der Alten” in die
einzelnen Nervenbahnen eintritt und dadurch nur zuckungsweise die Muskel-
bünd el in Thatigkeit zu setzen vermag.
Wir dürfen beim Nystagmus der Bergleute also von einer verlangsamten centralen
motorischen Leitung sprechen. Diese Anomalie des Innervationsreizes wird nun
einmal bedingt durch die in Folge der mangelhaften Beleuchtung durch Sicher-
heitslampen nothwendige Ueberanstrengung resp. Uebermüdung der das Auge
nach oben wendenden, im gewöhnlichen Leben an und für sich weniger benutzten,
grade bei der Arbeit als Kohlenhauer indess besonders angestrengten Muskel-
grnppen. Begünstigt wird dann sein Auftreten durch bestehende Hindernisse des
Lichteinfalles resp. der Perception desselben im Auge, und dadurch erforderte
Mehranstrengung, sowie schliesslich durch allgemeine Con stitutionsanomalien des
Individuums, die einen Debilitatszustand des Nervensystems mit sich führen.
Hilfe zu schaffen ist bei dieser Sachlage und dem relativ hohen Procentsatz von c.
5 per Cent aller Bergleute, die an dieser höchst störenden, ja unter Umständen
indirect das Leben gefährdenden Augenaffectio'n leiden, schon aus allgemein
socialen Berweggründen dringend geboten. Hilfe ist nur möglich durch Verbes-
serung des Beleuchtungsapparates der Bergleute. Wir wollen von dem nimmer
rastenden Erﬁndungsgeiste des Neuzeit hoffen, dass uns bald eine neue Construc-
tion des Grubenlichtes geliefert werde, wie a es schon in der begonnenen electrischen
Erleuchtung der Gruben von Newcastle zu leuchten scheint, welches nicht nur das
Leben, sondern auch das Augenlicht der schwarzen Arbeiter der Tiefe vor Schaden
sichert, und damit dem Nystagmus die erste Bedingung seines Entstehens benimmt.
Resolutions as z‘o “ Tesz‘s of Sag/z! suz'z‘aole [0 6e evefov/eea’ 2'72 Me
case of Sigma/[675 mm’ Loo/e-om‘ ﬁlm, am! oz‘kev/ per/sous oy
Lama’ 01/ Sea ,-
WITII SUGGESTIONS As To INTERNATIONAL ARRANGEMENTS FOR A UNIFORM srsTEiI OF
MARITIME, coAsT, AND HARBOUR. sIeNALLINe, WITH A vIEw To TIIE sAEETY on
LIFE AND PROPERTY.”
Followed by explanatory remarks under the several articles.
A.—WITII RESPECT TO LAND.
(l.)—That the recommendations of the last International Medical Congress, held
at Amsterdam, in 187 9, are accepted by the present Congress as forming the most suitable
basis upon which every Government may frame its own regulations as to its railway
service. They are contained chieﬂy in Article XII. of the “ Projet d'un règlement pour
l’examen des facultés visuelles du personnel des chemins de fer,” laid before and accepted
by the Ophthalmological Section of the Amsterdam Congress, which is nearly as
follows :—-
OPHTHALMOLOGY. 7 3
“For admission as Driver or Sloleer is required :——a healthy condition as regards
habitual congestion or irritation of the eyes and eyelids; for eae/r eye, complete ﬁeld of
vision, normal acuity and refraction, colour sense at least four-ﬁfths of the normal,
total. absence of commencing cataract or any other progressive disease.
“ For admission to other Railway Service is required :—a healthy condition as regards
habitual congestion or irritation of the eyes and eyelids ; for each eye, complete ﬁeld of
vision, total absence of cataract, or any other progressive disease; for one of the eyes,
normal acuity and refraction, colour sense at least three-ﬁfths of the normal; for the
other eye, sight of at least half the normal, as regards both acuity and colour sense.”
B.—W1'r11 nnsrnor TO SEA.
(2.)-—That in oeeaa-yoz'ny ships and in all steamers, especially those carrying
passengers, there should always be in actual control of the helm a person possessing
with the two eyes loyellzer, soil/rout glasses, normal sight, both as to acuity and colours ;
and that, in addition, in such ships, al least one of the persons actually on the look-out
should be similarly qualiﬁed.
(3.)——That in vessels engaged in the coasting trade, every person liable to take
charge of the helm, should possess wit/a the two eyes together, without glasses, sight equal
to at least two-thirds of the normal, both as to acuity and colours.
(em—That all persons engaged in Marine Signalling, ashore or aﬂoat, and all Pilots,
should have normal sight, both as to acuity and colours, as deﬁned in Article 2.
(5.)-—That hypermetropic persons, although satisfying the requirements of Articles
2, 3, and 4, should, nevertheless, not be admitted, if before the age of 18 they have a
manifest hypermetropia of 1 dioptre or more.
(6.)——That re-examinations should be made at the age of 45.
(7.)—~That the examinations should be conducted by persons of recognized com-
petency, under the direction of a Central Medical Authority in each country.
(8.)——That an International Commission should be constituted, to ﬁx upon such
further measures as to signals as may be necessary for safe navigation, and specially
upon the standard colours, and the sizes of the signals which should be employed.
EXPLANATORY REMARKS.
(The numbers refer to the Resolutions.)
A.—As TO LAND.
(1).—-The signal services on land, though quite as important, are not so purely an
International matter as those having reference to the sea. Many countries have already
‘established legislation in this respect, and others are introducing it by degrees. It is
believed that the standards now recommended may be of general utility, especially in the
case of conterminous countries. The mode of examination, for colours especially, is
here, as for service at sea, of the highest possible importance.
B.—-As TO SEA.
It is obvious that Regulations having an International character become every year
more urgently required, from the increasing number, size, and speed of vessels.
In view of the practical difficulties with which all compulsory examinations are
attended, it has been sought :—
(a.) To limit the examination in each case to what is strictly necessary.
(a) To require them only when absolutely indispensable, and of the smallest possible
number of persons. "
(0.) To simplify the methods as much as possible.
7 4 OPHTHALMOLOGY.
On large ships, many sailors not required for the helm, or to be reponsible for the
look-out, may be admitted without certiﬁcate of examination ; but as it will be in the
interest of all to he possessed of such a certiﬁcate, which would represent a higher
competency, it may be expected that many would themselves seek for it, from whom it
would not necessarily he demanded, and facilities for obtaining it should at all times be
at hand in maritime ports.
(2.)—Good sight wit/waif t/ze az'a7 of glasses is required, because glasses fail to help just
where clear sight is most needed—(2.9., in storm, rain, or fog.
Acuity 0f Szlaiaﬁ—Complete acuity is not more than sufﬁeient, and even scarcely
sufficient, having regard to the increasing number, size, and speed of steamers. But
it will be practically enough, if at sea, this complete acuity is attained by the use of
both eyes combined. The number of persons excluded under this rule will be much
less than if complete acuity for each eye separately is exacted.
The acuity is supposed to be determined by viewing letters or signs at a certain
distance, under a certain angle, on the principle of the test-types of Snellen.
Coloar-Sease is supposed to be tested by pseudo-iso-chromatic tables, on the
principle of those of Stilling, subject to control by the use of light transmitted through
coloured glass, in imitation of signal lights. This control will also aid in detecting
central scotoma for colours, in the very rare cases where it might eo-exist with the
required acuity.
Holmgren’s excellent tests have been already extensively adopted. But their use
demands more skill in the examiner. Tests well selected on the principle of Stilling
might be very well adopted as standards for ascertaining normal colour-sense, as well as
deﬁnite degrees of colour-sense below the normal. The principle of Stilling has been
recommended as affording a quantitative as well as a rapid qualitative test.
(3.)——A lower standard is ﬁxed in the Coasting Trade (excluding steamers) because
the vessels are smaller and the speed less. Moreover, a demand for full acuity would
render it difficult to procure a sutﬁcient number of sailors, as each hand must be liable in
small vessels to serve at the helm.
(4.)—It is obvious that the persons here named must have full acuity and colour-sense.
(5.)—Persons having a manifest hypermetropia above that here indicated would not
possess at the age of 35 or 110, without glasses, the needful degree of acuity; it is better
then, both for themselves and the service, that they should not be admitted at all.
(6.)—The attendant practical diiiieulties have caused one re-examination only to be
advised, at the age 01.415- It has been found that the very great majority of persons,
once admitted as having good sight, have retained it up to that age. A great number, no
doubt, have been admitted hitherto without suﬁicient examination. Still, it would not
be practicable to institute a general examination of those already in the service. ‘Never-
theless, it would be desirable to examine anew, in the case of Passenger Steamers, all
those responsible as helmsmen and look-out men.
The Congress recommends that surgeons of ships should be qualiﬁed to exercise
special surveillance as to the sight of those employed in these capacities on board.
(7 .)--A central medical authority is requisite to ensure the perfection of the system,
and its uniformity. He should propose the examiners, and be responsible for their
ﬁtness. They should be men of ascertained competency, and, as far as practicable,
qualiﬁed as medical specialists.
(8.)——The measures recommendedin Articles 2 to 7 should be brought into operation
without delay. But an International Commission would still have to determine the
precise colour of the glass, securing uniformity in that as well as in the size and dispo-
sition of the signal lights.
OPHTHALMOLOGY. 7 5
The Congress lay the greatest stress upon the appointment of this Commission in
respect of Marine Signalling, as quite indispensable for the attainment of the object in
view. The Commission would have to inquire into, and decide upon, many matters on
which information is at present incomplete, and regarding which only a few points have
been touched upon in Article 8.
Every Government, especially the Maritime Governments, should be requested to
place one or more members on the Commission, such being, whenever possible, ex-
perienced naval officers or medical specialists.
It is understood that this question of an International Commission is about to be
submitted to the Legislature of the United States of America, supported by a petition
largely signed by scientiﬁc men of that country.
Ueäez paZ/wlagz'scke V eräzzder/wzgm, weZc/ze dem Glaucom
vorﬁergeken oder dasselée verursaaﬁm.
Dr. ADOLF WEBER, Darmstadt.
In den meisten Fallen, wo wir einen Complex von Erscheinungen vor Augen
haben, wie ihn ein Krankheitsprocess darbietet, wissen wir nicht, welche die
Bedingungen der anderen, welche Ursache und welche ‘Virkung, oder ob es eine
von ihnen ist; ob sie nicht vielmehr verbundene Wirkungen von noch zu ent-
deckenden Ursachen, verﬁochtene Resultate von noch unbekannten Gesetzen sind.
Und wenn wir auch durch die uns zu Gebote stehenden Beobachtungsmethoden
am Krankenbett und am Sectionstisch unter geschickterAnwendung der praktischen
Regeln, welche der grosse Brite, dessen Andenken diese dankbare und stolze
Vaterstadt desselben in mehreren Denkmälern ehrt, welche John Stuart Mill
aufstellte, wenn wir auch mittelst dieser Regeln dahin gelangen, aus dem Chaos
der Erscheinungen die einfachen Thatsachen als Antecedentien und Folgen von
einander zu scheiden, so kann uns doch keine Beobachtung dazu führen, das Gesetz
der Succession der Erscheinungen zu enthüllen; zu diesem Nachweis der
Verursachung bedürfen wir unbedingt des Experiments—So lange aber die
Beobachtung auch diese Scheidung noch nicht vollzogen hat, sei es aus Nicht-
beachtung der logischen Regeln, sei es wegen Gomplicirtheit des Falles,‘ so bleibt
uns nichts übrig, als vor der Hand eine geistige Scheidung der Thatsachen vorzu-
nehmen, ausgehend von der Lehre derjenigen l/Vissenschaft, deren Gesetze bei der
Succession der Erscheinung sich geltend machen oder geltend machen könnten.
Und diese geistige Analyse ist nicht nur ein Auskunftsmittel, faate de m’z'eur, son-
dern sie sollte stets der erste Schritt bei dieser Forschung sein, und stets wenig-
stens so weit geführt werden, um zu erkennen, welcher Beobachtung und welcher
Experimente wir bedürfen, um auch die physikalische Scheidung vornehmen zu
können.
Dass bei den Krankheitserscheinungen, deren Complex den Begriff Glancom
darstellt, die verschiedenen Antecedentien und Folgen von einander noch nicht klar
unterschieden werden, zeigt die Literatur. Die Gründe warum dies noch nicht
geschieht, ist für jetzt nicht meine Aufgabe zu entwickeln, mir wurde vielmehr die
gestellt, diese Scheidung selbst vorzunehmen.
Dieselbe vollzieht sich am natürlichsten wenn wir die Entwickelungsbeding-
ungen der wesentlichen Merkmale des Krankheitsprocesses auseinanderlegen.
Als das Wesen des glaukomatösen Processes wurde zuerst von Mackenzie die
übernormale Spannung des Bulbus bezeichnet; Graefe erweiterte diese Deﬁnition
76k OPHTHALMOLOGY.
um den BegriEE des Verlustes der Selbststeuerung des intraooularen Drucks, welche
Eigenschaft unbedingt jedem erhohten Druek anhaften muss, wenn derselbe als
glaukomatos bezeichnet werden s01].
Naeh solcher Formulirung war die Frage naoh der Aufeinanderfolge der
Erscheinnngen zum grossten Theil eine physikalische geworden, und so konnte auoh
von den Lehren der Hydrodynamik ans, im Augenbliok, wo die Gompensations-
einriehtung fiir die Zu- und Abﬂiisse im menschlichen Ange bekannt wurden,
unter Beriieksiehtigung dieser sofort ausgeschlossen werden, dass die Hoke des
G-efdssdruckes eine dauernde Spannungserhohung des Bulbus hervorrufen konne ;
11nd es ﬁxirt sieh auch sehr raseh die Vorstellung, dass nur die Zu-und
Abﬁiisse der, die Bulbuskapsel erfiillende Fliissigkeit fiir diese gesteigerte Spannung
verantwortlich zu machen sei. Bis heute haben sich aber die Meinungen noeh
nioht geeinigt, Ob diese ans Vermehrung des Zu- Oder Verminderung des Abﬁusses
zu erkl'eiren sei, eine Diﬂ’erenz, welche naoh der Discussion dieses Gegenstandes .in
G-egenwart der Vertreter beider Anschauungen hoﬁentlioh endlioh sohwinden Wird.
Das zweite Merkmal des Wesens des Glauooms, der Verlust der Selbststeuerung,
machte mir die erstere Annahme, die eines ver-mehrten Zuﬂusses vom hydrodyna-
misohen Standpunkt aus ohne Zulassen. noch anderer unbekannter Faktoren,
durchaus unwahrscheinlich, und konnte meines Eraohtens die Erkl'zirung fiir diese
Eigenthiimliohkeit nur in einer Storung der Abﬂussbedingungen gefunden werden,
und zwau~ in einer Sterling, welehe eine stetige Neuerzeugung soloher Hemmnisse
bewirke.
Gestiizt auf diese, der einschléigigen WVissensOhaft entnommene Annahme
mussten fiir mioh alle Erscheinungen geteigerter Secretion und alle pathologisch
anatomische Thatsaohen, welche das Vorhandensein hierzu geeigneter Umst'zinde
Oonstatirten, bei der weiteren Forschung nach dem, was dem Krankheitsprocesse
vorausgeht, ausgeschlossen und in die Reihe der Folgen verwiesen werden. Auf
der anderen Seite mussten a11e Bedingungen gehemmter Abﬂiisse, alle patholo-
gische Ver'zinderungen léings des Stromweges der intraocularen Fliissigkeit in den
Kreis der Forsehung, sei es dureh Beobachtung, sei es durch Experiment, einbe-
zogen Werden.
In Verfolgung dieses Weges wurde in den letzten Jahren sehr Werthvolles
Material -gesa,n1me1t, an welohem unseren englischen Collegen der Lowenantheil
gebiihrt, in den sich besonders die hier anwesenden Oollegen Priestley Smith und
W. A. Brailey zu theilen haben.
Naohdem dureh Versuche, meines Eraehtens, jetzt hinreichend iiberzeugend
dargethan ist, dass der Strom der i11t1‘&00u1&1'_611 Fliissigkeit vOm Glaskol‘per aus
neben den Linsenmnd her in die hintere Kammer, von da duroh die Pupille zur
vordern Kammer und im Winkel derselben nach aussen seinen Abﬂuss nimmt,
blieb bis jetzt noch unentsehieden, W0 die Quelle dieses Fliissigkeitsstromes sich
beﬁnde. Die meisten Autoren sind geneigt, den ganzen Uvealtraktus dafiir zu
halten. Ieh glaube, dass es mir gegliiekt ist, durch unzweideutige Experimente
darzuthun, dass einzig die Geféisskn'ztuel der Giliarfortséitze als solohe zu bezeich-
nen sind, und dass die ganze sogenannte intraooulare Fliissigkeit, wie sie den
Glaskorper und die Linse durohdringt und den Baum der hintern und vorderen
Kammer erfiillt, nur dais V011ih11611 geiieferte Transsudat ist. #
Injicirt man einem starken Kaninchen stiindlieh zwei volle Pravaz’sche Spritzen
10 procentig Ferrocyankalium unter die Riickenhaut, saugt dureh ein feines Stilet,
welehes mit einem kleinen Ballon in Verbindung steht, eine Spur Glaskorper aus,
um ein Regenerationsbestreben anzufachen, todtet dann dZLS Thier nach Verlauf
OPHTHALMOLOGY. ‘ 7 7
von sieben Stunden, bald nach Injection der letzten Dose durch Erdrosselung,
während man in der Agone eine mit Essigsäure angesäuerte Eisenchloridlösung in
Alcohol von mehreren Einstichspunkten aus, in das orbitale Bindgewebe injicirt,
um die im Augenblick des Todes sich geltend machende Diffusion und das Entbluten
der intraocularen Gefässe bei der Enucleation zu verhüten, ‘so ﬁndet man, nachdem
das Auge in derselben Eisenchloridlösung erhartet ist, Folgendes: Netzhaut voll-
ständig ungefärbt; in der Ghorioidea, deren Gefässe alle dicht mit Blutkörperchen
erfüllt sind, hier und da die Perivascularräume der grossen und nur sehr sparsam
der kleinen Gefässe, vorzüglich an den Theilungsstellen, blaue Niederschläge enthal—
tend entweder als kleine oder grössere den Gefässen auﬂiegende blaue Körnermassen
oder dasselbe ganz einscheidend. Nirgends aber ﬁnden sich solche in den Maschen
des Gewebes oder deren angrenzenden Glashänten damit imbibirt. Auch im
Perichorioidealraum war es mir nicht möglich Niederschläge aufzuﬁnden. Die
Menge dieser blauen Niederschläge nimmt nach vorn hin, gegen die Ciliarfort-
sät-ze zu und erreicht in diesen selbst ihre grösste Ausbreitung, indem die kleinsten
Zweige ‘und fast das ganze Netz der Capillargefässe mit solchen bedeckt sind.
Dieser Reichthum ﬁndet sich besonders an denjenigen Cilia-rknäueln, welche in der
meridionalen Zone liegen, in welcher die Punktion des Glaskörpers stattgehabt hat.
Und eben gerade auch in dieser Flucht constatirt man, von hinten nach vorn bis zum
Petit’schen Canal an Mächtigkeit zunehmend, zu grossen oder kleinen Körnerhaufen
angesammelt, dieselben Niederschlage, und zwar nurin den oberﬂächlichen Schichten
des Glaskörpersn Bei Entnahme eines grösseren Tropfens beschränken sich diese, die
Zufuhr verrathende blaue Züge allerdings nicht blos auf die, in derselben Zone
liegende Gefässknäuel, sondern es betheiligen sich mit abnehmender Ergiebigkeit
nach beiden Seiten hin die benachbarten Ciliarfortsätze, so dass oft ein Drittel der
corona ciliaris und der, derselben anliegenden, oberﬂächlichen, Glaskörperschichten
mit blauen Niederschlägen übersäht sind—In der Iris unter Umständen keine
Spur derselben um die Gefässe herum. Solche treten vielmehr erst wieder an der
Hornhaut auf, wo nicht nur die ganze hintere Fläche derselben die zierliche blaue
Zeichnung der Kittleistenfügung präsentirt, sondern innerhalb dieser, in ziemlich
regelmässigem Abstand, kleine, scheibenförmige, blaue Körnerhaufen sich ﬁnden, die
wie ein breiter Ring um ein helleres oder dunkleres Centrum liegen. Die Des-
cemet’sche Haut, aber auch nur diese, von dem ganzen übrigen Hornhautgewebe, ist
intensive geblaut. Gleiche diﬂ‘use Blauung, untermischt mit grösseren oder klein-
eren Körnerhaufen ﬁndet sich im Maschenwerk des vorderen Kammerwinkels, und
zieht von hier breite, ästige, blaue Figuren nahezu quer durch die Dicke der Sclera,
von welchen ich aber bis jetzt noch nicht entscheiden konnte ob sie blos mit Blau
imbibirte, oder von Scleralgewebe bedeckte Züge blauer Niederschläge sind.
Ich meine, deutlicher kann das Experiment nicht sprechen: das vollständige
Fehlen blauer Niederschläge auf der inneren und äusseren N etzhautoberﬂäche, I’
selbst an der Durchtrittsstelle des Instrumentes durch die retina und längs des
Weges desselben durch den Glaskörper; die Spärlichkeit solcher in der Chorioidea,
und der Mangel jeglicher Spuren eines Uebergangs von dieser gegen die Netzhaut
und Glaskörper hin ; dem entgegen: der, in der oberﬂächlichen Schichte des Glas-
körpers direkt nach der Verluststelle sich hinziehende, gegen die entsprechenden
Ciliarfortsätze immer dichter werdende Strom blauer Niederschläge, und zwar
gerade die Beschränkung auf diesen, ich möchte sagen, Reizbezirk ; und diesem sich
anschliessend die reichliche Anfiillung der Ciliarfortsätze selbst mit solchen. Ich
glaube, Alles dies weisst deutlich genug auf ‘die Ciliarfortsätze als die Quelle, und
zwar die einzige Quelle, der Glaskörperﬂüssigkeit hin—Weiter dürfen wir aber
78 OPHTHALMOLOGY.
noch aus diesem Bilde schliessen, dass der Transsudatstrom im Glaskörper auf
pericentrischen Wegen von der Oberﬂäche nach der Mitte geht. Und verbinden wir
nun diese Wege mit dem, welcher noch ausserdem durch direkte Einspritzung dieses
Färbmittels in den Glaskörper auch von anderen Autoren offen gelegt wurde, so ist.
der ganze Kreislauf dieses Höhlentranssudats hergestellt, und der histologische
Aufbau des Glaskörpers in concentrischen Blättern mit einem Mittelcanal erhält
hiermit eine höhere physiologische Bedeutung.
Aber auch an lebenden Thieren ist ohne weiteren operativen Eingriff der Aus-
gang dieses Flüssigkeitsstromes aus den Oiliarfortsätzen in den Glaskörper, und
nur in‘den Glaskörper, mit aller Deutlichkeit zu verfolgen. Tröpfeln Sie einem
Kaninchen Atropin bis‘ zur vollständigen Erweiterung der Pupille ein, hängen
dasselbe an den Hinterfüssen auf, mit je zweistündiger Unterbrechung täglich
behufs Fütterung, so erscheint nach circa fünfzig Stunden die ganze Peripherie,
besonders der untere Umfang derselben, bis zur ora serrata diffus getrübt, und
durch diese Trübung hindurch bemerkt man grauweisse schmälere und breitere
Streifen selbst Plaques, die, wie aus der Einstellung des Ophthalmoscops hervor-
geht, in den oberﬂächlichen Schichten des Glaskörpers liegen. In der nächsten
Zeit rückt die Trübung gegen den Hintergrund vor, wird dabei aber lichter und
verschwindet, wenn das Thier nun freigelassen wird, in vier bis fünf Tagen voll-
ständig. Nirgends an der übrigen Ausbreitung der Ohorioidea entstehen ähnliche
Erscheinungen und auch der Humor aqueus bleibt hell. Ist das Thier sehr stark
und der Herzschlag kräftig, so beschleunigt man den Eintritt dieser Erscheinungen,
wenn man durch Unterbindung der beiden Carotiden während des Aufgehängtseins
den Arteriendruck in den entsprechenden Gefässen vorübergehend herabsetzt.——
W'enn man in der Blüthe der Erscheinung die vordere Kammer punktirt, so sieht
man innerhalb weniger Minuten aus der Iris, aber auch nur aus ihr, an verschiedenen
Punkten des circulus iridis minor kleine graue Strömchen hervorquellen, die in der
niedrigen vordern Kammer fast unverändert bleiben, wenn das Thier aufgehängt
bleibt, aber in dem neu angesammelten humor aqueus in wenigen Stunden
verschwinden, wenn Sie dasselbe aus seiner unnatürlichen Lage bringen.
Bedenken Sie, das trotz der Stauung in den intraocularen Gefässen durch die
hängende Stellung des Thieres, ünd trotz des, durch die Punktion der vorderen
Kammer erzeugten, negativen Druckes, keine Spur Transsudat von hinter der Iris
her erlangt wird, während solches in ansehnlicher Reichlichkeit um die Oiliarfort-
sätze im Glaskörper angesammelt ist, und nehmen Sie hierzu aus den früheren Ex-
perimenten, dass die Niederschläge in der Vorderkammer die Blauung der Kittleisten
und der Descemet’schen Membran die Anwesenheit von Ferrocyankalium im humor
aqueus verrathen, dass aber die Iris, in deren Gewebe sich keine Niederschläge
beﬁnden, zu diesem Gehalt an Ferrocyankalium keinen Beitrag geliefert haben kann,
so liegt, noch gestützt auf weitere, der Entwickelungsgeschichte, wie der Klinik
entnommene Thatsachen der Schluss sehr nahe, dass weder Iris, noch Ciliarkörper
direkt zur Constitution des humor aqueus etwas beitragen. Denn dass bei vollstän-
digem Pupillarabschluss eine steigende Menge Flüssigkeit hinter der Iris sich
ansammelt, die einzige Thatsache, welche man bis jetzt als Beweis für die direkte
Betheiligung der Giliarfortsätze an der Absonderung des Humor aqueus anführte,
‘kann nach dem unzweifelhaften Nachweise des Durchtritts der Glaskörperﬁüssigkeit
im perilenticulären Raum für das erstere von jetzt an nichts mehr beweisen.
Nach dem so die einzige Quelle und der ganze Weg des ciliaren Transsudats
festgestellt ist, haben wir die Bedingungen seiner Fortbewegung ins Auge zu fassen.
Über diese Kräfte ist so viel bekannt, dass der erste Anstoss von dem Filtrations-
OPHTHALMOLOGY. 7 9
druek in den absondernden Gefassen unter Beihiilfe der elastiscllen Bulbushaute
gegeben wird. Die Filtrationsvorgange dureh die Gef'alsswande konnen wir als so
ziemlieh festgestellt betraohten und auoh fiir die Gefasse der Ciliarfortsatzo
giiltig annehmen. Es handelte sich also noch um das Verhalten der zonula und
des vorderen Karnmerwinkels. Die von mir angestellten Versuehe, die allerdings
fast nur an Sehweinsangen, aber auoh nur an ganz frisohen, bei welehen mittelst
des Ophthalmoseops nooh die Details des Augenhintergrnndes erkannt werden
konnten, und bis jetzt nur mit einproeentiger Kochsalzlo'sung ausgefiihrt wurden,
bezogen sioh darnaoh auf den vorderen Kammerwinkel allein, indem die Filtrir-
nadel iiber demselben quer dureh die cornea durebgestoohen wurde; auf die
Zonula allein, indem die N adel durch den Glaskorper geﬁihrt, und die Kuppe der
Hornhaut abgetragen wurde, und auf beide gleiohzeitig, indem bei letzterer Anord-
nung die ‘Hornhaut unverletzt blieb. Die Ergebnisse derselben sind, so weit sie
den Cregenstand betreff'en, in Kiirze folgende : die Zonula besitzt trotz der geringen
Ausbreitung' die grosste Filtrirgeschwindigkeit und liefert bei normalem Augen-
druok von circa 25 Cts. Wasser : 18 Queoksilber, per Stnnde 7 Ctgram. Filtrat; der
Kammerwinkel, trotz seiner grossen Ausbreitung, liefert nnter gleichen Verhalt-
nissen im Durehsehnitt nur 5 Ctgram; beide gleiohzeitig unter denselben Verhalt-
nissen nur 4 Ctgram. Weiter stellte sich herans, dass die Zonnla bis zu GlIIEDJ.
sehr hohen Druek, 100 Ctm. Wasser, eine dem Druck proportionale Filtratmengen
liefert, der Kammerwinkel aber nur bei niederem Drueke eine proportionale, bei
hoherem, ﬁber 40 Ctm. Wasser, circa 28 Mm. Quecksilber, einem also an der Grenze
des normalen Augendrucks stehenden, eine mit der Hohe des Drlicks abnehmende
Henge liefert, sein Filter also impermeabler wird; endlioh dass beide gleielnzeitig fiir
rnittlerev Druokhohen, eine mehr als proportionale Besehleunigung zeigen. Letztere
Erscheinung griindet sioh, wie aus dem oben angegebenen Verhalten der Zonula
leioht dedueirt Werden kann, auf die von Runeberg ﬁ'u' die meisten thierisehen Filter
gefundene Cresetzmassigkeit, dass, Wenn von beiden Seiten der Filtrationsmembran
ein Druok von versohiedener Starks zur Geltung kommt, nieht der auf die Membran
wirkende holiere Oder niedere Druek die Permeabilitat beeinﬂusst, sondern
aussohliesslioh die Druek-diﬁ‘erenz, die zwisohen der Innen- und Aussenseite der
Membran herrsoht, Sobald diese Diﬁerenz verringert wird, nimmt die Permeabilitat
der Membran 211, d. 11. die Menge und auch der Gehalt des Filtrats steigt, und ist
es hierbei gleiehgiiltig, Ob die verminderte Diﬁ‘erenz dureh Herabsetzen des Innen-
Oder Erhohen des Aussendruoks erzeugt wird. Sobald andererseits die Differenz
wieder grosser wird, sei es duroh Sinken des Von aussen Oder Steigen des von innen
Wirkenden Druokes, vermindert sich die Menge und aueh die Concentration des
Filtrats, und zwar um so mehr als eine je grossere Diﬁ‘erenz entsteht.
Es erhellt hieraus wie aus diesen Versuchen, dass unter sonst normalen Verlialt-
nissen bei einer Vermehrung des Zuﬂusses d. h. bei einer Hyperseeretion in den
Glaskorperraum eineAnsammlung des Filtrats und damit eine dauernde Spannungs-
erhohung des Bulbus nieht zu Stande kommen kann, dass also fiir solehe abnorme
Vorgange in dem, bei Weitem raseheren Abﬂusse eine Compensation geliefert ist;
class dagegen eine ahnliehe Compensation bei vermindertem Abﬂusse nioht vor-
handen ist, sondern im Gegentheil in dieser Hemmung der Fortbewegung und in
dem hierduroh waehsenden Druek ant die Aussenseite des Filters, vermoge der
Eigenthiimliehkeit der thierisehen Membranen eine Quelle zur fortdauernden und
steigenden Druekerhohung eroﬁnet ist. Die V011 diesen Faktoren erzeugte Zunahme
kann selbstverstandlioh niolit weiter gehen, als bis zum Ausgleioh des Innen- und
Aussendrnoks und muss, wenn keine anderen Einﬂiisse sieh geltend maohen, unter
80 OPHTHALMOLOGY.
geringen Schwankungen, welcheVerdunstung und Diffusion erzeugen, nahezu stabil
bleiben, ‘ebenso ersichtlich ist, dass dieser stabil gewordene Druck je nach dem
Filtrationsdruck in den Gefässen auf verschiedene Höhen eingestellt sein kann. In
der That ﬁnden wir auch solche Spannungszustände, vor allem beim Glaucoma
simplex, welche mit geringer Schwankung durchaus unverändert bleiben und über-
hairpt keine andere Progredienz zeigen als solche, welche augenscheinlich nur
als die Wirkung der Dauer des erhöhten intraocularen Druckes zu deuten ist.
Aber nicht bei allen Glaucomen zeigt die Drucksteigerung diesen Charakter,
vielmehr documentirt sich häuﬁg mit oder ohne zeitweilig kürzeren, zeitweilig
längeren Remissionen, eine fortdauernde Steigerung bis zum Untergang des Organs.
Mit wenigen Ausnahmen sind dies aber, das wollen Sie wohl beachten, Glaucome,
welchen sich Erscheinungen zugesellen, die nicht zum Wesen desselben gehören
und die daher auch früher als complicirende aufgeführt wurden, ich meine Er-
scheinungen höheren oder geringeren Grades von Entzündung. N ichtsdestoweniger
ergiebt der Verfolg des Processes, dass hier keine reine Oornplication, sondern
eine gleichförmige Folge erhöhter Druckzustände vorliegt.
Mit der Steigerung des Druckes des, aus den Gefässen ﬁltrirten Höhlentranssudats
bis zur Ausgleichung mit dem innerhalb der Gefässe herrschenden ist nämlich
eine Compression derjenigen intraoculären Gefässe unabänderlich verbunden,
welche nicht, gleichsam frei schwimmend, allseitig von gleichem Drucke umgeben
sind, sondern eine unnachgiebige Unterlage besitzen, gegen welche sie angepresst
werden können.‘ Dies ist aber dem ganze Uvealtraktus bis zur Basis des Giliar-
muskels, und in diesem, dass fällt schwer ins Gewicht, zugleich die Blutabﬂüsse für
die frei schwimmenden Theile, die Iris und, je nach dem Bau des Auges die Giliar-
fortsätze in grösserer oder geringerer Breite, also, wie nachgewiesen, die Abflusswege
der allein das Höhlentranssudat liefernden Gefässpartieen. Die‘ Stärke der
Verengerung dieser Abﬁusswege muss proportional dem Drucke desHöhlentranssu-
dats auf- und niederschwanken und alle Erscheinungen einer passiven Hyperämie
von der geringsten Einengung bis zur vollständigsten Absperrung der venösen
Rückﬂüsse im Gefolge haben. Und so bestätigt es auch die klinische Beobach-
tung in den verchiedenen Charakteren des sogenannten entzündlichen Glaucoms.
Dass aber diese Erscheinungen nicht der Ausdruck aktiv entzündlicher Vorgänge,
oder der Ausdruck jenes Processes sind, welchen wir nach dem jetzigen Brauche der
Wissenschaft überhaupt erst entzündlich nennen, das hätte man, ausser anderen
Kennzeichen, aus den Eigenschaften des 'l‘ranssudats entnehmen können. Das
Stauungstranssudat unterscheidet ‚ sich bekanntlich von dem entzündlichen
Extravasat, ausser durch seinen geringen Gehalt an weissen Blutkörperchen, und
besonders deren relativen Sparsamkeit gegenüber den rothen, hauptsächlich, und
darin sogar von der normalen Lymphe, durch seinen geringen Eiweissgehalt und
das Unvermögen zu gerinnen, wenn auch Salze und Extraktivstoffe ungefähr
gleich sind. Diese Beschaffenheit wird aber durch den Mangel plasticher Vor-
gänge im Verlauf des sogenannten entzündlichen Glaucoms von der klinischen
Beobachtung und, nach der Deutung, welche ich den neueren Befunden von Brailey
geben zu müssen glaube, auch von der pathologisch-anatomischen bestätigt;
zudem ist es in die Hand des Experiments gegeben, und von mir in letzter Zeit
angestrebt worden, die chemischen Eigenschaften des Transsudats aus den ver-
schiedenen Stadien des entzündlichen Glaucoms festzustellen.
Wie weit wird nun der, durch diese Rückwirkung des gespannten Höhlen-
transsudats auf die absondernden Gefässe hinaufgetriebene Filtrationsdruck
steigen können? Selbstverständlich nur bis zur Höhe des Blutdrucks in den
OPHTHALMOLOGY. 8 I
Zweigen der art. ophthalmica, iiber welohe hinaus eine Spannungsvermehrung des
Bulbus nicht denkbar ist, indessen wegen der Folgen venoser Stauung auch nioht
erreicht Wird.
Soweit iiber die Reihenfolge der Bedingungen zur Entwiokelung abnormer
Druoksteigerung; es eriibrigt nooh ein rasoher Blick iiber die Reihenfolge der
Bedingungen zur Entwickelung des anderen Merkmals des Wesens des Glaucoms.
Es ist durohs Experiment nachgewiesen, wie dies fast ohne solches ver-
standlich ist, dass ein erhohter Druck im Glaskorperraum, nicht blos auf die von
den unnachgiebigen, bis" zu ihrer Elastioitatsgrenze ausgeniitzten, Scleralwande
gestiitzten Theil des Uvealtraktus wirkt, sondern dass die bewegliohen Theile
desselben, Iris und Ciliarfortsatze, soweit sie iiber die Basis des Ciliarmuskels
hervorragen, in entspreohendem Grade von diesem Druok betroﬁen werden, und
dies in entspreohender Weise duroh excentrisohe Verlagerung beantworten. Da-
duroh aber, dass gleichzeitig der Ciliarmuskel in seiner Conformation 11nd Ernahr-
ung auc'h die Consequenzen dieses Druokes tragt, und zu einer ﬂaohen Sohioht
sparlieher Muskelfasern wird, begiinstigen beide Momente die Annaherung der
Implantationsstelle der Iris an die Basis der Cornea. Mit der Einengung und
dem endliohen Versohlusse dieser Stelle ist aber der verhangnissvolle Sohritt
gesohehen, weleher dein Wesen des Glauooms sein zweites Merkmal, den Verlust der
Selbststeuerung zuzieht: die letzten Abﬁusswege des intraocularen Hohlentranssu-
dats sind versohlossen, und hierniit jede Aussioht auf eine Reparation normaler
Druokzustande abgeschnitten, selbst'fiir den Fall, dass die initialen Filtrations-
widerstiinde durohbroohen wiirden.
In dieser Darlegung, welohe die Reihenfolge der Bedingungen fiir die Entwiok-
lung der beiden Merkmale des Glauooms enthalt, sind Anteoedentien 11nd Folgen
scharf V011 einander geschieden, und auch die Soheidung der verschiedenen Ante-
Oedentien untereinander mit ihren zugehorigen Folgen ebenso scharf markirt.
VVenn dieselbe, um alle Falle zu umfassen, von der allgemeinen Annalime eines
Widerstandes in der Filtration des intraocularen Hohlentranssudats ausging, so
beriioksiohtigte sie selbstverst'andlioh die Certlichkeit der Stornng nicht, da der
Verlauf des Processes, nur mit Variationen im Bilde, stets der gleiolie bleibt, an
weloher Stelle des Stromwegs auch der Abﬁuss des Filtrats‘ beengt wird.
'Es sprechen klinisohe Wie pathologisch-anatomisohe Thatsaohen dafiir, dass
sohon im Glaskorper selbst solohe WViderstii-nde sich bilden konnen; es spreohen
klinische Wie pathologisoh~anatomisohe Thatsachen dafiir, da-ss eben solohe im
perilentikularen Filtrationskreis der Zonula sich etabliren konnen; es ist bekannt,
dass beim Durchtritt duroh die Pupille solohe Hemmnisse entstehen; es ist
gleic-h zweifellos, class vor dem Eingang zum Schlemm’sohen Canal solohes
statt haben kann; es ist sehr wahrsoheinlieh, dass der Eingang selbst und das
, Innere des Canals in Folge gewisser Altersveranderungen versohlossen werden
konnen; es ist weiter wahrscheinlioli, class nooh an der Seleraloberﬂaohe
die Ausﬂiisse verhindert werden konnen; es ist mehr als Wahrscheinlioh,
dass ein hoherer Eiweissgehalt, besonders eine Beimisohung von Eiweiss zum
Humor aqueus, z. B. unter Umstiinden, wie sie vor einigen Tagen Professor
Griinhagen angedeutet hat, solohe Hemmnisse bereiten konnen. Alle patholo—
gisohen Processe 11nd Steigerung normaler Bildungsvorg'ange, 11nd die Senescenz
ist wohl als solche aufzufassen, welohe diese Hemmm'sse produoiren, haben wir den
Anteoedentien des Glaucoms einzureihen. Und wenn wir den allen Fallen gemein-
samen 11nd unter allen Umstanden wirkenden Vorgang als die Ursaohe, als das
nnveranderliehe und unbedingte Anteoedens des glaukomatosen Processes bezeich-
PART III. e
82 OPHTHALMOILOGY.
nen wollen, so kann diese Bezeichnung nuiwder fortschreitenden Einengung der
Abﬂusswege des intraocularen Höhlentranssu‘dats beigelegt werden.
Die bis jetzt bekannten, pathologischen Veränderungen, welche die Einen-
gung der Abﬁusswege bedingen, sind für die Art des Glaucoms, welche man als
secundälre bezeichnet, so reichlich, dass ich der Kürze der mir zugemessenen Zeit
wegen die Aufzählung unterlassen muss; für das primäre Glaucom dagegen, wo
wir mit unsern Beobachtungsmitteln in Mitten der Folgeerscheinungen gesetzt sind,
belaufen sich unsere sicheren Kenntnisse, d.h., so weit die Thatsachen der Beobach-
tung mit den Ergebnissen des Experiments übereinstimmen, bis jetzt nur auf solche
pathologische Veränderungen welche einen mechanischen Verschluss des Vorder-
kammerwinkels erzeugen, einen Verschluss durch die Anlagerung der Iris; und
selbst hierbei herrscht in der Deutung, ob dieser Verschluss der Ausgangspunkt
für die Entwickelung der Druckstcigerung, oder nur die im Gefolge derselben
erzeugte Ursache des Verlustes der Selbststeuerung, oder beides sei, noch eine
Differenz der Meinungen. Es herrschen weiter noch getheilte Meinungen, 0b im
ersten Falle der Verschluss durch vorgangig entzündliche Zustände der Nach-
bargegend, vor allen des Oiliarkörpers, oder. durch eine mechanische Einwirkung
der hinter der Iris gelegenen Theile, d. h. durch Anschwellung und Vorrücken der
Ciliarfortsatze hervorgebracht wird. Indem ich der letzteren der drei Meinungen
huldige, d. h. für die grösste Anzahl der Falle von primären Glaucom den Ver-
schluss dieses Filtrationswinkels nicht nur als die Ursache der Drucksteigerung son-
dern auch die des Verlustes der Selbststeuerung ansehe, so erlaube ich mir, daran
zu erinnern, dass, wenn ich auch selbst für einige Formen von secundäirem Glaucom
die entzündliche Entstehung urgirt habe, ich doch betreffs des Modus des Ver-
schlusses der Vertreter der Ansicht bin, dass derselbe im typischen Glaucoma sim-
plex auf rein mechanischem Wege, durch eine mehr oder weniger lang vorberei-
tete Anschwellung und Vorrücken der Ciliarfortsatze zu Stande kommt. Es
musste also mein fortgesetztes Bemühen sein, und ist es noch jetzt, diese
Möglichkeit experimentell nachzuweisen, da die Beobachtungsmethoden nur
sehr zweifelhafte Antwort geben können: die klinische, weil sie sich ziem-
lich über das ganze Leben des Patienten und über eine unabsehbare Zahl
von solchen ausdehnen müsste; die anatomische, weil sie hier das Antecedens
von dem Consequenz nicht zu unterscheiden vermag, wenn sie ihre Thatsachen
nicht einer fortlaufenden Reihe von Untersuchungen der einzelnen Stadien, bis
zum initialen hinauf entnimmt, sondern, ihr Beobachtungsmaterial, wie es bis
jetzt der Fall war und auch zukünftig sein wird, nur denjenigen entnimmt, wo die
Anschwellung der Oiliarfortsatze langst dem Schicksal anheimgefallen sein kann,
dem jede andauernde Venenstauung, die nicht gelöst wird, verfällt: der Atrophie der
ganzen zugehörigen Grewebspartie.
Leider sind die Ergebnisse meiner Versuche erst bis zur Wahrscheinlichkeit
gelangt. Aber so weit will ich sie Ihnen nicht vorenthalten.
Nach Irschick erfahrt der Seitendruck in der Vena jugularis durch Abwärts-
hangen des Kopfes eine Steigerung um das; Dreifache, und dem entsprechend in
den weiter pcripherisch gelegenen Aesteu derselben eine noch ansehnlichere,
beispielsweise beim Hunde eine solche von 45 Mm. Normaldruck bis auf 1‘28 Mm.
Dieses Mittels bediente ich mich, um bei Kaninchen eine dauernde Erhöhung
des Venendrucks und dadurch allmalige Erweiterung der Gefasse zu erzielen. Ich
hängte die Thiere verschieden lange Zeit am den Hinterfüssen auf. Die sofortige
Wirkung dieser Procedur ist ein starker Exophthalmus und exorbitante Spannung
des Bulbus, die, wie leicht festzustellen, zum grössten 'l‘heil unabhängig von dem
OPHTHALMOLOGY. 8 3
von der orbita auswirkenden Drucke ist. Die vordere Kammer wird niedriger,
die äusseren Ciliarvenen erweitern sich. Nach circa dreissig Stunden bemerkt man,
ausser einem ansehnlichen Oedem der conjunctiva, schon einen deutlichen Unter-
schied in der Breite der Oentralarterien während der hängenden und natürlichen
Stellung; in ersterer Arterien eng, selbst bis zum Verschwinden kleiner Papil-
‚ laräste, in letzterer, weiter als selbst vor Beginn des Versuches; ausserdem nach
längerer Befreiung aus hängender Stellung eine Trübung und ein deutliches Ver-
waschensein des Gewebes der Papille, als ob sie serös durchtränkt sei. Nach
circa fünfzig Stunden gesellt sich, besonders wenn vorher Atropin angewandt
wurde, eine wolkige Trübung untermischt mit grauweissen Streifen in der aus-
sersten Peripherie des ophthalmoscopischen Gesichtfeldes hinzu. Nach achtzig
Stunden haben alle diese Erscheinungen eine bedeutende Zunahme erfahren und es
ist jetzt deutlich durch Gläser zu constatiren, dass während des aufgehängten
Zustandes eine Vertiefung des Papillargrundes, gleichzeitig mit Abnahme des
verticalen Durchmessers derselben stattgefunden hat. Bei der Section constatirt
man, wenn die Enucleation mit allen Cautelen vor Entbluten der intraocularen
Gefässe vorgenommen wurde, eine nicht zu verkennende, selbst variköse Erweiterung
der strotzend mit Blut gefüllten Ciliargefässe; ausserdem einen hyperämischen
Zustand der Papille und des aufliegenden Stücks der Opticusscheide. Weiter
konnten diese Versuche, der Thiere wegen, noch nicht fortgeführt werden. Bedenkt
man aber eine wie verschwindend kurze Zeit es ist, während der dieser erhöhte
Venendruck erhalten werden konnte, gegenüber derjenigen, welche sich nicht com-
pensirte Klappenfehler, Dilatation des Herzens, Pericardialaffectionen, Emphysem
etc., oder welche die verschiedenen Beschäftigungen, die mit einer zeitweisen
' Hemmung des venösen Rückﬂusses verbunden sind, der Zeit, welche alle diese
Einwirkungen sich nehmen, um einen dauernd erhöhten Venendruck mit Ausdeh-
nung der Gefässe zu erzeugen, so wird man dem einstweiligen Resultate meiner
Versuche immerhin einige Wahrscheinlichkeit zur Erzeugung glaukomatöser
Zustände vermittelst erhöhten Venendruckes zugestehen.
Trotzdem bin ich weit entfernt, diesen Modus des Verschlusses als den allein
vorkommenden aufstellen zu wollen. Die klinische Beobachtung sagt uns, und
die soeben gegebene Darlegung der Bedingungen zur Entwickelung des Glaucoms
bestätigt es, dass noch andere Verschlussarten hier und weitere auch an den übrigen
Durchgangspforten vorkommen können. Es kann nicht befremden und wird die
Richtigkeit des einmal Nachgewiesenen nicht umstossen, nur beschränken, wenn die
fortschreitende Forschung weitere Hemmnisse für die Fortbewegung des Transsu-
dationsstroms enthüllt; nur müssen wir, wemi wir sie den Ursachen einreihen
sollen, selbstverständlich verlangen, dass sie nicht blos durch die Beobachtungs-
methoden, ob klinische oder pathologisch-anatomische, sondern gerade in dieser
ihrer Eigenschaft als Ursachen experimentell nachgewiesen seien. Denn bei aller
Anerkennung des 'Werthes der Induktion im medicinischen Denken, muss es doch
bei einigem Nachdenken in die Augen springen, dass sie uns betreﬂis des Causali-
tätsverhältnisses in complicirten Fällen ohne die vom Experimente gestützte
Deduktion im Stiche lässt.
Professor LAQUEUR, Strasbourg, made a communication upon an increase in
the refraction of the eye which he had observed in twelve cases of iridectomy for
glaucoma. The increase varied from 0'75 D. to 4 D.‚ being least in the premonitory
stage, and in glaucoma simplex, and most marked in acute glaucoma. It was most
G 2
84 OPHTHALMOLOGY.
probably due to a change in the curvature of the front of the lens, and thus
pointed to the presence of pathological changes in or near the zonula Zinnii. Such
changes might explain the existence of a predisposition to glaucoma in cases where
there was no obliteration of Fontana’s canal. They could not, however, explain
the onset of an acute glaucoma for which, depending as it does upon deranged
compensation of ﬂuid, other causes must be sought.
T/ze Pat/zology of Glaucoma.
Mr. PRIESTLEY SMITH, Birmingham.
Much new light has been thrown on the pathology of glaucoma during the last
few years. Professor Leber has shown that the intra-ocular ﬂuid escapes from
the eye, chieﬂy, if not entirely, at the angle of the anterior chamber. Dr. Adolph
Weber and Dr. Max Knies have drawn attention to the fact that, in the large
majority of specimens of glaucoma, primary as well as secondary, the angle of the
anterior chamber is closed. It is no longer possible, I think, to doubt that this
closure of the chief outlet of the eye has an intimate connection with the causation
of glaucoma. The question which we have now chieﬂy to discuss is the manner in
which the closure is brought about.
Two years ago I put forward a deﬁnite theory with regard to the origin of
primary glaucoma. Further observations made since that time, and especially
within the last few months, have strengthened the position of that theory; I
therefore now venture to ask your attention to it again.
In the healthy eye, a stream of ﬂuid is constantly passing from the vitreous
chamber to the aqueous chamber through the circumlental space—the space which
separates the margin of the lens from the ciliary processes. With the advance of
life the circumlental spaces become narrower, in consequence of the increasing
size of the lens. Even in the senile eye, however, a space remains which is suﬂi—
cient for the passage of the intra-ocular ﬂuid. But if this space he still further
encroached upon, either by the lens on the one hand, or by the ciliary processes on
the other, a serious obstruction is set up. The escape of ﬂuid from the vitreous
chamber is retarded; the vitreous chamber becomes over-ﬁlled; the lens and its
suspensory ligament advance, pushing the ciliary processes against the periphery of
the iris ; the periphery of the iris applies itself to the posterior surface of the cornea,
the angle of the anterior chamber is closed, and glaucoma is established. Then,
as the pressure rises, a passive hypereemia is set up in a manner which has been
explained, completely, as I think, by Dr. Adolph Weber in his work, " Die Ursache
des Glaucoms.” The swelling of the processes intensiﬁes the glaucomatous con~
dition, by causing a still ﬁrmer occlusion of the angle of the anterior chamber.
That, very brieﬂy stated, is the theory by which I have sought to explain the
occurrence of primary glaucoma. I will now indicate as brieﬂy the evidence on
which it rests.
Certain experiments—a detailed account of which I have already published-—
revealed the fact that if we artiﬁcially raise the vitreous pressure slightly above
the aqueous pressure, the lens and suspensory ligament immediately advance, and
the angle of the anterior chamber immediately becomes closed, by the pressure of
the ciliary processes against the iris, in a manner which closely simulates the con-
OPHTHALMOLOGY. 8 5
ditions which are present in primary glaucoma. This result gave an important
clue. It appeared to indicate that the starting-point of primary glaucoma is some
change which tends to overﬁll the vitreous chamber as compared with the aqueous
chamber. It appeared reasonable to look for this change at the outlet of the
vitreous chamber—the circumlental space.
Now, as to the size of the lens at diiferent periods of life. At the meeting of
the British Medical Association held last year at Cambridge, I exhibited specimens
which shewed a progressive increase in the volume of the lens with the advance of
life. The increase affected both the diameter and the thickness. These speci-
mens were from the eyes of ﬁve individuals only, and it was properly objected
that the series was too small to establish a general rule. Professor Donders, who
was present on that occasion, suggested that it would be well to weigh a series of
lenses, inasmuch as the weight of a small solid body is ascertainable with much _
greater accuracy than its linear dimensions. I have proceeded in this manner.
I have accurately weighed a series of lenses and I have made a direct measurement
of the volume of each, by means of an apparatus specially designed for the
purpose. The principle of the apparatus is this: the lens is introduced into a
glass bulb containing a coloured ﬂuid, and causes a displacement of the ﬂuid along
a graduated glass tube; the amount of the displacement indicates the volume of
the lens. The accuracy of the instrument has been rigidly tested, with the help
of Professor Poynting, the Professor of Physics in the Mason Science College in
Birmingham. The average error was half a cubic millimetre, the maximum error
about one and a half cubic millimetres; seeing that the volume of the lens varies
from 140 to 240 cubic millimetres, errors of the amount mentioned are of no
practical importance. I have examined in this manner forty-ﬁve lenses from thirty
individuals. Only such as were perfectly transparent, and had an unruptured
capsule were employed. From the tables which exhibit the resultsﬁ't it is apparent
at a glance that, both as regards weight and volume, the lens undergoes a very
considerable progressive increase with the advance of life. Thus, at thirty years
of age, the average lens has a volume of about 160 cubic millimetres; at sixty
years of age, of about 210 cubic millimetres. So far as my observations go at
present, it appears that volume and weight increase in nearly equal proportion,
and hence, that the speciﬁc gravity remains nearly the same at different ages.
This fact concerning the increasing volume of the lens will be found, I believe,
to have a practical interest in several directions—for example, in connection with
the development of cataract, which condition I have found in two instances to be
associated with a marked deﬁciency in volume as compared with the healthy lens;
I and in connection with the shallowness of the anterior chamber proper to the
senile eye, which appears to be owing to increase in thickness, and not to displace-
ment of the lens. It certainly possesses a physiological interest. But of these
points this is not the time to speak; my present point is the bearing of the fact
upon the causation of glaucoma.
Glaucoma is pre-eminently a disease of advanced life. A large majority of the
cases met with are in persons of more than ﬁfty years of age; and when we remem-
ber that persons of this age are much less numerous than those representing the
earlier periods of life, this characteristic of the disease becomes still more prominent.
I venture to maintain that the special liability to glaucoma which characterizes the
senile eye depends upon the large size of the senile lens.

*‘P The Tables were displayed during the meeting.
86 OPHTHALMOLOGY.
The chief predisposing cause of primary glaucoma is, in my opinion, an in-
suﬂiciency of space between the margin of the lens and the ciliary processes. The
crucial question is this z—W'hen we dissect specimens of primary glaucoma, do we
ﬁnd the circumlental space narrowed or abolished, as we ought to do if this
theory is correct? In many specimens, on the contrary, we ﬁnd it even wider
than in the healthy eye ; but this is because such eyes come into our hands only
when the disease has already reached an advanced stage—a stage in which atrophy
of the ciliary muscle, a change to which Dr. Brailey has called attention, and
which he has ‘most accurately investigated, is extreme, and when the ciliary pro-
cesses, also, are shrunken and retracted. These structures, in undergoing atrophy,
retract from the margin of the lens, and re-open widely the circumlental space;
there is frequently, however, an impression in the periphery of the iris which
indicates that they have previously occupied a much more advanced position. It
is only in specimens of recent primary glaucoma, and in such as are examined
with special precaution as to non-disturbance of parts, that we must expect to ﬁnd
the initial change, the closure of the circumlental space, still existent. In two
such specimens I have found the margin of the lens in close and ﬁrm contact with
the ciliary processes, and the latter pressed thereby against the periphery of the
1r1s.
It may be objected that two instances alone have but little value ; but I would
point out that their value is greater than that of mere isolated observations, inas-
much as they are in complete accordance with an inference previously arrived at
by experiment and induction.
With regard to glaucoma as a whole, the position which I desire to maintain
may be expressed in general terms as follows z—Glaucoma of every form is essen-
tially a disease of retarded excretion; active hyperaemia and hyperseoretion are to
be regarded as exciting and auxiliary causes ; they act by causing a rapid develop-
ment of the obstructive changes. The obstruction is different in various forms
of the disease : its situation is usually such as to conceal it from inspection in the
living eye, but the visible changes which it induces frequently sufﬁce to reveal its
position. Thus, when, as in primary glaucoma, the lens and iris are driven
towards the cornea, we must conclude that the surplus fluid is in the vitreous
chamber, and seek the obstructive change in the circumlental space. When the
iris alone is driven forward by ﬂuid imprisoned in the posterior aqueous chamber,
as in cases of annular posterior synechia, we ﬁnd the impediment at the margin
of the pupil. In both these cases the displacement- of the iris leads to a closure of
the angle of the anterior chamber, which looks up the whole eyeball so far as
concerns the circulation of the intra-ocular ﬂuid. When, on the other hand, as in
the case of serous iritis, the surplus ﬂuid collects in the anterior chamber, and
displaces the iris and lens backwards, then the initial obstruction must lie in the
outlet of the anterior chamber itself, and must be sought in the neighbourhood of
the ligamentum pectinatum and Schlemm’s canal.
01¢ Me Ez‘z'ology 0f Glaucoma.
Dr. ANcELUccI, Rome.
The canal of Fontana is not a path of lymphatic ﬁltration. Iﬁnd that, embryo-
logica11y,it is developed by the penetration of ﬂuid from the aqueous chamber into
OPHTHALMOLOGY. ' 8 7
the tissues which surround it; in the adult ,it is the most posterior part of the
aqueous chamber. Descemet’s membrane takes no active part in the formation of
the meshwork of the canal of Fontana, since it is nothing else than a basal
production of the endothelium lining the posterior corneal surface. The opinion
held by some, that the canal of Schlemm is a lymphatic channel which communi-
cates by an open mouth with the canal-of Fontana—that is to say, with the aqueous
chamber—is quite wrong. For the canal of Schlemm is composed of a plexus of
veins, which have their own uninterrupted walls.
It is consistent with these facts that, by exosmosis, an escape of ﬂuid may take
place from the anterior chamber into Schlemm’s canal, but there can never be an
open communication between them. I grant that obstruction at the spaces of
Fontana may cause a latent glaucoma to appear‘ and may aggravate its symptoms,
but I deny that this is the primary condition, and that it is the conditio sine gwi
non for the development of glaucoma. .
Besides, microscopy shows that the occlusion of the canal of Fontana is not a
primary change. This is not obliterated by an active inﬂammation of the tissues
which surround the canal of Schlemm, because the canal of Fontana shows micro-
scopically all the appearance of an atrophic tissue, the result of continual compres-
sion. Where, then, must we seek the causes of this compression P
The condition of the bloodvessels explains everything. On the one hand, the
arteries become sclerosed, and on the other, some of the veins dilate while others
become obliterated by phlebitis and Peri-phlebitis.
The arteries, when sclerosed, have their calibre diminished; and not only that, but
the length of the blood-wave is also diminished. Thence results a venous stasis
from a dimished systolic impulse, and also a failure of nutrition in the tissues
supplied. Besides that, there is atrophy and obliteration of the lymphatic channels,
which in the eye attains an extremely high degree, since, as a result of vasculitis
and peri-vasculitis, the lymphatic spaces traversed by the bloodvessels of the iris
and choroid are obliterated.
Venous stases are compensated by an increased secretion of lymph, but in
glaucoma the lymph, ﬁnding no means of exit, because the ways of ﬁltration are
closed, causes that augmentation of the intra-ocular contents by which glaucoma is
produced. ‘
The disease of the bloodvessels, which is developed in the eye in these cases, is
a chronic process which is essentially progressive. Nevertheless, its rate of increase
may be irregular, or it may even remain stationary. On these points depend the
course and the varied forms of glaucoma.
DISGUS SION.
Dr. DE WECKER, Paris: It is hardly possible for me to criticize Dr. Weber’s
communication, as I have not been able fully to follow it. M. Ulrich was the
ﬁrst to carry out experiments with coloured intra-Ocular injections. From
these it appears that the nutritive current does not pass between the lens
and the posterior surface of the iris, but through the latter membrane, at its base,
so as to reach the peri-corneal ﬁltration zone. I think that the very interesting
observations of Mr. Priestley Smith would be still more valuable if they could be
put on a physiological basis—ta, if it could be ascertained by accurate measure-
ments whether the variations in the size of the lens were or were not compensated
for by corresponding natural variations in the diameter of the cornea. ‘
8 8 OPHTHALMOLOGY.
Dr. 0810, Madrid, narrated a case of dislocation of the lens which occurred
after several days’ use of eserine. The case was one of glaucoma secondary to
adherent leucoma, in which iridectomy had been performed with good result before
the use of eserine. The counter-puncture was made in the leucoma itself, and this,
he thought, should be avoided, as likely to set up prolonged ciliary mischief, from
the dragging of iris which it may cause.
Professor LEBER, Gottingen: I wish to call your attention ﬁrst to experiments
upon animals on the source of the secretion of the intra-ocular ﬂuids, which have been
made, on my proposition, by Dr.Deutschmann, and the results of which are published
in the Archives of Ophthalmology. It is possible to remove in rabbits the whole iris,
together with the ciliary processes, at one time; and if this operation is done with the
necessary precautions, it is followed by no inﬂammation, especially by no exudation
into the interior of the eye. Very soon afterwards the eyes become soft; not only
the aqueous humour is not renewed at all, but even the vitreous humour disappears
entirely. These experiments support the conclusion which Dr. Adolph Weber has
derived from his own experiments, that the secretion of the vitreous humour de-
pends on the ciliary processes and the iris; but they do not conﬁrm his opinion, if I
understand him correctly, that the aqueous humour is not secreted by these organs.
On the contrary, we have come to the conclusion that the secretion of all intra-
ocular ﬂuids ought to be attributed to the ciliary processes and the iris. I
have made a ﬁltration experiment on two excised human eyes with primary
inﬂammatory glaucoma, which is in favour of the view that there is some obstruc-
tion to the outﬂow of the humours from theinterior of the eye. If you connect a mano-
meter with the anterior chamber in a normal eye, after death, the ﬂuid goes out of
the eye very rapidly, so that the column of mercury is continually falling. On
the contrary, in the two glaucomatous eyes examined, the falling of the mercury
was very slow, so that an obstacle to the ﬁltration must have been present. As
to the theory of Mr. Priestley Smith, and the very interesting anatomical
and experimental researches he has published, I wish to hint at two facts which
seem to me to offer some diﬁiculty in respect to them. As he made his injections
into the vitreous body of dead eyes, I had the intention to repeat these experiments
on living animals. True, the number of the experiments I have made is very
limited, but in these I did not succeed in producing a constant increase of the
intra-ocular pressure by injection of indifferent ﬂuids into the vitreous humour. The
second fact is a clinical one; cases have been observed where glaucoma occurred
in eyes in which the lens had been removed. This seems to be difficult to explain
by the theory of Mr. Priestley Smith ; but such cases are rare, and glaucoma may
come on in different ways.
Mr. G. E. WALKER, Liverpool: The method of production of glaucoma put
forward by Mr. Priestley Smith, occurs probably only in cases of rapid swelling
of the lens from injury, as after needling of congenital cataract. In glam-
coma, the iris is not merely applied to the cornea, but is closely united to it
by adhesive inﬂammation. There is a want of evidence to show that there is
any considerable ﬂow of ﬂuid from the vitreous to the aqueous chamber. In
cases of loss of vitreous, or even wound of it, the very long time which elapses
before the vitreous even approximates to its normal condition, is very _ much
against the idea that the vitreous is anything but a comparatively passive body.
The theory of the production of glaucoma which I advocate, is that the continual
teasing of the ciliary body, through the over-action of the ciliary muscle, in hyper-
OPHTHALMOLOGY. 89
metropic eyes, leads to inﬂammation of the ciliary body, and retention of ﬂuid in
the eye through the blockage of the lymph-spaces in the ligamentum pectinatum.
Dr. BRAILEY, London : It will be very interesting if it should be conﬁrmed that
the lens gradually increased in size through life, even after the‘ growth of the rest
of the eye had ceased. But for this to have any bearing upon glaucoma, it must
also be shown that the lens in glaucomatous eyes is on the average larger than
in other conditions. My Own measurements, made in large numbers of eyes excised
on account of incurable glaucoma, point to the reverse conclusion. But perhaps
the lens had been in these cases larger at the outbreak of the disease, and had
afterwards shrunk. This explanation, however, is diﬂicult to accept in cases where
the lens remains clear. The theory of Priestley Smith fails to account for tempo-
rary glaucoma, for glaucoma without characteristic application of the iris, for
glaucoma in young persons, for one-sided glaucoma, for glaucoma in aphakic eyes,
and especially for cases where a traumatic dislocation of the lens backward has
been quickly followed by increased tension. It also does not explain the invariable
inﬂammation and atrophy of ciliary body and optic nerve. Lenses taken from the
cadaver are not so trustworthy for measurements as others, nor is the mode of
preparing them free from objection. Often, after the removal of a clear lens from
a glaucomatous eye, I have seen its diameter become very considerably less. This,
which perhaps was the cause of the phenomenon observed by Dr. Laqueur, appears
due to previous excessive tension of the zonula.
Dr. GALEzowsKI, Paris : I can only accept Mr. Priestley Smith’s theory for
certain cases. There are other cases of glaucoma which cannot be explained, either
by an increase in the size of the lens, or by narrowing or obliteration of the ﬁltra-
tion exits. There is another cause of glaucoma to be found in the inﬂuence which
the secretory nerves of the eye exert, as Donders has shown, upon the quantity of
liquid secreted. In support of the last named theory, that defective innervation of
these nerves might cause glaucoma without predisposing conditions, I may cite a
casein which glaucoma with cupping of the disc came on as the result of using atro-
pine for ﬁfteen days after the ablation of a pellucid staphyloma of the cornea. The
glaucoma was stayed by iridectomy. In several other cases I have seen glaucoma
come on in eyes which had not previously shown the slightest glaucomatous
symptoms.
Dr. WEBER, Darmstadt: Swelling of the ciliary folds is certainly not the only
mode of hindrance to the outﬂow of the intra-ocular ﬂuid. For impediments could
be set up in the vitreous itself, in the zonula, or in the course of the ﬂuid through
the pupil before entrance into Schlemm’s canal, in the canal itself, and ﬁnally, in
the superﬁcial layers of the sclera. Indeed, a higher albuminosity of the intra-
ocular ﬂuid may produce an impediment in the outﬂow.

Extraction of Cami/ac! 6y Peripheral Division of
2726 Capsule.
Dr. H. KNAPP, New York.
Mn. PRESIDENT AND GENTLEMEN,—I have tested this mode of extractionin about
175 successive cases. The ﬁrst 166, complicated as well as uncomplicated, will
form the basis of my remarks, as the others were operated on too short a time
90 /
OPHTHALMOLOGY.
before my leaving New York to have their acuteness of vision tested. They were,
however, all successful.
The method of operating was essentially that of Von Graefe—puncture and
counter-puncture, 1 mm., in the sclero-corneal junction, at the meeting of the
middle and upper thirds of the cornea, apex of section commonly close below
the upper transparent corneal margin. The iridectomy was extensive. When by
gentle pressure,‘ with the ﬁxing forceps the section was made to gape, a very
sharp, angular, or sickle-shaped needle (the instrument was shown) was passed
horizontally through that part of the capsule, which presented in the wound. In
large cataracts with a tough capsule, a small vertical division, joining the
horizontal in its middle, was added. The lens was expelled with a hard-rubber
spoon, applied to the lowest part of the cornea, and pressed directly toward the
centre of the globe. Remnants of cortex, if left, were forced out, with the eyelids,.
after the removal of the speculum. Particular care was taken to free the wound
from portions of iris, capsule and lens, and also from clots of blood. Cleanliness
was scrupulously observed, but no special antiseptic substance used. Anaesthesia
only in timid or uncontrollable patients—scarcely in one out of ten. The closed
eyelids were padded with picked linen, held in position by a ﬂannel roller—the old
binoculus. In the majority of cases the eye was inspected the second day, often
for the sake of clinical instruction, a practice which I do not recommend, and have
abandoned, as it violates one of the most important, perhaps the most important,
condition of obtaining primary union—immobility. Atropia was instilled a day, or
several hours before—not immediately after the operation.
Among the incidents to which this mode of operating is liable, I need speak of
one only—prolapse of vitreous—the others being neither more nor less common
than in the merely central, or the combined central and peripheral opening of the
capsule. In the last but one hundred cases prolapse of vitreous occurred in ten,
in the last hundred in six cases. This is not a very high number; yet I hasten to
say that of the six cases in which escape of vitreous after peripheral opening of the
capsule occurred, four were complicated cataracts, where the zonula was either frail
or defective, and the vitreous ﬂuid. When the capsule is really cut, and not torn
open, prolapse of vitreous in this method is as rare as in any other. A traction
instrument to get the lens out was used only twice, at the beginning of my prac-
tising this method; in the last hundred cases no instrument was introduced, either
for the removal of the entire lens, or of remnants of cortex.
The mode of healing is distinguished by a greater rarity of iritis, capsulitis,
cyclitis and hyalitis than in any other method that I am acquainted with. In
many cases—I have not noted the exact proportion, but I think it was more than
50 per cent—the capsular wound healed by ﬁrst intention—that is, when examined,
on the second, third, or fourth day, the capsule was found united, a white streak
running horizontally across the upper part‘ of the coloboma indicating the
capsular section. The iris was clear in front of the capsule, lustrous, and free
from congestion; the pupil dilated ad maximum. The capsule was evenly spread
across the pupillary ﬁeld, and if remnants of cortex were left—which at the
periphery was not uncommon—~they were shut up in the capsule without causing
any reaction. In a considerable minority of the cases this condition was not
observed. The horizontal capsular scar had offsets, rarely in its centre, but
mostly at one of its ends, running straight or obliquely a short distance down the
anterior capsule. In such cases ﬁliform synechiae were sometimes noticed, which,
with only one exception, tied the iris to a shred ‘of capsule, or to the capsular scar.
OPHTHALMOLOGY. 9 r
In these cases the capsular opening did not close, though the recovery was
mostly without notable irritation. In some cases the lips of the wound remained
separated from each other, but they were united to the posterior capsule, which lay
bare in an elliptical space. In others, portions of the posterior (upper) lip of the
capsular wound were united to the corneal scar; in others, again, the posterior lip
had retracted toward the ciliary body, while portions, and in exceptional cases
even the whole extent, of the anterior (lower) lip were united to the corneal scar.
It was almost exclusively in such cases that I saw any reaction take place, with
products of plastic inﬂammation in the upper part of the coloboma. It always
originated in, and mostly was conﬁned to, the places where the iris touched the
wound in the capsule. Near the corners of the corneal section the reactive pro-
cesses were most frequent and most intense, which is easily understood when we
consider that there the three wounded parts—cornea, iris, and capsule, come in
closest contact, and apart from any inﬂammatory irritation, easily unite, according
to the general law that raw surfaces will agglutinate wherever they come in contact.
The parts at the corners of the wound suifer more than the others from the passage
of the knife, and the cataract, particles of the latter being easily stripped OE‘ and
retained there, together with portions of bruised iris and capsule. I do not think
that in more than two cases out of a hundred I could trace the origin of reaction
to the centre of the wound.
The reactive processes which in the last hundred cases disturbed the recovery
more or less were, brieﬂy enumerated, the following :—
1. Slow closure of the wound, from a bead of vitreous keeping the lips of the
wound apart, in 2 cases; result good.
. Re-opening of the wound and diffuse hyalitis, 1 case ; result good.
. Superﬁcial corneal ulcer, probably accidental, 1 case; result good.
. Spongy exudation, 2 cases; results good.
. Genuine iritis, from subsequent exposure, 1 case; result good.
. Plastic capsulitis, 2 cases; results good.
. Gyclo-capsulitis, 1 case; failure.
. Diffuse and plastic hyalitis, 1 case; result good.
. Irido-cyolitis, 6 cases; result good in 1, moderate in 3, failure in 2.
10. Suppuration of the cornea, 2 cases, after smooth operations; one of the
patients had a chronic dacryocystitis, which, from exposure on a long winter
journey, developed two days after the operation into a phlegmon of the sac, with
inﬁltration of the corneal wound; the other patient, excessively timid and difli-
dent, kept himself in a profuse perspiration the ﬁrst night and next day; suppura-
tion on the third. Both cases failures, of course.
To recapitulate :——reactive processes in 19 cases out of a 100; 5 failures.
This brings me to the visual results.
In 166 successive cases of complicated as well as uncomplicated cataract.
¢OOOKICDCRIJ>CDN>
S was 20/20 in 15 cases, 6e, 9 per cent.
., 20/30 .. 28 ., ,. 17 .,
a: v a:
a’ a: s:
,, 20/70 .. 31 ,. .. 19 .,
,, 20/100 ,, 21 ,,
,, 20/200 ,, 11 ,,
S 20/200—20/20 in 1419 cases, : i.e., 89°70 per cent.

92 OPHTHALMOLOGY.
S was 15/200 in 2 cases.
10/200 ,, 1 case.
8/200 ,, 1 ,,
5/200 ,, 1 ,,
,, 4/200 ,, 2 cases.
3/200 ,, 1 case.
s s/200-15/200 in 8 cases, = m, 4182 percent.
S was 1/8 in 3 cases.
S 0—1/8_in 9 cases, : '5.e., 5'48 per cent. (100)
If, as is customary, we classify these three groups into good results, moderate
results, and failures, we obtain, disregarding the decimals, 90 per cent of good results,
5 per cent. of moderate results. and 5 per cent. of failures. You will notice that I
have put three cases with quantitative perception of light simply among the failures,
and that I have not excluded the complicated cataracts. These visual results were
compiled from the last notes to be obtained. Some of them were taken at the
discharge of the patients, others months or years later, and others, again, when
after-operations had been performed.
The number of after-operations was considerable. In the ﬁrst 66 cases, they
numbered 26 at the date of publication, but some have been added since. In the
last 100 cases, which are not yet published, 43 after-operations were performed,
namely :—
1. Iridectomy in 3 cases of closure of the pupil by irido-cyclitis. Result in
1 case moderate, in the 2 others the pupil closed again.
2. Iridotomy in 2 cases of false pupillary membranes. Results satisfactory.
3. Discission of the opaque or wrinkled capsule with a needle in 38 cases.
Result good in all. The form of needleﬂwhich I have found most suitable has
a sharp edge on one side, and is blunt on the other. It may be called a
knife-needle. I have a set of such needles, the cutting edge varying in
length from three to six millimetres. I prefer a straight to a curved needle,
because the latter does not pierce the tissues so easily as the former, which in
tough capsules is of importance. The discission should always be done under
oblique illumination, so that the course and effect of the needle can be accurately
watched. I do not make an irregular, multiple laceration of the capsule, as is
ordinarily done with one or two of Bowman’s stop needles ; I make a well-deﬁned
_|_ shaped, or crucial incision. It is essential to have the thickness of the stem of the
needle exactly proportioned to the size of the cutting part, so that no more than a
minimum quantity of aqueous escapes. The pupil being dilated by atropia, I
ﬁrst make a horizontal incision, corresponding in position to the lower edge of the
non-dilated pupil; then I turn the needle on the ﬂat, and push its point over the
upper part of the capsule, as high as the base of the coloboma, where the capsule
is transﬁxed again, and slit down to the horizontal incision. If the opening
thus gained appears insufficient, I split in the same way the lower part of the
capsule adjacent to the horizontal incision, thus converting the _|_ shaped into a
quadrangular opening. If the capsule is tough, and not readily out, another needle
is introduced, and the division made according to the well-known double-needle
procedure.
OPHTHALMOLOGY. 9 3
5
The reaction after the discission is very insigniﬁcant; either none at all, or
only a slight circumcorneal redness for a day or two. Vision is nearly always
improved; never, thus far, have I seen it made worse.
‘I perform this after-operation in all cases where the acuteness of vision is
20/70 or less, and have done it as early as the ﬁfteenth day after the operation,
or weeks or months later, with equal satisfaction. The indications should not be
furnished by the visual tests alone, but also by oblique illumination, and the
ophthalmoscope, which will determine how much the lack of good sight is due to
opacity and folding of the capsule.
In order to show how long after the extraction the discission was made,
and how much the sight was improved by it, I have tabulated the 38 cases in
which it was performed in the last 100 extractions.


s. I s.
N 0 Time of Discission No. Time of DiscissionI
after Extraction. Before . After after Extraction. Before After
Discission. Dlsclssion. Discission. Discission.
._ I ‘
I 14 days. 20/100 20/20 ' 2° 5 weeks. 20/70 20/20
2 ,, ,, 20/100 20/30 ‘ 21 ,, ,, 20/70 20/30
3 ,, ,, 20/100 20/50 I 22 ,, ,, 20 100 20/40
4 ,, ,, 20/100 20/70 23 ,, ,, 20/100 20/30
5 16 ,, 20/50 20/20 24 ,, ,, 20/100 20/30
6 ,, ,, 20/200 20/100 ! 25 ,, ,, 20,’:00 20 100
7 I9 » 20/100 20/30 i 26 ,, 20/60 20/30
8 ,, ,, 20/50 20/30 1 27 ,, ,, i 20’60 20/40
9 20 ,, 20/100 20/40 ’ 23 ,, 20 '200 20/ 50
10 3 weeks. 20/50 {20/40 ‘ 29 2 months. 20/200 20/50
11 4 ,, 20/100 20/40 , 3° ,, ,, 20’200 20/20
12 ,, ,, 8/200 20/200 SI ,, ,, 20 ‘200 20/40
13 u :2 20/100 2¢/’7o I 32 a: ,, l 20/‘100 2c>/'i<>
14 ,, ,, 20/200 20/ 30 33 3 ,, [ 1/200 1 5 / 200
15 ,, ,, 20/200 20/70 5 34 ,, ,, | 20150 20/30
16 a: ., 20/200 20/30 35 s ,, ' I 200 5/200
r7 ,, ,, 20/100 20/50 36 ,, I 20/200 20/200
18 31 days. 20/ 200 20/70 37 ,, ,, 20, 200 20/ 50
19 33 ,, 20/200 20/50 1 38 I year. I 20/200 20/40


The table shows that in 37 cases the vision was materially improved, in one left
as before. In one case only the operation was followed by low but long reaction.
It was a case of complicated cataract, in which also the extraction had been fol-
lowed by slow irido-cyclitis.
The essential features of the method of extraction with peripheric division
of the capsule may be summed up as follows :—~
(1.) It simpliﬁes the operative procedure of extraction, making unnecessary
the introduction of an instrument into the anterior chamber for the opening of
the capsule.
(2.) The capsule is out, not torn open, placing the healing of the lesion in a
much better condition, as an incised wound is less dangerous than a lacerated
wound.
(8.) Portions of capsule are not so easily and extensively crowded into the corneal
section as after central cystotomy.
(41.) The ready closure of the capsular opening shuts up remnants of cataract;
thus preventing them, as well as shreds of capsule, from coming in contact with
the iris and the walls of the anterior chamber, particularly the parts near the
corneal section.
(5.) These conditions unite in warding off many reactive processes to which the
central, multiple and irregular laceration of the capsule is liable.
9 4 ' OPHTHALMOLOGY.
D
(6.) The peripheric opening of the capsule makes a greater number of after-opera-
tions necessary than the central opening. This disadvantage is mitigated by the
possibility of performing the discission easily and safely as early as the third or
fourth week after the extraction, and it is counterbalanced by a higher rate of
permanent good vision than is obtained after central opening of the capsule.
(7.) It renders the removal of cataract a safer operation, by dividing it into
two operations. Of these, the ﬁrst, the extraction proper, increases the chances of
recovery, because the mode of performing it is simpliﬁed, and the extent of the
lesion diminished, whereas the second operation is virtually without danger.
I think the method of operating as described is indicated in all cases in which
extraction is indicated, except in those complicated and hypermature cataracts,
where the capsule is tough, and the suspensory ligament of the lens frail or defec-
tive. I concur with Pagenstecher, that in these cases the crystalline body can and
should be removed in totc, without risk of rupture of the capsule.
In conclusion, I beg to offer some historical remarks. In your programme,
pointing out desirable subjects for discussion before this section of the Congress,
the peripheric division of the capsule is called (in parenthesis) the method of the
present speaker. To this honour, gentleman, he is not entitled. He is not the
inventor of the procedure, for everyone of you has occasionally resorted to it when
an attempt at central opening proved ineﬁectual; nor has he made the ﬁrst pub-
lication on the subject—that was done, incidentally, by Dr. de Wecker, in 1873 ;
nor was he, as he formerly imagined, the ﬁrst to try it as a general method on a
larger scale—this was done by Professor Gayet, of Lyons, in 1873 and 1874.‘.
Gayet omitted the subsequent central division of the capsule, and gave the opera-
tion up as a general method. Drs. Martin and Griining recommended it for
Morgagnian cataract. I have cultivated it, exclusive of all other methods, since
1877, and was impelled to do so, not from reading, nor seeing it done by others,
but by the study of the manifold reactive processes to which a lacerated, and even
partially exsected capsule gives rise; processes which I have watched for many
years, and repeatedly and minutely described. Seeing that the lacerated capsule
acts injuriously in different ways, I wrote in the report of the ﬁrst_hundred ex-
tractions which I had performed according to Von Graefe’s method, and published
in his Archives, about ﬁfteen years ago, that I thought the greatest improvement
of which Graefe’s operation was still capable, lay in the successful dealing with the
anterior capsule. Small openings made the expulsion of the lens difficult in many
cases, and impossible in some, without traction instruments; large openings by
dilaceration entailed inﬂammatory processes in the iris and capsule, often fatal to
the eye. Thus, I was led to remove a quadrangular piece of the anterior capsule,
which I practised for more than ten years. The successful cases after this
method, about eighty-three per cent, obtained and preserved very good sight,
but the percentage of total loss was too great—eleven and a half per cent. For a
time I adopted Pagenstecher’s method of removing the lens with the capsule.
Though the results, on the whole, were satisfactory, I gave it up, because the loss
of vitreous, the introduction of a large spoon, and the occasional rupture of the
capsule where I had not expected it, wounded not only the eye, but also my
feelings—though both commonly recovered. For a certain group of cases—of which
I have spoken—I think it better than any other, though I believe this group to be
more restricted than Dr. H. Pagenstecher states it—namely, about thirty per cent,
of all the cases. Thus, no other course was left open, to my mind, than to navigate
just in the opposite direction—13.6., to open the capsule to as limited an extent as
OPHTHALMOLOGY. 9 5
would be compatible with a safe and sure exit of the lens. I made a large horizontal
opening along the edge of the lens, joining to it a vertical incision. This method,
gentleman, is, perhaps, the best of all. At ﬁrst I used it exclusively, assuming
that the escape of a large lens would be easier by it. The results were very good.
Graduaﬂy, however, I found that even a large lens may slip through a mere hori-
zontal opening; and having observed that this opening closed in the ﬁrst night, I
caught the idea that in this way the lens might be expelled, and yet the eye be
inﬂicted with no greater lesion than that which an iridectomy produces. Now I
began to experiment under guidance of this idea. I made small openings, which
were in many cases harmlessly enlarged by the emerging lens ; in others, however,
where the capsule was tough, they led to diﬂiculties in the exit of the lens, bruising
of the iris and corner of the wound, to rupture of the zonula and prolapse of
vitreous, necessitating in two instances the introduction of a traction instrument.
Even when the lens escaped readily through a small opening in the capsule, this
opening was commonly angular and irregular. Experience, therefore, demon-
strated the dangers of an insufficient capsular opening, as it has long demonstrated
those of an insufficient corneal section. Even with the correct performance of
every other step of the operation, and the most careful attendance to sanitary
rules, I think that the rate of success of cataract extraction, both in the number of
cures and the acuteness of vision, can be increased by replacing the central open-
ing of the capsule by the peripheral. In this country, Dr. Fitzgerald, of Dublin,
made a communication in favour of this method in 1879. In a paper appearing
in the forthcoming number of the Archives of Ophthalmology (A'rchiv far
Augenheilkzmcle), I have given a detailed and critical report of the last (the
seventh) hundred of peripheric linear extractions which I have made. The subject
of peripheric capsulotomy there is discussed more at length than I could have
permitted myself to do in this place. For literary statements I also refer to that
paper, thinking that my humble contributions to the work of the Congress would
be more acceptable if I gave you my personal experience and views, than lengthily
cited what others have written.
DISCUSSION.
Dr. GAYET, Lyons: As early as 1873 I proposed a similar operation, under the
name of “Equatorial discission.” My object was to avoid opening the centre of the
capsule, in order to prevent the formation of secondary opacities, which invaded it
when the lens had passed through that part of its capsule. It has, however, not
entirely fulﬁlled my expectation. I found the procedure easy, and do not think that
any new instruments are needed; the knife suﬁices for opening the capsule. It is
not applicable when the centre of the anterior part of the lens is changed. nor when
the lens is atrophied, nor when the zonula is stretched. In fact, the operation has
not realized my hopes by giving better and more lasting acuteness of vision.

Des ope'mz‘z'ons com‘re [e Glaucoma dams sesformes zigﬁe’rem‘es.
Dr. L. DE WECKER, Paris.
Bien qu’il s’agisse, pour les honorables membres de cette assemblée, de porter un
jugement sur les ope'rations anti-glaucomateuses en general, nous pensons que,
dans l’intérét de la clarté et de l’utilité pratique de la discussion, la question (1011-, étre
96 OPHTHALMOLOGY.
restreinte à l’emploi des deux seules opérations usitées pour le traitement du
glaucome: l’iridectomie et la sclérotomie.
Si les organisateurs de ce congrès ont bien voulu songer à moi pour ouvrir le
débat, c’est, je pense, qu’ils ont désiré faire choix d’un confrère qui, ayant pratiqué
sur une très-vaste échelle ces deux genres d’opérations, se trouverait par cela même
dans des conditions favorables pour aborder ce sujet. Je ferai tous mes efforts
pour justifier leur conﬁance, en exposant avec la plus entière franchise l’enseigne-
ment que m’a fourni mon expérience, quoique je ne puisse me défendre d’un cer-
tain embarras, en songeant a la suspicion que peut aisément faire naître un des
premiers instigateurs d’une des opérations curatives du glaucome.
La merveilleuse découverte de notre maître à. tous, de Gmefe, eut-elle été appli-
cable, avec un égal succès, à toutes les formes et genres de glaucome, personne évi-
demment n’aurait songé à substituer à. l’iridectomie une autre opération. Hélas I
non seulement pour un groupe important de glaucomes, l’iridectomie est impuis-
sante dans son action, mais encore dans certains cas trop fréquents, elle est même
désastreuse. '
Ceux qui se bornent a l’emploi exclusif de l’opération de notre maître et qui, se
déclarant satisfaits, repoussent, avec un sentiment de surprise, que nous croyons
sincère du reste, toute idée de substitution de la sclérotomie a l’iridectomie, sont
des confrères qui, sur un champ d’observation souvent peu vaste, ont eu la bonne
chance de ne rencontrer surtout que des cas favorables à l’iridectomie, et qui n’ont
pas été a même de contrôler pendant 15 ou 20 ans la vision d’un nombre assez
notable de leurs opérés.
Quant a ceux qui ont été appelés à traiter de très-grandes séries de glauco-
mateux, ils devaient forcément se convaincre que le précieux moyen curatif que de
Gmefc leur avait mis entre les mains était insuﬂîsant et encore assez souvent d’un
emploi dangereux. Aussi, suivant le tempérament de chacun, fallait-il ou se
résigner ou perfectionner.
Peu enclin à la résignation, mais très-désireux de guérir le plus grand nombre
possible de mes glaucomateux, je me suis tout d’abord préoccupé de séparer les
cas de glaucome où l’iridectomie montrait surtout son merveilleux pouvoir curatif,
de ceux dans lesquels cette opération offrait moins de certitude et pouvait même
devenir périlleuse. J e dois ajouter que de ce côté la voie se trouvait déjà aplanie
par les aveux mêmes de notre maître.
Incontestablement, l’acuite du processus glaucomateux ainsi que le degré
d’irritabilité de l’œil est en raison directe de l’action curative de l’iridectomie.
Par contre, plus le mal est chronique, plus les symptômes irritatifs font défaut,
moins on peut compter sur une action favorable résultant de l’excision d’un lam-
beau de l‘iris.
Et notons immédiatement ceci, c’est que la puissance curative de l’iridectomie
est_ d’autant plus manifeste que, par suite d’une exagération de plus en plus
accentuée de la pression, l’éxécution correcte de l’opération (sans enclavement de
l’iris) est rendue plus difﬁcile. Aussi n’y a-t-il rien de bien paradoxal a dire que
l’on guérit plus de glaucomes avec des iridectomies mal exécutées qu’avec des
excisions faites lege art/L'a
Comme notre but n'est pas d’entrer dans des discussions théoriques, mais bien
de chercher à élucider exclusivement le côté pratique de la thérapeutique du glau-
come, nous poserons immédiatemcntla question comme suit: à savoir si, connaissant
la puissance curative de l’iridectomie dans les cas de glaucome aigu et irritatif,
toute substitution d’une autre opération est rendue ici inutile, et si seules pour les
OPHTHALMOLOGY. 97
l
formes absolument chroniques et non irritatives l’opportunité d’une'pareille substi-
tution doit être agitée. _
Cette simpliﬁcation aurait été justiﬁée, si dans le groupe des formes aiguës ne se
glis‘saient pas des cas de glaucomes malins ou hémorrhagiques qui rendent l’emploi
de l’iridectomie parfois très-périlleuse, et si l’action curative de cette opération ne
s’épuisait pas a la longue pour un certain nombre de cas aigus, correctement
ou incorrectement opérés. La encore, dans le groupe des glaucomes irritatifs, on
se trouve donc dans l’obligation de recourir à un second mode’ opératoire qui, je le
pense, a prouvé son efficacité, c’est-à-dire à la sclérotomie.
Toutes les fois qu’il y a le moindre soupçon sur l’existence d’une fragilité des
vaisseaux ou d’un état variqueux imprimant au glaucome un caractère hémor-
rhagique, lorsque; l’attaque a succedé a une rétinite apoplectiforme, que le bord
pupillaire montre (ainsi que M. Abadie l’a fait observer) une couleur analogue à. la
rouille, ne précipitez rien, faites tout d'abord une sclérotomie, répétez même au
besoin cette opération, et vous pourrez alors sans péril faire suivre celle-ci d’une
iridectomie, si vous avez une plus grande conﬁance dans son action curative
déﬁnitive. En s’aidant de l’emploi des myotiques, la sclérotomie n’est pas plus diﬁi-
cile en pareil cas que l’excision de l’iris, et sa puissance d'action pour combattre
même les symptômes les plus violents de l’attaque glaucomateuse ne fera de doute
pour quiconque aura souvent eu recours à cette opération.
En faisant, tout d’abord, dans tous les cas de glaucome aigu sur la nature
bénigne desquels pourrait planer le moindre doute, une sclérotomie, on évitera_,la
rencontre si fâcheuse et parfois si imprévue d'un glaucome malin, et on élargira
notablement le terrain sur lequel peut s’exercer l’action curative de l’iridectomie
que personne moins que moi ne songe à chasser du domaine où elle s’est incontes-
tablement établie en souveraine.
, Cette même supériorité que garde l’iridectomie dans ces cas déterminés, je la
revendique pour la sclérotomie, quand il s’agit du groupe des glaucomes chroniques
simples, dépourvus de tout symptôme irritatif. Ici on échappera a deux dangers
sérieux auxquels expose l’iridectomie. En premier lieu on évitera une dépré-
ciation sensible de la vue si le rétrécissement du champ visuel menace déjà de
déborder le point de ﬁxation, l’excision de l’iris amenant fréquemment ce résultat
de faire sauter dans ce cas la limite interne du champ visuel au dela du point de
ﬁxation ; de façon a abolir toute vision centrale et a ne laisser subsister qu’une vision
indirecte en dehors. En second lieu l’iridectomie entraînera presque constam-
ment la production d’un astigmatisme et des éblouissements, phenomènes facheux
qui effraient et découragent le malade, alors même que l’opération n’a pas amené
une véritable réduction de l’acuité visuelle. Les recherches qu’un de mes élèves,
M. Manolescu de Buclzarest a presentées au congrès d’Amsterdam, ainsi que
l’expérience que j’ai encore acquise depuis, m’ont prouvé que l’action curative
d’une sclérotomie bien executée est supérieure ou au moins équivalente à celle de
l’iridectomie, et cela, sans présenter les inconvénients et les dangers de l’excision
de l’iris. Et, à ce sujet, nous supplions nos confrères qui débutent dans la
pratique de cette opération de bien vouloir ne pas attribuer à une impuissance
de la sclérotomie ce qui doit être mis sur le compte d’une exécution opératoire
imparfaite.
Que ceux qui hésitent à abandonner une opération dont les résultats souvent
brillants, il est vrai, expliquent leur attachement pour elle, veuillent bien néan»
moins commencer à appliquer la sclérotomie.
1° Dans les cas où l’excision de l’iris se montre fort périlleuse, c’est-a-dire dans
PART 111. H
98 OPHTHALMOLOGY.
le glaucome hémorrhagique et le glaucome congénital, autrement dit la buph-
thalmie.
2° Qu’ils pratiquent la simple section sclérale dans les cas de glaucome absolu,
où l’excision de l’iris, quoique toute virtuelle, peut conduire, par l’accroissement
des douleurs à l’énucléation, opération à laquelle on échappera surement par des
sclérotomies répétées.
3° Qu’ils aient recours à la sclérotomie comme opération complémentaire lorsque,
soit immédiatement, soit ultérieurement, l’iridectomie n’atteint qu’incomplètement
son but thérapeutique. Ici encore la sclérotomie répétée me parait, surtout en
ce qui concerne les formes chroniques du glaucome, d’un effet supérieur àla pupille
artiﬁcielle primitivement pratiquée, la seconde opération étant faite du côté opposé
à la première restée impuissante.
Si les partisans les plus ardents de l’iridectomie s'engagent dans cette voie, ils
arriveront sûrement ainsi a éviter les dangers imprévus de leur opération favorite
et à la seconder efficacement la où elle se montre défaillante dans son‘ action bien-
faitrice. Plus tard, l’expérience,qu’ils auront ainsi acquise les conduira presque
inconsciemment a substituer la sclérotomie a l’iridectomie dans les formes pure-
ment chroniques du glaucome.
Après avoir suivi moi-même cette ligne de conduite que mes honorables con-
frères voudront bien me permettre de leur conseiller, je puis me féliciter d’avoir
échappé aux surprises douloureuses que réservait parfois le traitement chirurgical
du glaucome. Certes, je n’aﬁirme pas que l’on puisse guérir ainsi toutes les
formes chroniques du glaucome et que les cas dans lesquels s’obscrve dès le début
une blancheur marquée des papilles soient sûrement traités avec succès par la
sclérotomie, cette infallibilitélchimérique n’est pas plus réservée à l’une qu’a
l’autre de ces opérations, mais ce que je soutiens avec une entière conviction, c’est
qu’en combinant ces deux modes opératoires on assistera bien plus rarement au
triste spectacle de voir dépèrir sous ses propres mains la vision des glaucomateux
refractaires, ainsi qu’il arrive nécessairement dans un certain nombre de cas
lorsqu’on s’obstine à. n’user exclusivement que de l’excision de l’iris.
J e n’ai été guidé dans mes recherches que par l’unique désir d’obtenir des
guérisons plus parfaites et plus nombreuses, la pratique de ces dernières années
m’ayant démontré que je m’étais engagé dans la bonne voie, j’ai maintenant la
conviction que les compagnons de route ne me feront pas défaut.
Sclemz‘omy 2'72 G/amoma.
Mr. C. BADER, London.
By bringing before you the following cases of glaucoma treated by sclerotomy,
I wish to prove~~ 1st, that the kinds of glaucoma usually treated by iridectomy can
be treated, and more successfully, by sclerotomy ; 2ndly, that, to secure success, it
is desirable to obtain, and to maintain, a staphyloma of the conjunctiva, with or
without prolapse of the iris.
These cases also show the truth of the second proposition—fie, the desirability
of a staphyloma of the conjunctiva, with or without prolapse of the iris. I know of
no better method to secure this than the kind of sclerotomy by which a small
sclerotic ﬂap is made close to the insertion of the iris, leaving part of the conjunc—
tiva adjoining the sclerotic wound undivided. I consider the occurrence of prolapse
of the iris a favourable accident, and the non-occurrence of staphyloma of the con-
OPHTHALMOLOGY. 99
'junctiva as an unfavourable symptom. All steps of the operation, and of the after-
treatment, must tend to secure a bulging of conjunctiva, or of the conjunctiva and
iris, as a safety-valve to too high tension of the eyeball.
The following living specimens were shown in conﬁrmation of Mr. Bader’s
statements :—
ScZerotomy.——Acate glaucoma both eyes—Case, aged 70. Seen in consultation
with Dr. Jackson, Church Street, Spitalﬁelds. Perception of light only.
October 11, 1875.—-Sclerotomy.
November, 1875.——T. n., small iris bulge and leakage.
August, 1881.——T. and elasticity normal; leakage as before. Since age of
forty-ﬁve patient used convex lenses for reading. For three years after operation
she could read the ﬁnest type with both eyes without spectacles.
Glaucoma after cataract extraction—Case, aged 50. Had cataract removed else-
where by upward section; adhesion of iris to cornea followed. I removed cataract
from left eye by downward section. Glaucoma appeared in the right eye, which I
sclerotomized, taking care to cut through the adherent iris.
August, 188l.-—Sight of left eye normal. Right, all glaucoma disappeared.
Glaucoma with chronic inﬂammation and myopia—Case, aged 63. Seen by
several London eye surgeons. Right eye, bare perception of light; left, good per-
ception of light. -
October, 1879.—Both eyes sclerotomizecl. On third day after operation T— and
good protrusion of conjunctiva and iris.
October, 1880.—-Good leakage. Left eye reads Ordinary type; right has good
perception of light.
Simple glaucoma—Case, age 35. Seen in consultation in 1871 with Dr. Still-
well, of Beckenham. Patient accidentally found left eye blind; right glaucoma.
Refused operation.
In 1876 guides himself with difficulty; simple glaucoma more advanced.
Iridectomy Operation.
In 1877 bare perception of light ; submitted to sclerotomy ,- very large protrusion
of conjunctiva and iris.
December, 1880.—Can see to guide himself with difficulty. T.n.

Indications de [a Sele‘vfotomz'e.
Dr. CH. ABAnIn, Paris.
La théorie indique que s’il existe certaines formes de glaucome réellement dues
a ce que les voies de ﬁltration de la région scléro-cornéenne sont Oblitérées, la
ohambre antérieure doit nécessairement ou augmenter en profondeur ou tout au
moins conserver ses dimensions normales. L’observation clinique conﬁrme pre-
cisément ces prévisions théoriques, et- o’est dans le glaucome chronique simple et dans
certaines formes d’hydrophthalmie, ou ces conditions existent, que la sclérotomie
donne les meilleurs résultats.
J’ai remarqué que l’inﬁuence exercée par la sclérotomie est d’autant plus grande
et d’autant plus durable que l’affection est moins ancienne. Cette Observation
est facile a faire dans les cas de glaucome chronique simple qui frappe les deux
yeux, l’oeil le plus désorganisé bénéﬁcie beaucoup moins que l’autre de l’opération.
J’ai obtenu dernierement un succes éclatant chez unjeune homme de dix-huit ans
atteint d’hydrophthalmie congénitale, qui apres etre restée stationuaire avait pris
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I 00 OPHTHALMOLOGY.
une marche progressive avec développement de phénomènes glaucomateux. Au
moment de mon intervention il ne restait plus qu’un peu de perception lumineuse
du côté temporal a droite. A gauche la maladie semblait prendre la même tour-
nure et la vision baissait rapidement; des deux côtés la tension était excessive. Une
double sclérotomie fut pratiquée. Elle a suffi pour ramener et maintenir déﬁni-
tivement a la normale la tension de l’oeil gauche. Tandis qu’à droite il a fallu la
répéter à trois reprises différentes et la tension reste encore elevée. Le succès obtenu
sur l’œil gauche est des plus encourageants cas; on sait combien ces cas-là. sont
rebelles à tous nos moyens d’action. La sclérotomie me parait appelée dans un
avenir plus ou moins éloigné a remplacer la paracentèse de la chambre antérieure.
Elle offre sur cette dernière l’avantage d’avoir une action plus durable, les lèvres de
la plaie se refermant moins facilement et assurant ainsi un écoulement plus pro-
longé de l’humeur aqueuse. En outre elle s’exécute avec le couteau de Græfe
qui est toujours d’un maniement plus facile et moins dangereux que le couteau
lancéolaire. En ce qui concerne le manuel opératoire on doit recommander de
faire la section aussi lentement que possible; on évite ainsi la hernie de l’iris,
et l’affrontement des lèvres de la plaie se fait moins facilement, ce qui est le but
à atteindre.
Dans le cas où le glaucome résiste à l’iridectomie et a la sclérotomie il y a lieu
d’essayer d’empêcher la perte fatale de l’oeil en agissant sur les vaisseaux et nerfs
ciliaires postérieurs et en pratiquant la dénudation du pôle postérieur. Mais c’est
un moyen qui reste encore plus théorique que pratique et qui abesoin d’être étudié
expérimentalement et cliniquement.
22W Sclemz‘omz'e.
Professor H. SCHOELER, Berlin.
(Communicated by Professor LEBER, Göttingen).
Ein Beitrag gegen die Fz'ltratz'onsfäln'gkez't der Sclemlnarben.
(Nach einem Vortrag in der Berliner .Mecl. Gesellschaft, vom 6 Juli, 1881.)
Soll die‘Sclerotomie fernerhin nicht das Schicksal der Hornhautparacentesen
beim Glaucom theilen, so muss die Filtrationsfahigkeit der Narbe erwiesen werden.
Diesen Nachweis zu führen, oder dieselbe von der ihr beigelegten Fähigkeit zu
befreien, war der Zweck folgender, kurzer experimenteller Versuchsreihen.
Als Versuchsthier benutzte ich das Kaninchen, bei welchem unzweifelhaft von
verschiedenen Beobachtern Glaucom beobachtet worden ist, wiewohl eine sichere
Methode der experimentellen Erzeugung derselben bisher noch fehlt.
In verschiedenster Ausdehnung von 4 bis 10 Mm. Lange wurden mit dem
schmalen Messer Sclerotomien am Scleralbord in einem Abstand von à— bis 1-;— Mm.
vom Limbus corn. entfernt ausgeführt.
Entweder wurde die Sclera vollständig durchschnitten oder eine Conjunctival-
brücke oder Scleralbrücke in dem Scheitel der Lappenwunde stehen gelassen. Die
Zahl der Sclerotomien an ein und demselben Auge schwankte von 1 bis 5, welche suc-
cessive nach Verheilung der zuvorgegangenen ausgeführt wurden. Desgleichen
wurde die Sclerotomie mit Irisexcision kombinirt und ferner cystoide Vernal‘-
bung absichtlich wie unabsichtlich herbeigeführt. Zur Bestimmung der Filtra—
OPHTHALMOLOGY. I O I
tionsgrosse aus dem Auge bediente ich mioh eines Manometer’s mit Leber’scher
Einstiohscaniile, welches in die vordere Kammer eingefiihrt wurde?‘
Bei allen Versuchen wurde die Ausgangstellung Von annéihernd 27 Mm. Hg.
Druck gefunden, etwaiige kleine Abweichungen dabei ausgegliohen durch
kiinstliche Herabsetzung oder Steigerung des intraoculéiren Druokes bis auf obigen
Werth. Die kiinstliche Steigerung erfolgte dann stets auf 100 Mm. Hg. Druok
iiber die Ausgangsstellung. Als Beobachtungsdauer warden 25 Minuten bestimmt,
welohe zur Wiederkehr normaler stéindiger Druckverhéltnisse erfahrungsgeméiss
meist reichlioh ausreichen. Die Filtrationsgeschwindigkeit wurde nicht nur
gemessen, sondern auoh nie verséiumt die Beschaffenheit der Narbe am? Fliissigkeits-
ausscheidung mittelst Fliesspapier wiederholt zu priifen und unter Loupenver-
grosserung ihre Oberﬁéiohe zu besichtigen. Nach Beendigung der Messung wurde
dann meist nochmals der Druck im Auge bis auf 200, 300, 1'esp.4.~00 Mm. Hg.
gesteigert, um eine kiinstliohe Berstung der Narbe zu. Stande zu bringen. Als
Injeotionsmasse bediente ioh mich einer schwachen Kochsalzlosung, welohe bis-
weilen mittelst Oarmin intensiv roth geféirbt wurde.
Was nun die Hauptfrage anbetriﬁ‘t, so ist bei siimmtlichen Versuohen niemals
eine Besohleunigung der Filtration am solerotomirten Auge gegeniiber dem
gesunden beobaohtet Worden.
Die einzelnen Messungen sind am 80., 41., 22., 14., 10., 8., und 4. Tage nach der
Ausfiihrunlg der Operation voi'genommen Worden. Unter den 8 F'zillen sind zwei mit
cystoider Vernarbung 11nd einer mit einer Irisexoision aufgeﬁihrt. Mit Ausnahme
eines Falles waren die Unterschiede in der Filtrationsgeschwindigkeit innerhalb
25 Minuten so geringfiigige, dass dieselben unter die Rubi-1]; der Beobaohtungsfehler
zu stellen sind. Will man das hingegen nicht, so spraohen die Diﬁ‘erenzen alle im
Sinne einer Verlangsamung der Filtration am sclerotomirten Auge. Nur in einem
Falle, wo nach llétiigiger Heildauer der Sclerotomiewunde manometrisohe Mes-
sungen vorgenommen wurden, beti'ug der Abfall am gesunden Auge 9?. Hum, am
sclerotomirten hingegen 80 Mm. Hg. innerhalb 25 Minuten. Die Ausgangsstellung
war Wie immer 27 Mm. Hg. gewesen, die Drucksteigerung 100 Mm. Hg.
Wie die Loupenbetrachtung und déLS Betupfen mit Fliesspapier lehrt, blieb in
allen Féillen bei diesen Druoksteigerungen die Narbe resp. ihr breites Zwisohen-
gewebe trocken. Selbst in dem Falle, wo mach 3 X 24 Stunden nach der Solerotomie
die Messung angestellt War, ﬁltrirte das Nai'bengewebe nioht. \Vurde hingegen der
Druck nooh weiter auf 200-300 Mm. Hg. iiber die Ausgangsstellung gesteigert,
also ein Druck erzeugt Wie derselbe sioher keinem pathologischen Processe am
Kaminohenauge eigcn ist, wobei der Bulbus steinhairt wurde, so blieb das Zwi-
schengewebe nicht mehr trocken. Mit Ausnahme eines Falles, wo die Sclero-
tomie mit Irisexoision kombinirt war, und naoh 22tz'igiger Heildauer selbst bei
300 Mm. Hg. Drue'ic die Narbe trooken blieb, trat bei dem Falle von 10t£igiger
Heildauer die Durohfeuchtung des Zwisohengewebes bei 240 Mm. Hg. Druck
ein, wiihrend bei den Fiillen von 141~und 4ltéigiger Heildauer dieselbe erst bei 300
Mm. Hg. Druck beobaiohtet wurde. Leider konnte an dem Versuohsthiere naoh
3tiigiger Heildauer die ‘Viderstandsféihigkeit des Zwischengewebes gegen
hoheren Druek nioht bestimmt werden, da dais Thier inzwisohen infolge des
Ohloroform’s verschied. Fiir den Fall von SOtiigiger (iiberh'z'uiteten Irisvorfall)
wie denjenigen V011 8tétgiger Heildauer, hatte ioh mioh beschr'zinkt auf den Nach-
weiss, dass bei 200, T681). 240 das Zwischengewebe noch trocken blieb, nioht aber

* Cf. Arch. f. Ophth., Bd. XXV. Abthl. 4.
I O 2 OPHTHALMOLOGY.
clen Berstungsdruck festgestellt. Walirend. in dem Falle Von 4sltagiger Heildauer
eine feine, gleiohmassig tropfenformige Durohfeuchtung (les Zwisohengewebes bei
Loupenbetraohtung Wahrgenommen Wurcle, platzte in dem Falle von IOtagiger
Heildauer das Zwisohengewebe an einem Punkte, aus welohem dann reiohlioh
Fliissigkeit hervorquoll.
Hoobst iiberraschend, zugleioh jeclooh hochst lelirreich gestaltete si ch nun das
Verhalten der Filtration bei oystoider Vern-arbung. In einenl diesel‘ Falle blieb,
wie bereits erwahnt, bei 200 Mm. Hg. Druok iiber der Ausgangsstellung der iiber-
hautete Irisvorfall vollig trooken, (SOt'agige Heildauer), Wahrend bei dem ancleren,
am unteren Wunclrande eine Stelle von Zeit zu Zeit einen punktformigen Fliis-
sigkeitstropfen austreten liess, wie mit Fliesspapier naohgewiesen wurde. Die bei
100 Mm. Hg. Druok fiir Fltissigkeiten permeable Parthie war bei der Loupen-
betraohtung nioht siclitbar, nahm auch bei 200 Mm. Hg. clie Ausscheiclung nioht
zu, sondern versiegte sogar bei nooh holierer Druoksteigerung, bis endlioh bei ca.
300 Mm. Hg. ein Platzen des Vorfalles eintrat. Wahrsoheinlioh war bei clem
hoheren Druok duroh starkere Vorwolbung cles Irisvorfalles ein pfropfartiger Ver-
schluss dieser nooh nioht iiberhauteten Stelle eingetreten. Die eigentliohe oystoide
Narbe liingegen blieb wahrencl der Zeit bis zu ihrem Bersten, wie im anderen Ver-
suohe, vollig trooken. Dieses Prototyp cler Filtrationsnarbe, Wie die oystoide
bisher gen annt wurde, ﬁltrirt demnach durohaus nicht, sondern liisst nur Fliissigkeit
(lurch, Wenn ein Bersten des verdiinnten Narbensoheitels statthat; damit \stimmt
nun ganz vortreﬂiioh das, was die klinisohe Beobachtung lehrt, bisherjedoch miss-
gecleutet wurcle. Auch hier sieht man nur von Zeit zu Zeit in grossen Intervallen
von Monaten ja selbst Jahren einen suboonjunotivalen Fliissigkeitserguss mit
gleiohzeitigem Einsinken ilires blasenformigen Scheitels ; Wohl Niemand hingegen
diirfte sioh riihmen, eine stetige Ausscheidung aus derselben wahrgenommen zu
haben, sobald die narbige Ueberhautung desselben, Welche hier bereits naoh 14¢-
tagiger resp. Alltagiger Heilclauer eingetreten war, sioh vollzogen hat. In dem
ersteren Falle von llitagiger Dauer war erst in Folge der zweiten Solerotomie ein
Irisvorfall eingetreten. Wahrend naoh der ersten Solerotomie die manometrisohe
Messung am gesunclen Ange in 25 Minuten einen Abfall VOIl 100 Mm. Hg. auf
0 Mm. Hg, im solerotomirten hingegen von 100 auf 2 Mm. Hg. ergeben hatte,
somit die Filtrationsgesohwincligkeit bei beiden als gleioh zu betrachten war, zeigte
eine erneuerte Messung nach cler zweiten Selerotomie Folgendes.
Trotz nioht volliger Impermeabilitat der Randparthie cler Narbe, erfolgte in 25
Minuten am sclerotomirten Ange jetzt der Abfall V011 100 Mm. Hg. auf nur 2O Mm.
wahrend am gesunclen die Abscheiclungsgrosse 98 Mm. betrug, somit der Hgstand
2 Min. iiber clie Ausgangsstellung betrug.
Hiermit beriihren wir die zweite Frage, wie wiederholte Solerotomien wirken.
Wahrend bei einer Solerotomie Ller besohleunigende Einﬂuss des Sohnittes auf die
Filtration mit grosster Bestimmtheit verneint werclen konnte, blieb eine Verlang_
samung der Filtration clurch dieselbe angesiohts eines einzigen dafiir redenden Falles
hoohst zweifelhaft.
Hingegen sincl nun in allen Fallen, wo mehrere Sclerotomien ausgeﬁihrt Wurden,
die zur Beobaohtung gelangten Werthe der Filtrationsgeschwincligkeit derartige
ganz ausnahmslos gewesen, class mit grosster Bestimmtheit daraus (lie verlangsa-
menole Wirkung mehrerer Sclerotomien auf die Filtration des Auges unmittelbar
hervorgeht. In 25 Minuten ﬁel der Druok Von 100 Mm. Hg. iiber der Ausgangs-
stellung naoh 2maliger Sclerotomie auf 20 Mm. Hg, Wahrencl bei gesundem Auge
bis auf 2 Mm. das Hg. sank. Naoh 3maliger Sclerotomie wurden am kranken
OPHTHALMOLOGY. I O 3
Auge 46 Mm. Hgstand, am gesunden Auge 28 Mm. Hgstand; in einem andern
Falle nach 4maliger Sclerotomie 4.41 Mm. Hgstand am kranken und O Mm. Hg.
am gesunden Auge bei der gleichen Drucksteigerung auf 100 Mm. _Hg. in 25 Min-
uten registrirt.
Nach 5maliger Sclerotomie betrug beim sclerotomirten Auge der Hgstand 14
Mm, unter gleichen Bedingungen am gesunden Auge der Hgstand O Mm.
1. Versuch.
Graues Kcm'inchem—Am 8. April d. J. wird am rechten Auge in einem Ab-
stande von ca. ä- Mm. vom Limbus corn. mit dem schmalen von Graefeschen Messer
eine Sclerotomie von '7—8 Mm. Lange ausgeführt. Nach Durchschneidung der
Sclera bleibt entsprechend dem mittleren Drittel des Schnittes eine Conjunetival-
brücke undurchschnitten stehen. Bei der Operation kommt es zu keinem Iris-
noch Glaskörpervorfall, desgleichen heilt die Wunde ohne bemerkenswerthe Wund-
reaktion. Am 16. April, also nach 8 Tagen, ist die Wunde mit breitem schwärz-
lichem Zwischengewebe geheilt. Iris frei, vordere Kammer von mittlerer Tiefe. In der
Narkose wird jetzt die Leber’sche Oanüle geschlossen in die vordere Kammer des
operirten Auges eingeführt. Nach Oeffnung derselben stellt sich in dem mit der
Canüle in Verbindung stehenden Manometer der Druck auf 27 Mm. Hg. Die Ein-
führung erfolgte ohne Abﬂuss von Kammerwasser, Stichöifnungen trocken. Durch
Inj ection einer schwachen OLN a. lösung von derselben Concentration (lc/'°),wie die im
Manometerrohre zur Füllung benutzte, wurde nun langsam der Druck auf 100 Mm.
Hg. über die Ausgangsstellung gesteigert und nach Abschluss des Kautchuk-
rohres an der dreischenkligen Canüle * der Abfall der Drucksteigerung beobachtet.
Am gesunden Auge war der Modus procedendi der gleiche.
Von 100 Mm. Hg. sinkt das Hg.
Nach ä Minute am sclerotomirten Auge auf 92 Mm.Hg., am gesunden auf 94 Mm. Hg.
7’ 1 ’ 3, \ 53 3! 3’ 3’
J, 2 3’ 3’ ß’ 9) "
5’ 3 3’ q’ 3’ 9’ 3,
7’ ä 5’ ß’ 3’ 3’ 5’
„ 8 „ a: 30 „ „ 38 „
„ 10 „ „ es ,, ,, 32 „
3, „ 3’ ,9 5, 3,
„ 15 „ „ 20 „ „ 20 „
Q’ 3, ,3 ä) 9’ 9!
Während der Versuchsdauer blieben nicht nur die Stichöifnungen trocken, son-
dern konnte auch mittelst Fliesspapier aus dem breiten Zwischengewebe der leicht
prominenten und reichlich vascularisirten Narbe keine Flüssigkeit aufgesogen
werden, wie häuﬁg wiederholte Versuche bestätigen. Steigert man den Druck auf
24‘0 Mm- Hg- über die Ausgangsstellung, so blieb die Scleralwunde völlig trocken,
und entwickelte sich unterhalb derselben entsprechend der Muskelinsertion eines
Geraden ein mächtiges Conjunctivaloedem, desgleichen durchfeuchtete sich der
übrige Limbus gleichmassig. .
Am 23. April wurde nun an demselben Kaninchen zum 2. Mal und am 29. dess_
Monats zum 3. Male die Sclerotomie ausgeführt. Das 2. Mal wurde dasselbe mit
w—f
* Of. Arch. f. Ophth. Bd. xxv. Abthl. 4»
I O4 OPHTHALMOLOGY.
Oonjunctivalbriicke, das 3. Mal ohne dieselbe sclerotomirt. Die Léinge der Schnitte
betrug 8-10 Mm. bei 0a,. 1 Mm. Abstand vom Limbus und entsprach ihre Lage der
Muskelinsertion des oberen und unteren geraden Augenmuskels. -
Am 6. Mai wurde, nachdem die Scleralwunde verheilt war, die gleiche mano-
metrische Bestimmung, Wie zuvor ausgefﬁhrt. Ausgangsstellung 2'7 Mm. Hg.
Druck. Drucksteigerung 100 Mm. Hg. iiber der Ausgangsstellung.
Von 100 ll/Im. H g. sinkt das Hg.
Nash % Minute am sclerotomirten Ange emf 90 Mm. Hg. am gesunden auf 88 Mm. Hg.
n 1 a: a: n a: n
n 2 a, a: n a: n
a: 3 a: u n n a:
a, 5 a, a: 2a :2 :9
a: 8 a: a: n n a:
a, a, :2 n a: :7
,, 12 ,, ,, 53 ,, ,, 3O ,,
n n n a: n n
a: a: n n n a:
a’ n a: n a: n
Stichéffnungen trocken, kein Kammerwasserabﬂuss beim Einstich. Commu-
nikation zwischen vorderer Kammer 11nd Manometer prompt.
In diesen zwei Versuchen ist die Filtrationsgeschwindigkeit am gesunden Auge
wéihrend der ersten 15 Minuten genau die gleiche geblieben, w'zihrend am scleroto-
mirten, nach der dritten Sclerotomie, bei der zweiten manometrischen Messung nur
412 Mm. Hg. gegen 80 Mm. Hg. Abfall bei der ersten constatirt Worden. Es hat
somit eine Verlangsamung der Ausoheidung um ungeféihr die Hétlfte stattge-
unden.
2. Versuch.
Weisses Kaninchem—Am 28. Februar d. J. Wurde eine Sclerotomie von 6 Mm.
L'zinge in 1 Mm. Abstamd vom Limbus mit Oonjunctivalbriicke ohne Irisvorfall 11nd
efﬂuvium corp. vitr. ausgeﬁihrt. 16. April 61. .I. Wird eine 2. Sclerotomie von 8 Mm.
L'zinge 1 Mm. vorn Limbus entfernt mit Oonjunctivalbriicke an demselben rechten
Ange ausgefiihrt. Dieselbe kommt naoh aussen in 1 Om. Abstand von der ersten
zu liegen. Kein Irisvorfall. 8. Mai (1.3‘. die dritte Sclerotomie verbindet die beiden
friiheren. LtLnge derselben 10 Mm., Abstand vom Limbus 1-1-3; Mm. Es bleibt
eine Oonjunctivalbriicke stehen. Kein Irisvorfall. 12. Mai 01. J. 4‘. Sclero’comie
von 8 Mm. Léinge mit Oonjunctivalbrﬁcke in 1 Mm. Entfernung vom Limbus
ausgeﬁihrt. Am 27. Mai d. J. ercheint das Ange bless, nur die néichste
Nachbarscbaft der Narben ist schwach vascularisirt. Iris frei mit prompter Beak-
tion, Pupille central. Die Narben bilden einen zusammenhéingenden Ring um den '
Limbus herum und bleibt nur der untere Theil desselben entsprechend der Insertion
des M. -1'ectus inf. in einer Ausdehnung von ca, 6-8 Mm. frei. Dabei ist die vordere
Kammer bedeutend abgeﬁacht. In gewbhnlicher Weise wird nun auf beiden
Augen die manometrische Messung ausgeﬁiht. Ausgangsstellung 27 Mm. Hg.
Druoksteigerung 100 Mm. Hg. In beiden F'sillen fand minimster Kammerwasser-
verlust beim Einfiihren der Stichkaniile statt, blieben aber die Stichéffnungen
w'athrend des Versuchs véllig trocken. Die Drucksteigerung wird in beiden Fiillen
gleich langsam bewirkt. Pupille mittelweit.
OPHTHALMOLOGY. I 05
Der Abfall erfolgte 220% 100 Zlfm. Hg.
Nach @— M innte am sclerotomirten Ange anf 90 Mm. Hg, am gesnnden anf 88 Mm. Hg.
,, 1 ,, ,, 86 ,, ,, '78 ,,
a: 2 n n u a’ a:
n 3 7; n n n a:
n 5 n n n n n
,, 8 ,, ,, 48 ,, ,, 20 ,,
,7 27 n v a, 8 a’
,, 12 ,, ,, 38 ,, ,, 0 ,,
1‘! 1’ n a; a: 0 as
s: a: n u as O n
n a’ n a’ s, O ”
Hier, W0 nach 4, Solerotomien eine manometrisohe Messnng angestellt wnrde, zeigt
sich eine so enorme Verlangsamnng (nach 12 Minnten Abfall von 62 gegen
Abfall von 100 Mm. Hg.) dass in sohlagendster Weise dadnroh der verlangsamende
Einﬂnss wiederholter Sclerotomien anf die Filtrationsgeschwindigkeit dargethan
ist.
Es lag nnn nahe den ganzen Limbns allmalig zn nmsohneiden nnd nm denselben
eine ringformige Sclerotomiennarbe dadnreh zn erzengen. Anf solche Weise
konnte man hoﬁen, die Filtration schliesslioh ganz znm Versiegen zn bringen.
Beim Kaninehen ist ein solches Vorhaben nnansfiihrloar, da die Narben ohne
Glaskorperverlnst nioht so peripher angelegt Werden konnen, nrn alle Filtrations-
bahnen dadnrch zn einem narbigen Verschlnss zn bringen. Ferner bilden sich, wie
man wohl ohne VVeiteres annehmen kann nnd die Beobachtnng bestatigt, jeden-
falls abnorme Abﬂnsswege ans, Wenn, wie es hier geschehen Innsste, die einzolnen
Solerotomien nm Tage, ja nm Wochen von einander getrennt, ansgefiihrt wnrden.
Um die R-ichtigkeit der meohanischen Erzengnngstheorie des Glancoms zn priifen,
stimmten hier nioht einmal, wie ersichtlich, die gesetzten Versnolisbedingnngen.
Angenommen jedoch, dieselben wiiren da gewesen, so hielte ich es dooh fin‘ hochst
nnwahrsoheinlich, anf diese YVoise ein Glancom zn erzengen, da dnrch Aendernng
der Zn- nnd Abﬁnssbedingnngen wohl die Entstelinng von Stannng, nieht aber von
Entziindnng erkléirt wird. Dass eine wiederholte Einfiihrnng der Stichcaniilennch
am gesnnden Ange die Filtrationsbedingnngen zn andern im Stande ist, dafiir
spreohen festgestellte W'erthe, wie 72 Mm. Hg. Abfall (naoh der 4*.) zn 100 Mm. Hg.
Abfall an demselben Ange (nach der 5. Solerotomie). Als constante Thatsaehe
' bleibt jedooh bestehen, woranf es hier allein ankommt, dass mehrere Solerotomien
stets die Filtration des operirten Anges im Vergleioh zn denijenigen des gesnnden
Anges herabsetzen nnd dieses Faktnm nicht nnr bei mehrfaoher, sondern anoli
nach einmaliger manometrischer Messnng (cf. Llmal sclerotoniirtes Ange) eintritt.
Resnmiren wir nnn die Ergebnisse ans den angestellten Versnchen, so ergiebt
sich:
1. Dass die Iridectomie- wie Soleralnarbe keine Filtrationsnarben sind, des-
gleichen die oystoide Vernarbnng keine stetige Fliissigkeitsanssoheidnng ans dein
Ange vermittelt, sondern nnr dnroh Berstnng derselben V011 Zeit zn Zeit eine
Kammerwasserentleernng stattﬁndet. Daher ist der Solilnss per analogiam wohl
znléissig, dass es iiberhanpt keine Filtration snarben giebt.
2. WVirkt selion eine Solerotomienarbe nioht beschlennigend anf die Filtration
ans dem Ange, sondern nnter Umstanden verlangsainend, so ist der Einﬂnss
mehrerer Solerotomienarben ein eminent verlangsamender anf die Filtration. \Vo
1 06 OPHTHALMOLOGY.
bereits Glaucom besteht, wird durch dieselbe demnach eine fortwirkende Schad-
lichkeitsursache gesetzt, welche nur in ungliicklichster Weise den giinstigen
Einﬁuss der Paracentese beeinﬁussen muss. ‘
3. Die Sclerotomie, ihrer Eigenschaft als Filtrationsnarbe entkleidet, wirkt
demnach nur, wie eine Paracentese bei gleicher Wundweite.
Alle gegen letztere durch die klinische Erfahrung befestigten Einwande, miissen
daher auch fiir erstere in Kraft und Geltung bestehen bleiben.
'DISOUSSION.
Mr. POWER, London : I have practised iridectomy very frequently; Hancock’s
operation, or cyclotomy, in a large number of cases, and sclerotomy in a few. I think
that in acute cases of glaucoma, any mode of opening the eye and. allowing the
escape of the contents would afford relief; in cases of subacute glaucoma I prefer
to do iridectomy; in cases of chronic glaucoma no operation is of much service.
My objection to sclerotomy is the protrusion of the iris, which is more unsightly
than a well-performed iridectomy, and much more dangerous. No operation
should be performed in glaucoma heemorrhagicum, nor in the glaucoma of young
people.
Professor PANAS, Paris: Admitting that the immediatelyi favourable effect of
sclerotomy is undoubted, the same is true of simple paracentesis, of Hancock’s opera-
tion, or, indeed, of any procedure in which the capsule of the eye is opened. The
effect, in such cases, is analogous to that of incising a whitlow or puncturing the
tunica vaginalis in orchitis. But what we really want is to know how long the
effect of sclerotomy will last, whether it has a really curative effect when per-
formed once or more on the same eye. The statistics necessary to clear up this
point have not yet been forthcoming. It would be needful to know, not only the
cases where the disease has been cured, as in one or two which I could quote, for
six or twelve months ; but the number in which only a ﬂeeting success is obtained.
From the clinical point of view, as between sclerotomy and iridectomy, the ques-
tion is, not whether or no the scar allows of ﬁltration, or whether glaucoma does
or does not depend upon obstruction at the periphery of the anterior chamber;
but whether statistics will show that sclerotomy yields the same permanently
curative results as, by universal consent, are obtained under iridectomy.
Dr. ARGYLL ROBERTSON, Edinburgh : About six years ago I introduced an opera-
tion for the reduction of increased intra-ocular tension, which I termed “ trephining
the sclerotic.” As indicated when ﬁrst described, the operation is only to be
had recourse to in those cases where an iridectomy is inadmissible, or where the
disease has progressed, notwithstanding the performance of an iridectomy. I have,
therefore, only employed the operation in a few cases,.and only those of a bad
type. In patients in whom there was a good hope of restoration of useful vision, I
always prefer to do an iridectomy, as it is a much less dangerous operation than
trephining the sclerotic, this latter being apt to be followed by intra-ocular heemor-
rhage. In the ﬁrst cases in which I operated, I perforated both the sclerotic and.
choroid with the trephine, but, latterly, 1 have modiﬁed the operation by merely
removing a disc of sclerotic, at the distance of about three lines from the margin of
the cornea, and then puncturing the choroid and retina so as to allow a little vitreous
humour to escape. The sclerotic removed is replaced by new tissue, which permits
the more ready transudation of fluid than the original sclerotic tissue, and. which
OPHTHALMOLOGY. I O 7
may, under the inﬂuence of increased intra-ocular pressure be projected forwards,
thus acting the part of a safety valve and relieving the more important parts of
the eye from the evil effects of pressure. In one case, in which both eyes were
aﬁected with-marked glaucoma, and in which I iridectomised the better eye and
trephined the sclerotic in the worse, vision eventually became entirely lost in
the iridectomised eye, while useful vision was retained in the other. In con-
clusion, in most cases I ﬁrst employ iridectomy, and when that proves insufﬁcient,
I either perform sclerotomy (with the view of getting a “ cystoid cicatrix,” which
very much corresponds to Mr. Bader’s “staphyloma of the conjunctiva”), or I
:trephine the sclerotic.
Dr. SAMELSOHN, Cologne, agreed with Prof. Schoeler’s theory of sclerotomy.
In an eye on which sclerotomy had been done ﬁve weeks before, he found, on micro-
scopical examination, that Fontana’s canal, although not entered by the knife, had
been enlarged, proving, he thought, that the efﬁcacy of the operation could not
depend on the canal being directly opened by the knife.
Dr. KNAPP, New York : I have practised sclerotomy for chronic and subacute
glaucoma exclusively for the last eighteen months. I have, thus far, escaped the dan-
gers of what is called malignant glaucoma after operation. ButIcannot consider
sclerotomy as being entirely innocent; for an eye, suﬁering from haemorrhagic
glaucoma, was destroyed by suppurative iridochoroiditis following upon the
operation. As to the value of sclerotomy, I concur with Dr. Panas, that extensive
and long-continued statistics are required, and in this connection I desire to
draw the attention of the profession to the fact that there are cases of chronic
glaucoma which become stationary. I, therefore, make the indications for the
operation of chronic glaucoma dependent upon its progressiveness.
Mr. G. E. WALKER, Liverpool: In order to avoid the danger of prolapse of the uvea
incidental to Hancock’s operation, ten years ago I devised the operation which I
have termed hyposcleral cyclotomy, and which consists of the division of the whole
oiliary body, without division of the sclera. I claim that, with the smallest extent of
wound, as much good is done by it as by either iridectomy or sclerotomy, without
the danger of loss of the eye by haemorrhage or other serious complications.
Dr. GALEZOWSKI, Paris: I accept completely Dr. de I’Vecker’s conclusions as to
sclerotomy. I agree with Dr. Panas as to the importance of knowing how long the
eﬁects of the operation last. Several conclusive cases might be cited : (1)A case of
glaucoma simplex cured by sclerotomy for two years; (2) Two cases of haemor-
rhagic glaucoma, in one of which the cure had lasted since October, 1880, and in
the other the operation had been successful for a year, when enucleation became
necessary. I think it very important to prevent any prolapse of the iris in the
operation of sclerotomy. I conﬁrm Dr. Samelsohn’s observation that the anterior
chamber and angle of ﬁltration are more enlarged at the seat of the sclerotomy
than elsewhere. It was for this reason that I prefer to make two scleral
incisions diametrically opposite to each other. I make them three or four mm.
from the corneal border, using a knife like Oritchett’s knife for iridodesis, but
three times as large, and curved on the ﬂat. The incisions made at the opposite
ends of the same diameter are each ﬁve or six mm. long. In this operation I
never get hernia of iris. '
1 08 OPHTHALMOLOGY.
Dr. DE 'WEOKER, Paris, replying, said : I do not contest Dr. Schoeler’s conclu-
sions from his experiments ; but I would allude to the discovery of Ulrich, that the
nutritive current passes through the base of the iris, and not between the iris and
lens, on its way to the peri-oorneal ﬁltration zone. Wherever this path is blocked by
apposition of the iris to the periphery of the cornea ﬁltration is stopped, as shown
by l/Veber and Knies. In sclerotomy performed on domestic animals, particularly
upon rabbits, this arrest occurs in consequence of the adhesion of the iris to the
periphery of the cornea, and hence in them the formation of a true ﬁltration-scar
by this operation is prevented. In reference to Mr. Bader’s communication, Imust
say that, for my own part, I am very strongly opposed to any prolapse of iris ; so
much so, that if, in spite of the action of myotios, the pupil becomes displaced
after sclerotomy, I always remove the iris through the scleral incision, converting
the operation into an iridectomy. I agree entirely with the remarks of Drs. Panas
and Galezowski, in regard to the importance of statistics, and would refer to those
of my pupil—Manolescu. I may here mention that I have performed sclerotomy
on six medical men, some of them as much as three years ago 5 and that the results
carefully tested by the patients have remained satisfactory. Although Ihave done
sclerotorny on hundreds of patients, I have never yet seen the disastrous result
which Dr. Knapp has mentioned. Once I saw abundant haemorrhage, after
sclerotomy, in a young medical man, but it disappeared after several weeks ; it was
due to the patient’s imprudence in returning to his work the day after the
operation; but, nevertheless, he escaped with V. g- in the Operated eye.
E in news Operm‘z'mzswi/fafzrem 22M’ Hez'lzmg der Pz‘osz's.
Dr. HERMANN PAGENSTECHER, Wiesbaden.
Die bisherigen Operationsmethoden, die man zur Heilung der Ptosis———ich spreche
hier von vollstandiger Oder doch fast vollstéindiger Ptosis, also Falls, in denen die
Function des Levator ganz Oder doch nahezu ganz aufgehoben ist angewandt hat,
leiden an zwei grossen Uebelst'zinden, entweder leisten sie zu wenig Oder zu viel.
Die Excision einer I-Iautfalte wird nur dann von Erfolg sein kOnnen, Wenn sie in
grosser Ausdehnung vorgenommen wird und dann hindert sie auf der anderen Seite
wieder den vollkommenen Lidschluss; fallt dieselbe zu klein aus, so ist die Opera-
tion eben ohne Erfolg. Nur bei partieller Ptosis, also Falle in denen noch eine
gewisse Function des Levator bestand, hatte diese Methode, sowie die von
v. Grafe angegeb'ene—Excision cines 8-10 Mm. breiten Streifen aus dem Musculus
Orbicularis noch Erfolg aufzuweisen.
Ich habe in letzterer Zeit folgendes Verfahren in Anwendung gezogen: das
Princip desselben beruht darauf, die Wirkung des musculus frontalis direct auf das
obere Lid z‘u i'ibertragen und somit den Levator selbst durch den frontalis zu
ersetzen. Ich wurcle zu dieser Idee durch die einfache Betrachtung von Ptosis-
Kranken hingeleitet. Ich bemerkte namlich, dass in der Ruhestellung beim Blick
gradeaus der arcus superciliaris der erkrankten Seite gewOhnlich betrachtlich
hoher stand als der der anderen Seite ; ein Umstand der durch das fortwahrende
Bestreben des Patienten das Lid zu heben und die dadurch zu Hilfe genommene
Contraction des frontalis hervorgerufen wird. In der Begel leistet nun diese Oon-
traction des frontalis so gut wie nichts, da keine Faserziige sich von da aus nach
dem oberen Lide erstrecken und auch die durch den frontalis bewirkte Verschie-
OPHTHALMOLOGY. I O 9
bung der Hant nnr ganz minimal oder garniclit anf das obere Lid ihre Wirknng
entfaltet. Ich kam desshalb anf den Gedanken das obere Lid mit dem Frontalis
in eine directere Verbindnng zn setzen nnd erreichte dies anch in der Weise, dass
ich einen oberﬁachlichen N arbenstrang herstellte, der die Wirknng des frontalis
direct anf das Lid resp. den Lidrand iibertrng. Ungefahr einen Finger breit iiber
der Mitte des Arcns snperciliaris steche ich eine mit einem dicken Faden versehcne
Nadel ein, fiihre dieselbe nnter der Hant weiter nnd steche nngefahr in der Mitte
des oberen Lides gerade am Cilienrand wieder ans, schiirze dann einen Knoten, den
ich nnr massig anziehe, 1iegen lasse, nnd nach nnd nach dnrch taglich starkeres
Anzielnen dnrch die Hant dnrchschneiden lasse. Die Reactionserscheinnngen sind
Verhaltnissmassig sehr geringe. Die Entstellnng dnrch die Narbe ist eine mini-
male nnd Wird schon cosmetisch reichlich anfgewogen dnrch das Wegfallen der
Ptosis.
In den Fallen, die ich bis jetzt operirthabe geniigte immer eine Sntnr; dieselbe
hatte eine etwas Wenig schief von nnten nnd innen nach oben nnd anssen verlanf-
ende Richtnng, da namlich der Einsichtspnnkt etwas nach anssen von der Mitte
(circa 2 Mm.) gefallen War. Es mag anch Falle geben, in denen es indicirt ist zwei
Sntnren in massigem Abstande von einander anznlegen, nnd in denen es anch nicht
nothig ist die Sntnr bis znm Oilienrande dnrchznfiihren es vielmehr geniigt dieselbe
schon etwa in der Mitte des oberen Lides ansznstechen. Anch bei incompleter
Ptosis wiirde ich dieses Verfahren allen iibrigen Operationsmethoden vorziehen,
doch in etwas modiﬁcirter Form. Da nanilich in solchcn Fallen ein dicker stark
wirkender N arbenstrang nicht nothig ist, so rathe ich die Narbe snbcntan anznlegen
nnd zwar in folgender *vVeise. Erforderlich ist hierzn eine mit 2 Nadeln versehene
Sntnr. Die eine Nadel wird 1 bis 2 Mm. parallel nnd nahe dem Cilienrand nnter
der Hant des oberen Lides hergefiiht; genan an dem Ansstichspnnkt wird dann
dieselbe Nadel wieder eingestochen nnd zwar in der Richtnn g nach oben oberhalb
des Tarsns nnter der Hant Weitergefiihrt nnd etwa einen Fingerbreit iiber der Mitte
des Acns snperciliaris Wieder ansgestochen; daranf wird die zweite Nadel am
Einstichspnnkt der ersten Nadel anch in der Richtnng 118.011 oben gefiihrt nnd am
zweiten Ansstichspnnkt (also oberhalb des Arcns snperciliaris) der ersten Nadel
ansgestochen, die beiden Faden werden dann nnr méissig angezogen nnd geschlnn-
gen. Man erhalt hierdnrch eine vollkommen snbcntan liegende Naht, die man
kiirzere oder langere Zeit 1iegen lassen, ja in extremen Fallen ganz dnrchschneiden
lassen kann nnd erzengt damit einen snbcntanen Narbenstrang der immer die
Wirknng des frontalis anf das obere Lid iibertragen mnss. In welchem Falle die
ersterwahnte oder die soeben beschriebene Modiﬁcation anznwenden ist, dariiber
lassen sich ganz bestimmte Angaben schwer machen, es muss dies dem Takte des
jeweiligen Operateurs iiberlassen bleiben ; ebenso wie lange die snbcntanen Sutnren
1iegen miissen nnd in Welchen Fallen man dieselben wird ganz dnrclischneiden
lassen.
Es bedarf wohl kanm der Erwahnnng, dass man beim Ein- oder Ansstechen der
Nadeln oberhalb des Arcns snperciliaris nicht zn tief etwa bis ins Periost eingelien
darf, denn sonst konnte man Gefahr lanfen, dass die Verschie bbarkeit der Narbe
vermittelst des frontalis dnrch Verwachsun g der Hant mit dem Periost stark beein-
traclitigt resp. ganz anfgehoben werden wiirde.
I I O OPHTHALMOLOGY.
Nouvelles Applieui‘ious du Fer Rouge eu Chirurgie Oculaire of
a’e quesques Modiﬁcations Apporz‘e‘es aux Galmuo-Cauzfe‘res.
Dr. G. MARTIN, Bordeaux.
Depuis que de nombreuses observations ont démontré les heureux effets de la
cautérisation ignée sur les phlyctènes kératiques et conjonctivales, et l’eﬁîcacité de
ce traitement dans les abcès et ulcères de la cornée, le champ d’action du fer rouge
a gagné du terrain dans la pratique opthalmologique.
La parfaite innocuité de cet agent, même dans les cas où il fallait pour arriver
a guérison transpercer de part en part la cornée nécrosée, a conduit les opérateurs
à généraliser son emploi.
En 1879, Pr. Gayet (de Lyon) a érigé en méthode la transﬁxion ignée de la
cornée dans le kératocône.
Au commencement de cette année, dans un article publié dans des Annales
d’Ocul'istique, nous avons montré les avantages (au point de vue d’une guérison
déﬁnitive) qu’il était permis d’attendre de la destruction par le feu, des lamelles
superﬁcielles de la cornée envahies par un ptérygion. '
A la même époque, il nous est venu a l’csprit de nous servir du cautère actuel
dans d’autres affections et sur d’autres membranes du globe oculaire.
Le tissu de l’iris, hernié consécutivement à un traumatisme accidentel ou
chirurgical, a été un de ceux que nous avons détruit par l’ignipuncture pour mettre
ﬁn a des étranglements douloureux.
Nous avons également transpercé la sclérotique au niveau de staphylômes
antérieures, et cela avec quelques avantages et sans engendrer de réaction. En
outre, nous avons perforé cette membrane dans un cas de décollement de la rétine.
Dans ce fait notre intervention n’a eu aucun résultat visuel. Ce n’était pas du:
reste, ce que nous avions cherché. Une première tentative de cette nature ne
pouvait être faite que sur un œil gravement compromis. Avant de prouver l’utilité
de la méthode, il fallait établir son innocuité. A l’heure actuelle, sachant la
ponction ignée de la sclérotique parfaitement tolérée par l’organe, il est permis de
fonder des espérances sur cette pratique. En outre de la persistance de la ﬁstule
qui permettra l’écoulement du liquide sous-rétinien au fur et a mesure de sa pro-
duction, il y a lieu d’espérer que l’irritation provoquée dans les tissus environnants
conduira à. un processus adhésif.
Toutes ces nouvelles applications du fer rouge nécessitaient des instruments
plus parfaits que ceux dont nous disposions.
Le stylet que l’on chauffe à une lampe à alcool perd trop vite son calorique.
Le plus petit modèle des cautères Paquelin est encore trop volumineux pour pra.
tiquer des transﬁxions. Les cautères de platine qui accompagnent la pile secon-
daire Planté à laquelle Trouvé (de Paris) a annexé un rhéostat pour graduer le
degré de chaleur sont doublement défectueux. La tige de platine est trop ﬁne et
n’offre pas, une fois rougie, assez de rigidité ; d’un autre côté, cette tige longue de
plus d’un centimètre, constitue un foyer d’incandescence trop étendue qui effraie
le patient et gêne l’opérateur.
Pour remédier à ces deux imperfections nous avons fait fabriquer par M.
Trouvé de petits cautères dont les tiges d’argent vont en s’amincissant et sont
réunies par une toute petite pointe de platine de deux millimètres de longueur.
Pour cautériser en surface, au lieu de cette pointe, les tiges d’argent reçoivent un
arc de platine à foyer très-limité.
OPHTHALMOLOGY. I I I
Oes instruments ont un si faible rayonnement qu’on peut sans crainte de
mortiﬁer la peau, brûler les poils du dos de la main; en outre, leurs tiges d’argent
s’échauﬁ'ent assez lentement de la sorte qu’il est possible de les tenir entre les doigts
pendant plusieurs secondes, à 6 ou 7 millimètres de leur pointe.
Une fois en possession de ces cautères nous nous sommes demandé si l’on ne
pourrait pas les introduire dans l’intéricur du globe de l’œil pour pratiquer du côté
de l’iris une ouverture centrale dans les cas d’occlusion de la pupille, a la suite
d’extraction de cataracte, lorsqu’il existe d’épaises masses exsudatives qui résistent
aux divers procédés d’irito-ectomie.
Les expériences que nous avons instituées sur les animaux ne nous permettent
pas de considérer le problème comme résolu. Plusieurs inconnus subsistent encore.
Mais par les résultats obtenus nous pouvons d’ores et déjà, aﬂirmer :—
1°. Que la destruction du centre de l’iris peut s’eﬁ’ectuer sans que le collet de
l’instrument altère la structure de la cornée au niveau de l’incision faite pour lui
donner passage, l’instrument n’étant allumé qu’après avoir pénétré dans la cham-
bre antérieure ;
2°. Que la cornée ne se trouve pas atteinte par le rayonnement calorique pen-
dant que le cautère incandescent traverse le septum iridien, pourvu qu’on prenne
soin de déprimer fortement en arrière cette membrane;
3°. Que la cautérisation de l’iris n’est pas suivie de réaction ;
41°. Que le corps vitré supporte parfaitement le contact du fer rouge.
‘La possibilité d’allumer les galvano-cautères une fois introduits dans l’intérieur
des tissus et le peu de calorique que possèdent nos modèles au niveau de leur collet,
nous ont porté à quelques applications cliniques du côté des annexes de l’œil.
Plusieurs fois nous avons fait pénétrer nos nouveaux cautères dans l’intérieur de
kystes palpébraux après avoir vidé leur contenu, et cela sans produire la moindre
eschare au niveau de l’ouverture qui leur livrait passage. Nous avons pu égale-
ment les introduire au travers des points et conduits lacrymaux presque dans
l’intérieur du sac pour modiﬁer ses parois dans des cas de dacryocystite.
BISOUS SION.
Dr. DE Wncxnn (Paris) had lately perforated the sclerotic in cases of detached
retina with a platinum wire made red-hot, with the double object of preventing bleed-
ing and obtaining a persistent opening. No reaction followed the operation.
0% Qculo-Neural Reﬁ’ex Irritation.
Dr. GEORGE T. STEVENS, Albany, New York.
Among important causes of functional nervous affections recognized by the best
authorities‘ on such subjects are—1. Various irritations, from whatever cause, of
peripheral nerves. 2. Apredisposition on the part of the subjects of such affections.
WVhile other causes, such as a change in the quality or quantity of blood, or some
general disturbance of nutrition, play their part in the production of functional
nervous disturbance, the two ﬁrst mentioned are doubtless admitted to be pre-eminent.
It follows that it is of supreme importance to determine, as far as possible, all sources
of such peripheral irritations and of such predisposition to nervous affections. It is
nevertheless true that because of the frequent obscurity of the irritating or of the pre-
disposing cause, functional nervous diseases are for the most part treated empirically,
and the immediate or remote cause of the neuralgia, the chorea, or other affection, is
I I 2 OPHTHALMOLOGY. ‘
wont to receive by far too little attention or effort to ascertain its exact nature.
Should the inherent predisposing tendency to neuroses, and the irritating inﬂuence,
starting from a certain part of the nervous system, be found to be frequently associated,
and should we be able to locate a very important source of both immediate and pre-
disposing inﬂuence, to which too little attention has been directed, the object of this
brief paper will be accomplished.
It is a principle generally admitted that an irritation of a nerve may induce dis-
turbance in the functions of other nerves, even at a distance from the nerve irritated,
and also that the same kind of excitation in the same nerve may, under different
circumstances, induce widely different effects in distant parts. A. distinguished Vice-
President of this Congress (Dr. Brown-Se'quard) has stated this principle as follows :
-——“ The same peripheric cause of irritation, acting on the same centripetal nerve, may
produce the greatest variety of effects, including every functional nervous affection or
disorder.” Keeping this principle in view, let us inquire whether the eyes can become
a source of reﬂex irritation; and, if so, whether they can be regarded as a frequent
source of nervous disorders, and as a reason for an inherited tendency to such disorders.
Severe injuries to the ciliary region of the eye, or a grave disease which causes
cicatricial degeneration of the front of the organ, so frequently induces severe reﬂex-
phenomena in the uninjured eye, that it is now universally conceded that such injured
and diseased eyes must be sacriﬁced as a defence against reﬂex or sympathetic disease
in the remaining eye?“< But if an injured eye can set up a sympathetic irritation,
which may be fatal to an uninjured one, then, if the principle above stated be true,
the same kind of irritation, originating in an injured or degenerated eye, may also give
rise to disturbances in distant organs—for instance, the heart, the kidneys, or the
muscles of the extremities. As a partial reply to this reasonable inquiry,
I refer to two cases reported by myself, more than a year ago, in the Aliem'st
and Neurologist, published in St. Louis, bearing precisely upon this point. In
the ﬁrst instance, a girl, set. 13, had, ﬁve years previous to her visit to me, thrust
a point of‘ scissors into one of her eyes, and was brought to me suffering from sym-
pathetic irritation of the other eye. Between the date of the injury and this visit
she had suffered from violent headaches, attacks of intense suffering in the stomach,
probably neuralgia, and from what proved to be of greatest interest, a severe form of
diabetes insipidus. This disease had run a uniform course, and the quantity of urine
passed daily had been astonishing. Removal of the injured eye was followed by an
immediate and surprising reduction in the amount of urine passed. Although it is now
nearly four years since the operation, there has been no serious return of the urinary
trouble or of the intense ncuralgic affections. In the second case a child, with a very
prominent staphyloma, was also an epileptic suffering from ﬁts occurring from once in
two or three days to once in a month, and, like the girl in the preceding case, subject to
diabetes insipidus. The deformed eye was removed, and from the time of the removal
more than three years ago the child had not, at a recent date when I saw him, suffered a
single convulsion, nor has he had any further trouble from the diabetic affection. Several
other similar cases have come under my observation. These cases are sufficient to
show that reﬂex irritation not only may, but does, extend from the nerves of severely
injured eyes to remote parts. Can difficulties in the function of accommodation or in
the proper adjustment of visual lines also produce reﬂex symptoms in other parts of the
body. We must admit that as refractive errors and muscular insufficiencies of the eyes
do induce asthenopia, which is expressed, not usually in the eye itself, but in its sur-
roundings, then the same causes may react upon more distant parts.
Time does not permit an elaborate recital of the manner in which such causes act,
nor of the special forms of nervous disturbance most frequently observed as resulting

* Does the author refer to sympathetic irritation or to true sympathetic inﬂammation?
—Eos.
OPHTHALMOLOGY. I I 3
from causes which would produce asthenopia; but the results of observations in several
hundred carefully recorded cases of such diseases as neuralgia, chorea, insomnia, head-
aches, and even epilepsy, have fully conﬁrmed the opinions long since expressed by me,
that difﬁculties in performing the function of sight are among the proliﬁc sources of.
functional nervous disease. I have at various times reported many instances* illus-
trating this fact. I will now add but a single illustration of the practical value of the
principle.
Mr. F. S. H., aged thirty-two, consulted me at the request of his attending
physician, Dr. Wm. H. Robb, March 12, 1880. He was apparently robust, but was,
as he informed me, an epileptic. His epileptic attacks commenced eight years previous
to this visit, and had occurred with regularity except during a short time in the year
1877. The ﬁts occurred once in about two weeks, severe attacks usually alternating
with milder ones. I The patient was subject to constant headaches in the temples and
brows, and had habitual pain in the lumbar region. For many years previous to the
epileptic disease he had been subject to most violent attacks of sick headaches, but
these had, in a measure, been replaced by the epileptic ﬁts. He was excessively nervous
and restless, and habitually rose from his bed to walk the ﬂoor at night. He had
always been constipated, a condition from which his only relief had been the daily use
of cathartics. I could detect no cause for all this nervousness, except in the condition
of the eyes. There was found insufficiency of the external recti muscles of 2°
at twenty feet. There was no apparent strabismus. A partial tenotomy of one of the
internal recti muscles was made with great care, and he was found immediately to have
ability to overcome a prism of ten degrees with the external recti muscles, while his
converging ability remained unimpaired. A few days after the operation he expressed
the greatest satisfaction at what he considered a radical change in his whole condition.
He was already free from headache, his nervousness had disappeared, and his sleep was
better than for years. A year and a half has passed; and in a letter written to me a
short time since, he says : “ I feel that I am perfectly well.” He takes no more
cathartics, has no headaches, rests well at night, and has had three attacks of pezfz't mal,
A great many cases might be adduced to show that refractive errors and muscular insnffn
ciencies are proliﬁc sources of sick headaches, neuralgias, chorea, hysteria, and other
nervous disorders; but I need only refer, in conﬁrmation, to cases already published.
If it be admitted that difficulties of refraction and of association of visual lines
may be important causes in producing nervous affections, we have then a rational err
planation in many cases of the hereditary tendency to such complaints; for if neu-
ralgia, headaches, chorea, and other forms of nervous disorders may be caused, for
instance, by hypermetropia, then we may readily see why the children of a hypermetrope
who’ has suffered, perchance, from one of these disorders, may be affected, not
necessarily with the same form of disease, but with one of the forms likely to be pro—
duced by hypermetropia. For while it is not at all probable that neuralgia is of itselﬂan
inherited condition, we know that hypermetropia is directly inherited. Now, if it has
caused neuralgia in the mother, it may also cause it or some other nervous aﬂ‘ection in
the child. Thus, while it is illogical to regard chorea as a direct heritage from
neuralgia, it is logical to suppose that the same physical characteristic may induce
the one or the other.

See “ Transactions of the Albany Institute, 1874, 1875.” “ Ohorea,” “Transactions
of New York Academy of Medicine,” 1876. “ Refractive Lesions and Functional Nervous
Diseases,” New Y 01-7.; Medical Record, September, 1876. “Light in some of its Relations to
Disease,” N ew Ym'k Medical Journal, J 11119, 1877. “Relations between Corneal Diseases
and Refractive Lesions of the Eye,” International Medical Congress, Philadelphia, 1879.
“Two Cases of Enucleation of the Eyeball,” Aliem'st and Neurologist, January, 1880.
“Ocular Muscular Defects and Nervous Troubles,” “Transactions of New York State
Medical Society,” 1880.
PART III. I
I I 4 OPHTHALMOLOGY.
During several years I havekept a areful record of thefamily histories of the majority
of my private patients who have refractive and muscular troubles of the eyes, and am sure
that no one can look over those records without being convinced that much of the
mystery of inheritance in disease is explained by the fact of the inherited physical form
of the eyes and physical proportion of the ocular muscles,
After several years of careful consideration of this subject I am led to the following
conclusions :—1. That among the peripheric inﬂuences which generate nervous affec-
tions, the irritation arising from a perplexity or exhaustion of nerves in performing
the functions of adjustments of the eyes must be regarded as of great importance.—
2. That when a family tendency to neurotic affections is found, the inherited tendency
is often transmitted in the form and condition of the eyes —-3. That inveterate cases
of nervous disease not amenable to other forms of treatment will often yield readily to
the simple process of relieving the eyes from muscular or refractive disabilities.
Relaz‘z'on em‘re le [(31526 set/aux sous-palpe’éral de Z’or/n'z‘e avec
micropﬁz‘almos ea‘ [6 coloôama de l'œil.
Dr. VAN :DUYSE7 Ghent.
Le Dr. Talko de Varsovie a présenté à la dernière réunion de Heidelberg ainsi
qu’au Congrés de Milan une observation de kyste séreux congénital de l’orbite
avec microphtalmos.
J e vous demande la permission d’exposer un cas semblable en formulant une
déduction que justiﬁent quelques unes de ses particularités.
Il se rapporte a un jeune homme de 22 ans, dont l’œil gauche microphtalmique
présente un colobome de l'iris, de la choroïde, de la couche pigmentaire de la rétine
et de la gaine du nerf optique. Les symptômes fonctionnels de ce microphtalmos
avec colobome sont l’amblyopie, la myopie axile, le nystagmus et le rétrécisse-
ment du champ visuel a sa partie supérieure.
A droite existe un kyste fluctuant repoussant la paupière inférieure (égale-
ment ectropionnée) en avant et en haut.
L’exploration de l’œil avant la ponction de cette tumeur élastique laissait croire
a un kyste séreuX sous-palpébral avec anophtalmos comme de Wecker et Talko
l’ont décrit.
Le liquide—très-riche en albumine et en chlorures—-—une fois extrait de la poche
par aspiration (analyse chimique et histologique); le kyste s’affaissa et dégagea
ainsi un microphtalmos primitivement caché par un repli de la conjonctive.
Comme le relation entre le kyste et l’œil était fort directe, je n’hésite pas a voir
dans ce cas un microphtalmos avec coloboma enkysté en m’appuyant, dans cette
vue, d’analyses anatomiques que nous ont léguées plusieurs auteurs et qui démon-
trent qu’a une certaine période de la vie intra-utérine le plancher oculaire colo-
bomateux s’est ectasié, enkysté, développé ne laissant l’œil ébauché qu’à l’état
d’appendice tout-a-fait secondaire.
Arguments.
1.——Dans la collection anatomo-pathologique du Prof. O. Becker 5. Heidelberg
existent deux spécimens de microphtalmos avec kystes adjacents au plancher
oculaire, recueillis chez un jeune enfant dont le père présentait un coloboma de la
gaine du nerf optique.
OPHTHALMOLOGY. I I 5
2.—Nous connaissons de longue date des observations de microphtalmos avec
colobome où ce dernier était devenu fortement staphylomateux ou dégénérait en
une vésicule énorme. Arlt a décrit un microphtalmos très-prononcé avec kyste
repoussant les paupières inférieures et contenant du liquide albumineux.
3.-—Wallman a vu chez un enfant un œil microphtalmique présentant un colo-
borne de l’iris. Le petit œil n’était séparé d’un kyste sous-jacent que par un
cordon solide et la vésicule était tapissée a l’intérieur d’une portion de rétine et de
choroïde.
Dans un second cas la vésicule communiquait directement avec l’œil microph-
talmique et présentait également une portion de rétine et de choroïde a sa face
interne.
Les seules observations qui semblent se rapporter à la variété de kystes con-
génitaux de l’orbite décrits ici sont celles qui appartiennent à Talko, de Wecker,
Wicherkiewicz et probablement une observation de Berlin.
L’absence de l’œil dans quelques uns des cas qui ont été décrits peut s’expliquer
par l’état de réplétion de la tumeur empêchant un examen convenable ou par l’état
très-rudimentaire de l’oeil.
Il convient de distinguer les kystes de cette espèce: (a) de l’encéphalocèle,
où l’examen chimique tranche immédiatement la question :—(b) des kystes
dermoïdes à contenu fort liquide, nés aux dépens du feuillet externe du blas-
toderme et en rapport direct avec l’œil (Manz, Chlapowski) ainsi que de la variété
dont l’origine a été rapporté au développement branchial (kystes branchiaux de
Gusset). (0) enﬁn des hauts degrés de dégénérescence du bulbe fœtal.
Contrairement à une donnée de Talko nous pouvons conclure des faits exposés
ici à une liaison génétique entre le kyste séreux intra-orbitaire, sous-palpébral et
l’œil lui-même.
fﬂjum'es Z0 Me Optic Nerve and Op/zz‘kalmz'c A7/Z67’j/ﬁ’0772
Fmzcz‘m/e cf Z/ze Optic Canal.
Dr. R. BERLIN7 Stuttgart.
It has only lately been shown (von Holder) that fracture of the optic canal is
very frequent in fractures of the base of the skull, and the author assumes that
sudden single amaurosis, following immediately after injuries to the head, is usually
due to this condition.
Hitherto there has been scarcely any post-mortem proof of the character of the
injury to the nerve. The author details (l) a case of gunshot injury, in which
there was a ﬁssure-fracture of the whole length of the roof of the canal, with lacera-
tion of the nerve in the canal and within the skull as far as the chiasma; the
laceration was chieﬂy in the axis of the nerve; the corresponding nerve ﬁbres were
disintegrated and bloodstained (but there was no blood either in the nerve or in its
sheath) ; (2) Fissure-fracture through both optic foramina, both nerve sheaths
ﬁlled with blood, and one nerve and its artery torn across ; (3) Three cases of
laceration of the internal carotid artery, in one of which both optic canals were
fractured, and the optic nerves torn across between the foramen and the chiasma.
I2
I 1 6 OPHTHALMOLOGY.
Tramÿlam‘az‘z‘mz des Mugueuses sur Z’æz'l.
Dr. DUFoUR, Lau‘sanne.
Résumé les observations qu’il a pu faire jusqu’ici sur la transplantation des
muqueuses à la place de la conjonctive—
Les opérations de transplantation complète sont au nombre de quatre.
Deux fois il transplanta la conjonctive du lapin a l’homme, et deux fois la
muqueuse buccale du malade lui-même.
1er Cas—Vieille femme; grande lacune de la conjunctiva bulbi par l’excision
d’une cicatrice adhérente à la paupière; transplantation du lapin, 1 centimètre
carré a peu près. Le morceau a transplanter est d’abord détaché du lapin, puis
cousu par cinq ﬁls de soie sur le bulbe de la malade.
Insuccès. Le troisième jour le lambeau conjonctival est nécrosé et tombe. Le
résultat facheux est dû :—
(a) A Page avancée de la malade.
(7)) A la place où il a fallu transplanter ; savoir, la surface du bulbe, moins vas-
cularisée et plus exposée aux déplacements venant des mouvements de la paupière.
(c) A l’usage des ﬁls de soie.
(cl) Au fait que dans la suture la pénétration de chaque ﬁl entraînait une plisse-
ment du lambeau a transplanter.
21ne Cas—Un garçon de 8 ans, grand symblepheron, suite d’une large brûlure
a le chaux, et de deux opérations non réussies. Adhérence absolue de la paupière
inférieure au bulbe et aux deux-tiers inférieurs de la cornée.
Transplantation de conjonctive du lapin; on prend sur le lapin environ 3 centi-
mètres de conjonctive, qui sont circonscrits par six sutures de catgut; chaque ﬁl
portait son aiguille placée d’abord sur le lapin.
Après avoir préparé l'œil de l’enfant, on excise 1e lambeau circonscrit sur le
lapin, et on le transporte sur la vapeur d’eau chaude, à l’enfant, où il est cousu.
Opération facile. Résultat excellent. Quatre jours après le lambeau était ﬁxe.
Deux mois ensuite on voyait encore dans le sac libre le morceau transplanté, couleur
normale, mais encore insensible au toucher.
8me Cas—Un homme, 60 ans, a la suite de trois opérations plastiques pour
enlever un cancro'ide grave de deux paupières gauches avait gardé un ankyloble-
pheron laissant une fente de 4: mm. seulement. Vision normale de cet œil, mais
impossible à cause des paupières. L’autre œil perdu par décollement de la rétine.
La conjonctive a dû être enlevée jusqu’a 2 mm. de la cornée pour participation
au néoplasme.
Ouverture de la commissure externe, jusqu’à son élargissement normal.
On recouvre cette partie de muqueuse prise a la bouche. Le malade a un
ipôme sous-muqueux derrière la lèvre. On entoure le lipôme avec des sutures.
Détachement du lipôme. Préparation de la muqueuse sur la vapeur d’eau. Trans-
port et ﬁxation à l’œil. Durée de la suture environ 16 minutes. La muqueuse
qui était rouge devient rapidement pâle, puis blanche, puis grise, et a la ﬁn de
l’opération elle ressemble a du papier gris. Surface transportée environ 6 centi-
mètres carrés.
Issue—Les deux-tiers internes du lambeau transplanté qui correspondaient
a l’ancienne conjonctive, ont très-bien vécu, surtout tout ce qui tapisse le bulbe.
Le tiers extérieur correspondant à la peau s’est nécrosé. Il se forme une excellente
OPHTHALMOLOGY. I I 7
commissure, et le malade pent onvrir son oeil. Il n’est gene que par la paresse de
la paupiere qui est formée de peau temporale. _
Ame Oas.—Semblable an troisieme, seulement on prend a la levre de la muqueuse
snr nn point normal. Issue bonne. Quant an mode opératoire je recommande de
circons'crire d’abord an couteau le lambean a transporter; puis y ﬁxer les sutures
en faisant sortir l’aiguille par la plaie dessinée. Pnis prendre le faisceau de ﬁls,
attirer doucement le lambeau, le détacher avec soin, et le transporter sur la vapenr
jusqu’au point on on vent le ﬁxer.
Prendre garde que toute hémorrhagie soit absolument arrétée a la surface sur
laquelle on vent transplanter.
Oomme on le voit, nne muqueuse devenue toute grise, et d’apparence mortiﬁée,
pent encore prendre pied. Le pansement a été fait a l’acide salicylique.
0% Tuéerculous [nﬂammaz‘imzs 0f the EyeoaZl.
Prof. J. HmscHBERe, Berlin.
Scrofulons or strumous inﬁammations of the eyeball were very well known
and often discussed in the ﬁrst and second halves of this century. Tuberculous
inﬁammations were formerly often diagnosed, sometimes without reason; then,
during the ﬁrst part of the ophthalmoscopic era, called in question; and, ﬁnally,
corroborated by the minutest histological researches.
The histological character of the tubercle was believed to be very different in
the three parts of our century; Laennec having especially accentuated the caseons
matter of tuberculous products; Lebert insisted upon the peculiar corpuscle
of the tuberculous growth—a shrunken cell ; Virchow upon the elementary greyish
tubercle, a conglomeration of round lymphatic cells, with tendency to necrobiosis;
Schiippel, Wagner, Friedlaender, and others of later times upon the giant cells, with
a surrounding network ﬁlled with little cells.
But, as these giant cells are met with in very various products of very different
diseases, for instance, syphilis, lupus, simple granulations, it is paradoxical, but
nevertheless true, that the histological diagnosis seems to be to-day almost more
difficult even than the clinical diagnosis ; and some authors, as Oohnheim, require
a physiological proof of a true tuberculous product; tuberculous matter being
that which may produce (in a living animal) a tuberculous infection. N otwith-
standing, I believe (with others) that it is possible to make a trustworthy
histological diagnosis of tuberculous product, if we ﬁnd a granular tissue with
giant cells and a surrounding network, and with a large quantity of dead caseons
matter.
I now beg to narrate three diiferent cases which I diagnosed to be true tuber-
culous inﬁammations of the eyeball; these being all that I have seen during four
years, in more than seventeen thousand new eye cases.
Case 1.—Tuberculous inﬂammation of the conjunctiva of the eyeball. A girl,
aged four, of healthy family, was admitted on July 31, 1878. Right eye normal.
Left without blepharospasm, pain, or discharge, but the conjunctiva of the
eyeball con verted into a conﬂuent caseons ulcer, surrounding the cornea, and from
six to eight millimetres broad; downwards the caseons ulceration occupied the
swollen fornix, and miliary ulcers scattered through normal tissue reached to the
posterior part of the tarsal conjunctiva. Similar ulcers were present in the upper
1 1 8 OPHTHALMOLOGY.
fornix. Forwards the epibulbar ulceration reached the equator. The caruncle
was detached from the eyeball. Between caruncle and eyeballapocket was formed
with inﬁltrated walls, and ﬁlled with a caseous dry matter, such as is not un-
frequently found in rabbits after operations or experiments. The edge of the cornea
was eroded, its anterior surface slightly pitted, and its parenchyma dim with new
blood vessels. The child had enormous submaxillary glands on the same side, the
left. I diagnosed a tuberculous inﬂammation and ulceration of the conjunctiva,
particularly of the eyeball; but I must confess that I had never seen a similar
case.
Internal and topical remedies of different kinds were applied without any
beneﬁt. The cornea became partially granulated, partially ulcerated, and the
caseous ulcer covered the greatest part of the eye. Pain set in; the child was
pale and unhealthy-looking, and the submaxillary glands increasing considerably.
Under these conditions, on the 27th of September, 1878, I proposed and per-
formed excision of the eyeball. The operation was rather diﬂicult, because the
forceps did not take hold of the dry conjunctiva. The Posterior half of the eyeball
was found to be normal; under the earuncle was a large caseous plug towards the
equator. Parts of the inﬁltrated conjunctiva were excised at the same time.
Recovery took place quickly. During the ﬁrst two months the conjunctiva,
which naturally formed a very short funnel, and did not allow an artiﬁcial eye,
seemed to be a little granulated, so that I feared a relapse. But gradually it
became smoother and smoother, like cicatricial tissue, and now it looks healthy.
The submaxillary glands shrunk rapidly after excision of the caseous product.
A good diet and appropriate remedies were of course ordered. The child is still
living, two years and a half after the Operation. I venture to believe that excision
has, perhaps, preserved life in this case.
The microscope showed typical tuberculous inﬂammation. In transverse sec-
tions, through the sclera and episcleral deposit, the deeper layers of the sclera are
normal; upon these follows a granular round-celled tissue with giant cells; ﬁnally
a perfectly amorphous layer of caseous matter, clearly distinguished from the
living parts by modern staining (eosine).
Histologists to whom I had the opportunity of showing the preparations,
acknowledged that they seldom had seen a better specimen of tuberculous inﬂam-
mation.
Case 2.——A boy, aged two years, with tuberculous inﬂammation of the iris, came
under my care last year (1880). Parents healthy; four out of ﬁve brothers and
sisters were serofulous. The patient himself had been twice attacked by severe ﬁts,
the last time three weeks ago. For some weeks his mother had observed in his
left eye a greyish spot, apparently increasing during the last week.
The child was not very ill,but was evidentlytortured by pains in his left eye. There
was a decided chronic hydrocephalus. The right eye was healthy; the left blind
and much injected around the cornea. A caseous matter ﬁlled the lateral half of
the aqueous chamber and reached the cornea, through which ran a large blood-
vessel of new formation. In the nasal half of the iris, there were some greyish
miliary nodules visible to the naked eye. Pupil closed by exudation. Upwards,
in the sclera, near the corneal edge, was a yellowish prominence.
I diagnosed tuberculous inﬂammation of the iris, and proposed excision of the
eyeball, but yielded to the mother’s urgency, to try ﬁrst an evacuation of the caseous
matter. On the 11th of July, 1880, I made a section at the outer margin of the
cornea with a keratome, and excised a piece of iris tissue ; but I could notevacuate
OPHTHALMOLOGY. I I 9
the dry caseous matter, which was continuous, as I had suspected, with the scleral
prominence. The wound healed well; but the caseous matter ﬁlled the aqueous
chamber rather more than before the operation, and a granulated tissue bulged
from the section. The eye was therefore enucleated on the 6th of August, 1880. The
wound healed in the usual manner, and the child was evidently more comfortable.
But, on the 1st of September, the boy was attacked by ﬁts. I saw him some
ten days later ; he was then lively and merry as before, but showed a slight para-
lysis of the left arm and leg; the fundus of the right eye was now, and continued,
normal. He died, in ﬁts, on the 16th of December, 1880, at the age of two years
and a half. No post-mortem.
There was found on histological examination by Dr. Riiter, tuberculosis of the
iris, beginning with little nodules, proceeding to a tuberculous inﬁltration of the
whole iris and of the corneal wound; with also anterior and posterior synechiae
inﬂammation of the ciliary body, and partial opacity of the lens. The other parts
of the eyeball were normal. ‘
Tuberculous inﬂammation of the iris is not so rare as that of the conjunctiva,
particularly if you agree with the view, advanced by some eminent authors, that
the so-called granuloma of the iris is, unless it be of traumatic origin, generally a
tuberculous affection. I would, however, mention the fact, without further com-
ment, that in eyeballs, destroyed by severe injuries, and enucleated, perhaps ten
weeks after, we may ﬁnd microscopical structures very similar to what is now called
local tuberculosis—via, giant cells.
Case 3 was one of tuberculous choroiditis. The disease formerly described
under this name had no etiological connection with tuberculosis, but was the true
purulent metastatis choroiditis.
There are two different tuberculous aﬁections of the choroid ; one relatively
common, the other very rare. The former is the miliary tuberculosis of the choroid,
accompanying general acute tuberculosis. The latter, tuberculous inﬂammation
of the choroid, was, prior to my own observation, only alluded to by Manfredi and
Poncet, but without ophthalmoscopical examination.*
On the 21st of April, 1875, I was asked by one of my friends, Dr. Schlesinger,
to see the eyes of one of his patients, a man, twenty-seven years of age, who was
suffering from fever and headache, and for sixteen days had had painful inﬂamma-
tion of his left eyeball. The right eye was normal. The left was slightly protruding,
Lmobility normal, the scleral conjunctiva bulging as a thick red roll. Media clear, except
i a very slight mistiness of the cornea, and very faint traces of exudation at the margin ‘
of the atropised pupil. The fundus presented the following peculiar appearances.
No disc visible. The retinal veins enormously dilated, some of them four or six times
the normal size, tortuous and accompanied by some bloodspots, the greater part of
the visible retina had a very whitish colour, and was decidedly protruded by a sort
of retrovascular or choroidal new formation of tissue. The eye was almost blind.
On the following day I punctured the orbit, but could not evacuate any puru-
lent matter. On the 23rd of April an epileptic attack set in with syncope. On the
25th of April the swelling was lessened, the retinal. vessels reduced to the half of
their former breadth, and fingers ‘could be counted upwards. The patient was
feeling much better. But soon after the disease became worse, and the patient died
comatose on ‘the 5th of May, 1875.

* A similar case is given by Gowers (Medical Ophthalmoscopy, 1879, case 5, p. 250).
—Ens.
I 2 O OPHTHALMOLOGY,
The post-mortem examination revealed a tuberculous form of meningitis. The
left eyeball was enucleated from the corpse, and sent by me to Professor Otto Becker
for his anatomical Atlas. Dr. Weiss, late assistant of Professor Becker, made
the minute dissection, and found the choroid much thickened, especially on the out-
side of the disc. The inﬁltration was eight millimetres long, three mm. broad, of
inﬂammatory character, and sprinkled with little tubercles, caseous in their centre.
According to this observation there are three differences between the common
miliary tuberculosis of the choroid and the rare tuberculous inflammation-of the
same coat. (1) The miliary tubercles are present in cases of general miliary tuber-
culosis. ‘Our case of tuberculous choroiditis was found in a person with a local
disease, namely meningitis. (2) Miliary tuberculosis of the choroid may exist without
amblyopia, and without any external changes of the eyeball. In our case of
tuberculous inﬂammation of the choroid there was blindness, a marked chemosis
and protrusion of the eyeball, and the signs of a slight iritis. (3) Miliary tubercles
are visible with the ophthalmoscope as little whitish round spots in the normal
fundus, generally growing, but their diameter remaining small. In our case of
tuberculous inﬂammation of the choroid the disc was blurred, the greater part of
the visible retina whitish, and protruded by a thick inﬁltration of the choroid;
the retinalyessels enormously dilated, running in front of this whitish inﬁltration.
Conclusions.
In all three cases there were accompanying symptoms, affording some sugges-
tions for the diagnosis—e.g., swollen lymphatic glands, hydrocephalus, or irritation
of the meninges. The alterations of the eye itself were always very different from
all common types of inﬂammation. As to treatment, I may allude to an interesting
discussion, held in the meeting of the Surgical Society of Paris, on July 9, 1879.
Some authors there advised excision in a case of tuberculosis iridis; the greater
number of them disapproved of it, and rejected Virchow’s theory, believing that
every person with a tuberculous deposit is attacked by general tuberculosis. With-
out touching upon the theoretical question, I venture to think that in practice
patients will gain, if we exterminate every tuberculous deposit which (as in our ﬁrst
case) is found in an accessible place, and in a person free from acute and
alarming symptoms.
Case of Amy/idea Cmegeyez'z‘a 0f doe/z Eyes, 2022/; Deﬁez'eney 0f
z‘lze Cz'Zz'm/y Bodies, and‘ am‘ev/z'orpam‘ 0f the C/zoi/oz'a’.
Dr. HILARIO DE GoUvﬁA, Rio de Janeiro.
The patient, a man aged 23, stated that his sight had always been defective,
and that shortly after birth Dr. Oarron du Villards had pronounced his defect to
be congenital. He came to me for recent muscae. -
Present condition, myopia 3-1,— and constant lateral nystagrnus ; eyes prominent,
corneae appear too flat, and anterior chambers shallow. Complete absence of iris -
in both eyes. Lenses irregularly elliptic in outline and displaced upwards, leaving
an aphakic space of crescent shape in the lower part; they apparently adhere to the
sclerotic at the upper part, no space being there visible, and no movements obtained
by motions of the eyes; some‘ slight superﬁcial opacities. No signs of ciliary pro—
cesses, ciliary body, or anterior parts of the choroid. Ohoroid in posterior part of
OPHTHALMOLOGY. I 2 I
eye normal in some parts, more or less deﬁcient in others, especially above and
below; vasa vorticosa formed entirely by tributaries from posterior part of eye-
A moderate posterior staphyloma on y. s. side of disc. Retinal vessels normal in
distribution and extent. Visual ﬁelds slightly contracted up-, down-, and out-
wards. v. a. 1 Sn., and with _ .5; = g- L. with same glass - 53-,
The author considers that the case proves that the iris and ciliary body are
developed, along with the choroid, from the outer layer of the secondary eye vesicle,
and not independently of the choroid, as was supposed by some of the earlier
embryologists.
Oései/vaz‘z'om 012 a Peculiar Expression of Z/ie Eyes of Z/ze
Colour-Mina’.
Dr. B. J or Jxrrnms, Boston, U.S.A.
Professor Wilson, in his monograph on colour-blindness (1855), gives, at pp. 152
and 173, an account of “ A singular expression in the eyes of certain of the colour-
blind,” causing “ a startled expression,” or an “ eager aimless glance,” or, in other
cases, “ an almost vacant stare,” &c.
In my manual on “ Colour-blindness : its Dangers and its Detection,” p. 67, I
have referred to the subject, and my present object is to supplement, by further
observations, the qualiﬁed adhesion to Professor Wilson’s statements which I then
gave.
Since writing the above work, I have seen very many more colour-blind, and
'hence had further opportunity of familiarizing myself with this peculiar look, which
belongs to them alone, and is not due to any ametropic condition, occurring as it
does in the emmetropic. I awaited some mention of it in the several monographs
which have touched on peculiarities connected with colour-blindness, but, not ﬁnd-
ing any, I called attention to it in a communication before the Boston Society of
Natural History, at the meeting, Nov. 17, 1880. I would, by this brief article,
draw the special attention of gentlemen who, oﬂicially or otherwise, test for chro-
matic defect to this peculiar look, as it cannot but exist among the now many
hundred colour-blind who have been examined by competent observers, with some
of whom the latter must come in frequent contact.
From my later experience I can, however, add but little to Professor Wilson’s
description. There is a certain liquid look in the eyes, as if slightly suﬁ'used. It
gives also the colour-blind person the appearance of not listening, or not being
interested'in what you are saying to him. I have, as I said, detected a colour-
blind person by this look, but I have also failed, being, I suppose, too anxious to
ﬁnd it before being sufﬁciently familiar with it. It has been readily recognized
by intelligent bystanders to whom I pointed it out.
A lady once asked me what was the matter with Mr. A.’s eyes P Knowing he
was colour-blind, I drew her on to describe what she meant, and her account was a
very good repetition of Professor Wilson’s above-quoted. She had never heard of
this peculiar look of the colour-blind. She has since noticed and spoken to me of
the same in reference to some other mutual acquaintances who are colour-blind.
I can now recall this peculiar look as connected with the facial expression of a
gentleman I knew for many years without detecting his chromatic defect, although
‘the question of colour had been entered into between us. His nephews I found
I 2 2 OPHTHALMOLOGY.
colour-blind, and they told me of the ridiculous mistakes of their maternal uncle.
One of these nephews told me only yesterday that he could detect no difference
when the brilliant skyrocket lights changed from red to green.
This peculiar expression of the colour-blind varies in amount, and even at
different times, in the same person. It, however, seems to always hover about the
eyes. I cannot answer positively whether it is more apparent in those most defec-
tive. I should say that it was. In speaking before the Natural History Society
last year, I said that I had not noticed it in the few colour-blind females whom I
had detected. Since then I have found a very colour-blind lady in whom it exists
to some degree. I probably should not have noticed it except for my considerable
experience with other colour-blind. An anecdote may here help to explain the
effect of this peculiar look. During my labour of testing the Boston public scholars,
I was one day at a boys’ school when the several classes, coming and going in the
hall, made such a disturbance that the principal stepped on to the edge of the
platform to stop it. He said nothing, but merely looked at the lads. Ithought
to myself, as I watched his face, “Well, that indeﬁnite aimless expression and
gazing into distance won’t quell such turbulence.” To my surprise, the noise
ceased as soon as he attracted attention. Shortly after, I called him to look at
the matches a colour-blind boy had made with Holmgren’s test, in which he saw, as
he said, nothing out of the way or to comment on. It then ﬂashed over me that he
was colour-blind, which, upon examination, proved true. His peculiar look was
that of the colour-blind. I met him once afterwards, coming hastily through a
door in the Post Office, when I caught his eye ﬁrst, and instantly noticed the ex-
pression as that of the colour-blind before I recognized the rest of his face.
I have thus brieﬂy called attention to this singular peculiarity, which may
prove of value in the detection of colour-blindness. I would attempt no explana-
tion of it. Ocular expression is, of course, due to the muscles of the lids and
face. .As these, however, are called into play from mental impressions derived
through the eye, it does not seem impossible that the colour-blind eye may have
its own peculiar facial expression.
De l’cfmwléaz‘z’mz a’e Z’cez'l dams [a panop/zz‘almz'e suppu-
mtz'zle azgu'e'.
Dr. DANIEL MOLLIERE, Lyons.*
En 1876, j’ai public’ dans le Lyon .Mcdical une observation d’énucléation du
globe oculaire pendant la période aigué du phlegmon de cet organe. J e ﬁs
alors remarquer que cette operation si simple avait donné un résultat rapide et
parfait. Ayant opére d’autres malades dans ces memes conditions, je proposai
d’ériger l’énucle'ation en méthode générale pour le traitement du phlegmon de
l’oeil (panophtalmie suppurative aigue). Ma proposition ne fut pas alors accueillie
tr‘es-favorablement et i1 me fut prédit que dans bien de cas j’aurais a redouter des
accidents cérébraux. Et des observations antérieures me furent citées. Il faut
dire qn’elles ne se rapportaient pas a des cas de phlegmon de l’oeil, mais bien a des
cas de phlegmon du tissu cellulaire de l’orbite. Depuis cette e’poque j’ai continue
a pratiquer cette operation et je lui reconnais les avantages suivants :—

* Ohirurgien-en-Ohef de l’Hotel Dieu de Lyon, de la Société de Ohirurgie de Paris.
OPHTHALMOLOGY. I 2 3
1° Elle fait cesser immédiatement les douleurs.
2° Le gonﬂement disparait ordinairement le soir du premier jour.
3° L’ophtalmie sympathique est prévenue ou arrétée.
4° La cavité oculaire reste libre et l’on pent des les premiers jours faire de la
prothese oculaire tandis que lorsque l’oeil s’atrophie il y a des brides cicatricielles
qui la rendent impossible ou douloureuse.
Les faits que j’ai observés sont au nombre de vingt-six. Plusieurs de mes
coll‘egues des hopitaux de Lyon ont suivi mon exemple. Les operations qu’ils ont
pratiquées dans des cas analogues quintupleraient le chiffre que je viens d’apporter.
Aucun d’eux n’a observé d’accident. J’ai opéré des malades de 70 et '72 ans, de
20 et de 18 ans. Chez tous les suites ont été absolument simples.
Dans plusieurs cas 1e phlegmon reconnaissait pour cause une operation de
cataracte.
Dans d’autres cas un traumatisme, brﬁlure, choc d’un épi de blé, corps
étrangers.
Dans d’autres cas j’ai vu le phlegmon se développer sous l’influence de causes
générales; on sur des yeux atteints depuis longtemps d’alte’rations chroniques.
Malgré cette diversité dans l’e’tiologie j’ai toujours pu renvoyer mes malades
guéris au bout d’une dixaine de jours en moyenne, memo dans un cas oil il y
avait en un phlegmon de l’orbite.
Je tiens a donner aujourd’hui ces re'sultats, car je crois avoir été le premier au
moins en France, a dire, que l’énucléation du globe oculaire pendant la période
aigué dOit are ]e traitement de tous les cas de panophtalmie suppurative.
‘
Desm/zfz‘z'mz 0 f a Regz'sz‘erz'ng Perz'mez‘er.
Dr. GEORGE 'I‘. STEVENS, Albany, New York.
Fixed to a standard is a ring of brass, about ﬁve inches in diameter, in which is
held another ring which is movable. To the inner ring is attached a series of
wheels, a rack carrying a pencil, and a bearing through which passes an arm of
thin brass, about twenty-ﬁve inches in length.
This arm is bent so as to form an art of a circle of twelve inches radius; one
edge of the arm is toothed. At one extremity of the arm is a dark plate on which
a steel spring is calculated to hold a small piece of white or coloured cardboard.
The arm, owing to the movement of the inner ring, to which it is held by the
bearing, can be set at any angle to the horizon ; by turning with the ring it
describes in space a hemisphere, and as it moves in a circle, the inner ring with its
attachments moves with it. In front, a dark disc of suﬁicient size hides the working
portions of the instrument from the eye to be examined. A small polished point
at the centre of this disc is the point of ﬁxation.
In practice, when the arm has been pushed along until the small piece of card-
board touches the polished point in the disc, the toothed edge of the arm has so
acted upon the series of wheels as to cause the rack bearing the pencil to have also
moved in such manner that the pencil is exactly opposite the central point. When
the arm is moved so as to carry the dark plate (and little card) through a space of
one hundred degrees, the pencil has ‘been carried as far as the outer border of the
outer ring. It will be seen that the pencil not only moves in a circle directed by
I 2 4 OPHTHALMOLOGY.
the position of the arm to the horizon, but also at different distances in the circle,
depending upon the position of the arm in its bearing. The movement of the arm
in its bearing is communicated by a milled head turned by the ﬁngers. By a hinge,
a tablet is attached to the upright support. Upon this tablet a printed diagram
—consisting of a series of concentric rings and radiating lines—may be so placed
that, when the diagram is brought into contact with the pencil, the centre of the
diagram is exactly opposite the point of ﬁxation. As the paper touches the pencil
the exact position of the pencil is registered upon the diagram.
The advantages of this instrument are—(1) That it is free from the objection of
the great weight and bulk which characterize all other perimeters with which I am
acquainted. (2) It is more exact in its record, being automatic in its registering
movements, and thus is free from the errors which are incident to observing with the
eye and registering upon a detached diagram by the hand. (3) The ﬁeld of vision
can be determined in much less time than when the surgeon must stop to observe
and then record his observations. In brief, the instrument is far more convenient,
is more exact in its record, and demands much less time in its use than any other
perimeter of which I have knowledge.
Dr. ELoUI (Egypt) exhibited a series of microscopical preparations, which were
intended to show (1) that the corneal tubes of Bowman are entirely artiﬁcial,
having no relation with the inter-fascicular spaces which have been named the
“ lacunar and linear interspaces,” which are normally nearly completely ﬁlled by the
ﬁxed corpuscles of the cornea and their protoplasmic prolongations. (2) That
these prolongations anastomose and form a continuous network throughout the
thickness of the cornea. (3) That there are nerve-cells uni- or bi-polar at the
corneal margin, forming a true ganglionic centre for the cornea.
n____—-_—.
C/M/omopz‘ome‘z‘y/e pour Z’Examerz a’es Employer a’e
Chemin de Fer ez‘ des Mai/i123.
Dr. PARINAUD, Paris.
Oet instrument est a la fois un chromoptometre et un photoptometre.
Il permet de determiner l’aptitude a reconnaitre les signaux colorés par deux
méthodes diﬁ'érentes, basées, l’une sur les variations d’intensité de la couleur, l’autre
sur les variations de la surface on de l’angle de vision.
A.——Dans la premiere méthode, la source lumineuse est représentée par l’ouver-
ture ﬁxe d’un diaphragme au devant duquel se trouve un verre dépoli qui diﬁuse la
lumiere. A l’aide d’une 1euti11e positive et d’un diaphragme a ouverture variable,
on donne a cette source lumineuse l’intensité que l’on desire.
Sur un second verre dépoli, placé au foyer conjugué d’une lentille par rapport
au premier, on obtient une image agrandie de la source lumineuse. L’intensité
de cette image est déterminée par l’ouverture d’un second diaphragme.
Si l’on place une substance colorée transparente dans un coulisse, au devant du
verre dépoli antérieur, on voit, par l’ouverture d’un écran, la couleur avec une
intensité proportionelle a l’ouverture du diaphragme.
L’examen se pratique a petite distance. L’intensité de la source lumineuse
reglée d’avance demeurant constante, ainsi que sa distance et celle de l’examiné,
OPHTHALMOLOGY. I 2 5
l’acuité, qui est inversement proportionnelle à l’intensité nécessaire pour que la
couleur soit reconnue, sera donnée par les indications d’une règle dont les gradua-
tions correspondent a l’ouverture du diaphragme.
Les trois couleurs, rouge, vert et bleu, suffisent aux besoins de l’examen.
Les avantages de cette méthode, pour le daltonisme congénital, résultent en
grande partie de ce que, en faisant varier l’intensité de chaque couleur, on enlève
aux viciés leur principal élément d’appréciation.
Le diagnostic repose :—
(a) Sur les erreurs de dénomination à peu près constantes et qui sont d’autant
plus signiﬁcatives que l’examen ne porte que sur des couleurs fondamentales.
(12) Sur les dénominations multiples données a une même couleur suivant
l’intensité.
(0) Sur la confusion du rouge et du vert présentés séparément ou simul-
tanément. .
(cl) Sur la dissociation entre la sensation lumineuse et la sensation chromatique
de la couleur pour laquelle il y a cécité, lorsque l’intensité augmente progressive-
ment en partant de 0. Avec un verre rouge sufﬁsamment saturé, l’œil normal
perçoit simultanément la couleur et la clarté. Le daltonien perçoit généralement
la sensation lumineuse avec la même intensité que l'œil normal, tandis qu'il faut
une intensité plus forte pour que la sensation chromatique vraie ou fausse
se produise. Si peu prononcée que soit cette dissociation pour le rouge, elle est
caractéristique. Pour le vert elle est encore plus accusée, mais elle n’a de signiﬁ-
cation qu’au delà d’une certaine intensité, parce qu‘il n’est pas possible de trouver
d’échantillons avec lesquels les deux sensations soient simultanées pour l‘œil
normal.
(ce) Sur l’absence de sensation chromatique et lumineuse, avec le rouge saturé
sous une faible intensité, chez quelques daltoniens dont le spectre est raccourci.
En ce qui concerne le daltonisme pathologique, cette méthode en rend le
diagnostic facile quels qu’en soient la forme et le degré. Elle permet de découvrir
et d’évaluer numériquement les plus légères altérations de la vision chromatique.
Elle est particulièrement favorable pour le scotome central.
Il est une forme de dyschromatopsie, qui passe le plus souvent inaperçue, bien
qu’elle réduise d’une manière considérable la faculté de distinguer les signaux de nuit
et ceux de jour par un temps sombre. Elle ne peut être reconnue sûrement que
par cette méthode. Ce faux daltonisme, dont j’ai donné les caractères dans une
communication a la Société de Biologie de Paris (18 Juin, 1881), résulte d’un
aiïaiblissement de la sensibilité pour la lumière qui entraîne un affaiblissement
corrélatif de la sensibilité pour les couleurs. Il est compatible avec une bonne
acuité visuelle.
B.——Dans la seconde méthode, ou se sert d’un disque rotatif percé d'ouvertures
graduées par demi-millimètre du diamètre. L’examen peut se faire avec des
couleurs transparentes ou opaques qui servent aux signaux de jour et de nuit.
Il se pratique à la distance de 4l ou 5 mètres suivant l’étendue de la pièce.
Pour les couleurs transparentes, on règle la source lumineuse l’aide du
diaphragme postérieur, de manière que l’oeil normal perçoive la couleur avec un
ouverture de l mm., a la distance adoptée. L’acuité est inversement proportionnelle
à la surface de l’ouverture nécessaire pour que la couleur soit reconnue.
Les avantages et les inconvénients de cette méthode, qui n’est qu’une modiﬁca-
tion de celle de Donders, sont suﬁîsamment connus pour qu’il soit inutile d’y
insister. Elle est insuffisante comme méthode générale, utile comme méthode de
I 26 OPHTHALMOLOGY.
contrôle, indispensable pour se rendre compte de l’inﬂuence de certains troubles
visuels, qui réduisent l’aptitude à reconnaître les signaux colorés, sans intéresser
directement la fonction chromatique.
Fig. 5.


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i I sinmmnnnmunuuupgmmmuﬂmm‘äl
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5,1 DOL/R 5.4 U. 55.

Un Appm/ez'lpenr Z’Appe/eez'm‘z'en de Z’Aenz'z‘é C/Wmnaz‘z'gzee deans
nn Examen Seinneaz're a’n Personnel de la Marine ez‘ des
C/zemz'm a'e Fee.
Dr. MARÉCHAL, Brest.
L’auteur a cherché à. réaliser les conditions de l’épreuve dite de “ terrain,” tout en
éliminant les repères du métier, qui trop souvent justifient les préférences que les
examinés-viciés accordent à ce genre d’épreuves, et leur fournissent des éléments
d’appréciation étrangers aux qualités visuelles ; de plus l’expérience ainsi conduite
parle pour ainsi dire aux yeux de tous, même des membres extra-médicaux des
commissions d’examen auxquels elle apporte des preuves matérielles tout-a-fait
convaincantes.
C’cst la réalisation simpliﬁée d’un procédé déjà exposé à Amsterdam en 1879,
(procédé dérivant de la méthode générale de comparaison du Professeur Holmgren),
mais le procédé actuel semble devoir échapper à certains reproches adressés au
premier qui consistait dans la reproduction par l’examiné d’une couleur identique
a celle du type proposé par l’examinateur.
Il en résultait en effet que l’assortiment bien exécuté ne démontrait pas néces-
sairement que l’appréciation de la couleur-type fût exacte et que la valeur a lui
attribuer pour les usages courants fût conforme a la valeur réelle, à la relation avec
les éléments du spectre, par exemple, mais seulement que l’examiné se rendait
compte de différences, même minimes, dans les tons d’une couleur quelconque, même
vicieusement appréciée.
Dans l’épreuve actuellement proposée, étant donné un échantillon-type repré-
senté par une mire transparente colorée de teintes plus ou moins saturées, fonda-
mentales ou de confusion, l’examiné est invité, sans dénommer ni reproduire la
OPHTHALMOLOGY. I 2 7
couleur, a manifester le jugement qu’il porte sur elle par la signiﬁcation qu’il lui
attribue en vue d’une manœuvre ou d’une détermination précisée a l’avance; c’est
l’opération complète de son esprit que l’assistance toute entière peut juger, et cela
a chacun des mouvements où elle s’accomplit. Par un signal muet l’examiné accuse
déﬁnitivement et sans ambages possibles, la précision ou la confusion, la rapidité
ou les hésitations delses impressions chromatiques, et fournit la mesure de ce qu’il
ferait sur le terrain, puisqu’il agit dans des conditions absolument similaires.
Voici les moyens d’exécution :-—-
Sur la paroi antérieure d’une même lanterne sont superposées deux fenêtres
éclairées par la même bougie, ou mieux par le fond blanc de la paroi intérieure
opposée. Derrière la fenêtre inférieure, mesurée par un diaphragme a ouvertures
ﬁxes, l'examinateur fait passer un chassis porteur de nombreux verres de couleur et
invite l’examiné a faire connaître, d’après l’idée qu’il se forme de la couleur de la
mire ainsi établie, ce qu’il ferait sur le terrain, étant donnée la signiﬁcation que l’on
attribue d’ordinairc à ces couleurs.
Celui-ci peut a l’aide de cordons de longueur convenable manier a distance un
petit chassis qui porte quatre signes ou plus, estampés a jour, a signiﬁcation bien
déterminée, et en rapport avec les manœuvres principales usitées dans chaque
profession.
Enﬁn, à l’aide de disques transparents partagés en deux moitiées colorées ou non,
dont on peut à volonté obscurcir chaque partie et qui peuvent tourner dans le plan
d’une des fenêtres, il est facile de conﬁrmer déﬁnitivement le vice chromatique
reconnu en faisant dénommer dans les différentes positions prises par le disque, la
couleur de chaque segment.
_—_-———
072 a Method of Opening C loser! Pupil afz‘er Opemz‘z'mz
for Cairn/an‘.
Dr. LUCIEN HOWE, Buffalo, U.S.A.
By “closed pupil,” the author especially refers to the pathological condition
so frequently met with when an operation for the extraction of cataract has been
followed by severe iritis. In these cases we ﬁnd the posterior surface of the iris
glued to the capsule, the pupil ﬁlled with a dense deposit, and more or less drawn
upward toward the line of the sclero-corneal incision.
The author considers that none of the methods of operation at present in use
are entirely satisfactory. He thinks that of de Wecker to be the best of them, but
that some of the diﬁiculties attending it might be partially or entirely obviated,
and the procedure considerably simpliﬁed by using a triangular “ punch ” or
“iritome,” instead of the scissors. The instrument consists, in general, of a tri-
angular blade, having a large aperture in its centre of similar shape, and into this
a second blade is made to ﬁt exactly. They are united by a hinge joint in the
line of their bases, and continued in the form of a pair of forceps. When the
blades are closed, a longitudinal section perpendicular to the plane of the triangles
would be represented by a straight line, and when they are open the same section
would be V-shaped.
In order to open the closed pupil, a large incision is ﬁrst made with an ordi-
nary keratome, in the corneo-scleral border, as in the usual method in iridectomy.
The instrument described is then passed through this aperture, and as it enters
I 2 8 , OPHTHALMOLOGY.
the anterior chamber, one blade is made to perforate the thickened capsule or
iris passing behind it, while the other advances in front. By closing the blades
a triangular piece is excised. This usually adheres to the cutting edges, and is
withdrawn, but, if not, a pair of iris forceps can be introduced and the frag-
ments removed. There are two disadvantages in the instrument, which it is
proper to mention. In the ﬁrst place, not being bent at an angle like the ordi-
nary keratome, it is a little difficult to introduce in the superior or internal
quadrants of the corneal border, especially if the globe be not prominent; and in
the second place, the corneal incision in this method is larger than is otherwise
necessary. The former objection may be obviated in the future, I think, by
some modiﬁcation in the instrument, and the latter must be regarded of but slight
importance, although fairness requires it to be mentioned.
The manner of operating here indicated, however, has the great advantage that
a sufﬁciently large piece is cut out of the iris by closing the blades together a single
time, and that, too, before any opportunity for haemorrhage has occurred, thus
rendering the execution of the manoeuvre more simple, and the result in general
more satisfactory than by any similar method which I have employed.
The following demonstrations were given during the afternoons of Friday, the
5th, and Monday, the 8th of August:
Living specimens by 211i’. 0. Bader (London).
1.-—Gonorrhoeal ophthalmia cured by an ointment of vaseline, mercury, and
daturin.—Seen with Dr. Amsden, of Hoxton. Case, age 17.
January 24, l879.—Left eye sound. Right eye : extreme swelling and redness
of eyelids, chemosis, purulent discharge; lower third of cornea yellowish, opaque,
ulcerating.
Treatment—Six leeches right temple; removal of discharge with tepid water;
use of ointment (Hydrarg. nitrico-oxid., gr. j ; daturin, gr. j ; vaseline, gj), taking
care to push plenty beneath right upper eyelid thrice daily. Left eye bound up
with lint and same ointment.
March, 1881.—Left sound. Right likewise, except some opacity near margin
of cornea. This is the ﬁrst case thus treated. Purulent ophthalmia in infants and
gonorrhoeal ophthalmia have up to now been treated by this ointment.
2. Conical cornea; abscission of the cone—Case, age 63. Seen in consultation
with Dr. W. A. Butler, of Woolwich. An opacity occupies apex of each cone; no
lenses assist; great difficulty in following employment.
June 22, l8'72.—Iridectomy; slight improvement. Left, no lenses of use; right
200 of Snellen at 10 feet.
September 1, l872.——Abscission of both cones. September 241.—All healed:
ﬁat central corneal opacity.
August, 188L—Reads well with + '7 at 10 inches; with + 11 recognizes 100 of
Snellen at 20 feet ; followed his ofﬁce pursuits since 1872.
Dr. Gayet (Lyons).—A complete series of large photographs of specimens of
‘diseased e yes.
llﬁcroscopz'cal Specimens.
Dr. I-Iirschberg, Berlin—Tuberculosis of the eyeball (see p. 117).
Mr. Story, Dublin.——Tuberculosis of eyeball.
OPHTHALMOLOGY. 1 29
Dr. Samelsohn, Gologne.——-Retrobulbar neuritis (see p. 60).
Mr. Marcus Gunn, London—Specimens of retina.
Dr. Brailey, London—Sympathetic ophthalmitis (see p. 35).
Mr. Nettleship, London.-—Syphilitic choroiditis, &c.
Mr. Priestley Smith, Birmingham.—~Glaucoma (see p. 84).
Dr. Eloui, Egypt—Specimens of cornea (see p. 124).
Apparatus and Instruments.
Dr. Parinaud (Paris).——A chromoptometer for the examination of railway ser-
vants, 82:0. (see p. 124').
Dr. Ole Bull, Ghristiania—His new tests for colour-blindness (see p. 126). -
Dr. Javal, Paris—Ophthalmometer of Javal and Schiotz (see p. 30).
Dr. Maréchal, Brest—An instrument for testing colour vision (see p. 126).
Dr. Pagenstecher, Wiesbaden.--Models in glass to show pathological changes
in the eye.
Mr. M‘Hardy, London.-A Snellen’s phakometer: with improved mechanical
arrangement. _
Dr. Lucien Howe, New York—A forceps-keratome for Opening closed pupil
(see p. 127).
Dr. Knapp, New York—Gystotome and knives used for peripheral cystotomy
and secondary operations.
Dr. Nieden, Bochum ——Artiﬁcial eyes of vulcanite.
Prof. Von Zehender, Rostock—Artiﬁcial eyes of a new material used in dentistry.
Dr. Stevens, Albany, New York—A registering perimeter (see p. 123).
Dr. Lopez Ocaﬁa, Madrid,‘ exhibited an instrument designed to facilitate the
cauterization of the lacrymal sac with acid nitrate of mercury. .
Dr. Lilobrecht, Ghent, showed (1) new scissors, the use of which is not attended
with heemorrhage; (2) a double-edged Graefe’s knife; (3) a knife designed for secon-
dary cataracts.
Exhibited in the Museum:—
By Dr. William Thomson, Philadelphia—New arrangements of wools for
colour-blindness (see Trans. Amer. Oplzih. 800., 1880).
By Dr. Jaesche, DOrpat.——Chin-rests for preventing myopia.
PART III. x
DISEASES OF THE SKIN.
—-_+——
President .
ERASMUS WILSON, Esop F.R.S.
Vice-Presidents.
Dr. W. B. CHEADLE. I Dr. R. LIVEING.
Cozmcz'l.
Monnnnr BAKER, Esq., London. Professor M. Karosr, Vienna.
Dr. CESAR. Boon, Christiania. Dr. S. MACKENZIE, London.
Dr. L. D. BULKLEY, New York. MALCOLM Monnrs, Esq., London.
Dr. R. CROCKER, London. Dr. E. RAsoRI, Rome.
Dr. A. B. DUFFIN, London. Dr. A. SANGSTER, London.
Dr. GOLCO'I‘T Fox, London. Professor E. SCHWIMMER, Buda—
Professor HARDY, Paris. Pesth.
Dr. A. JAMIEsoN, Edinburgh. Dr. WALTER G. SMITH, Dublin.

Secretaries.
Dr. Jomv CAVAFY. I Dr. GEORGE THIN.
_+—
INAUGURAL ADDRESS,
BY THE PRESIDENT,
ERASMUS WILSON, ESQ., F.R.S.
MY BRETHREN,-—
The Council of the Dermatological Section of this great Medical Congress
offers you a hearty welcome.
We assemble to-day as a part of a great International body, for intercom—
munion of friendship, of information and of thought ; and, just as the Congress,
taken as a Whole, has for its main purpose to diminish pain and suffering, and
. to promote the health of the people, so we, in our department, have met to
co-operate with a similar intention.
The important object now stated, we hope to arrive at, partly by means of the
new ideas, which you, our foreign brethren, are about to sow amongst us, and
partly by a judicial re-investigation and exposition of the principles which we,
at present, adopt for the diagnosis and treatment of cutaneous disease.
' The bias of the British medical mind is strongly in favour of those studies
which lead directly to the cure of disease 3 and whilst We recognize fully the
advantages and necessity of pathological research in every variety, the conclusion
which we seek most ardently to attain, is—the means of restoring our patients
most certainly and most readily to a state of health.
As a groundwork for our operations, in this respect, we aim at the regulation
K 2 '
L32 DISEASES OF THE SKIN.
of the general functions of the economy—of those all-important forces, the func-
tions of digestion, of assimilation and of nutrition ; for, experience daily proves to
us, that when such regularity is obtained, many of the diseases which we are
called upon to treat yield to the ordinary processes of Nature, and return to a
state of health without further delay. And this we regard as the true signiﬁcance
of constitutional treatment ; by means of which every known disease of the skin
may be ameliorated and, in most instances, cured.
But, whilst we thus place constitutional medicine on a pedestal, as deserving
the highest consideration of the practitioner, we by no means disregard the value
of topical medicine. lVe have to contend with local lesions, and with local pain ;
and for the relief of these we seek for remedies which shall be, at once, the most
convenient and the most effectual. In one case, a purge will relieve the patient ;
but the addition of a soothing, local application will be requisite for his cure.
In another case, a local application alone will accomplish a great deal, but the
addition of a constitutional remedy will assist and facilitate the cure.
But, before we can answer the question : “ What is the best constitutional,”
and, “What the best local remedy Z” we must have made up our minds as to the
cause of the disease, and as to the precise method, by which we shall attempt
the removal of that cause. Our treatment must not be haphazard or simply
routine, but must be directed according to a ﬁxed intention. Under such cir-
cumstances, the treatment of the disease itself is of comparatively secondary
importance. Let us remove the cause, and the disease will be cured sponta-
neously. Our patient may be a sufferer from eczema; but our patient, at the
same time, is a victim to dyspepsia. In such a case it becomes our duty to effect
the treatment of the dyspepsia ﬁrst, and the chances are, that when the dyspepsia
is alleviated, the eczema will be wellnigh cured.
In another case, the eczema may be associated with more or less irritability of
the nervous system, without any leading dyspeptic symptoms; in this instance
our remedies should be directed towards the soothing and quieting of the nerve
centres and nerves ; and, both constitutional and local treatment should be
invested with a sedative character. If there were any suspicion of impurity of
blood in the ﬁrst instance, there can be none in the second ; the ﬁrst may be
regarded as, in some sort, a blood-disease ; the second as a nerve-disease. But, in
both, the local treatment would be essentially the same, the difference between
them being a difference not of disease but of cause.
N ow, what we should endeavour to establish in these cases is not only a
principle of treatment, but also the material of treatment. In the neurotic case,
arsenic will be found a most useful, and probably an essential remedy; in the
other, or assimilative case, arsenic would be utterly worthless.
If all cutaneous diseases depended on the presence of a poison in the blood, as
in the instance of syphilis, the elimination of the poison would be the aim of our
treatment in every case, and the results would be as satisfactory as we know them
to be in syphilitic affections. But in other cutaneous diseases it becomes neces-
sary to settle in our minds whether We have to deal with a disease taking its
origin in disturbance of the digestive functions, or whether it be neurotic to a
greater or less degree ; whilst it must likewise be admitted that in certain cases,
particularly those of long duration, both causes are apt to prevail.
For therapeutical purposes all diseases of the skin might be assembled, if we
except syphilis and diseases proceeding from local causes, under three heads——
namely, diseases depending on disorder of digestion and assimilation; diseases
DISEASES OF THE SKIN. 133
depending on disorder of innervation ; and diseases of nutrition. As an example
of the ﬁrst kind we might take eczema, with its multitudinous manifestations.
As an example of the second we should have pruritus and prurigo; and, as
examples of the third, papilloma and ﬁbrosis. But, we cannot fail to recognize the
fact, that, practically, there is a greater or less blending of the whole. The
pruritus of eczema belongs to disordered innervation ; and aberration of nutri-
tion may be accompanied with symptoms which appertain to both the others.
Thus, in the lepra of Willan— the psoriasis of modern sch ools—we have a disease
which is due to altered nutrition of the skin from defective. organization of that
structure. But as the nerve-power or life-power of the skin is insufﬁcient to
restrain abnormal function, so capillary congestion constitutes a part of the
disease; and. the hypertrophous growth of papillae and excessive production of
morbid epidermis must be regarded as a passive nutritive change or passive
growth. In ichthyosis, with a starved condition of the skin as far as nutrition is
concerned, We have an excessive papillary growth, and excessive accumulation in
the shape of altered epidermis. But still more interesting illustrations of ab-
normal nutrition are evinced by excess or defect of pigment; by the substitution
of a lowly for a more highly organized tissue, as in ﬁbrosis, and by the exuberant
proliferation of cell-tissue of low organization which is met with in the instances
of tinea, of favus, and of epithelioma.
If I were called upon to summarize the diseases of the skin such as they exist
most commonly in this country ;—-I should begin with eczema, as occurring at
all ages and in every condition of life; tinea might follow next, as a disorder of
childhood; then the acne of youth; and next, the so-called acne rosacea of the
adult, which latter is actually a form of eczema. The lepra of Willan is not very
common; neither is scrofula in its cutaneous forms. Looking to the cause of
these diseases, we ﬁnd, mal-assimilation and nerve-irritability ; aberration of
nutrition and defective nutrition. And, therapeutically, our most reliable re-
medies are— mild purgatives, with tonics, in the diseases of dyspeptic origin;
nutritive tonics ; and especially arsenic, as a nutritive tonic, and in that sense a
direct nerve-tonic.
What I have now said is intended to open up to the minds of my hearers a
picture of the broad ﬁeld in which we all mutually labour ; to point out that many
portions of that ﬁeld admit of independent exploration ; and to show that, starting
from the line of our existing knowledge, there yet remains very much to investigate:
singly, for the perfection of the parts ; and collectively, for the perfection of
the whole. This is the ﬁeld of dermatological culture and research; and with
this brief introduction I now call you to the work of our section.
Once more, brethren, We bid you welcome as friends and fellow-workers.
Du Pz'z‘yrz'asz's Cz'xcz'né er‘ Mar/(grind ,- Descrzfzfz'on a’e son Myco-
der/me, [e Mz'crorpormz anomaorz (Mz'w/ospororz dz'spar).
Dr. EMILE VIDAL, Paris.
En 1862, dans un mémoire intitulé, Neue Beobachtungen iiber Herpes (Annalen
des Gha/rité Kra-nkenhauses, p. 140, Berlin), le savant professeur von Barensprung
écrivait les lignes suivantes que e traduis textuellement :
“ Nous connaissons mainten ant quatre affections parasitaires de la peau, bien
I 34 DISEASES OF THE SKIN.
distinctes, qui sont engendrées par quatre mycodermes également bien différents
les uns des autres, ce sont:
“1°.——Le pityriasis 've'rsicolor, produit par le champignon découvert par Eichstädt,
le microsporon furfur.
“ 2°.-—L’erythrasma : j’appelle ainsi, dit von Bärensprung, une éruption conta-
gieuse, bornée le plus souvent aux régions inguinale ou axillaire, se présentant en
taches nettement limitées sous l’apparence d’un pityriasis rubra en forme arrondie.
Le Dr. Burchardt (P'reuss. Vereinszeitung, 1859) y a découvert un champignon
différent de ceux connus jusqu’alors. Vu la ténuité particulière de ses éléments, il
a donné a ce parasite le nom bien justiﬁé de microsporon mmutéssimwn.
“ 3°.—La teigne (porrigo luminosa de Willan, appelée à. tort favus par Alibert),
affection due au développement de l’achorion Schônleini.
“ 4°.——L’herpès parasitaire qui reconnaît pour cause le tricophyton tonsurans
découvert par Gruby et Malmsten.”
En laissant de côté le parasite de la pelade (alopecia areata) le microsporon
Audouini, dont l’existence est controversée, on peut actuellement ajouter de
nouvelles espèces de mycodermes a la courte. nomenclature de Bärensprung.
J e citerai d’abord le parasite observé par le Dr. L. Malassez, dans les squames
du pityriasis capitis (alopécie pityrode), et qu’il a très-bien décrit, en 1874:, dans
une Note sur le Champignon du Pityriasis simple (Archives de Physiologie,
p. 491).
Ce champignon n’est pas toujours plus abondant la où le pityriasis est le plus
intense.
Il est caractérisé:
1°. Par l’absence des tubes de mycelium.
2°. Par des spores a double contour, les unes rondes, les autres ovoïdes, se
développant par bourgeonnement.
Les plus grosses ont de 4 a a 9 p. dans le plus grand axe et 2 y. à 2 ,u. et demi
dans la largeur.
Les plus petites n’ont que 2 p. dans leur plus grand diamètre.
Ces spores qui n’ont pas encore été classées et dénommées par les naturalistes
sont de la même espèce que celles que l’on désigne sous le nom de spores banales
(Nystrom), celles que l’on rencontre dans toutes les exfoliations épidermiques, dans
les croûtes, dans l’épiderme de la. peau saine, celles qu’on trouve aussi mêlées avec
les autres mycodermes, et qu’en raison de leur banalité je nomme les spores de la
torula vulgaris.
Outre cette torula, on trouve sur la peau, même chez les sujets bien portants,
plusieurs variétés de parasites: des micrococcus, des bactéries, même parfois des
vibrions, ainsi que des spores en core mal étudiées et qui vraisemblablement appar-
tiennent à plusieurs variétés.
I. Description du Microspoo'on Anomœon.
Le parasite que j’ai découvert dans une forme spéciale de pityriasis circiné et
que j’ai montré, dans une séance du mois de Juillet, 1879, à la Société de Biologie,
est parfaitement déﬁni. L’aiÏection qu’il détermine est facile à diagnostiquer. ~
La facilité avec laquelle guérit le pityriasis, l’extrême petitesse des champignons
qu’on ne peut reconnaître au microscope qu’avec les plus forts grossissements, sont
les raisons pour lesquelles ils ont pu jusqu’à ce jour passer inaperçus.
En examinant, avec l’objectif à. immersion N o. ]O de Hartnack, des cellules
épithéliales grattées sur un pityriasis circiné, on constate des spores rondes ayant
DISEASES OF THE SKIN. I
en moyenne 1 p. Beaucoup sont plus petites. Les spores d’une dimension plus
grandes sont les moins nombreuses; elles ont 2 p, et, très-exceptionnellement,
3 y. de diamètre.
Les caractères principaux de ce mycoderme sont:
1°.-—L’extrême petitesse des spores et une irrégularité (le volume très-parti-
culière, qui m’a fait donner a ce parasite le nom de microsporon anomæon ou
dispar.
2°.——La disposition en cercle autour d’une cellule épithéliale. On voit aussi des
groupes, des amas de spores, inégalement répartis sur des cellules ou entre des
cellules qu’ils semblent écarter ou refouler en détruisant leur coalescence.
3°.——La rareté des chaînes de spores. 'Dans quelques préparations microscopiques
ou trouve des chapelets de 5 à 6 sporules, ayant moins d’un y. de diamètre en
préservant l’aspect de petits points noirs rangés en lignes.
4u°.——L’absence ou, tout au moins, la rareté extrême d’un mycelium.
Bien que deux ou trois fois j’aie cru voir quelques ﬁlaments excessivement ﬁns,
je n’oserais affirmer l’existence d’un mycelium, et je serais plutôt enclin ‘a la mettre
en doute. . _ -
Tous ceux 'qui ayant étudié pendant plusieurs années les champignons de
l’épiderme, connaissent, comme moi, toutes les difficultés d’examen microscopique
et toutes les causes d’erreur—même en prenant les plus minutieuses précautions—-
comprendront ma réserve.
C’est sur les cellules de la couche superﬁcielle, et surtout sur celles de la couche
moyenne de l’épiderme, que paraît habiter le microsporon anomæon.
J’ai constaté la présence de ce parasite, non seulement dans l’épiderme qu’il
soulève et qu’il exfolie, en produisant une desquamation furfuracée, mais aussi à
l’oriﬁce des poils dont la base peut être entourée d’une gaine blanche, formée de
débris épithéliaux et de spores en grande quantité. C’est sur la face, dans la barbe
et aussi sur le cou, que j’ai vu cette sorte de pityriasis pilaris. Le poil reste
indemne. Le follicule pileux n’est pas enﬂammé et semble ne subir aucune réaction.
De tous les poils que j’ai examinés, aucun n’était altéré et ce n’est que sur la
partie la plus rapprochée de l’oriﬁce que la gaine épidermique contenait des
parasites.
II. Signes Cliniques du Pityriasis circinata. et marginata.
L’éruption pityriasique produite par le microsporon anomæon débute par de
petites taches rosées, a peine saillantes, au dessus du niveau de la peau. La
surface en est sèche, et en frottant on détache facilement une desquamation
furfuracée.
Ces taches sont irrégulièrement distribuées. Elles commencent ordinairement
sur le tronc, mais je les a vues aussi envahir d‘abord les bras ou même les cuisses.
Leur accroissement est assez lent. Au bout de quinze jours elles atteignent à
peine le diamètre d’une pièce de 50 centimes, après un mois, celui d’une pièce d’un
franc. J’en ai vu de plus larges; quelques-unes sont ovales. Dans certaines
régions, sous l’aisselle, dans la région inguinale, elles peuvent, devenant d’abord
conférentes, puis conﬂuentes, se réunir en plaques qui prennent la forme
marginée.
Celles qui restent isolées, guérissant par leur centre et s’étendant par leurs bords,
prennent une forme annulaire. Le bord est rose ou rose jaunâtre, en desquama-
tion furfuracée; c’est un vrai pityriasis circiné. Sur quelques plaques, mais
1 36 DISEASES OF TI-IE SKIN.
très-exceptionellement, l’épiderme plus largement soulevé forme une collerette
épidermique.
Quand l’affection parasitaire a envahi depuis plusieurs mois la région axillaire
ou la région inguinale, elle peut‘ provoquer une irritation plus vive, un intertrigo,
ou même une éruption eczémateuse, et constituer ainsi une des variétés, la plus
légère assurément, de l’affection complexe étudiée par l’illustre professeur Hebra,
sous le nom d’eczema marginatum.
Pour le dire en passant, l’eczema marginatum peut être provoqué par plusieurs
espèces de parasites, dont les plus habituels sont :—
lo—Le tricophyton, ce qui est le cas le plus fréquent, celui qui détermine les
formes les plus sérieuses et les plus résistantes au traitement.
2°.——Le microsporon furfur d’Eichstadt.
3°.—+‘Le microsporon minutissimum de Burchardt, avec l’éruption désignée par
von Barensprung sous le nom d’érythrasma.
AIR—Le microsporon anomæon qui peut donner lieu aux formes les moins pro»
noncées et les plus faciles à guérir,
Le pityriasis circiné s’accompagne d’un certain degré de démangeaison variable,
suivant la disposition nerveuse des sujets. Le prurit est plus intense lorsque
l’éruption parasitaire a pris possession des régions inguinales ou axillaires.
Chez plusieurs des malades que j’ai observés, l’aﬁ‘ection durait depuis trois ou
quatre mois, et même chez l’un d’eux, depuis cinq mois.
III. Diagnostic cliﬁ’ére‘ntiel avec le Pityriasis rosea, le Pityriasis versicolo'r,
Z’E’yﬂwasma et la TTicoph/ytie circinée.
(ce) L’affection séparée du pityriasis rubra de Dévergie et étudiée par Gibert
et Bazin, sous le nom de pityriasis rosea, est généralement confondue avec le
pityriasis produit par le microsporon anomæon. -
Même apparence de desquamation furfuracée, même teinte rosée ou jaune rosée,
des taches, voila pour les traits de ressemblance. Mais le pseudo-cxanthème de
I Bazin, qui ne s’observe guère qu’au printemps, a une marche régulière et une durée
moyenne de quatre à six semaines, ne dépassant pas deux mois. Son évolution est
régulière. Il débute constamment par la région sternale ou par la région dorsale,
pour s’éloigner graduellement de la ligne médiane et s’étendre symétriquement sur
les membres, guérissant spontanément sur le tronc, pendant que sur les extrémités
récemment envahies, l’éruption est en pleine activité. La décroissance est symé-
trique et suit une marche régulièrement descendante. L’état papuleux des nouvelles
poussées permet de regarder cette éruption comme une variété d’érythème papuleux
que je distingue sous le nom de pseudo-exanthème érythémato-desquamatif.
Le pityriasis déterminé par le microsporon anomæon n’est jamais symétrique,
Sa distribution a l’irrégularité capricieuse des affections parasitaires. Il débute
tantôt sur la peau du tronc, tantôt sur celle des membres. Sa marche est irrégu—
lière: il peut se prolonger pendant plusieurs mois, tandis que la durée du pityriasis
rosea ne dépasse pas deux mois. Enﬁn en cas de doute, le microscope, en faisant
reconnaître le microsporon anomæon, aﬁrmerait le diagnostic. Dans les Squames
du pityriasis rosea on ne trouve guère que la torula vulgaris, la spore commune à.
toutes les exfoliations épidermiques.
(12.) Le pityriasis versicolor, facile à distinguer par‘sa teinte jaunâtre ou jaune
brun, Se présente sous forme de plaques, plus ou moins étendues, et ne pourrait
être confondu avec les formes circinées de l’aﬁection qui nous occupe. Le diagnostic
DISEASES OF THE SKIN. I 3 7
à première vue, ne devient diﬁicile que dans les régions axillaires et inguinales où.
l’éruption peut prendre la forme d’eczema marginatum. Non seulement on trou-
verait alors le pityriasis versicolor sur d’autres régions du corps, avec tous ses
caractères, mais, en dernière analyse, le microscope montrerait le microsporon
furfur d’Eichstadt, avec ses spores volumineuses et son mycelium abondant et si
caractéristique.
(0.) _L’érythrasma de Bäirensprimg est d’une coloration plus foncée que celle du_
pityriasis circiné; il est d’un rouge sombre, ne prend que rarement la forme annu»
laire, produit des plaques plus ou moins étendues, couvertes d’une desquamation
furfuracée. Sa durée est plus longue. Il peut persister pendant plusieurs années,
comme je l’ai vu sur un malade que m’a montré le Dr. Besnier, mon savant collègue
de l’hôpital St. Louis. La résistance plus grande à des agents anti-parasitaires
peu énergiques concorde du reste avec cette durée plus longue.
Le champignon de l’érythrasma, décrit pour la première fois par Burchardt,*'
plus abondant dans les couches superﬁcielles et moyennes de l’épiderme, atteint
jusqu’aux couches profondes. Les spores, très-petites et de volume irrégulier,
ressemblent assez à celles du microsporon anomæon, mais elles ne sont pas, comme
nous l’avons vu pour celui-ci, disposées en cercle autour des cellules. Ce qui con-
stitue le caractère distinctif du parasite de l’érythrasma, c’est un mycelium formé
de ﬁlaments d’une ténuité extrême, d’ ,2100 de millimètre, les uns droits, les autres
recourbés, a contours lisses, ni articulés, ni ramiﬁés, enchevêtrés les uns dans les
autres et très-nombreux. Nous avons déjà dit que le microsporon anomæon n’a
probablement pas de mycelium.
(CL) La tricophytie circinée (herpès circiné parasitaire, ringworm) ne pourrait
être confondu qu’en raison de sa forme annulaire; mais la multiplication moins
rapide des points envahis, leur nombre beaucoup moins grand, son début sur les
régions découvertes, sa contagion évidente et facile, les symptômes d’une exci-
tation plus prononcée de la peau, irritation pouvant produire des vésicules et des
croûtes, l’altération des poils dissociés par le parasite, tous ces signes si différents
du pityriasis circiné et marginé rendent le diagnostic facile.
Les spores relativement volumineuses du tricophyton tonsurans, leur volume
régulièrement égal, leur apparence brillante, leur mode de groupement, le mycelium
ramiﬁé, font facilement reconnaître ce champignon et lui donnent uneﬁgure tout-a-
fait individuelle et bien différente de celle du microsporon anomæon.

IV. Etiologie, Pronostic, et Traitement.
Je n’ai pas encore vu le microsporon anomæon sur des sujets âgés de plus de
40 ans. L’âge des malades dont j ’ai recueilli les observations est compris entre
6 ans et demi et 36 ans.
J ’ai eu à soigner plus de femmes que d’hommes. Cela tient-il a ce que les femmes
viennent consulter plus volontiers; cela dépend-il de la délicatesse plus grande de
leur peau? c’est ce que je ne saurais affirmer.
Je ne connais encore aucun exemple de contagion du pityriasis circiné; et pour-
tant la nature parasitaire de l’aﬁ‘ection rend probable sa transmission, et cela, malgré
mes essais infructueux d’inoculation. Vainement sur moi-même et sur plusieurs
de mes élèves j’ai insinué sous l’épiderme des cellules épithéliales couvertes du
microsporon anomæon. Vainement encore les ai-je laissées pendant plusieurs jours

* Ueber eîne bei Chloasma vorkommende Pilzform, in M ediz. Zeitmzg, No. 29,
Juillet, 1859. Berlin.
r 38 DISEASES or THE SKIN.
sur la peau saine ou encore sur la peau dont j’avais raclé la couche épidermique la
plus superﬁcielle.
J e me suis demandé si ce parasite ne serait pas transmis a l’homme par les
animaux. 11 a quelque ressemblance avec un microsporon trouvé par Mégnin sur
les plumes de certains oiseaux. Deux de mes malades exercaient des métiers qui
les mettaient en contact journalier avec des plumes.‘ J e me propose de tenter de
nouvelles experiences pour voir s’il est possible de reproduire ce parasite sur les
mammiferes ou sur les oiseaux.
Le pronostic est des plus bénins, tant est grande la facilite' avec laquelle cette
affection parasitaire cede aux traitements les plus faibles.
J c l’ai vu guérir apres l’aclministration de quelques bains sulfureux, apres de
lotions au savon de goudron. J e combine habituellement ces deux moyens et je
fais laver le malade, matin et soir, avec de l’eau sulfureuse additionnée de savon de
goudron.
J’ai employé aussi avec succes les glycerolés an calomel, on an précipité jaune,
ainsi que la pommade au turbith.
Un malade dont l’affeetion durait depuis deux mois et demi a été guéri apres
15 bains au savon ordinaire.
Gette extreme facilité de guérison est tout-a-fait particuliere a l’éruption causée
par le microsporon anomaeon ; c’est ce qui l’a fait confondre jusqu’a ce jour avec le
pityriasis rosea dont elle se rapproche le plus par les caracteres objectifs.
O12 Balarzo-posZ/zomykoszk.
Professor 0 s CAR S I M 0 N, Breslau.
My attention has of late been called to a certain affection of the preputial sac,
which is very obstinate, and sometimes causes great inconvenience. At ﬁrst I
believed the cases that came under my notice to be cases of simple balano-posthitis,
and I applied the ordinary remedies, without seeing any noticeable effect. On the
contrary, the cases grew worse and worse, and led gradually to very remarkable
conditions, which, I believe, have till now not been sufficiently appreciated.
Closer examination proved these cases always to be the effect of avegetable
parasite, and so the difference in their relations to ordinary forms of balano-posthitis
became clearer.
The different appearances which this affection showed—partly successively in the
same patient, partly in different patients—may easily be grouped in a series of
several consecutive stages.
In the beginning, the patient complains of slight itching and burning on the
glans and the inner surface of the prepuce, and generally, for a certain time,
nothing is apparent but a slight erythema. By-and-by a more pronounced irrita-
tion sets in, the disagreeable sensations above referred to increase, and, in some
cases, a yellowish puriform secretion commences, which sometimes is so profuse as
to lead the patient to suppose a gonorrhoeal infection. This secretion gradually
provokes superﬁcial erosions. The skin, especially on the preputial margin, is apt
to crack with painful sores. In the meanwhile the chronic inﬂammation and
swelling induce a disproportion between the circumference of the glans and the
swollen prepuce, and the drawing back of the latter becomes from time to time more
difﬁcult. At the same time, retraction and shrinking take place in the inner layer
of the prepuce, ﬁnally resulting in a phimosis, sometimes so complete that the
DISEASES OF THE SKIN. I 39
drawing back is absolutely impossible. All along, the inﬂammation and abundant
secretion in the preputial sac continue.
Whilst, in some cases, the process now comes to a standstill, I have observed
in rare cases still graver forms. Under the inﬂuence of the fungus, various
kinds of proliferation ensued. Sometimes it affected the epithelial layer, and we
then see, especially on the surface of the glans, thickened white callous masses,
which are permeated by fungus elements. In other cases, the connective
tissue is the chief seat of the disease, resulting in papillary growths, which closely
resemble papilloma acuminatum (or pointed condyloma). In other cases, larger
growths are formed, which are disposed to break down and to ulcerate on the
surface, while, on the preputial margin, deep sores (rhagades) originate. All these
growths are permeated through and through with the fungus.
Up till now I have not observed communication of this parasitic affection from
patient to patient ; but, nevertheless, attention might well be directed to this point.
Fig. 6.

Myoelium and Spores.
As to the nature of the fungus under the microscope, it is observed to consist of
both mycelium and spores in great profusion and in all stages of development.
The spores, or conidia (as the accompanying sketch tries to show), are chieﬂy
round, sometimes oval. They vary in size, averaging from mm. 0002 to mm. 0004:
in diameter. Generally, free spores are met with everywhere, sometimes two and
two together; more rarely they are grouped in the form of chains. The mycelium
consists of formations varying from mm. 00015 to mm. 00045 in diameter. They
are sometimes short, and without ramiﬁcations; sometimes long, and with a rich
display of branches. They are either forked, or send off their branches at different
points. They are sometimes empty, or they may contain spores. The tops of the
branches frequently Show a separation of the outmost parts in form of single
spores. Sometimes the mycelium thread bulges out in the midst of its length, up
to mm. 0005. I never found sporangiums or organs of fructiﬁcation.
I40 DISEASES OF THE SKIN.
The fundamental cause of the disease was always diabetes mellitus. It is
apparent that the fungus ﬁnds a good nourishing ﬂuid in the diabetic urine, re-
tained in the preputial sac. Moreover, masses of smegma, liable to decomposition,
will favour its development.
I now give a short abstract of two cases :—
1.——Mr. G., 55 years old, manufacturer, had complained for some time'of incon-
venient itching, and burning at the glans and prepuce. He had been diabetic for
nine years, and made annual visits to Oarlsbad. At present the urine contains 3% per
cent. of sugar. On the prepuce, slightly phirnotic from infancy, we ﬁnd morbid
changes, chieﬂy affecting the inner layer. The whole of the mucous membrane is
dry and smooth, and the tissues seem to be shrunk. Deep sores and ﬁssures occupy
the margin of the prepuce, while the surface of the glans is cracked and chapped.
From the inner surface of the prepuce springs a large growth, similar to a cauli-
ﬂower excrescence, and ﬁlls up a great part of the preputial sac. Scrapings from
all parts of the surface show masses of fungus, consisting of spores and mycelium
threads. The patient was ordered a carbolic lotion and salicylic powder. After
some days, the papillary growth was removed with the scissors, and the wound
healed with carbolic oil. The patient was relieved for some time, when fresh
painful excoriations, combined with a blennorrhagic secretion, appeared. Patient
left for Carlsbad.
2.—~Mr. L., refreshment-room keeper, 44 years old, had a syphilitic infection
years ago, and was subjected to a mercurial treatment. Twelve years ago diabetes
was ﬁrst noticed. I saw the patient for the ﬁrst time in February, 1880. He
complained for a long time, at least ﬁve years, of troubles in the penis. For some
years he has observed a secretion, which he believes to be gonorrhoeal. At the
present moment, the urine contains 5'17 per cent. of sugar, besides albumen. He
feels low and fatigued. The inner layer of the prepuce and the surface of the glans
look red and moist, as if they were highly eczematous. Some parts are covered
by thick callous-like epithelial layers, others show deep ﬁssures of the tissues, prin-
cipally at the anterior margin of the prepuce. Everywhere fungoid elements can
be scraped with the back of the knife from the diseased surfaces, and also from the
interior parts of the epithelial callosity. The patient is advised to use alcoholic
solution of soap, with 2 per cent. of thymol and salicylic powder.
For some time I believed I was dealing with an affection hitherto unknown in
the male subject, only remembering the description of a similar affection in Women.
However, I afterwards found some remarks in literature referring to the same sub-
ject. One of these is by Friedreich (Vio'chow’s Archiv, vol. xxx. p. 476, 1864.‘), who
gives a short notice, On the Oonstant Occurrence of Fungus in Diabetic Patients.
His observation is based on the fact, already described by Hannover (Mvlillc'r’s
Archiv, 18412, p. 281), and Hassall (Bled. Chi/r. Trans, vol. xxxvi. p. 23, 1853), that
fungus develops in the diabetic urine, even after very short exposure to the air.
These same fungi Friedreich constantly found on the genitalia of diabetic indi-
viduals. Referring to the clinical symptoms, Friedreich only says, that “ the fungus
seems to play no small part as a source of the irritating symptoms so often found
on the genital organs of diabetic persons, and gives rise to the itching and burning,
and even painful excoriations, so annoying to the sufferers.” Gubler (Dilation. des
Sciences Médicales, 1864) affirms similar facts. Another author, de Beauvais, has
more closely investigated this matter, as I only discovered after having ﬁnished my
own observations. De Beauvais (De la Balanite, de la Balano-posthite Parasitaire
et du Phimosis Symptomatique du Diabete: Gaz. des Ho’p'itauaz, 1874‘, pp. 867 et 876)
- DISEASES OF THE SKIN. I41
has likewise found the fungi, discovered by Friedreich, and the same irritating
symptoms, which I have described as the ﬁrst stages of the disease—viz., erythema
and phimosis. He has observed complications of the disease with herpes praepu-
tialis, carbuncular affections, and gangrene, which in one case stretched as far as
the scrotum. De Beauvais quotes Bardsley, of Manchester, as the ﬁrst who, in
1807, drew attention to diabetic phimosis. However, I found that it had been
already mentioned by Rollo, who, in the year 1798, in his “ Cases of the Diabetes
Mellitus” (London, 2nd ed. p. 337) writes about a diabetic patient: “ a phimosis,
with excoriation and itching of the prepuce, except after voiding the urine, at which
time there is an intolerable smarting.” A further remark we ﬁnd in Naumann
(“ Handbuch der Medic. Klinik,” Berlin, 1836, Band vi. p. 588) to this effect: “in
several cases of diabetes I have found caseous exudations on the surface of the
glans, with excoriations and sores. Swelling of the prepuce, and even a certain
amount of phimosis, is not uncommon; ﬁnally, the prepuce can become the seat of
eczematous (ﬂechteo'z cm‘tiger) eruptions.” Later on, Trousseau (Medic. Klinik,
Deutsch von Calmann, 1868, Band ii. p. 724), Niemeyer, Demarquay (Gaz. des
Hdpitaum, 1869, p. 153), and others, mention the genital organs as subject to irrita-
tion in diabetes, without knowing the mycotic nature of the disease.
In spite of the frequency of these publications, the disease in question does not
seem to have met with the attention it deserves in many and not unimportant
respects. The handbooks and monographs on diabetes only mention the irritations
of the genitalia. Above all, I have vainly searched in all the dermatological and
syphilographical treatises for any remark alluding to these facts, although they
are of the greatest consequence for the diagnosis, prognosis, and especially the
treatment.
As to the frequency of the disease, it appears to be not at all uncommon in
its milder form, although it seems never to occur on the circumcised, who, on
the other hand, we know to be so subject to diabetes. Graver cases, at any rate,
are rare. .
The prognosis of the disease is always far more unfavourable than in balanc-
posthitis non parasitica. Nevertheless, if diagnosed in time, it is possible to hinder
the development of the more aggravated conditions.
As prophylactic measures, next to the general and dietary treatment of the
fundamental disease, we shall have to advise the diabetic patients to clean the
preputial sac thoroughly after every evacuation of urine. To ensure the necessary
dryness of the preputial sac and the disinfection, he must always use a disinfecting
powder, which I prescribe according to the following formula :—
Oxide of zinc,
Amylum, each 25 parts,
Salicylic acid, one part.
When the disease has actually set in, we must ﬁrst try to remove the fungus
layer with lotions of carbolic acid or soap solutions, if the patient can stand them.
In graver cases, I think we ought to have resort chieﬂy to galvano-caustic treat-
ment, on account of the well-known inclination of diabetic persons to gangrenous
processes, even after the slightest operative interference, and the unlimited exten-
sion of this gangrene. At any rate, we shall have, before and during the operative
cure, to deal with the general condition of the patient, and always combine the
surgical treatment with an energetic and thorough treatment of the diathesis.
I42 DISEASES OF THE SKIN.‘
Therefore, it is of great consequence to come to a correct diagnosis in all these
cases. For, if we immediately circumcise the prepuce, or have recourse to the
knife or scraping-spoon to remove the hypertrophic growths, we may endanger the
life of the patient.
Finally, I should like to draw general attention to the fact, that sometimes the
above disease is the only symptom the diabetic patient- complains of, and is in itself
suﬁicient, especially when exactly and microscopically investigated, to diagnose
diabetes, for the parasitic balano-posthitis, or balano-posthomykosis, is limited to
diabetic individuals.
DISCUSSION.
Professor Kxrosr, Vienna, mentioned that he knew by practical experience that
diabetic patients are disposed to balanitis, and in a case of chronic balanitis he was
induced by this experience to make an examination, and to discover the diabetes.
Now, it is known that sugar in decomposition may be an irritant for the mugous mem.
brane, but, at the same time, serves as a favourizing medium for the proliferation
of fungus matter. He asked Dr. Simon if he did not ﬁnd fungus in balanitis
having a different origin. If such is the case, it could be supposed that the fungus
is merely accidental.
Dr. LIYEING, London, remarked that sugar is an irritant to the skin. In diabetes
the irritation is more common in women than in men.
Mr. MALcoLM MORRIS, London, said that he had examined microscopically the
smegma removed after the operation of phimosis performed on a man of 21 years,
and found fungus somewhat similar to that shown by Professor Simon.
Dr. UNNA, Hamburg, remarked that sugar must not in all circumstances be
considered as favourable to the development of fungi. In certain conditions—-
for example, in impetigo contagiosa—sugar acted destructively on fungi.
The PRESIDENT remarked that the papers read before the Section, and the micro-
scopic research which had been pursued by different and numerous investigators,
served to conﬁrm the opinion that wherever there was organic matter in a state of
decay, there likewise would be found organic beings, animal or vegetable, ready to
save such matter from destruction. No doubt, it was owing to a law of this kind
that the world was made ﬁt for the occupation of higher beings; and that without
such a law putrefaction and destruction might gain the ascendency. It was an
economical law of Nature that organic matter should not be lost, but only change
its place. The accumulated secretions within the prepuce were necessarily loaded
with organic matter, and afforded a rich soil for the propagation and develop-
ment of a fungus-vegetation such as that described in his Paper on Balanc-
posthomykosis, by Dr. Oscar Simon, of Breslau.
Mr. BALMANNO SQUIRE, London, said that it could not be assumed, as against Dr.
Simon’s view of the parasite being the chief cause of irritation in diabetes, that
glucose was necessarily as irritating to the skin as raw sugar was well known to be.
Information was wanting as to whether glucose was an irritant to the skin. It was
DISEASES OF THE SKIN.
I 43
t
therefore quite possible that the irritation of the genitals found in diabetes was
due chieﬂy to the presence of the parasite Dr. Simon had described.
Dr. OscAn S1MON,Bres1au, in reference to the statements of the President, replied
that the disease must be much rarer here than in North Germany,because cleanliness
is much greater here. In his country, poor people, when they retract the prepuce,
show very often great masses of smegma, in all stages of degeneration. In
reference to the remarks of Prof. Kaposi, he had examined microscopically other
(non-parasitic) cases of balano-posthitis, and had found torula in masses, then
spirochaeta, in movement, very similar to that in recurrens. He found sometimes
spores, but not many, and no mycelium. That the disease is produced by the
parasite, and not by the sugar, is proved by the following points :—-The parasite
develops outside of the body in the urine of diabetic patients, and the same is
found in the preputial sac, and internally in the layers of the skin. Further,
we know that parasites cause irritation even on the dry external skin; so it is
much more probable that they will cause irritation on the more sensitive glans
and prepuee.
A Papillary Tumour of ﬁre Scalp, 2027/2 a Sam/z‘ Accozmz‘
of its Hzlrz'ology.
Dr. ALFRED SANGSTER, London.
The patient, a lad aged 16, was quite healthy, and came into Oharing Cross
Hospital for the purpose of having the tumour about to be described, removed.
On the hairy scalp, low down on the right side of the occipital region, was
a tumour, rather larger than a pigeon’s egg. It was oval in outline, and rising
somewhat abruptly, its most prominent portion attained the height of about half
an inch above the general surface of the scalp. The surface was, all over, thickly
set with papules, as large as hempseed in the centre, and gradually getting smaller
towards the margin. The colour in the latter situation was brown, changing to a,
dusky violaceous tint, towards the centre, except in places where superﬁcial ulcer-
ation was going on : these were covered by a thin scab.
Hairs were plentiful at the margin, but over the central portion of the tumour they
were sparsely scattered, many being white and devoid of pigment. On examination
with a lens, the hairs were seen to crop up between the papules, not to pierce them.
The general appearance of the 13111110111‘ was strikingly like that of a sea-mouse
(aphrodita). It evidently grew from the superﬁcial structures. The patient stated
that he had had the tumour since birth, and that it had gradually increased in size.
There was another, similar in appearance, but smaller, over the left car; this had
been removed by Mr. Morgan, in the out-patient department. I judged the growth
to be of the nature of a mole. Mr. Barwell, ‘who excised it, and kindly gave it to
me, considered it to be a pigmentary sarcoma. I now hand round what is left of
the tumour for inspection.
On examining vertical sections through the advancing margin, and tracing the
changes from the normal tissue, the ﬁrst deﬁnite departure was seen as elongated
branching collections of cells, at ﬁrst conﬁned to the superﬁcial layers of the cutis:
144 DISEASES on THE SKIN.
these apparently corresponded to proliferating cells in the natural channels of the
ﬁbrous tissue, some of them running horizontally. Amongst some of these cell
collections sweat tubes could be identiﬁed. As yet, the Malpighian layers showed
no irregularity or hypertrophy. Pigment could be seen dotting the papillary body
in places. Next, somewhat abruptly, whole collections of the new-growth cells
came into view, monopolizing the papillary body, here and there, and scattered
freely in the cutis. Pigment cells, single and in masses, came into view, and were
specially noticeable in the papillary body. The Malpighian layer now became
irregular, but with its deep limits still plainly discernible.
On moving the section towards the
part where the disease was thoroughly
established, the identity of structures
became obscured in the new-growth,
which now formed a continuous mass,
divided up by delicate ﬁbrous septa, and
traversed by strands of epidermic cells,
tu\\ ‘ the latter prolonged from the distorted
Q!“ l root-sheaths and Malpighianlayer. The
' deeper ﬁbrous layers of the skin, which
were hypertrophic, were thickly studded
with cells.
On examining the new growth with
a higher power, it may be stated that it
was mainly composed of oval, or elon-
gated, nuclei, lying in faintly granular
protoplasmic matter, and more or less
loosely packed, without any special
arrangement, in round, oval, or tubular
loculi, bounded by delicate ﬁbrous tissue.
In places, the above-described ap-
pearances closely simulated gland tissue,
especially where sweat tubes could be
identiﬁed in proximity, with lining cells
proliferating, and lumen more or less obscured.
This type was, however, departed from in many situations where the growth
was advancing. Here the appearances were ﬂaore those of a densely nucleated
ﬁbrous tissue in which the oval nuclei before alluded to could be seen intermixed
with connective-tissue cells.

a, Rete mucosum.
b, Neoplastic growth.
DISCUSSION.
Prof. KArosI, Vienna, does not maintain that what Dr. Sangster has demon-
strated is the same process which he has described, in 1869, as dermatitis papillaris
capillaris. To do so, it would have been necessary for him to have seen the patient,
or a drawing of the tumour. But the impression he has had from seeing the
microscopic sketch, and the portion of the tumour, he is disposed to take it as being
of the same nature as the dermatitis papillaris capillaris (Kaposi) quoted by Dr.
Sangster. The process begins with symptoms of inﬂammation in circumscribed
patches on the occiput and on the neck, showing primarily a tissue which is very
rich in cellular bodies and blood-vessels—in short, having the characters of young
cellular-tissue, with proliferation of epithelium and outgrowth of the papillary
DISEASES OF THE SKIN. I45
layer. Thus a papilloma is formed, which later is transformed by organization into
a ﬁbrous tissue, destroying the hair follicles. He saw no reason to believe that the
process was of the nature of epithelioma, either epitheliomatous or glandular. It
is not provoked nor sustained by local irritation.
Dr. THIN, London, remarked that the drawings, and more especially the micro-
scopical preparations, shown by Dr. Sangster, afforded conclusive evidence regarding
the nature of the tumour. The essential feature of the growth was a mass of epithe-
lial columns having special characters—these characters identifying the neoplasm
as being the same in nature as the morbid growth found in the raised border of
rodent cancer. This epithelium is to be distinguished from the epidermic epithelium
of ordinary epithelioma, and shows signs, more or less marked, of its glandular
origin. During the last two years several cases have been shown to the Patho-
logical Society of London, in which a free growth of this glandular epithelium
has given rise to tumours of considerable size, instead of the advancing growth
breaking down by ulceration.
M. HILLAIRET, Paris, remarked that the affection described by Dr. Sangster
might not be more than a superﬁcial inﬂammation, in which causes of irritation
have determined proliferation of epithelial and connective tissue-cells, so that a
papilloma was produced, which, however, had not become an epithelioma.
Mr. GAsKoIN, London, believes the description of this case to be such as he has
seen in a young girl.
Q
Dr. SANesrEn’s reply :—
Prof. Kaposi contends that the tumour I am now describing is the same as he
described, in 1869, under the name of dermatitis papillomatorum capillaris. As
I said before, I cannot consider that they resemble each other in their histological
characters.‘ I will simply ask any member who may be interested, to turn to Prof.
Kaposi’s article and compare his ﬁgures with the appearances seen under the micro-
scope in my case.
Dr. Thin contends that the new growth in the case I describe is the same as
that seen in rodent ulcer. I am not unfamiliar with the histology of rodent ulcer.
No sections, in my possession, of that disease bear any close similarity to those I
show now—the vertical arrangement of the peripheral cells, so characteristic in
rodent ulcer, is not seen in the section I show; then, again, the nuclei are larger
than those of rodent ulcer cells. The clinical facts of rodent ulcer are also suggestive
in this connection; our ideas being somewhat strange to the appearance of rodent
ulcer on the scalp of a lad 17 years of age. Prof. Hillairet sees nothing extra;
ordinary in the growth, it being simply a papilloma attacked by secondary
epithelial trouble, probably as a consequence of irritation. In this opinion I
quite agree, except that I think the secondary trouble to be of a sarcomatous
nature. Every one present knows that the diagnosis between certain types of
sarcoma and carcinoma is a simple matter, but it is altogether different in other
instances. Prof. Butlin, who kindly examined these specimens for me, thought
that the tumour was of a sarcomatous nature.
PART III. I,
I46 DISEASES or THE'sKIN.
U14 cas d’IJydmsaa’e’m'z‘e dzﬁ’use pma’uz'z‘ par Z’emploz' de la
Pz'loam'pz'ne.
Dr. H. RASORI, Rome.
Si nous passons en revue les principales œuvres de dermopathie et particu—
lièrement celles qui ont été publiées pendant ces dix dernières années, nous ne
trouvons dans la plus grande partie de ces ouvrages aucune description de l’hydro-
sadénite ou inﬂammation des glandes sudoripares. On ne trouve même pas une
note brève relative à ce sujet dans les œuvres d’ Anderson (1872), Milton (1872),
Cauty (1874), Purdon (1875), Piffard (1876), Hebra (1876), Liveing (1878), Behrend
(1879), Morris (1879), Neumann (1880).
L’hydrosadénite n’a été décrite comme entité morbide distincte que par
Verneuil, qui en parla le premier en 1854: (Archives Générales de llfédecine). Après
lui, Bazin a fait un traité complet sur l’hydrosadénite (1865) en décrivant des formes
arthritique, scrofuleuse et syphilitique, avec des exemples variés. Dans leurs
ouvrages Wilson (“Lectures on Dermatology,”1876—7—8), Gamberini (1871), Tilbury
Fox (1873), Duhring (1879), Proféta (1881), ont traité de l’hydrosadénite. Mais
ces auteurs n’ont pas eu l’ocoasion de l’étudier comme Wilson, et ils n’ont observé
que quelques cas limités à une région du corps.
Beaucoup la confondent avec le furoncle et en font une seule entité morbide.
L’étiologie de l’hydrosadénite est le plus souvent spontanée. On l’attribue
aussi à la suractivité des glandes sudoripares, qui se produit principalement pen-
dant l’été, aux sueurs âcres, au manque de propreté, à. l’irritation produite sur la _
peau par des corps rugueux. On l’attribue encore à la succion pratiquée par les
nourissons sur les seins qui ont des ragades. Proféta l’a vue se produire sur les mains
à. la suite du contact de ces parties avec des acides ou des essences. Bazin a décrit
une hydrosadénite syphilitique qu’il faisait dériver des gommes des glandes
sudoripares; cette variété n’est pas encore admise. Gamberini a observé un cas
qui pourrait se rapporter à cette dernière variété. Toutefois dans son observation,
il ne s’agit pas des gommes, mais de petites nodosités siégeant sur la paume de la
main, dans lesquelles le microscope a révélé des traces de conduits excréteurs
déformés.
Depuis la découverte de la pilocarpine et son introduction dans la théra-
peutique des affections cutanées, j’ai lu beaucoup de journaux et de revues derma-
tologiques, et je crois que le cas que je vais rapporter est unique dans la science au
point de vue de l’étiologie et de l’extension du processus morbide.
Louise Grossi, née a Oaserte, âgée de 12 ans, entra dans la Clinique Dermo-
syphilopathique de Rome le 5 Novembre, 1880.
Aucun de ses parents n’avait en de maladies cutanées. Deux frères et une sœur
plus âgés qu’elle ont toujours joui d’une parfaite santé. Dans son pays elle
habitait une maison bien aérée et son régime se composait beaucoup plus de végé-
taux que de viandes. Quand nous l’avons vue l’état de sa nutrition était bon, son
système musculaire était parfaitement développé, sa taille était de 1m.31,et son poids
de 32 kilog.‘ Elle avait de grands yeux bleus, la pupille mobile; les muqueuses
oculaires et buccales étaient normales. Les dents étaient blanches, mais il lui
manquait une molaire et elle en avait une de cariée, les gencives étaient quelque
peu tuméﬁées. Sur son cou régulier on ne voyait aucune trace de pulsation,
DISEASES OF THE SKIN. I4 7
et on ne percevait aucun bruit anormal. La thyroide était légèrement dé-
veloppée, les fosses susclaviculaires peu apparentes, le thorax, de forme conique
et l’examen méthodique des viscères par l’inspection, la palpation, la per-
cussion et l’auscultation ne révélait aucune anomalie. L’impulsion cardiaque
était légèrement augmentée. Pouls 80, respiration 20, température moyenne,
37. L’abdomen était légèrement prominent à. cause d’une légère ecstasie stoma-
cale, les organes et les viscères abdominaux étaient sains. Elle n’avait jamais eu
de ﬁèvres intermittentes. Les sécrétions et les excrétions ne présentaient rien de
particulier, les chlorures étaient légèrement abondants dans l’urine, mais les autres
éléments s’y trouvaient en proportions normales. Les excrétions alvines étaient
régulières, et se produisaient environ chaque 48 heures.
La peau était de consistence normale et glissait bien sur les parties profondes,
elle était sèche et le pannicule adipeux était très-développé. La coloration était
brune sur le corps et blanc rosé sur le cou et sur la ﬁgure. Elle n’avait jamais
porté de laine sur la peau, mais seulement des chemises de toile. Dans l’été elle
suait facilement. Quoique la surface de la peau ne fût pas propre, elle prétendait
qu’elle se lavait souvent le cou et les pieds, mais que cependant elle n’avait jamais
pris de bain général. A. son entrée a la Clinique elle présentait un léger épaississe-
ment de la peau aux extrémités inférieures et aux bras, sur lesquels on voyait de
petites papules disséminées de la grandeur d’une tête d’épingle, surmontées, chacune
d’une petite croûte, produite par le grattement que la malade avait du prurit, sur-
tout pendant la nuit. On observait des papules semblables sur le dos; il n’y en
avait que quelques—unes disséminées sur la poitrine. Du côté des extenseurs de
la’ jambe, elles étaient plus nombreuses, et il y en avait de 6 à 10 environ sur
un espace de 10 centimètres carrés.
En passant la main sur la surface cutanée on avait l’impression d’un corps
squammeux ou d’une râpe. En la palpant plus attentivement on percevait quelques
petites papules profondes, que le toucher seul pouvait révéler. La peau, comme
nous l’avons dit, était brune sur tout le corps excepté sur la face, mais la pigmen-
tation était plus considérable aux extrémités. A la région cervicale et inguinale
on sentait que le volume des ganglions lymphatiques était un peu développé, ceux
de l’aine étaient un peu sensibles au toucher. Les parents de la ﬁllette assuraient
qu’ils avaient remarqué cette altération de la peau chez elle, depuis sa plus tendre
enfance. '
, D’après l’ensemble de ces caractères, M. le Professeur Manassei, Directeur de la
Clinique, se crut autorisé de diagnostiquer un prurit simple, pour le traitement du—
quel il se décida a, prescrire l’hydrochlorate de pilocarpine à l’intérieur, à l’exclusion
de tout autre médicament. Tenant compte de la nature des lésions qui se pro-
duisent dans les dermatoses chroniques, il était rationnel de produire une action qui
aurait une inﬂuence continue sur les autres sécrétions cutanées.
En conséquence, l’administration stomacale de la pilocarpine se ﬁt à petite
dose (% centigramme dans 1 gramme d’eau). Le médicament fut vadministré tous
les jours a la même heure avant le repas, a partir du 22 Nov. 1880. La malade
I était tout de suite enveloppée dans une couverture de laine, et couchée sur le dos
dans son lit. L’action du remède était assez rapide. Cinq ou dix minutes après
son administration les sueurs commençaient par la poitrine et envahissaient succes-
sivement la tête et le tronc. Les premiers jours, la salivation et les sueurs des
extrémités manquèrent entièrement. La réaction durait en général deux heures,
après lesquelles la malade était essuyée, recouverte de sa chemise et placée dans
son lit.
L 2
148 DISEASES OF THE SKIN.
Au premier Décembre, n’y ayant rien de nouveau, la dose de pilocarpine fut
portée à 1 centigramme. La salivation était alors très-abondante et précédait la
sueur. Depuis peu de jours il s’était produit des sueurs, surtout dans les régions
articulaires. Il n’y eut jamais aucun malaise stomacal, ni de céphalie; la nutri-
tion et l’appétit s’étaient améliorés.
Le 18 Décembre la salivation et la sueur étaient très-abondantes, mais ne voyant
aucune modiﬁcation dans l’état de la peau, on prescrivit trois bains par semaine
d’une durée de 30 minutes chacun, en continuant l’emploi journalier de 1 centi-
gramme de pilocarpine. .
Dans les premiers jours de 1881 on adjoignit au traitement des frictions de
glycérole d’amidon. La salivation était toujours très-abondante, la sudation
diminuait et se limitait au visage, à la poitrine et a l’abdomen. Il était a sup-
poser que l’organisme s’habituant peu a peu au médicament, ne réagissait pas alors
comme quand on avait commencé a l’employer. On songeait a en augmenter
légèrement la dose quand survint une nouvelle altération de la peau qui en ﬁt, au
contraire, cesser l’administration.
Sur la peau des épaules, du dos, des extrémités supérieures et inférieures, aux
aisselles, aux aines, en plus petit nombre sur la poitrine, sur le ventre, sur la face,
et a la paume des mains, sur tout le corps en un mot, excepté à la plante des pieds,
commencèrent à apparaître de petits points durs, indolents, mobiles, souscutanés,
qui se soulevaient en plissant la peau, et s’approchaient a la surface cutanée.
Ils différaient essentiellement des papules du prurigo en ce qu'ils n’étaient pas
surmontés de la petite croûte qui caractérise celles-ci, mais ils présentaient un
petit point rouge qui était peut être le conduit excréteur. Cependant ces petites
nodosités, grosses comme une tête d’épingle, commencèrent à devenir douloureuses,
et la peau qui avoisinait le point rouge prit une teinte violacée.
Dans quelques points, surtout aux aisselles, ces papules atteignirent le volume
d’une cerise, et on avait au toucher la sensation d’une mollesse ﬁuctuante qui
devenait plus nette à mesure que la tumeur s’avançait vers la superﬁcie du derme.
Aucune de ces tumeurs n’avait le sommet acuminé comme le furoncle. Beau-
coup s’ouvrirent spontanément à. leur sommet, quelques-unes s’ouvrirent en les
comprimant avec les doigts, pour très-peu, enﬁn, il fut nécessaire d’avoir recours
au bistouri. Une légère quantité de pus écoulée, la cicatrice se fermait rapidement,
et le petit abcès laissait après lui une induration qui persistait encore après trois
mois dans divers points.
Bien que ces petites tumeurs eussent occupé presque to ut ledos, la poitrine, les
extrémités où la peau était soulevée en plaques douleureuses mamelonnées, et
quoique sur d’autres régions du corps, la face y comprise, elles ne fussent pas plus
distantes que de cinq centimètres, sauf la douleur, elles n’occasionnaient pas de
malaise ou de réaction fébrile.
On diagnostiqua une idrosadénite survenue à la suite de l’emploi de la pilo-
carpine, et l’on institua un traitement approprié: suspension du médicament, bains
généraux avec de la ﬂeur de farine, onctions avec la vaseline, et le glycérole d’ami-
don. '
Du 14: Janvier au 15 Février il y eut, principalement dans les premiers jours,
une succession de tumeurs qui s’abcédaient et de nouvelles qui apparaissaient.
Au mois de Mars s’effectua la résolution de beaucoup d’indurations de sorte que,
au commencement de Mai, il ne restait que quelques points indurés et de nom-
breuses taches sur la peau, qui avait acquis une souplesse et une onctuosité con-
sidérable.
DISEASES or THE SKIN. 149
Si la petite malade court, ou se livre a un exercice violent, on remarque qu’elle
sue modérément; on observe une rougeur diffuse de la peau, surtout de la peau du
visage.
DISCUSSION.
Professor SCHWIMMER, Buda Pesth, had employed pilocarpin in cases of syphilis,
prurigo, and pruritus, giving it in subcutaneous injections of the strength of 0'01
gramme, and only in syphilis had obtained any noteworthy results. In one case
there supervened on its use a circumscribed inﬂammation of the skin, which was
probably caused by the affection of the sweat glands.
Professor OSCAR SIMON, Breslau,had frequently given pilocarpin in different affec-
tions, and found the eﬁ'ects on the skin similar to those produced by simple perspirac
tion. He failed to ﬁnd exact evidence that in Dr. Rasori’s case it was the sweat
glands that were aﬂ‘ected; that could only have been proved by microscopic sections.
Dr. UNNA, Hamburg, also thought that it was not proved that the sweat glands
in this case had been affected. He is persuaded that pilocarpin has no direct
action on the glomeruli of the sweat glands, its action being on the blood-vessels
of the whole papillary body.
Professor KAPOSI, Vienna, also thought that it is not proved that the process
which has been described by Dr. Rasori is produced by pilocarpin, but thought that
the facts related are worthy of notice. It will be shown by further observations,
if they were the eﬁ'ect of sweat, or a special result‘ of the remedy, like the
bromide eruption.
Sur l’Ez‘z'ologz'e de guelques Maladies Desguamaz‘z'ves
de la Peau.
Dr. ANGELUCCI, Rome.
Parmi les maladies desquamatives de la peau il y en a très-peu jusqu’ a présent
qui ont été considérées comme parasitaires. Les parasites qui ont été démontrés
appartiennent tous à la classe des hyphomycètes. Dans l’hôpital de St. Gallicano
à Rome, ’ai eu l’oceasion d’examiner bien des cas de maladies desquamatives, qui
jusqu’à présent n’ont pas été considérées comme parasitaires. J’ai trouvé cons-
tamment de petites bactéries dans les squames des plaques du psoriasis, de
l’eczéma papuleux, et dans les petits nœuds du molluscum contagieux. Elles ont
toutes montré dans l’aspect et par la cultivation, des caractéresidentiques, de sorte
qu’il faut admettre qu’elles appartiennent a une même espèce.
Elles proviennent de cellules elliptiques, allongées, ou un peu cylindriques.
longues de 1'5 à, 1'? et larges de 07 à 08 mm. légèrement colorées en gris. Elles
sont mobiles, solitaires, ou unies en petites ohaines de 2 a 4, rarement de plus, et
forment encore des masses de Zoäglée. Dans les cultivations elles se multiplient
par ﬁssion, et se reproduisent aussi par spores à une température de 38“ à 40° C.
Les spores se forment dans toute leur étendue, et se rangent en chames. Mais
celles du molluscum contagieux se disposent en zoôglée, vivant isolées, ou tout
au plus réunies deux a deux. Une température plus basse ou plus haute leur est
I 50 DISEASES OF THE SKIN.
défavorable, et un liquide pauvre en matières nutritives est très-contraire a leur
développement. Quand on les cultive dans du sérum après 8 a 10 heures elles
prennent l’aspect caractéristique d’une petite chaine composée de petits corps
légèrement ovales (spores) séparés par des espaces claires. Après 5 ou 6 jours de
culture les spores se détachent, et vivent le plus souvent isolées, grossissent, et
s’allongent. Cette bactérie se rapproche par la forme du Bacterium termo, mais elle
est un peu plus courte, et ne possède pas, comme ce dernier, des appendices aux
extrémités. ,Elle a aussi une grande ressemblance au Bacterium œrugmosum
(Schrôter); pourtant, tandis que dans celui-ci les cellules font voir a leur contour
une coloration bleue, la nôtre, que je voudrais appeler Baoter'zhmz Zepogenum
(de Àe’wos, squama.) apparaît au contraire d’une couleur gris-sale, par laquelle elle
s’éloigne encore plus des autres espèces.
Les altérations pathologiques provoquées par ces bactéries s’étudient le plus
facilement dans le molluscum contagieux. Les premières traces de cette maladie
se montrent comme un épaississement de l’épiderme, légèrement recouvert par des
squames dans lesquelles on trouve de petites bactéries. Ensuite il se fait un
travail destructif plus marqué au centre qu’a la périphérie, lequel conduit a la forma-
tion de cavités centrales qui renferment des squames et des corpuscules de mollus-
cum. Les squames contiennent des spores en petite quantité, au-dessus desquelles,
dans les parties les plus périphériques de l’utricule, se trouve la couche kératogène
formée par une accumulation de granules d’éléidine; cette couche délimite les
bactéries et les sépare des parois de l’utricule formés par des cellules granuleuses
et gonﬂées qui ne contiennent pas de bactéries.
Pendant la période de guérison spontanée du molluscum on ne trouve aucune
cellule épithéliale normale au-dessus du tissu propre du derme, qui se montre en ce
lieu inﬁltré de jeunes cellules, en contraste avec les squames et les corpuscules de
molluscum entourés de zoôglée.
Le processus qui produit et détruit le molluscum, contagieux présente tous les
caractères de la nécrose progressive décrite par Koch. Il s’agit de micrôorganismes
qui amènent une prolifération dans le commencement et le développement con-
sécutif du petit nœud mollusco‘ide. Cette prolifération est simultanément ac-
compagnée de momiﬁcation des éléments proliférés. La nécrose du molluscum,
comme la nécrose progressive de Koch, ne paraît pas être due a des causes
mécaniques, mais chimiques. Dans toutes les deux on trouve une couche de tissu
altéré qui ne contient pas de microbies, et qui démarque le tissu sain inﬁltré de
parasites. Même ici est valable l’hypothèse que les bactéries, en agissant de près
amènent la momiﬁcation, et de loin, la prolifération du tissu.
Dans le psoriasis et dans l’eczéma papuleux se développent des processus patho-
logiques identiques, et l’image microscopique correspond a celle du molluscum,
exception faite de la dégénérescence du protoplasme des cellules et de la forme de
de la néoplasie. Dans les squames les plus superﬁcielles de ces affections, les
bactéries vivent en petit nombre et isolées, et ce n’est que dans les plus profondes
qu’on les trouve en zoôglée, séparées des cellules saines de l’épiderme par une couche
légère de squames et de cellules épithéliales gonﬂées et en voie d’altération.
J e ne dirai que peu de mots pour prouver que le Bacterium Zcpogenum est le
genérateur de ces formes de desquamation. Avant tout, on y trouve la même
bactérie, et il se développe un processus pathologique identique. Celui-ci ressemble
en tous points a la nécrose progressive des tissus induite expérimentalement par
Koch au moyen de greffes contenant des microôrganismes. De plus, il est
cliniquement prouvé que le molluscum est contagieux.
DISEASES OF THE SKIN. I 5 I
En dernier lieu les signes cliniques et la forme circulaire du psoriasis, la mani‘ere
de s’étendre du pityriasis rubra sont semblables aux signes cliniques et a la forme
des maladies desquamatives produites par les hyphomycetes. Sila forme clinique
des trois affections dont j’ai parlé est diffe'rente, cela est probablement as 21. ce que
la peau dans des individus difi'érents réagit d’une maniere diffe'rente a l’action du
Bactcrmm Zepogenum.
DISCUSSION.
Professor OSCAR SIMON, Breslau, stated that the same bacteria were found, not
only in psoriasis, eczema, and molluscum, but in nearly all other skin diseases, in
variola (as shown by Klebs), and ﬁnally in healthy skin. In molluscum the change
begins in the deeper parts (in, the formation of molluscum bodies) ; but the bacteria
do not occur in these points, but more to the inner portions, where the non-
molluscous degeneration of epidermis takes place. He must, therefore, distinctly
reject Dr. Angelucci’s conclusions.
Dr. UNNA, Hamburgh, agreed completely with Professor Simon, and pointed out
that before we can regard granules of any kind occurring in the stratum granulosum
as vegetable parasites, we must be able to distinguish them from the normal
granules of elaidin which are always found in this position.
Dr. VIDAL, Paris, said that not only micrococci and bacteria were found in
molluscum, but also spores of various sizes, some budding, among which it was not
possible to distinguish which micro-organism might be the cause of contagion. He
had once succeeded in inoculating molluscum, and therefore considered it con-
tagious; but had been unable to isolate any parasitic agent. The same organisms
are found in comedones and in healthy sebaceous secretion. '
Professor KAPosI, Vienna, believed the greatest care was necessary in drawing
conclusions. Hallier and others long ago found vegetable parasites everywhere,
but his views were abandoned, especially as clinical experience demonstrated the
confusion of diseases to which his theories led. Lang declares that he has even
found a mycelium in psoriasis; but has not been conﬁrmed. We should not forget
that Nageli, who has passed all his life in studying microscopic vegetable organ-
isms, declares that he is not able to distinguish between the granules of decaying
protoplasm and these minute organisms; we, therefore, are not yet justiﬁed in
attributing any etiological importance to these bodies, even if they are proved to
be truly organisms.
Dr. ALLAN JAMIESON, Edinburgh, remarked on the cycles of opinion as to the
causation of skin diseases, the humoral, the parasitic, the neurotic, and, as a sub-
division, the vasomotor. Now it was the fashion to refer many diseases to bacteria.
.and skin diseases were having their turn; but he thought observers proved too
much, as all diseases were now being brought under the head of bacteria.
Dr.THIN, London,remarked that he had recently examined a number of molluscum
tumours, and had satisﬁed himself that the growth took its origin in the root-
sheaths of the hair follicle, and on the free surface of the epidermis. The tumours
he examined had been hardened in bichromate of potash, and he had been struck
by ﬁnding masses of objects resembling micrococci and cocoo—bacteria amongst the
I 52 DISEASES OF THE SKIN.
cells which were undergoing the peculiar molluscum transformation. He had, in
the meanwhile, suspended his judgment regarding these appearances, as the pre-
parations had not been made under the rigorous conditions necessary in a question
of this kind; but in preparations of psoriasis-skin, similarly prepared, and in other
preparations of skin, he had not found the same appearances.
Dr. GAVAFY, London, thought that Dr. Angelucci’s position would be'strengthened
if he could show that his bacteria were competent to produce the diseases they were
supposed to cause, on transference to healthy skins. He therefore asked whether
Dr. Angelucci had made any experiments in inoculation (especially of psoriasis) ;
and, if so, with what results.
Dr. ANGELUCCI, Rome, replied that it was true enough that bacteria were to be
found on the healthy skin ; but we should remember that these organisms not only
require special conditions for their development, but also that their action, and even
their essential nature, is subject to modiﬁcation according to circumstances. This
has been proved by the recent experiments of Pasteur, and explains the immunity of
certain persons during epidemics, and when exposed to malaria. Parasites, more-
over, select certain animal species, and leave others untouched; hence, there is
nothing surprising in the fact that bacteria produce pathological results only on
some skins, and not on others. Bacteria are easily distinguished from ela'idin
granules, as they are coloured by aniline dyes, which the latter are not. On culti-
vating pieces of molluscum in nutrient ﬂuids, at 380 to 410° 0., the bacteria increase
much in number, and also the granular ela'idin layer doubles in thickness. The
epidermic cell undergoes transformation into a molluscum body after it has been
converted into ela'idin by the action of the bacteria. He had once succeeded in
obtaining a scaly patch on the arm of a person by the application of psoriasis
scales.

Ueéer/ vawz'nale Ham’erupz‘z'mzm.
Dr. GUSTAV BEHREND, Berlin.
Die nach der Vaccination auftretenden Hauteruptionen sind bisher so wenig
beachtet, und die in der Literatur vorhandenen Einzelbeobachtungen so sparlich,
dass ich mich nicht in der Lage beﬁnde, an der Hand meines immerhin geringen
Materials, alle diejenigen Fragen eingehend zu beantworten, welche sich an die-
selben kniipfen, namentlich nicht die letzten Beziehungen dieser Ausschlage zum
Vaccinestoﬁ’e und ihre Stellung zu den Hautkrankheiten im Allgemeinen, in end-
giiltiger Weise zu ﬁxiren. Gleichwohl hoffe ich Ihnen darthun zu konnen, dass
alle bisherigen Angaben, welche sich fast ausschliesslich auf die sogenannte
Roseola vaccinica beziehen, wesentliche Unrichtigkeiten in Bezug auf die klinischc
Erscheinung und die pathologische Bedeutung dieser Ausschlage enthalten, in
zweiter Reihe aber, dass dieselben mit der speciﬁschen Vaccinewirkung nichts zu
thun haben, sondern wie eine grosse Reihe anderer symptomatischer Hautkrank-
heiten nur eine allgemein-pathologische Bedeutung besitzen.
Die Erfahrung lehrt, dass nach der Vaccination an der allgemeinen Korperdecke
zwei vcrschiedene Reihen pathologischer Veranderungen auftreten konnen, die mit
ein ander in keiner Beziehung stehen und auch in Bezug aufihre klinische Bedeutung
von einander differiren. Die eine Reihe dieserVeranderungen,Welche ich als vaccinale
DISEASES OF THE SKIN. 153
Localcrkmnkungen der Haut bezeichne, nimmt ihren Ausgangspunkt von den
Impfstellen selber und bleibt entweder auf die unmittelbare Nachbarschaft derselben
beschränkt, oder verbreitet sich von hier aus in continuo auf weitere Körperstrecken,
und kann unter Umständen die Impfeﬁiorescenzen an Dauer übertreffen. Hierher
gehören dieRöthungen und entzündlichen Inﬁltrationen der Haut‚welche die Impfef-
ﬂorescenzen auf mehr oder weniger weite Strecken umgeben, die Erysipele sowie
Eczeme aller Art. Namentlich sind es die letzteren,welche Monate hindurch persis-
tiren können, und welche auch ein wesentliches Glied in der Reihe aller jener
Beschuldigungen bilden, welche wieder und immer wieder von den Gegnern der
Impfung gegen die letztere erhoben werden.
Die zweite Reihe von Erkrankungen bilden Allgemeineruptionen, die entfernt
von der Impfstelle, mit oder ohne lj‘iebererscheinungen, ganz acut hervorbrechen
und mehr oder weniger ausgedehnte Strecken der Haut im Zusammenhangs befal-
len. Diese Ausschlagsformen, welche ich als vaccinale AZlgemcineruptionen
bezeichne, und auf welche sich meine Mittheilungen beschränken, sind ziemlich
seltene Erscheinungen. Ich habe sie in meiner Stellung als öffentlicher Impfarzt
unter den etwa 300 Impfungen, welche ich im vorigen Jahre zu impfen hatte, nur
sechsmal beobachtet; hierzu kommt ein weiterer Fall aus der Praxis eines be-
freundeten Gollegen (Dr. David) sowie einige andere Fälle, deren Zahl ich nicht
genau bestimmen kann, da ich von denselben nur aus den Mittheilungen der
Mütter Kenntniss erhielt, und sie selbst nicht gesehen habe.
Unter diesen Exanthemen ist bisher ausführlich nur die sogenannte Boseola
vaccinica beschrieben worden, ein hyperaemisches Fleckenerythem, von welchem
Heb-21* sagt, dass es am dritten bis achtzehnten Tage nach der Vaccination auf-
trete, dass es sich zuerst in der Umgebung der Impfstellen zeige, von hier aus
Schritt für Schritt sich auf weitere Hautstrecken ausdehne, und als eine Lymphan-
gitis der Haut zu bezeichnen sei. Diese Angaben muss ich in wesentlichen Punkten
modiﬁciren. In den Fallen meiner Beobachtung trat dasselbe als masernartiges
Exanthem ganz acut und gleichmassig an der Körperoberfläche auf, war am
schwächsten an den Extremitäten ausgebildet und hatte das Gesicht vollkommen
verschont. Gesehen habe ich das Exanthem nur in zwei Fallen ; in beiden trat es
am achten Tage nach der Impfung auf und schwand nach einem zweitägigen Be-
stande. Da ich die in den öffentlichen Terminen geimpften Kinder nur am siebenten
Tage nach der Impfung zu sehen bekomme, so weiss ich nicht, wie häuﬁg nach
diesem Termine derartige Erytheme aufgetreten waren, dagegen theilten mir die
Mütter zuweilen mit, dass ihre Kinder schon am Tage nach der Vaccination
derartige Erytheme bekommen hatten, die jedoch bald wieder geschwunden waren,
so dass sie am Tage der Revision nicht mehr gesehen wurden.
Eine zweite Gruppe von Exanthemen bildeten Urticaria-Erzqn‘ionen. Sie
kamen gleichfalls am Tage nach der Vaccination zum Ausbruch und Schwanden
in ebenso kurzer Zeit, so dass ich sie am Revisionstage nicht mehr zu sehen bekam.
Ich erhielt von ihrer Existenz vielmehr nur aus den Mittheilungen der Mütter
Kenntniss und kann daher etwas bestimmtes über dieselben nicht aussagen.
Eine dritte Gruppe von Hauterkrankungen‚bildeten erythemm‘öse Exsud’ativ—
proccsse. Es waren diese Ausschlagsformen genau von dem Charakter des Erythema
exsudativu‘m multiforme, welche als über den ganzen Körper ausgebreitete Erup-
tionen mit ihren typischen Localisationen an den Hand- und Fussrücken zweimal
zur Beobachtung kamen. Sie hatten am Revisionstage schon die charakteristische

* Hebra und Kaposi, “Lehrbuch der Hautkrankheiten.” Zweite Auﬂage, Bd. i. p. 50.
154 DISEASES OF THE SKIN.
Umwandlung in Form und Farbe erlitten. In dem einen Falle gab die Mutter an,
dass die Eruption schon am zweiten Tage nach der Vaccination begonnen und sich
von den Hand- und Fussrücken, wo sie zuerst aufgetreten war, über weitere
Körperstrecken verbreitet hatte; in dem zweiten Falle, der mit jenen gleichzeitig
vorkam, konnte nur aus dem gleichen Stande der Um- und Rückbildung der
Efflorescenzen auf den gleichen Eruptionstermin geschlossen werden.
In einem anderen Falle zeigte der Impfausschlag sich in Form einer vesiculosen
Eruption, welche an manchen Stellen den Charakter eines Herpes, ‘an anderen den
eines gruppirten Eczems besass. Die Mutter gab an, dass die ersten Bläschen-
gruppen sich am Tage nach der Impfung, zuerst am linken Arme gezeigt hätten,
dass aber, während die älteren EfHorescenzen eintrockneten, täglich neue Nach-
schübe an entfernten Körperstellen aufgetreten seien. Am siebenten Tage nach
der Impfung constatirte ich in Uebereinstimmung mit dieser Angabe eingetrocknete
Bläschen am linken Arme, Gruppen von Bläschen mit molkig getrübtem Inhalt
am übrigen Körper, namentlich im Gesicht und an den Beinen. Mit dem
Eintrocknen der Vaccinepusteln schwand das Exanthem spontan. Auf einen
anderen ganz analogen Fall komme ich an einer späteren Stelle noch zurück.
Die letzte Form, welche zur Beobachtung gelangte, bildete ein Blasenausschlag.
Er wurde nur einmal beobachtet, und betraf einen ganz gesunden, wohlgenährten,
neun Monate alten Knaben, bei welchem sich schon am Abend des Impftages im
Gesicht einzelne Blasen zeigten, die sich im Laufe der nächsten Tage durch weitere
N achschübe an den verschiedensten Körperstellen vermehrten. Am achten Tage
nach der Impfung waren die ältesten Eﬂiorescenzen theils abgeheilt, theils zu einer
ganz dünnen braunen Borke eingetrocknet, während die anderen, je nach dem
Verhältniss ihres Alters, einen molkig getrübten oder mehr klaren Inhalt hatten.
Die Eruption bildete sich unter indifferenter Behandlung (Kleienbäder, &c.) voll-
kommen zurück.
l/Vie aus diesen Beobachtungen hervorgeht, können im Verlaufe des Vaccine-
processes an der Haut gewisser Individuen, ausser dem bisher allein beschriebenen
hyperaemischen Fleckenerythem—ganz verschiedene Formen entzündlicher Exsuda-
tions-processe auftreten, die, wie ich hinzufügen muss, auf den normalen Verlauf
der Vaccine keinen Einﬂuss ausüben und als zufällige Begleiterscheinungen
derselben betrachtet werden müssen.
Was die Pathogencse der Impfausschläge betrifft, so möchte ich zunächst darauf
hinweisen, dass einige unserer französischen Collagen mit Rücksicht auf gewisse
vesiculöse und pustulöse Eruptionen von einer “ Vaccine generalisee” sprechen.
Dieser Bezeichnung liegt die Auﬂassung zu Grunde, dass es sich hier ganz
analog wie bei der Variola um eine allgemeine Manifestation des Vaccinegiftes
handele, um Allgemeinemptionen, wie sie den Pocken-Inoculatoren des vorigen
Jahrhunderts, den Sacco, &c., gar nicht selten begegneten, und die auch
für Hutchinsonät und "William Stokes? ohne Zweifel die Veranlassung gewesen
sind, von einer allgemeinen Vaccinia gangraenosa zu sprechen. Eine Allgemein-
eruption von Blasen, ist aber noch keine Allgemeineruption von Vaccineeﬁlorescen-
zen, selbzt dann noch nicht, wenn sie den letzteren in ihrer äusseren Form analog
sind: sie sind nur dann unzweifelhafte Vaccineefflorescenzen, wenn sich der
Nachweis führen lässt, dass ihr Inhalt vcrimpfbar ist und normale Vaccinebläschen

Hutchinson, BT’ltiSh Medical Journal, December 13, 1879, p. 960.
‘I' W. Stokes, Dublin Journal of Medical Science, 1880, vol. lxix. p. 497.
DISEASES OF THE SKIN. I5 5
erzeugt. Auffallenderweise liegen derartige Beobachtungen nur aus der älteren.
Literatur, aus den frühesten Zeiten der Vaccination vor, während alle späteren
Beobachter von allgemeinen vesiculösen Eruptionen nach der Vaccination die Ver-
impfbarkeit ihres Inhaltes nicht erwiesen haben, und daher, meiner Ansicht nach,
nicht berechtigt sind von einer Vaccine généralisée zu sprechen. Ebensowenig
wie diesen Autoren kann ich Friedinger beistimmen, der in der Roseola vaccinica
das überzeugendste Symptom der Vaccinewirkung auf den Gesammtorganismus
erblickt und dasselbe in eine gleiche Beziehung zum Vaccinestoffe bringt wie das
Masern- und Scharlachexanthem zu ihren speciﬁschen Oontagien. Dass hier jedoch
thatsächlich andere Verhältnisse obwalten, dass es sich bei den Impfausschlägen
nicht um eine speciﬁsche Wirkung der Vaccine handeln kann, ergiebt sich:
l.——Aus der Mannigfaltigkeit in der Form derselben. Eine solche Variabilität
wie hier ist mit unserer Vorstellung von der Speciﬁtät der Contagien und der Con-
stanz der durch sie erzeugten Krankheitssymptome schwer in Einklang zu bringen.
Das Masern- und Scharlachcontagium und das der Vaccine so nahe verwandte
Variolagift variiren in ihren Wirkungen keineswegs so von Individuum zu Indivi-
duum wie die Impfausschläge ; sie erzeugen vielmehr bei allen Personen bei denen
sie zur Wirkung gelangen, ganz bestimmte und in allen Fällen gleiche und so
wohlcharakterisirte Symptome, dass wir aus ihnen im Stande sind einen Rück-
schluss auf die Natur des Oontagiums zu machen, welches in einem gegebenen Falle
eingewirkt hat, und noch niemals hat beispielsweise das Scharlachcontagium bei
einer Person ein exsudatives Erythem, bei einer anderen eine vesiculöse, bullöse,
oder pustulöse Hauteruption erzeugt. '
‚ 2.-—-Spricht gegen die speciﬁsche Natur der Impfausschläge die Zeit, während
welcher die ersten Ausbrüche derselben stattfinden oder genauer gesagt, während
welcher die Eruption beginnt. In Bezug auf diesen Punkt variiren die Angaben
der Autoren, die sich natürlich wieder nur auf die Roseola vaccinica beziehen,
ziemlich genau nach der Nationalität. "Während nämlich die deutschen Autoren
den dritten bis achtzehnten Tag nach der Vaccination als den Eruptionstermin
angeben, plädiren unsere englischen und manche französische Collegen für den
neunten bis zehnten Tag nach der Vaccination, und es ergiebt sich bei einem
näheren Studium, dass die deutschen Autoren hierbei der Autorität Bednar’s, die
anderen der VVillan’s gefolgt sind. Im Gegensatz zu diesen Angaben muss ich
darauf hinweisen, dass sowohl in den mitgetheilten Fällen, als in einem anderen
auf den ich noch zurückkomme, der Beginn der Eruption niemals in die Zeit vom
dritten his siebenten Tag nach der Vaccination ﬁel; vielmehr trat in zwei Fällen
die Eruption am achten, in den übrigen dagegen am ersten oder zweiten auf. Es
geht hieraus hervor, dass im Verlaufe des Vaccineprocesses zwei ganz bestimmte
Phasen existiren, in denen die Eruptionen stattfinden, von denen die erste spätestens
am zweiten, die zweite dagegen am achten Tage nach der Impfung beginnt. Wollte
man nun die Impfausschläge auf eine specifische ‘Nirkung der Vaccine zurück-
führen, so kämme man zu einem Widerspruchs, da die Ausschläge der ersten Phase
gerade in das Stadium der Incubation der Vaccine, die der zweiten dagegen zu
einer Zeit auftreten, in welcher dieselbe ihre ‘Virkung auf den Organismus bereits
beendet hat.
3.—Spricht gegen die Speciﬁtät der Impfausschläge der Umstand, dass wir Exan-
theme von genau demselben Charakter auch nach anderen Stoﬁen, namentlich nach
Gebrauch von Arzneimitteln beobachten. Auch diese erzeugen zuweilen Ausschläge
‚die bei verschiedenen Personen verschiedene Formen darstellen, und die, wie ich in
meinen Arbeiten über Arzneiausschläge dargethan habe, nicht von der speciﬁschen
I 56 DISEASES OF THE SKIN.
Wirkung der Arzneistoffe selber abhängen. Ich habe in Bezug auf die Arznei-
exantheme schon darauf hingewiesen, dass überhaupt die Anwesenheit fremder
Stoffe im Blute die Veranlassung zur Entstehung acuter Hauteruptionen geben
kann, und so sehen wir zuweilen nach der Aufnahme von pyaemischen Stoffen ins
Blut oder nach zufälligen Verletzungen, nach Entbindungen und Operationen
selbst geringeren Umfanges, in diesen Fällen wahrscheinlich durch die Aufnahme
von Wundsecret oder von Gewebstrümmern bedingt, die eine oder die andere Form
acuter Hauteruptionen auftreten, als deren Analoge die Impfausschläge zu be-
trachten sind.
Unter diesen Verhältnissen beweisen die Impfausschläge bei den betreffenden
Individuen nichts weiter, als dass ein fremder Stoff im Blute circulirt; und zwar
muss dieser Stoff für die Ausschläge der ersten Phase die Vaccinelymphe selber
sein, während wir die Ausschläge der zweiten Phase nicht mehr auf sie zurück-
führen können, sondern vielmehr, da ihre Eruption mit dem Beginn des Suppura-
tionsstadiums zusammenfällt, der Resorption von Pustelinhalt zuschreiben
müssen.
Aber abgesehen von der abnormen Constitution des Blutes ist zur Entstehung
derartiger Exantheme noch eine gewisse Prädisposition des Individuums, eine
gewisse Beizempfänglichkeit der Haut erforderlich, weil nicht alle Personen, welche
einer derartigen Diathese unterliegen, von Hauteruptionen befallen werden. So
wurde jedes der Kinder, welche Gegenstand obiger Mittheilungen sind, zugleich
mit zwanzig bis dreissig anderen von demselben Stammimpﬂing geimpft, ohne
dass eins der anderen erkrankte.
Sie sehen also, meine Herren, dass wir genöthigt sind für gewisse Fälle von
Hauterkrankungen einen diathetisohen Ursprung anzuerkennen. Dass bei der
‘ Entstehung aller dieser Erkrankungen die Nerven eine gewisse Rolle spielen, ist in
neuerer Zeit, namentlich durch die bekannten Arbeiten von Lewin, dargelegt
worden, indess kann in den vorliegenden Fällen der Einﬂuss der Nerven doch
keineswegs als ein primärer aufgefasst werden. Denn mag man ihnen bei der
Genese derartiger Erkrankungen eine Rolle zuertheilen, welche man wolle, immer
werden sie noch eines Instrumentes bedürfen, um in dieser Weise zu reagiren. Das
Primäre wird demnach hier doch immer die Alteration des Blutes sein, und es führt
nur die Kenntniss der in Rede stehenden symptomatischen Ausschlagsformen
nothwendigerweise dahin, nicht allein gewissen acuten Hauteruptionen, sondern
auch manchen Fällen chronischer Hauterkrankungen, einen haematogenetischen
Ursprung zuzuerkennen.
Denn wenngleich die Impfausschläge an sich gutartiger Natur sind und in der
Regel einer spontanen Involution unterliegen, sokönnen sie doch unter Umständen
bei gewissen dazu disponirten Individuen zu lästigen Erscheinungen führen, was
namentlich in Bezug auf die Eczeme der Fall ist. So wurde von mir im vorigen
Jahre gleichfalls ein etwas rachitisches Kind mit aufgetriebenem Abdomen geimpft,
welches hinter dem linken Ohre ein kleines nässendes Eczem hatte, und es zeigte
sich bei demselben am siebenten Tage, abgesehen von einzelnen isolirten Pusteln
grösseren Umfanges und einigen eingetrockneten stecknadelkopfgrossen Bläschen
nicht allein eine Ausbreitung des schon bestehenden Eczems, sondern es traten auch
an verschiedenen anderen Stellen, namentlich des Gesichtes, verschiedene Gruppen
von Eczemeﬂorescenzen auf, welche die Impfeﬁiorescenzen mehrere Monate
überdauerten und zu secundären Drüsen anschwellungen führten.
Unter diesen Verhältnissen wird eine Thatsache erklärlich, die schon seit langer
Zeit bekannt ist, aber nicht richtig verstanden, den Impfgegnern eine Hand-
DISEASES OF THE SKIN. I
habe zu ihren Agitationen gegen die Impfung gegeben hat. Es bezieht sich dies
namentlich auf die Anschuldigung, dass durch die Vaccination Scrofulose über-
tragen werden könne. In vielen Fallen hat man hierbei das Auftreten von Ecze-
men im Auge gehabt, indess kann es nunmehr keinem Zweifel unterliegen, dass bei
Kindern, deren Haut zu eczematösen Erkrankungen neigt, Eczeme ganz in der-
selben Weise zum Ausbruch kommen wie bei anderen Roseola, Urticaria, und ex-
sudative Erytheme, und da die Eczeme sich häuﬁg an die Impfung anschliessen,
dieselbe zuweilen überdauern, und nach ihrer Beseitigung Drüsenschwellungen
hinterlassen können, so hat es den Anschein als sei in derartigen Fallen Scrofulose
übertragen worden. Ich habe häuﬁg nach der Impfung Eczeme entstehen sehen,
obwohl ich niemals Lymphe von scrofulosern Kindern verimpfe, und ich kann nach
meinen obigen Beobachtungen meine Überzeugung nur dahin aussprechen, dass
wenn ein Kind nach ddr Impfung von einem Eczem befallen wird, die Schuld
hieran nicht die Impfung, sondern vielmehr die individuelle Reizempfänglichkeit
des Kindes trifft, und das diejenigen, welche hieraus einen Grund für ihre Agita-
tionen gegen die Vaccination herleiten, in richtiger Consequenz auch gegen den
Gebrauch von Arzneimitteln sprechen müssten, die zuweilen Eruptionen erzeugen,
welche den Impfausschlagen als gleichwerthig an die Seite zu stellen sind.
Zum Schluss möchte ich noch auf die vollkommene Analogie dieser Impfaus-
schlage mit gewissen Ausschlagen bei Variolakranken hinweisen. Auch bei diesen
werden in zwei ganz verschiedenen Perioden der Erkrankung Ausschläge beobachtef,
emn denen die Frühformen vor dem Ausbruch der Variola, also im Prodromalsta-
dium auftreten und als Prodromalexantheme bezeichnet werden, während andere
wiederum später im Maturationsstadium hervorbrechen. Diese Analogie der die
Pocken begleitenden Exantheme mit den Impfausschlägen beweist, dass auch jene
nicht auf einer speciﬁschen Wirkung des Variolagiftes beruhen, dass sie vielmehr
nur eine allgemein-pathologische Bedeutung haben, d. h. nur beweisen, dass ein
remder Stoff im Blute circulire, und dass demnach das Prodromalexanihem der
Pocken nicht die prognostische Bedeutung besitze, welche demselben allgemein
beigelegt wird.
DISCUSSION.
Dr. Von HEBRA (Vienna) agreed with the division of the vaccine exanthemata
'which had been made by Dr. Behrend. He himself had observed similar cases in
the Vienna Foundling Hospital. The appearance of the rash after vaccination
corresponds to the prodromal exanthem of variola, which is characteristic of the
disease, and which, when it spreads over the whole body and becomes hsemorrhagic,
causes the death of the patient before the variola eruption has developed.
Professor HARDY, P aris, does not know the German language sufficiently to have
followed the details of Dr. Behrend’s cases, but wished to communicate the result
of his experience relative to the eruptions which appear after vaccination, of which
he had observed a certain number. These eruptions can be divided into three
orders :—-1. Pustular vacciniform eruptions, which are nothing else than generalized
vaccine—a general vaccine infection instead of a local vaccine infection; 2. Non-
pustular exanthematous eruptions, such as roseola, various erythemata and urticaria.
These rashes develop usually before the vaccinal eruption, and last from three to
eight days; they\have no inﬂuence on the vaccinal eruption; 3. Diathetic erup-
tions, and particularly eczema and impetigo, which develop in persons predisposed
to these affections. In these cases the vaccine provokes the eruption accidentally.
158 DISEASES OF THE SKlN.
Hence the rule that children affected with eczema should not be vaccinated until
the eruption is cured. These vaccinal eruptions have nothing characteristic, and
the prognosis is usually favourable. Nevertheless, in some cases they may become
serious. M. Hardy referred to a case in which the eruption was fatal. It was a
case of pustular eruption, in which gangrene developed around the pustules, and
the child, aged two months and a half, died in eight days, with symptoms of pros-
tration. Another case, of which M. Hardy retains an unpleasant reminiscence, is
that of a grave attack of urticaria, of which he was the subject in 1870. Three
days after being revaccinated, he was attacked by an intense urticaria developed
on the skin and on the bronchial mucous membrane, in the latter situation, exciting
attacks of suffocation so serious as to put his life in danger. But these cases are
exceptional; and most usually in eruptions due to vaccine, the prognosis is favour-
able.

On the Causes of Alopecza Areata.
Dr. ROBERT Lrvnnve, London.
In bringing before you the subject of Alopecia Areata, and in trying to disprove
the parasitic origin of the disease, I am aware that I lay myself open to the charge
of an attempt to “ slay the slain.” A reference, however, to many writers on this
subject will satisfy anyone that a belief in the parasitic nature of the disease is
still widely entertained. I shall, therefore, without further apology, apply myself
to the subject.
I purpose to say but little on the fungus theory directly, but rather to attack
it indirectly. In short, the theme of my paper is—that the clinical fGCLt’LWGS 0f the
disease, alopeeia areata, cannot be eazplainecl on the parasitic hypothesis.
I. As to positive evidence. Ever since Gruby described, in]84.~3, a microscopic
fungus in area, there have always been able supporters of the parasitic theory.
The late Dr. Bazin was for many years its most powerful exponent, and he
carefully describes and ﬁgures the microscopic appearance of the hairs affected;
but while he supports generally Gruby’s view, he gives a totally different descrip-_
tion of the fungus, and at the same time draws a distinction between two varieties
of the disease, both parasitic. Comparing the fungus with that of tinea tonsurans,
he says that in alopecia areata the spores are smaller and more numerous, and that
the mycelium is more abundant ,- and with this his plates exactly correspond.
Contrast this description with that of a distinguished and more recent observer,
Professor Malassez. He says that the spores, some of which are nearly as large
as those of the tricophyton, are found abundantly in the epidermis, as well as in
the hairs, but that there is a complete absence of mycelium. I will not extend my
remarks on this point. ’
I have referred very brieﬂy to the history of the observations of three represen-
tative men, and you will notice that they do not agree even on the most essential
points.
Next, as to negative evidence—it is almost overwhelming. Many competent,
observers in Europe and America have searched, but searched in vain for a micro-
scopic fungus. We must remember, however, that negative evidence counts for
little in comparison with positive statement; and as it is impossible to deny great
ability to those who have been advocates of the parasitic hypothesis, it may be
DISEASES OF THE SKIN. I 59
well to refer to a possible source of error. In 1870, I recorded the occasional occur-
rence of perfectly smooth bald patches in tinea tonsurans exactly resembling those
of common alopecia areataflt and a little later, I offered this fact as an explanation of‘
some of the mistakes that had arisen. Quite lately, Eichhorst has found abundance of
spores in one case out of nine very carefully examined, and I have little doubt that
this ninth case was really one of bald tinea tonsurans. I would remark, in passing,
that when in common tinea tonsurans, one patch becomes quite bald the others
quickly follow suit.
II.—I pass now to the second, and main part of my subject, in which I shall
endeavour to show that alopecia areata is a disease of nutrition, the result of
faulty innervation; and that the clinical characters of the disease cannot be
explained on the parasitic hypothesis.
» 1.-—Let me brieﬂy refer to the constitution of those who are liable to it. We
know that it may occur at almost any age, and that it is rather more common in
the young than in the old. It is probably more common also in persons of nervous
temperament than in others, but on this I do not wish to lay any stress. There
are, however, two points of importance to which I would draw especial attention;
ﬁrst, its great tendency to recur, and secondly, its slight, yet notable disposition to
appear in different members of the same family. The former fact has been but
little dwelt upon by writers, and yet I should say that it was one of the most con-
stant features of the disease. A second attack is very common, and I have met with
patients suffering from their fourth or ﬁfth attack, with considerable intervals of
complete immunity.
Our President, Mr Erasmus Wilson, has recorded several cases of very frequent
recurrence of this disease ; but it is not necessary to quote cases; the point, will be
conceded by all who have had opportunities of seeing many examples of the malady.
This would surely indicate the existence of a constitutional tendency to the
disease, which is conﬁrmed by the fact that there is an undoubted hereditary
disposition to area in some families.
2.—-—I shall next ask your attention to the various local forms of functional
nerve disturbance, which often precede or follow the loss of hair.
It is now about eight years since my attention was ﬁrst called to an example of
almost complete insensibility of the skin over patches of area in a young lady, the
daughter of a medical man ; and since that time I have met with many similar cases,
in which the sensibility of the skin has been, for a short time, lost, or very much
impaired. Only quite lately I have had under my care a lady aged about thirty,
who is suffering from a second attack of almost complete alopecia areata of the scalp,
and who could not distinguish between cold and hot water applied with a sponge.
I have still under my occasional observation a middle-aged man who was in the
Middlesex Hospital, with three large patches of area, associated with complete
loss of sensibility, which lasted for several weeks. The hair has now grown per-
fectly over all three patches; on one it remains white, while on the other two it has _
resumed its natural colour.
I would make one observation with regard to almost all the cases of loss of
sensibility that I have met with, and it is this—that it appears as a very early and
temporary symptom, and is not usually present in those cases which are attended

it First Edition of “ Notes on the Treatment of‘Skin Diseases,” and more fully in the
Third Edition.
160 DISEASES or THE SKIN.
with atrophy of the skin, in which one might have expected to ﬁnd it; in short,
what I refer to is a functional disturbance, passing away long before the hair is
restored. A. more common nervous symptom is that of neuralgia and nervous
headache, or a sense of tenderness of the skin on being touched; but all these
subjective symptoms often disappear quickly, though the trophic nerves do not
readily resume their proper functions.
3.—The action of blistering ﬂuids on patches of area is instructive. It often
happens that ﬂuid quite strong enough to blister other parts of the scalp will not
produce a blister on the spot of area. I have noticed this so often that I am sure
it is not a very rare phenomenon. It certainly points to a low state of nervous
vitality in the part affected.
4a—With regard to the regions especially liable to be attacked, we meet with
examples of alopecia areata of every degree of severity, from a single bald patch on
the head to a complete loss of every hair on the body. Now, whatever we may
hold with regard to a bald spot on the scalp, it is very difficult to believe that these
latter cases, in which the shedding of the hair is often very rapid, can be produced
by a vegetable parasite, which, according to analogy, should spread by slow and
gradual growth. I would remark, in passing, that true leprosy, a constitutional
disease, will occasionally completely strip the body of hair, as we know it commonly
does the face.
Again, the special liability of area to affect the lower occipital, and the regions
behind the ears, and the outer portion of the eyebrows rather than, or before, the
inner portion, is at least unlike anything we see in tinea tonsurans. I do not,
however, regard this fact as of much value, either for or against my argument.
5.—The visible early changes in the skin are usually those of increased vascu-
larity, so that the patch looks redder than the surrounding scalp; this redness is
due simply to a passive dilatation of the small vessels, from impaired action of the
vasomotor nerves. The increased redness is often followed by exactly the reverse
appearance—an abnormal whiteness—due, in part, to the loss of pigment. At a
still later stage we sometimes] ﬁnd a slight but distinct depression of the skin,
which is the consequence of atrophy. The visible changes in the hair are well known,
and are essentially those of mal-nutrition and atrophy of the bulb, with absence of
pigment in the new hairs. Every one of these atrophic changes is such as we should
expect to result from impaired action of the trophic nerves.
6.—Under the head of allied diseases, I would just refer to the fact that
we occasionally meet with circumscribed patches of grey hair following neuralgia
and other nervous symptoms, unattended with baldness, and which present all the
appearance of area in process of recovery; and we also meet with what I would
call, for convenience, traumatic area, of which our President, Mr. Erasmus Wilson,
has recorded several cases where a local disturbance of nutrition. has been produced
by a blow, sting, or some other external causeix‘
Let me brieﬂy recapitulate the three leading features of the disease. They are ;
(l) a strong tendency to recur; (:2) local functional nerve disturbances; and (3)
various atrophic changes in the skin and hair, often of long duration. How are
we to explain these facts on the parasitic hypothesis P
I would remark, in conclusion, that though I do not suppose that there are
many present who believe in the parasitic origin of area, yet, as the view is widely
entertained by the profession, and is also supported by a certain number of highly

*4 See also paper by Dr. John Collier, Lancet, June 11, 1881.
DISEASES or THE SKIN. 161
scientiﬁc men, such as Malassez, Eichhorst, and others, it seems to me that a
congress like the present affords an important opportunity for the diﬁus'io'n, of
sound views on this and other subjects, as well as for the discussion of strictly new
and more technical questions.
DISCUSSION.
Dr. VIDAL, Paris, distinguished several varieties of alopecia areata—(l) decal-
vcms, has a rapid course, and tends to become generalized; invades the whole scalp or
a single nervous zone; (2) pelade achromatic/use (area), in which the skin of the bald
patches is pale and depressed, the surface smooth and shining, and satiny to the
touch; (3) pelade pseudo-tonclante, which might be confounded with tinea tonsurans.
The hairs break off short, but are atrophied at their roots. The ﬁrst form may be
limited to nervous zones, or may rapidly invade the whole body. It may have as ante-
cedents general disturbance of the nervous System, as strong emotion, terror, grief,
&c., or local nervous symptoms as pruritus, hyperaesthesia, or incomplete anws-
thesia. This form is never contagious and is a trophoneurosis. In the two
other forms, and especially the last, he was not able to declare that they were non-
parasitic, and had seen several instances of obvious contagion. He recollected one
remarkable example, in which four children were attacked at intervals of about two
months, and the father ﬁnally had alopecia of the beard. It is, therefore, probable
that a parasite is present in this form, but he was unable to discover it ; the fungus
described by M. Malassez was torula valga'ris, which occurs in all epidermic desqua-
mations. In sections through the scalp, parasites were not found deeper than the
sebaceous glands, and never in the hair. The latter is in a condition which pre-
cisely resembles senile atrophy. M. Vidal had found pigment granules in the hair-
bulb and neighbouring connective tissue, and atrophy with keratosis of the sebaceous
glands. He thought the question of parasitism in certain forms could not yet be
settled with certainty.
Professor HARDY, Paris, instanced Several decided cases of contagion in alopecia.
He thought the disease was of parasitic origin, but was divisible into two very dis-
tinct stages; an early parasitic stage, in which contagion was possible; and a secon-
dary, neuropathic stage, in which the unknown parasite which causes alopecia has
disappeared, and in which the disease is solely a trophoneurosis, contagion being
no longer possible. With this view, it is possible to harmonize observations which
appear at ﬁrst sight contradictory. He stated further that alopecia required a
certain special predisposition for its development, with the conditions of which we
are as yet unacquainted.
Dr. HEBRA, Vienna, supported the hypothesis of Dr. Liveing by the case of a
patient who had suffered from alopecia for ten years, and who ultimately died of
pneumonia; on post-mortem examination, Dr. Jarisch found changes in the grey
matter of the spinal cord.
Professor KAPOSI, Vienna, did not favour the parasitic theory, and thought it pos-
sible that there might have been an error of diagnosis in some of the contagious
cases. He remembered that the late Professor Hebra and he diagnosed a case as
alopecia which turned out to be tinea tonsurans. Leloir had published an account
of nervous lesions in alopecia, but there was some doubt as to their truly patho-
logical nature. He was sure that many cases occurred without any nervous symp-
toms or antecedents whatever.
PART III. M
162 DISEASES or THE SKIN.
Dr. UNNA, Hamburg, mentioned a case in which (1) epilepsy, (2) hemicrania, (3)
Graves’ disease, and (4‘) alopecia areata, all appeared simultaneously after a severe
fright; and another case of alopecia areata capitis, in which, after six months’
fruitless treatment, with every possible anti-parasitic and anti-neurotic remedy,
treatment by the electric brush produced beneﬁt in one week. He thought both
cases supported the neurotic view. ,
Prof. SCHWIMMER, Buda Pesth, also believed that alopecia was a neurosis, and
had seen good results from electricity, after failure of the usual irritant applications.
Dr. THIN, London, remarked that, in the great majority of cases of alopecia areata,
the patches did not follow the distribution of nerves, and no pathological changes
in nerve-elements had been shown to be associated with the disease. Under these
conditions the neurosis theory was a simple confession of ignorance. He attributed
the highest value to the cases of infection related by M. Hardy and by M. Vidal.
The only escape from the conclusions forced upon us by these cases is by assuming
that there has been an error of diagnosis——an assumption that, in the present
instance, in view of the high authority of the reporters, was inadmissible. The
possibility of contagion once admitted, the nerve hypothesis falls of itself. His
examinations of the hairs in this disease had led him to believe that its cause is to
be found in a bacterium, which develops between the root-sheaths and the hair-
shaft, and in the hair-root, leading to disintegration of the shaft of the hair.
Prof. Oscar. SIMoN, Breslau, had never found parasites, but had observed many
cases with trophic or nervous derangement, and believed the disease was always a
trophoneurosis, as ﬁrst stated by Barensprung. He thought the examples of
contagion adduced might be explained on the hypothesis that there are two distinct
diseases with the same general features; one a trophoneurosis, and the other a
contagious disease.
Dr. ALLAN J AMIESON, Edinburgh, had noticed that the disease occurs specially in
dark-haired persons, rarely in the fair, and scarcely ever in the red-haired. He had
seen a case of morphoea, accompanied by alopecia areata, and thought that nervous
symptoms predominated in the disease.
Mr. GASKOIN, London, had seen several undoubted contagious cases.
The PRESIDENT believed that there was no ground whatever for regarding area
as being of parasitic origin. It was a nerve-paresis, accompanied with exhausted
nutrition, and sometimes complete atrophy of the skin. The indication for treat-
ment was not the destruction of a parasitic vegetation, but the restoration of the
nerve power and nutritive power of the affected integument.
Lupus Erythemaz‘osas.
Professor KAPosI, Vienna.
GENTLnMEN,—I have been honoured by the Committee with the task of opening
the discussion on the second question of our programme, to wit: “ On the Nature
and the Treatment of Lupus Erythematosus.”
DISEASES or THE SKIN. 16 3
This question should, to my thinking, be pointedly put as follows: Is lupus
erythematosus an inﬂammatory process or a neoplastic one ? For, the answer implies
the conditions under which all that constitutes this process (as its symptoms,
course, and consequences) is viewed.
In all these respects it must be stated that no agreement is to be met with
amongst authors and practitioners, either in theory or in practice.
After having given, more than ten years ago, an exhaustive description of this
disease, which I was pleased to see met with the general acceptance of my
colleagues, I was somewhat surprised by the remarks made on the subject two
years ago (August, 1879), at the Annual Meeting of the British Medical Associa-
tion, in Cork, by some of our English, as well as by some of our French,
colleagues.
Since the disease is known by the name of lupus erythematosus, the name itself
has been an obstacle to its being correctly understood. Practitioners have always
been disposed to confound it with lupus vulgaris, or at least to bring it very near
the latter. Long ago I stated that, merely to make a concession to custom, I
ranked lupus erythematosus among the neoplasms, next to lupus vulgaris, but I
have always insisted upon its inﬂammatory nature, and on its being thoroughly
different from lupus vulgaris.
Everyone who knows the history of this disease, and the different names
formerly applied to it, must be aware that its name was not founded upon an
agreement of its symptoms with those of lupus vulgaris, but merely upon the fact
that, besides the generally congruent localization of both diseases in the face, they
both, also, generally end in a cicatrization of the affected skin.
But what a diiference in the road which either has to traverse till they arrive at
this end !
I cannot now enter into an exposition of the symptoms of lupus vulgaris, which
would be necessary to make my opinions perfectly clear.
You are aware that, before the publication of the plates in Hebra’s “ Atlas,”
there was only one form of the disease known—21a, the form of circular
patches, sub-divided into many varieties—ﬁrst, into three, by Cazenave ; and that
some of the older names correspond to it, as—Erythema centrifuge, dartre ron-
geante, qui détruit en surface, 850. In the plates mentioned two forms are
depicted, which I show here: one, representing the circular form in its localiza-
tion on the nose and the cheeks, compared to a butterﬂy-shape ; and on the other
plate, a disease consisting of discrete and lentil-sized patches of an otherwise well-
pronounced character. But none—not even Hebra himself—made any distinction
between them. Nor do I. On the contrary, I have for a special purpose taught
that the process generally begins by the small spots, which I have called the
“‘ primary eruptive spots” (primar-eﬁlo'rescenzen) of lupus erythematosus.
I need not fully describe these spots before a meeting of professional brethren;
but I merely state that every spot is characterized by a red, elevated, hyperaemic,
.and inﬁltrated border, and a central cicatrix-like depression, smooth, or covered
with a dry, ﬁrmly-adherent scab.
But as to the further development of the process, I have been compelled to
distinguish two forms, which I have designated—1st, as lupus erythematosus
disco'icles ,- and 2nd, as lupus erythematosus aggregatas.
The clisco'ld form, which results from the spreading of single spots peripherally,
is generally characterized by an exceedingly chronic course, not only of the
individual patches, but also of the process as a whole. F111‘tl1€1‘,1ll3 is usually
in 2
164 DISEASES or THE SKIN.
conﬁned to the region of the face and the head (including the mucous membrane of
the mouth) occasionally attacking the ﬁngers also.
Even in this form, the clinical symptoms are easily recognized as belonging
to an inﬂammatory process. This is strikingly expressed in the attribute
“ congestiva,” which Hebra originally applied to the disease, and may be seen from
the disappearance of the redness under the pressure of the ﬁnger, and its reappear-
ance when the pressure has ceased; from the character of the inﬁltration, from the
quick outbreak of hyperaemia, and its frequent disappearance without any trace;
and last, not least, from the symptoms of very high and acute inﬂammation which
occasionally complicate the discoid form, but which emphatically belong to the
second form of the disease.
In the latter, to wit, in lupus erythematosus aggregatus, the symptoms of
inﬂammation are far more striking.
Even in the lowest state of the disease, which has been called seborrhoea
congestiva, from its character (congestion and its consequence, abundant secretion
of the sebaceous glands), no doubt can arise concerning its inﬂammatory nature.
So it is also in the other forms of eruption.
Patches, of the size of a pin’s head or a split lentil to that of a ﬁnger-nail arise
suddenly, slightly elevated, hyperaemic, hot and hard to touch, paling under
pressure, burning; in brief, on the whole, not unlike urticaria spots, or those of
erythema urticatum, or the ﬁrst stage of eczema. As yet there is nothing character-
istic of lupus erythematosus. There may appear single ones, 20-100 and more,
crowded in the face, or dispersed in other parts of the body. Many of these spots
may disappear in the course of a few days without leaving any trace behind, while
some of them remain and become characteristic by the atrophic depression of the
centre.
It is known that what I have called lupus erythematosus aggregatus consists of
such forms, and that the disease does not spread in this variety by increase of indi-
vidual spots, and their transformation into disks, but by the augmentation of the
number of single spots, which are crowded locally into large uniform patches, and
in their dispersion over large parts of the body.
Every outbreak of this kind may be accompanied by higher degrees of
inﬂammation and exudation of the skin so as to form crusts and scabs, as in
eczema; or even blebs, as in herpes and pemphigus, with serous, purulent, or
haemorrhagic contents.
I must not forget to call your attention to the inﬂammatory and painful
tumours, which I have described as‘ arising acutely in the depths of the subcu-
taneous cellular tissue, in the oints, and in the glands, over which, after a few days,
patches of lupus erythematosus are formed, while this deep inﬁltration disappears,
and, above all these, to the state of inﬂammation of the face, which I have
described and designated as e'rysipelas perstansfaciei, which often leads to death.
I ﬁnd it superﬂuous before such an audience to further detail the clinical symp-
toms, all pointing to an inﬂammatory process.
The same thing is proved by the result of anatomical investigations which
have been made by Neumann, Geddings, Thin, Stroganow, Geber, and others, and
by myself.
Whereas it was formerly believed that there was merely an inﬂammation of the
sebaceous glands and their adjacent tissue, I was able to show that the anatomical
changes belonging to inﬂammation may be found in any layer of the skin, super.
ﬁcially, or more deeply; and that very often they are met with in the depths of
DISEASES or THE SKIN. 16 5
sweat-glands, spreading from there, along the blood vessels, into the papillar layer
of the skin. Also the heemorrhages, the formation of blebs and pustules above
mentioned, are among the symptoms of the inﬂammatory congestion and changes
of the blood vessels, whereas the numerous telangiektases, which are apt to remain
at the very place of the lupus patches, are inerely a consequence of the cicatrization,
as may happen also in cicatrices of other origin.
To further penetrate into the nature of the process, we must inquire: What
hincl of inflammation it is which so rapidly leads to the cicatrization of the shin .7
This question must be divided into two parts. First, What is going on locally .7
And in the second place, What rremote causes may underlie the process .7
As to the ﬁrst, I may afﬁrm that this is not a cicatrix, properly speaking, but a
local atrophy of the skin.
I have demonstrated in my publications of 1870, that in the midst of the inﬂam-
matory changes of the tissues, and at a very early stage, fatty and molecular
cloudiness of the cells of the rete and the glands, and of the formed elements
resulting from inﬂammation, makes its appearance. A similar, or a hyaloid, or a
waxy degeneration takes place in the connective tissue elements of the papillary
layer, and of the blood vessels, in consequence of which they in part become
absorbed, and in part shrivel up, whilst the follicules also disappear, the blood
vessels become partly dilated, partly obliterated; brieﬂy, all the symptoms of
cicatricial degeneration and atrophy, including telangiektases, are to be recognized.
But for us it is essential to remember that many other processes of an inﬂam-
matory character and of cellular inﬁltration end in cicatrization ; or, rather, in
cicatrix-like atrophy, as scleroderrna, lichen ruber, lichen scrophulosorum, and
others ; whereas, the true cicatrix is the organized product of granulation—that is, of
a neoplasm.
The remote cause may also be considered as belonging to the Etiology of the
disease.
To me it is obvious that in many cases the affection has begun as a local disease,
and runs its whole course locally, without in the least afflicting the constitution
during the whole duration of the malady. I remember cases in which lupus erythe-
matosus has proceeded from a seborrhoea of the nose and the face, which had its
recent origin in the scars of small-pox. In those cases there is not the least
inducement to consider it as a constitutional disease.
I mention another fact, which has been also pointed out by others, that two-
thirds of the cases of lupus erythematosus are to be met with in females, and that
the latter are mostly chloranaemic. But this is by no means peculiar to lupus
erythematosus, which, moreover, frequently occurs in healthy females, and also in
men.
But, undoubtedly, we must afﬁrm the existence of a decided sympathy of the
whole organism in those stages, which I have called acute general eruption of
lupus erythematosus.
There is no doubt that the high fever, the symptoms of pressure on the brain,
the typhoid state, the vomiting, the pleuro-pneumonia, the delirium, sopor, and
the convulsions which we have observed in such cases, are in immediate relation to
the inﬂammatory process of the skin; as also the aﬁections of the joints, the bones,
the glands, the erysipelas perstans faciei ——in short, the outbreak—and to the exacer-
bation of characteristic lupus spots.
Of course, here we might ask : Whether the eruption is a consequence of a clisorcler
of the ncrvo us centres, or the rev crse ?
166 - DISEASES or THE SKIN.
Although I think I have seen more autopsies in connection with this disease
than anyone else, yet I could not give a decided opinion.
I have observed 8 cases of death in the number of 53 cases of lupus erythema-
tosus (18 men, 35 women) treated in the Vienna Clinic in the course of ten years,
1871-1881. Amongst these eight cases were 2 men, 6 women.
The autopsies have shown in six cases pleuro-pneumonia; in two cases, tubercu-
losis pulmonum as immediate causes of death. Besides that, atrophy of the
cortical substance of the brain and oedema of the meninges (once marasmus
and anaemia) has been noticed. In a case of lupus erythematosus acutus, fatal last
year, J arisch has found inﬂammatory changes in the middle lateral parts of the
anterior cornua of the medulla, as well as in its commissure. But neither this case,
nor the results of investigation we have made in a case of lupus erythematosus
acutus, fatal during this year, of the medulla spinalis, the intervertebral ganglions
and those of the sympathicus of the neck, could as yet authorize us to the opinion
that the primary cause of the disturbance lies in the hypothetic trophic centres,
or in the centre of vasomotor nerves.
On the other hand, it is not unusual for us to see, that in consequence of un-
doubtedly local diseases of the skin, as burns, cauterization, loss of epidermis to a
great extent from any cause, the severest symptoms of fever, of nervous disorder,
singultus, convulsions, sopor, vomiting, and even death may ensue.
I am not inclined to interpret these symptoms otherwise, than that they may be
provoked by reﬂex action from the affected skin. We are taught to do so by many
other observations made in Dermato-pathology; and we ﬁnd this opinion here
more convenient than that of neuritis ascendens.
Still, there remains a wide ﬁeld for the theoryof general repression of nutrition,
which may cause the degenerative character of the inﬂammation. But neither is
such a state of general weakness to be found in all cases, nor can it explain the
outbreak of the inﬂammation itself.
Before closing, in regard to the pathology of the disease, I submit another ques-
tion: Whether my division of lupus erythematosus does not most correspond to the
clinical features ? For, to me, it seems that the subdivisions according to certain
morphological differences—as, erythematosus, or haemorrhagic, or acnéic—do not
touch any of the essentials, while my division of discoid and aggregate, though
making no difference as to the origin, still indicates the twofold manner of the clinical
process; one chronic and indifferent, and the other acute, severe, and even fatal.
Now I pass to the practical question of the best treatment. On this I shall be
short.
The general and etiological conditions have given us no indications for an efﬁca-
cious treatment. For, whatever generally invigorating remedy is given, as iron,
cod-liver oil, strengthening diet, &c., it has no direct inﬂuence on the disease. About
iodine with starch, recommended by McCall Anderson, and the iodiform, approved
in two cases by our distinguished friend, E. Besnier, I have no sufficient experience.
That the anti-syphilitic therapeutics are of no use at all I have amply experienced.
On the other hand, we are, as you are aware, very rich in external and local
remedies. To the all but exhaustive number I published in 1869, I may at present
add a few new ones, as sublimate-collodiu-m, salicylic acid, pyrogallic acid, chry-
sarobin, iodoform and naphthol, lately introduced by me.
Further, I can_but repeat my former words, that each remedy and method of
procedure may be found thoroughly eﬂicacious in lupus erythematosus, but that
this statement only applies to particular cases, since a method which has been put
I
DISEASES or THE SKIN. ' 167
to the test in a number of cases successfully, will leave us in the lurch in the very
next case.
In judging of the efficacy of any remedy, we must not forget that the patches of
lupus erythematosus very often disappear spontaneously, or under the slightest
inﬂuences.
Of the large number of well-known remedies, all of which may be useful in
special cases, the application of cold not excepted, I have in my experience found as
most eﬂicacious, soaps in all forms, especially spiritus saponis alkalinus, dilute acids
and alkalies, tar, sulphur, and iodine; most particularly emplastrum hydrargyri,
which I have ﬁrst applied successfully ; sometimes pyrogallic acid; lastly, naphthol;
ﬁnally, mechanical treatment by puncturing, scraping with a scoop and scariﬁcation,
which are most useful in destroying the disﬁguring teleangiektases, which very often
remain on the spots of lupus erythematosus which have recovered.
Lzqpus Eryzf/zematosus.
Dr. TH. VEIEL, Oanstatt.
Hochverehrte Versammlung! Der liebenswürdigen Aufforderung unserer
hochverehrten englischen Collegen folgend, beehre ich mich, Ihnen in Kurzem,
meine Ansichten über die Natur und die Behandlung des Lupus erythematosus
mitzutheilen.
Unter Lupus erythematosus verstehe ich selbstverständlich den Lupus ery-
thematosus Cazenave’s oder “ der Deutschen” wie ein Theil unserer englischen
Oollegen ihn im Gegensatz zum Lupus erythematosus der Engländer nennt, welcher
die leichteste Form des Lupus vulgaris bildet.
Fünf und fünfzig Falle dieser Art wurden in der von meinem Vater begründeten,
von meinem Bruder Dr. Ernst Veiel und mir geleiteten Heilanstalt für Haut-
krankheiten in Oanstatt behandelt.
Der Verlauf in allen diesen Fallen war ein chronischer, die Form meist die
scheibenförmige, seltener die disseminirte, der Sitz meist Nase, Wangen, Augen-
lider, Ohren und der behaarte Kopf.
Meist war die Krankheit zwischen dem zwanzigsten bis vierzigsten Lebensjahre
aufgetreten, nur in zwei Fällen unter zehn Jahren, in einem nach dem sechzigsten
Lebensj ahre.
Jene bösartige, von Kaposi, Stern und Bock beschriebene, mit acuten und subacu-
ten, ﬁeberhaften Eruptionen auftretende, über den ganzen Körper zerstreute Form
von Lupus erythematosus aggregatus habe ich in Canstatt nie gesehen, wohl aber
im Jahre 1872 auf der Klinik meines leider zu früh verstorbenen hochverehrten
Lehrers, Hebra in ‘Wien.
Folgende Fragen habe ich mir für heute in Betreﬁ der Natur des Lupus erythe-
matosus zur Beantwortung vorgelegt :—
1.——Ist der Lupus erythematosus eine Krankheit eigner Art oder bildet er nur
eine Unterabtheilung des Lupus vulgaris?
2.—-Ist der Lupus erythematosus eine Theilerscheinung einer uns bekannten Al-
gemeinerkrankung des Organismus wie der Scrophulose, 'l‘uberculose, Gicht und
Syphilis P
3,-—Bildet die Erkrankung der Talgdrüsen resp. der Schweissdrüsen, wo keine
Talgdrüsen vorhanden sind, das Wesen der Krankheit?
Die Antwort auf die erste Frage lautet ; der Lupus erythematosus ist eine selbst
168 DISEASES OF THE SKIN.
ständige Krankheit nach seinem ersten Auftreten, seinem Ansehen und seinem
Verlaufe.
Dafür sprechen folgende Gründe: die verschiedenen Formen des Lupus vulgaris
gehen häuﬁg in einander über, aus einem Lupus erythematosus wird nie ein Lupus
vulgaris. Ein gleichzeitiges Vorkommen beider Erkrankungen bei demselben In.
dividuum wurde meines Wissens noch nie beobachtet.
Der Lupus erythematosus tritt in kleinen, obeoﬂächlichen, rothen Punkten auf,
auf denen sich fest adhärirende Schuppen bilden, welche zapfenartige Fortsätze
zwischen die verlängerten Papillen entsenden. Der Lupus vnlgaris beginnt mit
tiefer in der Cutis gelegenen, kleinen, bräunlichen Knötchen.
Der Lupus erythematosus geht nie in Erweichung, Vereiterung und Ver-
schwärung über. Nie bildet er Knoten, wie der Lupus vulgaris.
Der Lupus erythem atosus bleibt stets auf die Cutis und das Unterhautzellgewebe
beschränkt. Tiefer liegende Gebilde wie die Knorpel ergreift er nie.
Der Lupus erythematosus ist fast stets eine Krankheit des reiferen Alters, der
Lupus vulgaris tritt nicht vor der Entwickelung der Mannbarkeit auf.
Die zweite Frage wäre dahin zu beantworten:
Wenn es auch nicht zu leugnen ist, dass der Lupus erythematosus häuﬁg ver-
bunden mit Scrophulose, Tuberculose, Gicht und Chlorose vorkommt und die
Patienten sehr oft ein anämisches Aussehen zeigen, so ist dies doch keineswegs die
Regel. Sehr häuﬁg trifft man ihn bei ganz gesunden Menschen.
Obschon sich also auch eine Verwandschaft mit obigen Erkrankungen, speciell
mit der Scrophulose und Tuberculose nach den von Kaposi beschriebenen, tödtlich
verlaufenen Fällen vermuthen lässt, der Nachweis ist noch nicht erbracht,
Mit Syphilis hat der Lupus erythematosus gar nichts gemein und lassen auch
alle antisyphilitischen Kuren bei der Behandlung desselben im Stiche.
In Betreff der dritten Frage, ob die Erkrankung der Talg- resp. Schweissdrüsen
den Lupus erythematosus bilden, habe ich schon im Jahre 1872* dargethan, dass,
wenn auch in vielen Fällen die Erkrankung der Talgdrüsen dem Bilde des Lupus
erythematosus einen ganz besonderen Charakter verleiht, doch die Erkrankung der
' Talgdrüsen nur eine accidentelle ist, eine Ansicht, die seit dieser Zeit die mikros-
kopischen Untersuchungen von Geber, Thin, und Vidal mir bestätigt haben.
Das primäre und wesentliche der Erkrankung ist eine Anhäufung von Blutkör-
perchen in den erweiterten Capillaren des Papillarkörpers und des Corium und die
Zelleninﬁltration in der Umgebung der Gefässe. Diese Veränderungen lassen sich
zu einer Zeit nachweisen, wo Talg- und Schweissdrüsen noch vollständig intakt sind.
Die Erkrankung der Drüsen ist die Folge der Erkrankung des sie reichlich um-
spinnenden Blutgefässnetzes.
So erklärt es sich auch, dass in einzelnen Fällen die akute Dermatitis der Variola,
in anderen Fällen die des Erysipelas, die erste Veranlassung zur Entstehung des
Lupus erythernatosus giebt. J e nach der secundären Betheiligung der Talgdrüsen
an der Erkrankung sind die Bilder des Lupus erythematosus verschieden. Nehmen
die reichlichen Antheil, so fühlt sich die Haut fettig an, die kranken Stellen sind
mit talgreichen Krusten und Schuppen bedeckt, nehmen sie geringen oder gar
keinen Antheil, so bildet sich von Anfang an eine spröde, harte, hornartige,
fettarme, verdickte Epidermisschichte.
Für die Ansicht, dass die Erkrankung der Gefässe und ihrer Umgebung das

* Th. Veiel, “ Ueber Lupus Erythematosus.” Tübingen.
DISEASES OF THE SKIN. 169
Primäre ist, spricht auch der Umstand, dass die Pradilektionsstellen des Lupus
‘erythematosus gerade diejenigen sind, an welchen Stauungen und Gefässerweiter-
ungen_auch bei anderen Erkrankungen vorkommen, so Nase und WVangen bei
Acne rosacea und Erfrierungen, Ohren und Rückenﬂache der Finger und Zehen
'bei den Erfrierungen.
Die von Oscar Simon* gegen diese Ansicht angeführte Beobachtung, dass in
‘einer Brandnarbe in welcher die Follikel zu Grunde gegangen waren kein Lupus
»erythema,tosus auftrat, während in der Umgebung derselben sich ein solcher
"bildete, dürfte wohl zur .VViderlegung nicht vollständig ausreichen, da in einem
Narbengewebe neben den Follikeln auch der Papillarkörper des Corium und das die
Follikel umspindende Gefassnetz zu Grunde gegangen ist. In jungen gefassrei—
‘chen Narben sehen wir sehr häuﬁg Recidive entstehen, selbst wenn sie von sehr tief
wirkenden Aetzmitteln, wie vom Aetzkaligriffel herrühren, wobei voraussichtlich
auch die Follikel zerstört worden sind.
Nach diesen Ausführungen, glaube ich, sollten alle die Bezeichnungen des Lupus
erythematosus, welche sich auf die Erkrankung der Talgdrüsen beziehen, aufge-
geben werden, wie der Lupus acneiformis (Tilbury Fox), Lupus acne'ique (Hardy),
Lupus seborrhagicus (Volkmann), wie dies Hebra in Betreff der Seborrhoa conges-
‘biva schon früher gethan hat.
Gehen wir nun zur Behandlung des Lupus erythematosus über, so müssen wir
vor allem vorausschicken, dass es einzelne, zum Glück seltene Fälle, von Lupus
erythematosus giebt, die eder, auch der energischsten Behandlung spotten, indem
sich, in den durch die Behandlung gebildeten Narben, stets Rückfälle bilden.
Folgende beide Fragen habe ich mir zur Beantwortung vorgelegt 1-—
1.-——Ist neben der örtlichen Behandlung auch eine allgemeine Behandlung des
Lupus erythematosus angezeigt und worin hat dieselbe zu bestehen?
2.——Welches Mittel hat sich bei der localen Behandlung am besten bewahrt?
Ad 1.—Es ist uns noch nie gelungen einen Lupus erythematosus durch Darrei-
chung anderer Mittel zur Heilung zu bringen. Es giebt kein Speciﬁcum gegen
‘diese Krankheit; Jodkali und Arsenik haben uns stets im Stiche gelassen. Ueber
die von M‘Oall Anderson empfohlene Jodstärke stehen uns noch keine genügenden
Erfahrungen zur Seite. Dennoch möchte ich, besonders seit dem Bekanntwerden
der schweren, tödtlich verlaufenden Fälle nicht darauf verzichten, den Gesammtor-
ganismus des Kranken möglichst zu kräftigen. Sind Symptome von Scrophulose,
Tuberculose, Gicht, Ghlorose vorhanden, so richten sich die Heilmittel nach diesen
Indicationen. Wo diese nicht vorhanden und auch aus Gründen der Erblichkeit
nicht zu fürchten sind, müssen wir uns auf die Darreichung möglichst kräftiger
Kost und guter Luft beschränken.
Ad 2.——Die Wahl des örtlichen Mittels richtet sich nach den einzelnen Fallen.
Von den vielen empfohlenen Mitteln haben sich uns die folgenden am wirksamsten
gezeigt :—
Bei kleineren umschriebenen Flecken des Lupus erythematosus sebaceus ist das
‚schon von Oasenave empfohlene Quecksilberjodid (in einer Stärke von 1:5—15
Fett) von ausgezeichneter ‘Wirkung. Dasselbe wird nach Entfettung der Haut so
lange aufgetragen bis sich mit Eiter gefüllte Blasen gebildet haben. Die Krusten
lässt man eintrocknen und abfallen. In einzelnen Fallen ist die wiederholte
Anwendung dieses allerdings schmerzhaften Mittels nöthig.
Kräftiger und besonders bei dem Lupus erythematosus corneus sehr empfehlens-

* “ Localisation der Hautkrankheiten,” p. 100.
I70 DISEASES or THE SKIN.
werth wirkt die Ohloreseigsc'i-m'e. Sie zeichnet sich aus durch rasche, nicht zu tief
gehende Wirkung, geringe Schmerzhaftigkeit, genaue Beschränkung ihrer Wirkung
auf die Anwendungsstelle, geringe Entzündung in der Umgebung des Aetzschorfes
und glatte Narbenbildung. Sie ist den meisten anderen Sauren entschieden
vorzuziehen. Sie wird mit einen Glaspinsel aufgetragen und dann mit einem
Glasstift in den Schorf eingebohrt.
Bei grösseren Flächen ziehen wir obigen Mitteln die von J arisch empfohlene
Pyrogallussäwre vor. In Salbenumschlägen (1 : 10 Vaselin) wird sie drei oder vier
Tage aufgelegt, der Erfolg nach Abtheilung des Schorfes ist oft ein geradezu über-
raschender.
Führt keines der obigen Mittel zum Ziele, so gehen wir mit Umgehung der
Ausschabungsmethode mit dem scharfen Löﬁel, nach welcher sich stets rasch
Rückfälle bilden, zu der tiefer wirkenden multiple Scariﬁcation mit nachfol—
gender Chlorzinkatzung über. Ohne die Aetzung sind die Erfolge schlecht.
Sie wird bei uns ausgeführt mit dem von meinem Bruder 1878i‘< angegebenen,
jetzt verbessertem, aus sechs nebeneinander stehenden Lancetten bestehenden
Instrument. Nach Stillung der Blutung wird eine concentrirte, spirituöse Chlor-
zinklösung eingepinselt. Wegen der grossen Schmerzhaftigkeit wird bei kleineren
Stellen die locale Anästhesie mit dem Richardson’schen Aetherzerstauber her-
beigeführt; werden grössere Stellen scariﬁcirt, so muss chloroformirt werden.
Fassen wir zum Schlusse das Ergebniss obiger Ausführungen zusammen, so
lassen sich folgende Sätze aufstellen :-—
1.——Der Lupus erythematosus ist eine selbstständige Krankheit und nicht eine
Form des Lupus vulgaris.
2.—Ein Zusammenhang des Lupus erythematosus mit Scrophulose, 'I‘uberculose
und Syphilis lasst sich nicht nachweisen.
3.—Die Erkrankung der Talgdrüsen, resp. Schweissdrüsen bildet eine zufällige
Begleiterscheinung. Das Wesen des Lupus erythematosus bildet die Erkrankung
entlang dem Verlauf der Blutgefässe.
4.—Es ist bis jetzt kein Mittel bekannt, das, innerlich gereicht, den Lupus
erythematosus zur Heilung bringt. .
5.——Das wirksamste örtliche Mittel gegen den Lupus erythematosus ist die
multiple, mit nachfolgender Ohlorzinkatzung verbundene, Scariﬁcation.
DISCUSSION. ‚p
The PRESIDENT considered the aﬂ‘ection inﬂammatory, arising after exposure to
irritating inﬂuences. It begins as an erythema, which becomes permanent, and
ﬁnally lupoid. He cited the case of a woman in whom, during pregnancy,
erytbema appeared on the face ; then, after exposure to cold, the erythema spread
over the trunk, and in the end became lupus erythematosus.
M. VIDAL, Paris, believed the disease not to be inﬂammatory, but to be interme-
diate between inﬂammation and neoplasm. It is cured by producing inﬂammation
of the patches. In the superﬁcial forms the lesion extends only in the superﬁcial
papillary layer. ‚ Embryonic cells, like those present in lupus vulgaris, are found in
the deeper forms. He recommended treatment by Spiritus sapomls alkali/mos ; but
the best treatment is scariﬁcation, and then, to obtain inﬂammation, e'mpldtre
dc Vc'go.

* “ Archiv. für Dermatologie und Syphilis.”
DISEASES OF THE SKIN. I 7 I
Dr. UNNA, Hamburg, remarked that clinically we can distinguish between inﬂam-
mation and a neoplasm, but that in lupus erythematosus we cannot even clinically
draw the line. We have a disease, which is at ﬁrst inﬂammatory, and eventually
becomes a new growth.
Professor SCHWIMMER, Buda-Pesth, believed that the disease was purely local
and inﬂammatory.
Dr. THIN, London, observed that the disease was essentially distinct from lupus
vulgaris, and that it was inﬂammatory, and not a neoplasm.
U666?’ Lezz/rzoplakz'a éucmlz's.
Professor ERNST SCHWIMMER, Buda-Pesth.
Die Erkrankung der Mundhöhlenschleimhaut bildet entweder eine Theilerschei-
nung einer allgemeinen Erkrankung oder sie stellt eine ganz selbständige Affection
dar, welche dem Character des Mutterbodens entsprechend von den Krankheiten
der Haut mit welchen man sie zu vergleichen liebt, wesentlich differiren, wesshalb
man auf selbe auch nicht solche Bezeichnungen anwenden soll, welche für typische
Affectionen der allgemeinen Decke gebräuchlich sind. Den meisten Anlass für
das Entstehen der Schleimhautaffectionen bieten die syphilitischen Prozesse im
allgemeinen, und es ist bekannt, dass in gewissen Phasen des Allgemeinleidens
Zungen- Wangen- und Rachenschleimhaut characteristische Veränderungen dar-
bieten, welche seit langer Zeit als “Plaques opalines ” u. s. w. belegt werden.
Wir wollen aus der grossen Reihe der Veränderungen, welche in der Mundhöhle
auftreten, nur jene Formen speciell hervorheben, welche vermöge der Localität der
Erkrankung ‘und ihrer äussern Form gerade mit den Syphiliden der Schleimhaut
eine so frappante Aehnlichkeit haben, dass man häuﬁg in die Versuchung kommt,
diese Affection immer nur als eine speciﬁsche zu betrachten. Zahlreiche Aerzte
begehen in solchen Fällen einen beklagenswerthen Irrthum und da bekanntlich die
Syphilis oft nur durch eine einzelne Symptomengruppe diagnosticirt werden kann,
so genügt es, eine oder die andere von den zu beschreibenden Veränderungen in der
Mundhöhle wahrzunehmen, um auf falscher Diagnose fussend, auch eine nicht ent-
sprechende lTherapie einzuleiten.
Die characteristischen Veränderungen der idiopathischen Aﬁectionen, die ich
zum Ausgangspunkte meiner Schilderung nehme, entwickeln sich in Form von
rothgefärbten, umschriebenen Flecken,welche sowohl auf der Zunge,dem Innenrande
der Lippe und der Wangenschleimhaut auftreten können und eine umschriebene
Hyperämie darstellen. Die Dauer dieser Veränderung ist eine ungleiche und kann
von einigen Wochen bis zu einigen Monaten anhalten um sich entweder wieder
rückzubilden oder zu weiterer Umwandlung zu entwickeln, wobei statt der rothen
Flecke, umschriebene grauliche oder weisse Verfärbungen sich bilden. In einer
ähnlichen Weise kommt bei der Syphilis die Schleimhauterkrankung zu Stande,
indem aus hyperämischen Bezirken auch weissliche Verfärbungen sich herausbilden,
nur mit dem Unterschiede, dass die Umwandlung des Epithels viel rascher erfolgt
als bei der idiopathischen Erkrankung. Letztere zeigt eine grössere Widerstands-
fähigkeit gegen jene Einﬂüsse, welche auf die kranke Mundschleimhaut nachtheilig
einwirken können, und während bei der Syphilis theils spontan, theils durch
I 72 DISEASES OF THE SKIN.
Behandlung leicht eine Rückbildung der Erkrankung erfolgt, ist dies bei der
andern Form nicht in der WVeise zu beobachten, im Gegentheil, die erkrankten
Epithelschichten beginnen sich allmälig zu verdicken und man ﬁndet nach und nach
auf der Schleimhaut der Zunge und der übrigen Mundhöhle allmälig dickere in’s
Gewebe reichende Massen, welche der erkrankten Oberﬂäche ein verdicktes und
schwartiges Aussehen verleihen. Die Ausbreitung der Erkrankung ist eine
ungleichförmige, indem man bald rundliche, bald elliptoide Stellen, bald wieder
längliche Platten und Streifen bildende Auﬁagerungen ﬁndet. Am häufigsten ist die
Zunge dieser Erkrankung unterworfen, sowie die Uebergangsfalten der Mund-
winkel; an den Lippen ﬁndet man selbe seltener so ausgeprägt. Der ganze Pro—
zess ist durch Inﬁltration des Coriums und bedeutender Zellenwucherung in dessen
einzelnen Lagen characterisirt und dies erklärt auch die grössere Persistenz dieser
Plaques und deren Umwandlungsfähigkeit zu anderen Prozessen. Einzelne
Autoren haben die Affection, was deren idiopathischen Character anlangt, als
Psoriasis oder Keratosis membranae mucosae beschrieben und der grösste Theil der
Aerzte neigt der Ansicht zu, dass dieses Leiden stets auf syphilitischem Boden
sich entwickelt. Dies ist jedoch, in solcher Allgemeinheit hingestellt, nicht der
Fall und den besten Massstab für die Unterschiede beider Affectionen liefert der
Verlauf und Ausgang der Erkrankung selbst. Man beobachtet nämlich in
einzelnen Fällen eine Rückbildung des Krankheitsprozesses, wenn das Uebel
frühzeitig erkannt wird und die Schädlichkeiten hintanzuhalten sind, welche eine
Verschlimmerung des Zustandes veranlassen ; in andern Fällen kommt es wieder
zu bösartigen Wucherungen mit Ausgang in Carcinom, wie dies von Chirurgen
häuﬁg zu beobachten ist. Ich habe schon vor mehrern Jahren auf das Wesen dieser
idiopathischen Erkrankung hingewiesen und auf die diagnostische Wichtigkeit dersel -
ben aufmerksam gemacht und vorgeschlagen dieses Uebel, wegen der präcisen Beur-
theilung, Leukoplakia (Rev/Ms weiss, mag Fläche) zu benennen. Während ich
früher ‘aus einer grossen Reihe von Schleimhautaffectionen auf 20 diesfällige
Beobachtungen mich stützte, bin ich heute in der Lage auf 50 einschlägige Fälle
mich zu berufen. Meine Auffassung in Bezug auf die histologischen Unter-
suchungen lehrte mich, dass die Zellwucherung ringsum die Gefässe beginnend,
den Anlass zur Ausbreitung und Persistenz des Prozesses bildet und die klein-
zellige Granulation von da aus ihre hauptsächlichste Nahrung ﬁndet. Dieses
Verhalten unterscheidet sich auch schon von den bei den syphilitischen Pro-
ducten nachweisbaren Zellinﬁltrationen, indem daselbst die Blutgefässe nicht in
dem Masse von Zellen durchsetzt werden, sondern mehr die obern Oorium- und
Papillarschichten inﬁltrirt sind, wenngleich hier wie dort die kleinzellige
Wucherung aufzuﬁnden ist.
Als aetiologisch wichtig fand ich in allen Fällen, entweder Erkrankungen von
Seite des Verdauungstractes oder vieles Rauchen und Genuss starken Tabaks zu
beschuldigen ; die Syphilis selbst kann auch als constitutionelles Moment dienen,
indem selbe namentlich die Disposition zu einer derartigen Erkrankung abgibt.
Besonders letzterer Umstand macht die Schwierigkeit in der Beurtheilung
einzelner Fälle so bedeutend. Doch zeigt eben die Therapie, dass die idiopa-
thischen Prozesse einer antisyphilitischen Cur eben nicht weichen, sondern in
ungeschwächter Stärke fortdauern.
Betreff der Therapie fand'ich in erster Linie Vermeidung aller Schädlichkeiten,
welche die kranke Schleimhaut noch mehr zu reizen vermögen, insofern von
günstiger Einwirkung, als ein Fortschreiten des Prozesses hierdurch verhindert
werden kann. Pflege und Reinhaltung des Mundes sowie der Gebrauch alcalischer
DISEASES OF THE SKIN. I73
Mundwasser erscheint von grossem Vortheil. Irritirende Behandlung durch starke
Aetzmittel zeigte sich im Allgemeinen nicht giinstig, hie und da pﬂegt einc starke
Lapislosung fiir kurze Zeit Ruhe zu schaﬂ’en, dauernde Heilung sah ich durch
dieselbe nie. Desto giinstigere Wirkung fand ich jedoch durch ortliche Behandlung
mit einer % o/o Sublimat- oder einer 1 0/o Chromsaurelosung und ich verfiige iiber
eine grossere Reihe von Fallen, wo’hierdurch eine anhaltende Besserung erzielt und
der Uebergang in die maligne oder krebsartige Form verhiitet werden konnte.
. DISCUSSION.
Dr. HILLAIRET, Paris, agreed with Prof. Schwimmer. The disease is not really
psoriasis. He had seen many cases in the last twenty years, and considered their
etiology obscure; the abuse of tobacco is, doubtless, a common cause. It occurs in
both syphilitic persons and those who have never suffered from this disease. It
is often the starting-point of epithelioma, is most obstinate, and even incurable.
The best results in alleviation are obtained by the application of chromic acid
(1 to 8), repeated for three or four days in succession, and subsequently at greater
intervals ; the mouth should also be frequently washed out with an alkaline
solution, such as Vichy water. ‘
Professor KAPOSI, Vienna, called attention to the distinction between the earlier
and later stages ; he had called the latter, in 1866, keratosz's mucosce orz's. It might
become epithelioma, not because the latter is due to syphilis, but because we have to
do with epithelial hyperplasia supervening on a chronic inﬂammation, which leads to
atrophy of the mucous membrane, He does not deny that similar affections exist,
due to other causes than syphilis—as gastric derangement, diabetes, anaemia——
among which he has’ seen cases with hyperaesthesia of the tongue; but he would
like to know what are the differential characters between Schwimmer’s non—
syphilitic leukoplakia and the aﬁection which he himself regards as having a
syphilitic origin. No distinction can be drawn by the results of treatment, as it
is certain that anti-syphilitic medication is without inﬂuence in cases of undoubted
syphilitic origin.
Dr. VIDAL, Paris, said that Leukoplakia buccalis was the best name for the
disease, which had nothing to do with psoriasis, ichthyosis, &c. He considered
it an idiopathic affection distinct from the chronic glossitis of smokers, and from
syphilis. It was characterized by pearly white patches, with abundant ﬂaky
desquamation, and by more or less deep and ulcerated ﬁssures ; microscopic examina-
tion shows flattening of the papillae, dilatation of blood-vessels, and proliferation
of embryonic cells in the corium, especially its upper layers. It does not occur
exclusively in smokers, and he had seen cases in women. It may be compared to
the chronic desquamation which sometimes precedes for several years epithelioma
of the face. Leukoplakia in its later stages may become complicated with
papillomatous growths, and should be looked upon as the first stage of epithelioma,
but is very slow, like the ﬂat rodent ulcer, which may remain localized for more
than twenty years. Chronic superﬁcial glossitis, due to tobacco, is less clesquama-
tive, and more commonly accompanied by lesions at the commissures of the lips and
inner surfaces of the cheeks. It may be cured by complete abstinence from
smoking. Syphilitic lesions have special characters; desquamation is less
abundant, and the epithelium cannot be removed in ﬂakes, as in idiopathic
I 74 DISEASES OF THE SKIN.
leukoplakia; the surface of the tongue has been well described by Fairlie Clarke
as separated into islands by longitudinal and transverse depressions, which are
mostly not ulcerated; the tongue feels indurated on palpation, which is not the
case in idiopathic leukoplakia. But diagnosis is difﬁcult when we have the three
conditions combined; in a person predisposed to idiopathic leukoplakia (nearly
always a rheumatic or arthritic subject) who is suffering from dyspepsia, we may
ﬁnd that smoking gives rise to superﬁcial glossitis, which may develop into
leukoplakia. This may be diagnosed if the lesion persists ﬁve or six months after
giving up tobacco. In syphilitics, the sensibility of the mucous membrane is
greater, and in these, also, the irritation of smoking will lead to the localization of
syphiloma. Abstinence from tobacco, and a prolonged antisyphilitic treatment, will
lead to gradual amelioration and even cure. Mercurials are most serviceable and
useful in differential diagnosis, as they are without influence on the early stages of
leukoplakia, are often injurious in the more advanced forms, and are invariably so
when there is a distinct epitheliomatous tumour. When this has been developed,
surgical treatment by removal is our only resource.
Mr. MORRANT BAKER, London, expressed his general concurrence with Professor
Schwimmer’s views. The affection was ﬁrst described in this country by Mr. Hulke,
and was familiar to English surgeons. It is not syphilitic, nor does it at all closely
resemble it; but it is too often diagnosed as syphilitic. It is, perhaps, not too much
to say that not one case in ten of those chronic affections of the tongue which are
hastily diagnosed as syphilitic are really clue to this disease. Syphilis is, of course,
one of the causes of the glossitis to which these very long-standing aﬁections
owe their origin, but it is not the most frequent.
Mr. CLEMENT Lucas, London, said the affection was known in England as
ichthyosis, or psoriasis—~both bad terms, as the affection bore no relation to the
above-named skin diseases. Professor Schwimmer admits syphilis as one of the
causes of the idiopathic affection; when this is the case there has generally been
recurrent superﬁcial ulceration for years from the secondary stage; this may continue
for ﬁve to thirty years before the white patches become permanent. The buccal
ulcers are at ﬁrst inﬂuenced by potassium iodide, but the later stages can only be
treated locally. Smoking is the common cause of the syphilitic affection becoming
chronic, and mercury often helps to keep it up. Smoking, alone, may also be the
cause of leukoplakia, and, further, the presence of foul teeth. He showed two
drawings, representing white patches on the cheeks and hard white patches on the
tongue; in the ﬁrst there was no syphilis, and the affection originated in bad
teeth ; the second, which was precisely similar, was taken from a patient who had
syphilis nineteen years ago, and had a child with distinct marks of the disease.
A circular ulcer on the tongue yielded to potassium iodide, but the white patches
remain. The importance of leukoplakia is that it terminates in epithelioma; it is
the result of chronic irritation, and although it may be idiopathic, we must admit
syphilis to be one potent cause of its production.
Dr. BEIIREND, Berlin, agreedwith Professor Schwimmer as to the existence of an
idiopathic affection of the oral mucous membrane, as described by him, which has
nothing to do with syphilis. He considered it syphilitic before Professor Schwim-
mer’s paper on the subject appeared, but was surprised at the inefﬁoacy of all
speciﬁc treatment, and was obliged to have recourse to caustics. He mentioned the
DISEASES or THE SKIN. I 75
case of a friend of his who contemplated marriage, but feared, although there
was no history of infection, that he was syphilitic, owing to the presence of opaque
white patches at both angles of the mouth, and on the inner surface of the lower
lip. A long and careful local and general mercurial treatment produced no
improvement. It was then discovered that the affection had appeared soon after
the insertion of a set of false teeth; on ceasing to wear these the patches rapidly
healed, but returned again on the false teeth being resumed.
Dr. L. DUNCAN BULKLEY, New York, remarked that the affection had been long
recognized in the United States as distinct from syphilis, and many cases had been
shown at the New York Dermatological Society. The term leukoplakia had been
used in the Archives of Dermatology about ﬁve years ago, but might have been
taken from Dr. Schwimmer. Dr. Weir, of New York, and others, had written on
this affection. He himself considered the affection might be quite distinct from
syphilis, and certainly it had no connection with ichthyosis, or psoriasis of the
skin.
The PRESIDENT observed that the Section was indebted to Professor Schwimmer
for directing attention to leukoplakia buccalis. The formation of blotches of white
epithelium was well known to us as a frequent complication of syphilis, and such
patches yielded with facility to the syphilitic treatment. But idiopathic leuko-
plakia remained entirely uninﬂuenced by syphilitic treatment, and exhibited a ten-
dency to take on those further changes of cell growth and development which were
apt to issue in epithelioma.
Professor SCHWIMMER, Buda-Pesth, in reply, stated that he had ﬁrst described
leukoplakia buccalis in 1877, in the Vica-z‘eljalm'essclw'ift fz'ir Dewnaz‘ologie. He con-
sidered the discussion to have conﬁrmed his views as to the idiopathic nature of
leukoplakia, and the frequent absence of syphilis as an initial cause.
Lymp/zade’rzz'e Cm‘mze’e.
Dr. VIDAL, Paris.
L’affection dont j’ai l’honneur d’entretenir la section a été particulierement
étudiée en France. Malgré sa rarete' j ’ai e11 l’occasion d’en voir six exemples dans
mon service et deux dans les salles de mon Savant collegue, le Dr. Hillairet.
C’est la malaclie désignée par Alibert sous le nom de mycosis fongo'ide, bien
distinguée par Bazin, qui dés 1862, en avait parfaitement décrit les symptomes
cliniques, et qui plus tard devait en tracer de main de maitre la nosographie dans
un travail auquel je puis renvoyer pour l’historique. (Art. Mycosis fongo'ide,
diathése lymphadénique 1876.)
G’est le lymphome ou lymphadenome de Virchow, produisant dans la peau
une alteration identique 2». cells de l’adénie de Trousseau (maladie de Hodgkin),
identique a celle qui a été signalée dans les ganglions, dans les amygdales, dans la
rate, le foie, les reins, les os, &c. Gette lesion est caractérisée par la production
anormale d’un néoplasme adénoide (tissu adéno'ide de His) avec reticulum lym-
phatique, dont les mailles sont remplies de cellules embryonnaires et cl’éléments
176 DIsEAsE's OF THE SKIN.
lymphatiques. Pour bien voir les mailles du reticulum lymphatique, il est néces-
saire de brosser avec soin avec un pinceau. C’est ce mode de préparation, bien
indiqué par notre illustre histologiste Ranvier, qui lui a permis en 1869 de recon-
naître que le mycosis fongoïde est un lymphadenome de la peau.
M. Hillairet vous exposera les symptômes et la marche de cette affection, dont
la terminaison est pour ainsi dire toujours mortelle. J e ne connais qu’un exemple
de guérison, a la suite d’une érysipèle, observé et publié par Bazin.
De tous les moyens que j’ai essayé comme traitement local, le seul qui m’ait
donné des résultats satisfaisants est la pommade avec vaseline 5, acide pyrogallique 1;
sous l’inﬁuence de cette pommade j ’ai obtenu la résolution des tumeurs et l’appa-
rence de guérison.
N.B.—La pièce de mycosis fongoïde de la jambe et du pied (Museum of Royal
College of Surgeons), modelée sur un malade du service de M. Vidal (hôpital St.
Louis) ne représente pas un mycosis fongoïde, mais bien un exemple de sarcomes
multiples de la peau—dermato-sarcome généralisé (sarcome érectile).
M. HILLAIRET, Paris: Cette affection, confondue par Bontius et étudiée sous le
nom d’affection fongoïde, a été classée par Alibert dans les dermatoses véroleuses.
Bazin en avait fait une diathèse sous le nom de diathèse fongoïde. Hardy l'avait
confondue avec le lichen hypertrophique.
Le début peut avoir lieu par un état eczématiforme chronique, ou un état
lichenoïde, puis se forment des tumeurs, les unes lisses, les autres mamelonnées
comme une tomate, d’autres petites, pyriformes. Les tumeurs grossissent, puis
s’ulcèrent par un point; l’ulcération se fait très-rapidement. Elle peut envahir la
glande mammaire qui devient d’une dureté presque cartilagineuse. D’autres fois,
les tumeurs se résolvent, s’affaissant avec une rapidité excessive; l’affection semble
marcher vers la guérison, puis tout d’un coup les tumeurs reparaissent et s’ulcè-
rent ; bientôt arrive la période cachectique—c’est alors seulement que l’on constate
la dérivation des globules rouges et l’augmentation quelquefois considérable des
globules blancs (leucocytes)-—bien que quelques auteurs aient avancé que les
leucocytes se cleveloppaient dès le début de la maladie, et en constituaient le
caractère essentiel, ce qui les avait déterminé à les comprendre dans l’histoire de
la leucocythémie. Mes recherches m’autorisent a dire que la leucæmie, dans cette
affection est tout a fait secondaire et l’un des caractères de la période cachectique.
La terminaison de cette affection se fait de différentes manières. Les accidents
hémorrhagiques sont les plus habituels.
DISCUSSION.
Prof. KAPOSI, Vienna, believes that the disease described by Vidal and Hillairet
may be the same which has been described by him under the name of Sarcomatosz's
generalis of the skin; by Geber as a special form of fungoid dermatitis of the skin;
by Duhring under the above-mentioned name.
Prof. OSCAR SIMON, Breslau, remarked that he had seen several cases of this
disease, which he calls granuloma multiplex, Cases of it are described by Geber,
Duhring. and others. The microscopic structure is the same as that which M. Vidal
has described. But as to the etiology, he found that nearly in all cases the patients
were for years before, eczematous or psoriatic. He believes that the tumours are
the result of malignant proliferation of connective tissue in chronic eczema or
DISEASES OF THE SKIN. I 77
psoriasis, in the same manner as epithelium can tend to malignant epithelial
growth (epithelioma) in leucoplakia. He has treated the disease with ac. pyro-
gallicum T15. He found that tumours disappeared, but came again, The disease
is always malignant, and ends in death.
0% Prumlgo, 01/ Eczemaz‘ous Pi/m/zgo.
Mr. W. MORRANT BAKER, London.
In the present brief communication I am desirous of drawing attention to a
disease of which I have seen many examples during the last few years, and which,
as I gather also from conversation with others, is not very rare in this country.
The leading feature of the disease, as commonly seen, is eczema, wide-spread and
most intractable. The face and upper part of the neck, the arms and forearms, the
thighs and legs, usually their extensor surfaces, are the parts most affected; but
the trunk does not escape, and the disease may be as had here, in patches, as
elsewhere.
The eczematous patches, as usually seen, are partly scabbed, partly raw, here
and there pustular, especially at the margins; while their outlines are suggestive of
the scratching to which they have been subjected. But, on looking more closely, it
is obvious that the term eczema does not express all that is present. Between and
around the patches of eczema the skin is more or less thickened and dry and, on
passing the ﬁnger over it, it feels rough and sand-paper-like, or even prickly, but
often it seems as if the rough papules were seated on a glazed and almost scar-like
base. In some parts the skin is merely dry and a little scaly, as if xerodermatous;
and, again, a large tract of skin may be healthy, especially on the ﬂexor aspects of
limbs.
The intense itching to which the patient is subject is represented by lines of
scratched skin more or less marked, and the pruriginous aspect is heightened by the
tiny blood-topped hard pimples which are scattered in the neighbourhood more or
less profusely. Scattered pustules are also not rare, and the disease may bear a
close resemblance to scabies.
The lymphatic glands corresponding with the diseased districts are enlarged; the
femoral the most notably. Pigmentation has not been a very marked feature in
more than a small proportion of the cases which I have seen.
The general health is not very much affected, but sometimes the patients are
anaemic.
In all the cases which I have seen the disease is said to have begun in early
infancy, and to have continued with merely remissions since that time. And in no
case have I seen any other than temporary beneﬁt as the result of treatment.
I have described thus brieﬂy the characters of the disease for identiﬁcation, but
have avoided minute details, as my immediate object in bringing these cases before
the Congress is that I may obtain an expression of opinion as to whether these
cases are identical with those to which the late Professor Hebra more particularly
applied the term Prurigo.
I had been long familiar with the disease before I had begun to associate it in
my own mind with Prof. Hebra’s prurigo; and I am indebted to Dr. Buchanan
Baxter, with whom I saw one of the cases in consultation at the Evelina Hospital,
PART III. N
1 78 DISEASES or THE SKIN.
for the information that such cases had been called prurigo by dermatologists from
the Continent who had seen them in England. I have since discovered that others
had come to a similar conclusion ; and I may refer especially to Dr. Liveing, who,
in the last edition of his work on the diseases of the skin, calls attention to the
existence of cases of Hebra’s prurigo in England, and to the causes which have led
to its being‘ frequently overlooked.
Dr. Liveing remarks :—“ The malady has hardly received the attention and
recognition that it merits from English observers. Some modern writers deny
altogether its existence in England. There can be little doubt that by many the
disease is not recognized from Hebra’s description, and indeed this is scarcely to
be wondered at. . . . . There are several reasons why we often fail to ﬁnd what
I may call the typical eruption of prurigo. (1) The papules he describes (they
have not at all the appearance of vesicles) exist as such only for a very short time,
and they are quickly injured by the scratching of the patient; this fact, together
with the constant presence of excoriations, eczema, and other changes in the skin,
makes it difﬁcult to ﬁnd them ; (2) The large papules, though pale, are not
always of the same colour as the surrounding skin, but often of a distinctly redder
tint; (3) Hebra has, for the purpose of diagnosis, laid too much stress on the
elementary form of the eruption, and not enough, by comparison, on the history of
the disease, which is, after all, a more important diagnostic featuref’i’s
At the same time, I may quote the following remarks as a justiﬁcation for my
endeavour to elicit opinions on this subject :——-Mr. Hutchinson, whose opinion on
any matter connected with diseases of the skin is entitled, as all will acknowledge,
to the profoundest attention, has devoted a chapter, in his “ Lectures on Clinical
Surgery,” to the question, “ Is Hebra’s prurigo met with in English practice P” and,
as all here are aware, he replies in the negative.
Dr. Duhring, in the last edition of his work on “ Diseases of the Skinf’j" re-
marks :—“ Prurigo, as described by German writers, is an aﬁection so rare in
England and the United States as scarcely to exist in those countries.”
Dr. Tilbury Fox, in the third edition of his work on “ Diseases of the Skin”
(1873), says :——“ I have been on the look out for a case of the most marked form of
disease, such as Hebra describes, for years past, and have only met with one
case in England.”
The question therefore arises, “ Is the disease here referred to, and of which I
exhibited cases on Saturday last to the members of the Congress, the prurigo of
Professor Hebra P” If it be so, then we must give up the_very generally accepted
belief that prurigo is rare in this country; although, to judge from Professor
Hebra’s description of typical cases, the disease would appear to exist amongst us
in a far milder form, in most cases, than on the Continent. If, on the other
hand, the disease be distinct from Hebra’s prurigo, we have before us, I venture to
think, a variety of prurigo to which the terms eczematous prurigo and pruriginous
eczema seem about equally applicable, and which deserves a recognition which
has not yet been accorded to it. The symptoms appear to me to be quite distinc-
tive from those of any other disease. So far as I nave been able to observe, it is
quite a different malady from infantile prurigo, or lichen urticatus, with which
one is tempted to ﬁnd an alliance.

* “A Handbook on Diseases of the Skin.” By Robert Liveing, M.D. 1880. P. 141.
'f‘ “Diseases of the Skin.” By Louis A. Duhring, M.D. 1881. P. 247, note.
DISEASES or THE SKIN. I 79
I believe it to be also distinct from the relapsing prurigo of Mr. Hutchinson ;
but regarding this I will not venture to speak with conﬁdence, as I have not had
an opportunity of seeing cases to which I am warranted in saying that Mr. '
Hutchinson would apply the term.
Instead of occupying the time of the Section by the narration of cases, I have
exhibited living examples of the disease to which I venture to call attention.
DIS GUS SION.
Prof. KAPOSI, Vienna, stated that the three cases shown by Mr. Baker were un-
doubtedly true prurigo of Hebra, and therefore the disease exists in England. The
reason of its being often overlooked was that too much stress was laid on the colour
of the papules, and not enough on its total characters. Prof. Hebra attached much
importance to its localization on the outer surface of the extremities, to its increase
in severity from above downwards, so that the legs were most affected, and to its
beginning during the ﬁrst year of infancy. It does not commence as a papular
eruption, but by urticaria, which becomes localized in the second year in the above-
mentioned positions; papules now make their appearance, and the disease is
established, but we are unable to say whether the case will be prurigo agria or
prurigo mitis. Hebra’s statement that the disease is incurable requires modiﬁca-
tion. Prurigo mitis, when treated from its earliest onset, and for some years
continuously, is undoubtedly susceptible of complete or nearly complete cure.
Dr. HEBRA, Vienna, had often wondered that prurigo was not diagnosed in
England, as Willan was the ﬁrst to describe the affection. He thought that was to be
attributed to the fact that attention was directed only to the eczema, without taking
into account its cause—excessive itching. Eczema is only one symptom of prurigo,
and may be absent at the time of examination, especially if proper treatment has
been previously carried out. Prurigo must be viewed as a sort of diathesis, which
occurs chieﬂy in badly nourished individuals of the poorer classes, and in the
children of tuberculous parents. The'papules of the same colour as the skin, de~
scribed by Willan and Hebra, have been lately considered to be due to scratching,
and very recently Auspitz has viewed the pruritus and harshness of the skin as
caused by a special congenital sensory neurosis. If we bear in mind the well-known
features of prurigo, it will certainly be diagnosed as often in London as in Vienna.
Dr. Hebra had already seen several undoubted cases at St. Bartholomew’s Hospital.
Treatment is only eﬁectual when‘ commenced in early infancy.
Mr. MALCOLM MORRIS, London, pointed out that Mr. Baker had not mentioned
the age to which the disease lasted. Mr. Hutchinson had denied that Hebra’s prurigo
existed in this country, because no case had been reported lasting beyond the age of
twenty-one years, whereas Hebra’s prurigo lasted for life.
Dr. IiIvEINe, London, said he had met with cases lasting to thirty years of age.
Dr. CAvAEY, London, had now one case under his care aged over thirty years.
Dr. WALTER SMITH, Dublin, had seen prurigo in a gentleman who is now omen-
twenty-ﬁve. He had seen cases of prurigo unaccompanied by eczema.
n 2
180 DISEASES or THE SKIN.
The PRESIDENT observed that his diagnosis of the cases which had been brought
under the notice of the section by his colleague, Mr. Morrant Baker, was one of
chronic eczema—an infantile eczema, which had continued to infest the skin from
a very early period of life. Eczema, like other diseases, presented several factors,
amongst which two of the most prominent were pruritus and exudation, and these
two factors in some sort counterbalanced each other. Now, in the cases before us
exudation had ceased, although inﬁltration was present, and precisely that state of
the tissues remained in which pruritus was in excess. This state of the skin would
warrant such an appellation as pruriginous eczema, but not that of eczematous
prurigo. Prurigo was essentially a neurotic affection, perfectly distinct in its
pathological nature from eczema; and it should be the effort of dermatologists to
keep them as separate as possible.
Dr. SANGSTER, London, would like to allude to the condition of xeroderma noticed
by Mr. Baker. He had heard it said that ichthyotic patients were liable to frequent
attacks of eczema, and had veriﬁed this statement, not in ichthyosis, but in xero- ‘
dermia, which is its mildest form. He now had a patient under his care whose
skin was markedly xerodermic; she is now suffering from eczema, and has not been
free from it for some years. Her skin is now thickened and pigmented, especially
on the arms. She has a sister who is also aﬁected with xeroderma.
Dr. L. DUNCAN BULKLEY, New York, thought that a certain confusion had been
made between prurigo and pruritus. He would be sorry to have the prurigo of Hebra
deprived of its characteristic features as described by Hebra himself, for he believed
that the cases seen under this name in Vienna represented a peculiar and well-
marked disease, quite different from those met with in other countries. The alfection
was certainly very rare in the United States, not more than two or three well-authen-
ticated cases having been reported, although the disease was known to American
dermatologists, who had learned to recognize it in Vienna. The speaker had not seen
many cases elsewhere which he would be willing to call prurigo; many of those
thus called he would denominate papular eczema, while others were but pruritus or
pruritus hiemalis. He was familiar with the affection spoken of as lichen urti-
catus, or, more properly, urticaria papulosa, and thought that these cases should be
very carefully differentiated from prurigo.
Dr. UNNA, Hamburg, said that the description of prurigo vera given by Mr.
Morrant Baker and Dr. Liveing completely agreed with the disease as seen by him
in Hamburg.
Prof. OSCAR SIMON, Breslau, did not agree with Dr. Bulkley that true prurigo is
only to be seen in Vienna ; it is very common in Breslau and Berlin. The features
of the disease are those pointed out by Hebra, who, however, described not only
prurigo agria, but also prurigo mitis. He had some years’ favourable experience
of pilocarpine in the treatment of this disease; most of the cases either not
having relapsed, or only in a slight degree.
Dr. ALLAN J AMIESON, Edinburgh, asked, since the features of Hebra’s prurigo had
now undergone some alteration, as described by Prof. Kaposi and Dr. Hebra,
DISEASES OF THE SKIN. 1 81
I
whether we might not proceed a step further, and believe that sometimes prurigo
might commence late in life, and not invariably in infancy?
Prof. KAPOSI, Vienna, replied that in his experience prurigo never begins in
later life. That which is seen in children before the age of two months is not true
prurigo, but eczema, and is curable. It is sometimes called prurigo infantum.
Mr. MORRANT BAKER, London, replied that he was very glad there was a general
agreement among the speakers that the cases which he had exhibited were really in-
stances of Hebra’s prurigo, although he regretted that the President of the Section
took a somewhat different view of their nature. His reasons for believing that the
disease was different from lichen urticatus of children were chieﬂy that he had seen
complete and rapid recovery in cases of lichen urticatus, or infantile prurigo, when
they were admitted into a hospital, and that the symptoms seemed essentially differ-
ent when cases of true prurigo and of lichen urticatus of children were compared
in patients of like age. He was not disposed to believe that the disease was due
to a neurosis only, although the symptoms were doubtless much exaggerated by
the secondary results of the irritation from which the patient suffered. Mr. Baker
said he had seen cases of prurigo without eczema, such as those referred to by
Dr. Walter Smith; and he had seen two cases of what he could term nothing else
but prurigo, the ﬁrst symptoms of which occurred in adult life; the patients were
two sisters.
0% a Case 0f {/26 066257767266‘ 0f Dz'pz‘erom Law/a? 2'12 Z/ze
Human Skin.
Dr. WALTER G. SMITH, Dublin.
Some months ago my friend, Dr. Whittaker, of Valentia, co. Kerry, forwarded
to me two specimens of a grub, preserved in glycerine, which he had extracted in
the living state from the skin of a young girl under his observation. With the
larvae he was good enough to send an interesting account of the child’s case, which
I have his permission to publish.
Catherine G., twelve years of age, thin, pale, and delicate, was brought to
Dr. Whittaker by her mother, on the 25th of November, 1880, with the following
history. Two or three months previously, a swelling about the size of a pigeon’s
egg appeared on the outer ankle ‘of the right foot, causing her some pain and
uneasiness in walking. By degrees this tumour slowly moved up the leg and
thigh, towards the body, and thence to the right axilla. From this it travelled to
the right elbow, then back to the axilla, the right breast, and ﬁnally to the back of
the neck on the right side. In this situation a small dark spot appeared in the
centre of the tumour, which then subsided, leaving in its place a small welt.
The dark spot developed into a small oriﬁce, and the girl, upon pressing the welt,
gave exit to a grub along with some semi-purulent matter. A few days afterwards
a swelling similar to the ﬁrst appeared a short distance from the place last named
(back of the neck) and again disappeared leaving behind it a welt as before.
When Dr. Whittaker saw the girl, his attention was drawn to this peculiar welt,
and to the ﬁnger it felt as if there were a piece of whipcord coiled under the skin
in the subcutaneous cellular tissue. In the centre was a small oriﬁce, and by
pressing the little swelling between the ﬁnger and thumb a white grub, about one
182 DISEASES or THE SKIN.
inch in length, annulated and alive, protruded through the opening, and escaped
along with a quantity of dirty-looking pus. The girl said that she expected the
tumour would next appear somewhere in the sternal region, as she could generally
tell by an uncomfortable sensation or a feeling of soreness whereabouts it was
likely to appear. On the 3rd of December she returned and informed the doctor
that the swelling, as she had anticipated, did appear a day or two after her previous
visit, over the lower part of the sternum, from whence it travelled to the right
axilla, and thence to the inferior angle of the right scapula. Here it remained for
three days, and then slowly decreased, the usual welt and oriﬁce remaining behind;
pressure upon the welt gave egress to another grub exactly similar to the ﬁrst
specimen. The patient’s mother could assign no cause for this curious phenomenon.
All the other members of the family are healthy, and the child enjoyed good health
up to the time when the swelling ﬁrst manifested itself, but since that she had
failed a good deal in her general condition and had lost ﬂesh.
December 9th.—The child was brought back by her mother, who said that the
swelling appeared last night in the right side, moved up to the right axilla,and thence
down the right arm. Upon examination an undeﬁned swelling was visible at the
back of the right arm above the elbow. This part had a brawny feel, was tender
to the touch, but exhibited no redness of the surface. The girl was kept under
observation for some days, and Dr. Whittaker ascertained that the swelling rapidly
migrated to the deltoid region, and in a few hours more removed to the neighbour-
hood of the right acromion.
Dec. 11th.—The swelling seemed more superﬁcial and had moved to the left
of the spine of the right scapula. At this juncture, unfortunately, the child left for
her own home, and on Dec. 22nd was brought back by her mother, who stated
that a few days after returning home, the right side of her daughter’s head and
face swelled and became discoloured, and the right eye was closed. Subsequently
the peculiar tumour appeared on the right side of the forehead, ran the usual
course, and yielded on expression a grub similar to the former specimens. After
this date the patient ceased her attendance, and nothing more was heard of the
case. It may be noted as a curious fact that all throughout only the right side
of the body was affected.
Rcmarka—The authenticity of the above curious and rare case being above
question, the points of interest that suggest themselves are, how and when did the
eggs or grubs gain access to the patient’s skin, and to what genus should the
larvae be referred. Upon the ﬁrst point I can throw no light. I submitted the
specimens (which I now exhibit) to some of my zoological friends, who were
Fig. 8.


Dipterous larva. Drawn with camera, under 2-inch objective,
unable to give me any deﬁnite information, beyond assigning the larvae to the
dipterous order of insects. The largest in my possession is 9 mm. in length and
about 2 mm. in breadth.
A number of cases of the development of dipterous larvae beneath the surface of
the human body are reported in medical literature, but their zoological identiﬁca-
DISEASES or THE SKIN. 1 8 3
tion is unfortunately shrouded in considerable obscurity. Humboldt gave the
name of CEstrus humanus (O. hominis) to a parasite by no means rare in the
south of America, and which is met with upon the arms, back, abdomen, and
scrotum of man; but as Kiichenmeister‘x‘ points out, there is not sufficient
justification for this nomenclature. Wagnert brieﬂy states that (Estrus hominis
lays its ova in the skin of man, giving rise to boils. In an interesting article on
the so-called CEstrus hominis, Dr. S. Schreiberi maintains that all the cases of
reported (Estrus larvae in man‘in Europe have, on closer investigation, turned out
to be larvae of the genera Musca,§ Anthomyia, Lucilia, Sarcophaga, 4850., especially
' whenever tested by breeding experiments. It is further very probable, or indeed
certain, that when maggots have been found in man in boils under the skin, in the
frontal or nasal cavities, wounds, 850., they only rarely correspond with larvae
of the four genera of the (Estrus family known in Europe (CEstrus, Hypoderma,
Aphenomyia, and Gephalomyia), but have either forthwith been taken for CElstrus
hominis or for larvae of Hypoderma bovis.“ All the hitherto certain and credible
descriptions of‘ larvae found in boils beneath the skin of man, and actually proved to
belong to CEstrus, emanate exclusively from the south and middle of America,
where they are known as “ver macaque,” “Torcel,” &c. There is no CEstrus
hominis proper to man only, as yet proven.
At a meeting of the Glasgow Pathological and Clinical Society Dr. John
Young showed, for Dr. M‘Galman, some larvae removed from a girl who, on
December 17, 1878, began to suffer from severe gnawing pain in the left elbow,
attended with slight febrile disturbance. The elbow was swollen, and there was
no history of injury. The swelling soon subsided under fomentations, and she
felt quite well until January 17, 1879, when she experienced acute pain in the
right forearm, with slight swelling. This also subsided, after extending to the upper
arm, but on the twenty-third day a larva was noticed making its way through the
skin, above the elbow, and was extracted by Dr. M‘Oalman. It had been preceded
by a small vesicle, which the patient destroyed with her nail. Three days later a
dusky blue tract was observed extending in a sinuous course from the middle of
the forearm to the point of exit of the larva. The animal was an undoubted
dipterous larva. (British llfedical Journal, July 19, 1879; Archives of Derma-
iology, April, 1880, p. 174.)
Compare with the above the interesting case, reported by Dr. Fischer, of a
peculiar squamo-vesicular skin disease, caused by the intrusion of a hymenopterous
insect on the skin of an old lady. (British Medical Journal, March 20, 1880;
from Deatsche Med. l'Vochensclwx, October 25, 1879.)
In Dr. (lobbold’s work on Entozoa, a formidable list is given of insects and
their larvae which have been said to have taken up their residence in the human
body, and I append a few references bearing upon the subject of my communi-
cation :—

* “Manual of Parasites,” Syd. Soc., 1857, p. 94.
1' “ General Pathology,” p. 130.
1' Virchow, Archi'v, xxvi. (1863), p. 209.
' § A solitary larva of a species of Musca took up its residence in Dr. Livingstone’s leg.
Dr. Kirk removed the parasite by incision, and on a second occasion he obtained a similar
specimen from the shoulder of a negro. —OOBBoLD, “ Entozoa,” p. 420.
[I Dr. J. M. Duncan has recorded a case of CEstrus bovis occurring in the human sub-
ject.--00;BBOLD, “ Entozoa.”
I84 DISEASES or THE SKIN.
Duncan, Dr. J. M., “On Bots :” Edinburgh Veterinary Review, i. 1858-59;
Monthly Journal of Medical Science, July, 1854.
Spence, G. N ., “ On CEstrus :” Edinburgh Medical Journal, 1858; Edinburgh
Veterinary Review, i. 1858—59.
Lessona, G., “On the Bot of the Horse :” Recueil dc llfe'd. Vét. ; Veteri-
narian, xxxvi. 1850.
Gamgee, l, “ On Bots :” Edinburgh. Veterinary Review, July, 1858.
Clark, “ On CEstrus ;” Linn. Trans, iii. 1797.
Do., “ On Bots :” An Essay. London, 1815.
Howship, “ On QEstrus :” Medical and Ohirurgioal Society, 1832.
A Case of Supposed “Nenroz‘z'c Excor/zaz‘z'on.”
Dr. ALFRED SANGSTER, London.
The case about to be described was originally brought before the Clinical
Society of London three years ago as one of abortive herpes.
The sequel, however, has led me to think that the eruption (if genuine) is one
of a most rare class to which the name “Neurotic Excoriation ” had already been
applied by Mr. Erasmus Wilson.
Moreover, I thought the further history of the case of extreme interest and
worthy of record. When ﬁrst seen by me, the patient was a delicate-looking little
girl, aged 13, very nervous, and shy in her behaviour. She presented herself at the
Out-patient Department of Oharing Cross, with a sharply margined patch of sero-
purulent incrustation on the back of the left forearm; the patch was oval in
shape, and measured 1%; inches in its long diameter. She at this time also showed
two smaller livid and desquamating patches on the back of the left hand ; these,
she said, had presented a similar appearance to the patch before described. N o
diagnosis was made. In a few days she returned with a patch about the size of a
half-crown on the forearm of the same side, but nearer to the elbow. The appear-
ance of this lesion was so peculiar that some artiﬁcial mode of production was at
once thought of. It was abruptly margined, and erythematous, hot, and painful
to the touch, not raised, or exhibiting any readily appreciable inﬂammatory
hardening or thickening of base.‘
Occupying almost the entire area of the patch was an unbroken and thin pellicle
of dry, tawny-coloured epidermis, presenting a quite even appearance as to colour
and surface. The patch looked as if it had been painted with some rather mild
escharotic; the tawny brownish epidermis representing the part acted on by the
chemical, the surrounding erythematous margin the halo of inﬂammation. It
corresponded to no type of disease known to me. In a day or two the pain and
heat subsided, the erythema disappeared from the margin, and there was left at the
part a thin epidermic cake; soon this cracked, serum and Sero-pus exuded through
the cracks, and, drying on the surface, produced the heaped-up crusts before alluded
to. Finally, in about ten days the crusts fell off, leaving the part livid and desqua-
mating, but with no loss of substance. The rest is soon told. The girl has been
under my observation off and on for a period of three years; during that time
patches such as I have described, running a typical course of ten to fourteen days,
have continued to make their appearance; three months is stated to be the longest
DISEASES .011‘ THE SKIN. 185
interval during which she has been free from them. Twice has she been in Charing
Cross Hospital, carefully watched, and such means adopted as were permitted by
her mother to establish the genuineness or artiﬁcial character of the eruption.
During the patient’s stay in the Hospital the legs were bandaged, and the
bandage secured by plaster, so as to prevent their being tampered with: notwith-
standing, patches came out beneath the bandages, but so high up near the edge of
the bandage that I could not say positively that the ﬁngers or some instrument
might not have been introduced beneath. ()f one thing I was sure—namely, that the
appearance of these lesions beneath the bandage negatived the theory of their
production by painting on some chemical substance, as had been suggested.
I have examined debris from the patches microscopically, without result. From
time to time I have noticed ecthymatous lesions between the patches such as
never would arouse suspicion. On one occasion, when the case was seen by Dr.
Liveing, such lesions were present.
Although the patches were most abundant on the extremities (often taking a
ribbon-like form, and always in the long axis of the limb), my notes record others
on the trunk, and even in positions such as the scapular region, hard to get at.
The patient was above twelve years old when I ﬁrst saw her. At this time there
was nothing marked in her behaviour. Soon, when she found out that she was
suspected of fraud—for it was impossible to keep our suspicions from her—she
became morose, surly in her replies, and answered with head averted. Her mother
states that she is a very wayward and disobedient child.
She has an hysterical look. I have never seen her cry, nor have I ever been
told (as I should have been) of ﬁts or hysterical attacks. There was something
said about her having had two ﬁts when she ﬁrst came under notice, but these
were more of the character of “ faints,” certainly not of an hystero-epileptic
nature.
At times there has been difficulty in making her take food, according to
the mother’s statement. She commenced to menstruate about eighteen months
ago, and the periods are said to occur at fortnightly intervals.
She has grown rapidly, and is now well nourished, without any signs of cachexia.
She has never evinced any desire to show the patches; on the contrary, has
only done so reluctantly.
She has taken iron, antimony, arsenic, valerianate of zinc, 850., without the least
effect, guoad the eruption. '
DISCUSSION.
The PRESIDENT observed that he should regard Mr. Sangster‘s case as thoroughly
genuine, and free from any intentional participation on the part of the patient. It
was a case of erythema somewhat like erythema nodosum in ﬁgure, with slight
sanguineous effusion beneath the cuticle, which, adhering to the dried cuticle,
gave rise to the peculiar appearance of the thin crust. This slight effusion of blood
might, doubtless, be occasioned by the action of the nails; but the nails or friction
could not produce such a lesion in the absence of a peculiar condition of the skin,
and a peculiar state of the constitution of the patient, such as we are in the habit
of denominating hysterical. An erythema circumscriptum, in an hysterical
patient and with an exudative condition of the skin, would, he believed, explain
all the symptoms of the case. This was not precisely the form of disease to which
he had given the name of Neurotic excoriation, although it was undoubtedly allied
I 86 DISEASES or THE SKIN.
with it distantly. The neurotic excoriations were a form of prurigo associated
with superﬁcial vesication of the skin and an effusion of blood when rubbed or
scratched. The neurosis produced both itching and superﬁcial exudation; very
slight pressure, or the action of the nails, did the rest—that is, broke the vesicated
surface and occasioned the haemorrhage. Then the neurotic excoriations were
chronic, and crept along the skin, presenting at the growing end a semilunar
border, and leaving behind a trail over which they had slowly crept. \The points
of interest in all these cases were :—The neurotic affection, sometimes indicated by
severe itching; then that other well-known accompaniment of neurosis, effusion
of serum or lymph, as in herpes; and, next of all, haemorrhage. Thus we have
formed a chain, of which one extremity is represented by simple prurigo, in the
middle there may be herpes, and at the other extremity those haemorrhagic
excoriations which have been noted in Catholic countries and amongst religious
women under the name of bleeding stigmata.
Dr. R. LIVEING, London, had observed Dr. Sangster’s case for a long time, and
had come to the conclusion that the lesions were artiﬁcially produced, owing to the
very great variety of eruptions shown, but there was also probably an extra-sensitive
condition of the skin. Two years ago the case was certainly very like the neurotic
excoriation of Wilson. He had lately seen two somewhat similar cases; in one
the eruption was situated on the face and accompanied by marked hysteria—it was
completely cured by valerian; the other was a case of hysteria with hasmatemesis,
in which haemorrhagic patches appeared on the face and on the arms. Haemor-
rhage in this case was produced with the greatest ease by very slight suction
of the skin, which was therefore probably in an abnormal condition.
Dr. UNNA, Hamburg, said that the excoriation which he saw in Dr. Sangster’s
case impressed him as artiﬁcial, because it was bounded by sharply deﬁned recti-
linear margins.
Prof. Oscnn SIMON, Breslau, stated that Appenbrodt had described a very
similar case as a vaso-motor neurosis, in which all possibility of artiﬁcial production
was rigidly excluded.
Dr. THIN, London, believed that if the girl’s hands were kept tied behind her
back there would be an end of the eruption. He had seen the patient some months
previously, and was shown an oblong erythematous patch on the thigh, with four
lines of excoriation running parallel from one end of it to the other, produced,
as he believed, by the girl’s four ﬁnger nails.
Mr. SrAnTIN, London, had a similar case in a little child, in which the eruption
appeared to follow the course of the superﬁcial nerves of the abdomen and front of
thigh. No doubt imposture might easily produce similar appearances; he had
seen them follow the application of mustard.
Mr. Monannr Bnxnn, London, said he agreed with the opinions generally
expressed by others that Dr. Sangster’s case was one of an eruption artiﬁcially
produced. And he would lay especial stress upon the shape assumed by some of the
patches upon the patient’s arm, which had a quadrilateral outline—an outline which
could scarcely be present in an eruption the result of real disease. He thought the
DISEASES or THE SKIN. 187
term neurotic excoriation would be allowable if it were taken to indicate that the
neurotic element was essentially cerebro-spinal, and the excoriation the result of
artiﬁcial irritation of the skin. Perhaps a better term still would be “ neuro-
mimetic ”—a term which Sir James Paget had some years ago suggested as a good
equivalent for what is commonly called hysterical.
Mr. GASKOIN, London, was acquainted with linear and quadrilateral forms of
erythema which he did not consider artiﬁcial.
Dr. SANGSTER, London, in reply, was glad the President thought the case genuine.
The case was probably partially hysterical, but mechanical irritation produced
effects which would not occur on a healthy skin. The patient had often been care-
fully watched for a long time without fraud being detected. N o lesions had ever
appeared on the face.
Prof. KAI’OSI, Vienna, suggested that it might be a case of urticaria bullosa with
abortive bullae. '
A Cr/z'z‘z'cal and Hz'sz‘m/z'cal Essay on the SweaZ-Seca/ezfz'on.
Dr. UNNA, Hamburg.
Although the parts of the nervous system which are concerned in the production
of sweat have been deﬁned by recent physiological research, which has also shown
the mutual independence of circulatory and sweat-phenomena, yet the old puzzle
of “ cold swea ” and “ dry heat” are for each individual case still involved in
obscurity. This failure on the part of a one-sided nerve-theory has led the author to
undertake a criticism of the opinions hitherto held as the basis of the ordinary
theories of the sweat-secretion. It has not been shown, either by physiology or
pathology, that the sweat which exudes from the sweat pores comes exclusively
from the sweat coils, nor does such a conception harmonize with the facts of com-
parative anatomy. No one has hitherto contested that there exists an unbroken
histological series of gradations between the ordinary sweat glands and the glands
surrounding the anus, in the axilla and the wax-glands of the ear, and that the
latter continually, and the former intermittingly, pour out a secretion containing
mucus, fat, or pigment. The watery element of the sweat, on the other hand, which
no one has yet followed from the coil to the mouth of the duct, must in part be
drawn from the blood-vessels of the papillary layer, perhaps also partly from those
surrounding the duct, and from the rete mucosum, there being free communication
between the inter-epithelial spaces of the prickle-cell layer and the lumen of the duct.
The sweat is therefore a mixed ﬂuid, derived from different sources, and its reaction
varies according to its composition. Nerve-physiology has only shown that the
sweat secretion is independent of blood pressure, and of the rapidity of the circula-
tion, but not of the circulation as a whole, and the theory which holds that the
sweat coil secretes watery sweat under continual nerve-stimulus must be rejected.
The best theory is that derived from a vaso-motor and a musculo-motor hypothesis,
which explains the action of the involuntary muscles connected with the gland,
the remarkable transitions between fatty, mucoid, and pigmented sweat, and
especially the phenomena of “ cold sweat.” The “ dry heat,” on the other hand,
which is observed chieﬂy in general febrile states, and in certain skin diseases,
I 88 DISEASES or THE SKIN.
requires other factors outside the range of the nervous system for its explanation.
Amongst these the expansion by heat of the horny layer of the epidermis specially
deserves attention, as by this means the cleft-shape lumen of the canal in the
stratum lucidum is shut.
WVe are thus led to a wider view of the sweat secretion, and to the idea of a
division of labour amongst the different sweat-producing organs. The conception is
calculated to throw new light on certain skin diseases.
DISCUSSION.
Prof. OSCAR SIMON, Breslau, remarked that Dr. Unna had assigned too unimportant
a role to the sebaceous glands. He had himself made experiments which showed the
inﬂuence of the nerves on the sebaceous glands. It is impossible to do this in man;
but there is an analogous gland on the back of the duck, the nerves of which can
be easily laid bare, and by stimulating these nerves by an electric current, seba-
ceous secretion follows. Further, he did not think that the oily impregnation of
the skin came from the deeper parts. In seborrhoea oleosa it can be directly
observed that the secretion comes from the sebaceous glands. When the surface is
cleaned with chloroform it is dry.
Dr. HEEKA, Vienna, directed the attention of the Section to the anatomical dis-
tribution of the two different kinds of glands, the sweat glands being in greatest
quantity in the planta pedis and vola manus ; the sebaceous glands, on the contrary,
in the scalp. And when we see a diseased hypersecretion in each of them, we see
that on the scalp we have a greasy layer in different degrees, whilst we ﬁnd in
hyperidrosis a watery liquid Secretion, which doubtless contains also a small quantity
of fat, but certainly not in so great proportion as the secretion of the sebaceous
glands. Therefore, Di‘. Hebra thinks that Dr. Unna has attributed a part of the
functions of the sebaceous glands to the Sweat glands. In reply to the remark of
Dr. Unna, that the sebaceous glands are associated only with the very superﬁcial
layers of the epidermis, Dr. Hebra is able to Show, that by dyeing the skin with a
mixture of salicylic acid and ferrum sesquichloratum, the superﬁcial layers of the
epidermis acquire a different colour from the deeper ones; and that it could be
shown that only the layers deeper than Schron’s stratum lucidum give rise to the
walls of the sebaceous glands, so that their openings are not so superﬁcial as Dr.
Unna believes them to be.
Dr. UNNA, Hamburg, remarked, in reply: 1, that nerves have not yet been
demonstrated for the sebaceous glands, whilst in the Sweat glands they have been
demonstrated as far as the tunica propria; 2, that the experiments which had been
made on the gland on the back of the duck do not warrant conclusions for the
sebaceous glands in man, as the histological position of that gland—whether it
belongs to the sweat or the sebaceous system—does not seem to have been deﬁnitely
ﬁxed. In reference to Dr. Hebra’s remarks, he said that frequently the sweat glands
(on the nose, for example) poured their secretion into the sebaceous glands.
DISEASES or THE SKIN. ‘ I89
Scleroa'ermz'a Dzj’usa. (Sclére‘me des Adultes— Thz'r/z'al.)
Skim/emu AdzzZz‘m/zmz.
Dr. J. HERBERT STowERs, London.
The author related the history of a case of this disease which he had had under
observation for aperiod of nearly six years, the patient herself having been pre-
viously exhibited to the members of the Section. The following is a brief abstract
of the case :— Lydia , a married woman, with dark hair and complexion, was
born in 18345 of healthy parents. She had three brothers and two sisters. One of
the former died of phthisis at the age of 4.4 years, and one of the latter is now
suffering from pulmonary consumption. For three months before his death, her
brother was noticed to have an unnaturally hard and dry skin, while that of the
two surviving is stated to be also unnaturally thickened. L. H. was fairly
strong and well nourished until the period of her ﬁrst pregnancy, at the age of
23 years. At that time she commenced to lose ﬂesh, and complained of various
subjective nervous symptoms, during the existence of which her right hand and
ﬁngers became swollen and stiff.
During the next ﬁve years the morbid process, still limited to the one hand,
gradually developed, the skin over the phalangeal joints becoming inﬂamed with
some discharge of pus from small ulcerations over the knuckles, and slowly con-
tracting. By degrees the integument, at ﬁrst tender and hypersensitive, became
absolutely painful, sharp “ ﬂashes” of pain of a neuralgic kind starting from the
ﬁnger points, frequently radiating over the hand, and passing up the forearm.
As months elapsed the integument over each articulation again swelled, and
inﬂamed so much that the least movement was accompanied with acute suffering.
The skin did not present excessive pigmentation, the colour remaining natural or
of a reddish hue, the tightened and contracted state being observable at the ex-
tremities or pulps of the ﬁngers previous to its extension to the joints, which
followed during the ﬁve subsequent years.
As near as possible ﬁve years after the right hand became affected, the left com-
menced to undergo similar changes.
Besides the shortenings and contractions of the ﬁngers from bone absorption,
the author pointed out that all the joints, excepting the upper of each thumb (meta-
earpo-phalangeal), are quite ﬁxed, and that the abnormal excessive pigmentation
visible upon the dorsal surface of each had developed during the last twelve
months. Skin changes of the same kind, though less intense, include the thighs
and lower extremities.
In 1870 an altered and abnormal appearance of the integument of the face
was ﬁrst noticed.
Gradually from that date until the present the structural alterations have pro-
gressed, and now conspicuous among them are :—the angular outline of the face——
the relative prominence of the malar bones; the shrinking and falling in of the
checks; the retraction of the eyelids, producing considerable space between the
globes and their coverings; the shrivelling and irregular contractions of the lips.
Besides these, the whole of the integument is dense, hard, and unyielding; the sur-
face is dotted here and there with numerous small capillary stases; and lastly,
the existence, more particularly on each side of the forehead and towards the hair
border, of marked excessive pigmentation.

190 DISEASES OF THE SKIN.
A Case of Congem'zfal Aénommlz'z‘y 2'12 Z/ze Haz'r-pr/oducz‘z'm
012 Z/ze Saalp.
Dr. GEORGE THIN, London.
Maria Style, aged four years, is a ﬂabby, round-faced child, and squints. She
is the second of ﬁve children, four of whom are alive. The father is healthy; but
the mother has been completely bald from birth, and has marks of old keratitis in
the right eye. The father is said to have an unusually stiff beard. The hair in the
other children is natural. When this child was about ﬁve or six months old, her
mother began to notice that the hair came off when the head was being washed. At
present her head is covered with short, dry hairs, which come out easily and freely
when subjected to very slight traction. The number of hairs growing on the scalp is
normal. On the back of the head, forward as far as the ears, and on the back part of
the vertex the hairs measure from a sixteenth to a quarter of an inch long. The
longest hairs are on the fore part of the vertex, where the longest are nearly three
inches long. Towards the forehead they become shorter, being about an inch
long, and less. All over the head the hairs are hard and rough to the touch, the
scalp feeling like a pig’s skin. The rest of the skin of the body is natural, except
that the genitals frequently become tender. The hairs, when examined under the
microscope, are seen, many but not all of them, to be varicose in outline, being dis-
tinguished by alternate swellings and constrictions, such as are to be found in
various abnormal conditions connected with the growth of the hair. I regard the
case as an example of congenital deﬁciency in the cells of the hair papilla, which
do not form epithelial cells capable of being knit into a hair shaft of the usual
strength.
DISCUSSION.
Professor KAPOSI, Vienna, had seen two such cases, which he believed were
referred to as lichen pilaris, in his last work on skin diseases. He foundimprovement
followed on treatment by soap, and the application of sulphur and tar-paste.
Dr. VIDAL, Paris, had also seen two cases in children, aged four and ten years
respectively. The affection seemed to be congenital. The scalp was very dry, the
sebaceous system appearing ill-developed, and may be, atrophied. He found atrophy
of the sebaceous glands in an adult suffering from seborrhoea sicca, whose hair,
especially over the temples, was broken and twisted in a similar manner.
Dr. UNNA, Hamburg, had met with the same affection in a young lady, but
limited to the vertex. In her case it came on after nervous shock (grief), and some
what resembled alopecia, but there was great dryness of the skin, with a coarse,
wiry condition of the hair, and the scalp was decidedly indurated. He thought
it had some resemblance to scleroderma circumscripta; great improvement took
place under sulphur ointment.
Dr. LIvEINe, London, had seen one case similar to Dr. Thin’s. The affection
had existed from earliest infancy.
Dr. L. DUNCAN BULKLEY, New York, had seen an exactly similar case in a boy,
aged about six years, which had lasted since earliest infancy. The body presented a
DISEASES OF THE SKIN. IQI
characteristic lichen pilaris, and upon the arms the hairs were all surrounded by
pointed epidermal accumulations, the same occurring to a very slight degree about
the hairs of the scalp where they existed, although they were very scant and brittle.
The disease in the hairs in this case appeared to be quite akin to the abnormal
epidermic growth found in lichen pilaris.
Dr. TIIIN, London, in reply, remarked that he did not consider his case as similar
to those which had been observed by Dr. Walter Smith and Dr. Liveing. Varicose
hairs occur in various conditions, and would seem to imply intermittin g energy in
the growth of the hair. Their occurrence is not sufﬁcient for the identiﬁcation of a
speciﬁc affection of the hair.
Selected Notes 0% Dermato- Taerapeia, illustrating t/ze A at/zor’s
Views area’ Met/toils of Treatment of some Cataaeoas Diseases.
Mr. ERASMUS WILsoN, F.R.S., President.
A trustworthy remedy, like a trustworthy friend, is a possession most warmly
to be cherished. Such a remedy we possess in the “ Benzoated Oxide of Zinc
Ointment.” But it is not sufficient to possess a remedy; we must also know in
what manner and when to make use of it.
The benzoated oxide of zinc ointment is a preparation of puriﬁed lard, through
which the vapour of gum benjamin has been diffused in order to preserve it from
rancidity ; and, at the same time, this prepared lard is inspissated with oxide of
zinc. In its nature this ointment is perfectly unirritating ; it is easily spread on
the skin, and when so spread it adheres closely and becomes a perfect shield to the
skin, protecting it against the irritant action of the atmosphere. It assumes, in
fact, the character of an artiﬁcial epidermis ; it maintains an agreeable temperature
and moisture of the skin ; it preserves a state of tranquillity and comfort of the
skin, favourable to the relief of irritability and itching, and equally favourable to '
the processes of healing. In a. word, it is essentially a sedative remedy.
Let me illustrate the method of use of this valuable remedy by an example : in
a severe case of eczema infantile, the skin is so much broken up and excoriated
that the child may be said to be denuded of its epidermis. What can be more
reasonable than to supply its place by a substituted skin? The oxide of zinc
ointment fulﬁls this purpose admirably; but now our anxiety is to preserve our
substituted skin unbroken and to maintain its supply as constantly as it may be
rubbed oﬁ or dispersed. To effect these objects the skin must never be washed;
and, whenever practicable, a covering should be applied to prevent the removal of
the remedy. Mothers who have not yet tried the ointment will express their .
astonishment at being prohibited from washing or bathing their infants ; and yet
they are ready to acknowledge that the disease is always worse after ablution than
it was before. The question which they put may be :——-.When shall I be per-
mitted to wash my infant? To which the answer may be returned :—-VVhen the
skin is sound enough to bear the washing without suffering. The question of
cleanliness is very soon disposed of, for they speedily ﬁnd that the ointment main-
tains the skin in a perfect state of nicety.
O
.. C(-
b’b.
O O
O
O
(
Q
Q
192 DISEASES OF THE SKIN.
With the exception of eczema madidans and eczema amidst the hair, there is
no form or stage of eczema in which the benzoated oxide of zinc ointment will
not be found the very best remedy which could be employed. When crusts and
scales have formed, both are softened and loosened by the ointment, and both may
be removed by a gentle movement of the ﬁnger in the course of applying the
remedy.
But I will take another case—a patch of dry eczema with more or less
desquamation, such as we so frequently meet with on one or both legs. This‘ is a
patch which has been many months in existence, which has resisted every kind of
torture with strong mercurial ointments and tar, which has been treated by
envelopment, by the application of nitrate of silver, and blistered with a strong
solution of caustic potash; but yet it yields not and persists most provokingly.
It is a case which I should select as an illustration of a process of treatment which
I have termed the sealing method. The process is very simple, but in general
irresistible. I rub the zinc ointment into the whole of the inflamed surface gently
but thoroughly; I use the remedy as if I were sealing up the skin, but the seal is
nevertheless perfectly permeable from within, although impermeable from without;
night and morning the inunction is to be repeated, and any impurities removed
gently with a soft cloth. After the inunction I place a piece of ﬁne chamois
leather, large enough to cover the diseased patch, neatly and smoothly over the
ointment; and then a binder should be applied, which should keep the dressing in
its place without disturbance. Here then we have a process by which air and light
are excluded; the morbid surface is, as it were, scaled up; external irritants are
kept at a distance, and the weakened tissues are maintainedin perfect tranquillity,
and therefore in the best state to further the reparative processes. The dressing
may not require to be disturbed more than once, or at most twice, in the twenty-
four hours, and then the chamois leather covering is wiped and put back in its
place. The cure in this case is quite certain, without pain or suffering, and more
speedy than by any other process with which I am acquainted.
There are regions of the body where the healing process cannot be adopted, on
account of inequality of surface or the movement of the part; but even in this
instance it may be partially effected, as by means of a chamois-leather sleeve or
gaiter, a slipper, a acket, or a pair of drawers. The purposes to be aimed at are a
a perfect and continuous coating with ointment, the preservation of the coating
so formed, and as much tranquillity and rest of the tissues as may thereby be
attained. But when the protective dressings cannot be applied there, we must
rely on the frequent repetition of the ointment, and the avoidance of such opera-
tions as are calculated to remove it.
It will, of course, be understood that, except in purely local cases, this topical
treatment can only be regarded as ancillary to a well-intentioned constitutional
treatment. Again, in eczema of the hairy scalp, the oxide of zinc ointment is
prohibited on account of those very qualities which render it so valuable elsewhere
—-its tenacity, and tendency to cling to and accrete upon the skin. These qualities
produce clogging and matting of the hair, whilst its whiteness is equally objec-
tionable. But we are at no loss in this respect, for an ointment composed of one
part of the nitric oxide of mercury ointment to three of petroleum ointment or
vaseline, is as valuable a remedy on the scalp as is the benzoated oxide of zinc
ointment on the rest of the body. There are parts of the skin likewise, and also
stages of eczema, in which a lotion of lime-water, suspending the oxide of zinc and
its congener, calamine (the latter for the sake of colour), would be found highly
DISEASES OF THE SKIN. I 93
deserving of favour. But even in the latter case the same intention is fulﬁlled——
the formation of a protective layer, albeit of powder, over the inﬂamed surface.
The following gentlemen were appointed a Committee, to consider the question
of nomenclature in reference to skin diseases, and to report at a future meeting of
the Congress :- '
Dr. Bulkley (Chairman), as representing America.
Dr. E. Vidal, as representing France.
Dr. R. Liveing, as representing England.
Dr. Kaposi, as representing Austria.
Dr. Oscar Simon, as representing Germany.
PART III- 0
DISEASES 0]? THE THROAT.
_.__+___
Chairman.
Dr. Grouse JOHNSON, F.R.S.
Secretaries.
Dr. DE HAVILLAND HALL.
Dr. FELIX SEMON.
Dr. THOMAS J. WALKER.

INAUGURAL ADDRESS,
BY THE CHAIRMAN,
DR. GEORGE JoHNsoN,
» One of the Vice-Presidents of the Section of Medicine.
GENTLEMEN,——Tlle ﬁrst duty that I have to perform is to express my high
appreciation of the honour conferred upon me in the appointment to preside
over this important sub-section of medicine. I have next the pleasure to offer
a hearty British Welcome to the many very eminent laryngologists, who, from
various parts of the Continents of Europe and America, have done us the favour
and the honour to join this Congress, and to make, as they are about to do,
numerous important and highly instructive communications to this department of
medicine. The history of the laryngoscope has been often written, and is well
known to this learned assembly. I am sure, however, that I shall have your
sympathy and your approval in giving a brlef expression of our indebtedness to
Signor Garcia—whom we have the pleasure to welcome amongst us here to-day
—for the important share which he has had in the invention of that instrument.
While all previous attempts to inspect the living larynx have been incomplete
and barren of further results, Signor Garcia, who has the unquestionable dis-
tinction of having been the ﬁrst man whose thoughtful ingenuity enabled him
to see his own larynx, published the results of his autoscopic observations in
the “Proceedings of the Royal Society” (vol. vii. 1855), and this publication led
on, through the appreciative mind of Professor T'urck and the indefatigable
zeal and exertions of the late lamented Professor Ozermak, to the creation and
the rapid development of the art of lnryngoscopy.
It is scarcely possible to over—estimate the practical importance of this
simple invention. I have been long enough in practice as a physician to have
had ample experience of the enormous difficulties which often attended the
diagnosis, and therefore the treatment, of diseases of the throat in the dark
pre-laryngoscopic age. And now, by contrast, the result of the new light thrown
upon this region by the throat mirror has been that within the last twenty
years our knowledge of laryngeal diseases, including accuracy of diagnosis
with certain and successful treatment, has made greater progress than that of
any other department of medicine or surgery during the same period of time.
In making this statement I am not unmindful of the immense advance Which has
been made in the diagnosis and treatment of eye diseases since the genius of
Helmholtz conferred upon mankind the inestimable gift of the ophthalmoscope.
o 2
196 DISEASES OF THE THROAT.
It is not without interest to compare the practical gains with regard to both
diagnosis and treatment which have been derived respectively from the two
analogous instruments—the ophthalmoscope and the 1aryngoscope. In regard
to facility and accuracy of diagnosis, the ophthalmic surgeon and the laryngo-
logist may be considered to have been about equally beneﬁted by the use of
their respective instruments. If we take into account the numerous remote
diseases, more especially those of the nervous system, upon which the ophthal-
moscope has thrown a new light, that instrument may perhaps be considered, in
the matter of mere diagnosis, to take precedence of the laryngoscope. With
regard, however, to improved methods of treatment, and in particular to the
introduction of entirely new and previously impossible mechanical operations,
there can, I think, be no question that the laryngoscope has done more than can
fairly be claimed for the ophthalmoscope. Without doubt the exact diagnosis of
eye diseases has led to improved and more successful treatment, but the ophthal-
moscope has afforded no direct aid to treatment comparable, for example, with
the safe and easy removal of morbid growths and foreign bodies which the
laryngoscope has made an every-day proceeding.
Amongst the most interesting and important of the scientiﬁc and practical
gains which have resulted from the use of these two instruments—and which
may be claimed alike, if not equally for both—is the fact, that, by the inspec~
tion respectively of the interior of the eye and of the larynx, valuable light is
often thrown upon the diseases of remote but physiologically correlated organs.
If, for example, the ophthalmoscopist sees in the eye a retinitis signiﬁcant of
renal disease, a neuritis indicating cerebral tumour, or an embolism the result of
valvular disease of the heart, so in like manner the laryngologist is often led by
the observation of the paralytic or spasmodic condition of one or more laryn~
geal muscles to the diagnosis of a general neurotic condition to which the term
hysteria is often applied, or of a special local disease in the nervous centre, or
it may be of a tumour, cervical or intra-thoracic, pressing on the pneumogastric
nerve or its branches.
It is obvious that all clinical facts of this kind, indicating as they do the
interdependence and the close physiological relationship between various tissues
and organs, are of great scientiﬁc and practical importance. There is reason
for the belief that the more thorough and profound is the investigation of any
disease or class of diseases, the more numerous and intimate will be found to be
the relationship with other morbid states. The study of renal diseases affords
abundant and most instructive illustrations of this proposition.
The more special, therefore, is any department of practice, the greater is the
need to recur often to general principles, and to bear in mind that so close is
the solidarity of the animal organism, that there is a literal and physiological
truth in the apostolic statement: “ If one member Suffer, all the members
suffer with it.” The ill-informed public are apt to look upon a man who has a
reputation for skill in the treatment of a particular class of diseases, as of
necessity unacquainted with all other diseases. We, on the other hand, main-
tain that of the specialist it should be said with truth that he is one, not who
knows less of disease in general, but who knows more of the particular
class of diseases to which he has devoted most time and especial attention and’
study.
The Hippocratic maxim, “ Life is short and Art is long,” is as true now as
it was two thousand years ago. Bearing this in mind, and knowing, as I do,
how many valuable communications are in store for us, I will occupy no more
of your time, but will at once call on the gentleman whose name stands ﬁrst on.
the list to read his promised paper.
DISEASES OF THE THROAT. I
On the [m/emz'mz 0f the Laryngascojﬁe.
Signor MANUEL GARCIA, M.D. (Honorz's causa), London.
To make a suitable reply to the ﬂattering expressions addressed to me by
our Chairman, and sanctioned by your approbation, would require a habit of
speaking and an eloquence that I do not possess. Para/‘us inter magnos, I can
but assure you how highly I appreciate the honour you have done me, and
hope for your indulgent acceptance of my simple, sincere, and humble thanks.
In compliance with the desire which Dr. Semon was good enough to
express in your name, I will tell you how the idea of the laryngoscope pre-
sented itself to me, and what were the results to which it led me. I fear,
however, that this fragment of autobiography may prove a greater tax on your
patience than you anticipate.
When I began to teach singing, the physiological explanations I was
obliged to give to my pupils were purely empirical, and did not inspire me with
any conﬁdence as to results. At that time the vocal phenomena had been
very imperfectly studied; thus, the number of registers, their extent, their
individual characteristics, were not identical in the minds of all musicians.
The timbres were often confounded with the registers; for no treatise of
singing had yet appeared based upon anatomical and physiological considera-
tions. In all cases instinct alone, sometimes happy, sometimes erroneous, was
the only substitute for accurate knowledge.
Desirous of ﬁnding a more trustworthy guide, I began a course of ana-
tomical and physiological studies, and the information thus acquired, added to
the results of experience, were published in a method of singing; but some of
the deepest and most interesting questions of physiology remained to me still
unsolved.
I was especially anxious to ﬁnd out what was the actual wile played by the
glottis in the production of the voice ; but where to ﬁnd the necessary
information ?
The authors who wrote on the voice took their ideas of what the action
of the healthy, living glottis might be from glimpses they caught of it through
wounds, or from experiments on dead bodies, or from vivisectional researches.
As for the acoustic laws that govern the movements of the glottis, every writer
on the subject explained them by analogies found in musical instruments of
different kinds. Thus, the stringed instruments, the reed instruments, the
appeau, &c., have all served as means of comparison.
These two systems, one of induction the other of comparison, though the
only systems then possible, inevitably led to different theories on the part of
different observers, and could not fail to keep the mind of the student in a
state of perplexity. To dissipate my own doubts, I could think of but one 0
method—it was, to see a healthy glottis exposed in the very act of singing;
but how could the mysteries of an organ so well hidden be unveiled? One
September day, in 1854, I was strolling in the Palais Royal, preoccupied with
the ever-recurring wish so often repressed as unrealizable, when suddenly I saw
the two mirrors of the laryngoscope in their respective positions, as if actually
present before my eyes.
I went straight to Charriere, the surgical-instrument maker, and asking if
he happened to possess a small mirror with a long handle, was informed that
he had a little dentist’s mirror, which had been one of the failures of the London
Exhibition of 1851. I bought it for six francs. Having obtained also a, hand
198 DISEASES or THE THROAT.
mirror, I returned home at once, very impatient to begin my experiments. I
placed against the uvula the little mirror (which I had heated in warm water
and carefully dried): then, ﬂashing upon its surface with the hand mirror a
ray of sunlight, I saw at once, to my great joy, the glottis wide open before me,
and so fully exposed, that I could perceive a portion of the trachea.
When my excitement had somewhat subsided, I began to examine what
was passing before my eyes. The manner in which the glottis silently opened
and shut, and moved in the act of phonation, ﬁlled me with wonder.
From what I then witnessed, it was easy to conclude that the theory which
attributed to the glottis alone the power of engendering sound was absolutely
conﬁrmed, from which it followed that the different positions taken by the
larynx in front of the throat have no action whatever in the formation of
‘sound; although, combined with divers elevations of the soft palate, they
change the shape and the dimensions of the pharynx. In these changes we
ﬁnd the means of varying the qualities of the voice known as timbres or Far-
benlcléinge.
I also perceived that vocal sounds are the results of explosions, not of com-
municated vibrations. This is proved by the fact that each separate lip of the
glottis is incapable of producing any kind of sound. Besides, the lips do not
protrude sufficiently to form vibrating reeds; and, if protruding, how could
they vibrate in spite of recurring contact with each other?
Having thus seen the vocal organ in action, I next began to study the
mechanism of the scale. This mechanism has two aspects—an exterior
movement, visible with the mirrors; and an internal cause of that movement,
which anatomy alone can explain. The exterior movement becomes manifest
in the development of the scale.
Beginning from the lowest note, the glottis is put in motion throughout its
whole length; but as the voice rises, the anterior apophyses are gradually
pressed closer by a movement which spreads from back to front, and they are
alternately in close contact. These continuous encroachments diminish the
vibrating portion of the glottis until it becomes reduced to the ligaments alone.
The internal cause resides in the intrinsic muscles ; and, among these, that
which coats the outer surface of the crico-thyroid membrane—namely, the
thyro-arytenoid muscle—was to me of the greatest interest. The ﬁbres of which
it is composed, although all starting from the anterior and lower cavity of the
arytenoid cartilage, are not all of equal length. The most internal are the
shortest. Each successive ﬁbre becomes progressively longer and terminates in
a more distant point of the ligament; the longest and most external only
reaching the thyroid cartilage.
From this remarkable disposition, it follows that only the shortest ﬁbres
contract for the deepest notes, and, as the voice ascends, successive ﬁbres come
accumulatively into play.
To complete the subject, I ought to speak of the action of the other
intrinsic muscles ; but that has been already treated in the pamphlet read at
the Royal Society in 1855. In the same paper I have also expressed» my ideas
as to the formation of the registers.
If I have spoken somewhat in detail of the thyro-arytenoid muscle, it is
that its special characteristics—the unequal length of its ﬁbres and their inser—
tion in the ligaments—have been disputed. But before venturing to represent
as fact this result of my observations, I wished to make sure that I had not
been mistaken; and, therefore, consulted Professor Thane, who, with a cordial
interest for which I cannot suﬁiciently thank him, not only examined the
contested point, but presented me to Mr. Shattock, begging him to assist me
with his experience.
DISEASES OF THE THROAT. 199
This is the drawing which that most skilful anatomist has been good
enough to make for me. It entirely conﬁrms the view which I have had the
honour to place before you. I will not trouble you with further details.
The laryngoscope in itself is not an invention—it is a simple idea; and
when I suggested to Dr. Mandl and to Dr. Segond that they should test its
usefulness in the practice of healing, I was far from anticipating the brilliant
future your science and skill reserved for it.
Lora! Trealmem‘ 0f Dz'p/zz‘kem'a.
Dr. MoRELL MACKENZIE, London.
When I was honoured by an invitation to read a paper on the local
treatment of diphtheria, I felt some hesitation in responding to the compliment,
owing to the fact that I had little to add to the views which I had recently
placed before the profession in connection with this important subject.
Feeling, however, that the local treatment of diphtheria is a question on which
there is not at present any general consensus of opinion, it appeared to me not
unlikely that my paper might elicit valuable information from my confr‘eres;
whilst it would give me an opportunity of stating that further experience of
antaerics, or varnishes, has yielded in my hands a far larger percentage of cures
than any other local treatment. Under these circumstances two courses were
open to me. One was to pass in brief review all the various remedies which
have been extolled by practitioners; the other is to lay before you as concisely
as possible the results of my own experience.
For practical purposes the latter plan appeared preferable. But before
carrying it out, it may be permissible to ask—How is it that such opposite
modes of treatment have been enthusiastically recommended by different
physicians ? \
Now, when a large number of remedies of different and even conﬂicting
character are strongly recommended for the cure of a disease, it shows either
that the malady is not infrequently of a mild and tractable nature, or else that
some triﬂing disorder is liable to be mistaken for the more serious complaint.‘
Both these conditions exist in connection with diphtheria, for the disease is
often very slight and tends to spontaneous cure, whilst again it is closely
simulated by some forms of follicular tonsillitis. These circumstances afford
an ample explanation of the large series of cases that have been published from
time to time in which recovery has taken place in every instance.
In dealing with the question committed to nae—via, “ The local treatment of
diphtheria”—I have considered that the title was meant to bear on the action of
drugs used locally. Hence I have not considered the important operations of
tracheotomy, or tubage of the trachea, or other surgical methods which may be
often requisite.
Before proceeding to details, one more query may perhaps be allowed—
viz._. What is the object of local treatment? It appears to me to be threefold.
1st, To limit the further extension of the false membrane; 2ndly, To promote
its separation ; and 3rdly, To render its presence innocuous whilst it remains in
contact with the tissues. These ends may be sought to be accomplished both
by direct and indirect measures. Amongst the former agents may be mentioned
those which retard or hasten the circulation, such as cold or heat 3 amongst the
latter there are certain remedies which destroy, dissolve, and disinfect the false
membrane.
Both cold and heat are useful under different conditions, and fortunately
ZOO DISEASES OF THE THROAT.
these conditions can be easily laid down. For cold acts most beneﬁcially in the
early stage of the disease, and either produces no effect or acts injuriously
later on; whilst heat is harmful at ﬁrst, and only comes into useful operation
when the complaint has become thoroughly established.
As a rule ice should be used both externally and internally—that is to say,
it may be taken into the mouth and allowed to melt slowly, and it should be
applied to the neck by means of a bladder or ice—bag. Sometimes, however,
the external application of ice greatly alleviates, whilst its internal use is
disagreeable or even hurtful. It is especially serviceable in the inﬂammatory
type of the disease, but in nearly all cases, if used at the outbreak, it checks the
vascular action on which the intensity of the affection So largely depends. As
a rule cold acts better in the case of adults than in that of children, infants
being seldom beneﬁted by its employment.
Its use, however, is especially contra-indicated when suppuration has
commenced, and it therefore seldom does good after the third or fourth day
from the establishment of the morbid process. When the false membrane has
begun to separate, cold is apt to check this curative process; and should there
be any tendency to gangrene, the use of ice must be strictly forbidden.
Steam acts beneﬁcially in most cases when the membrane has been formed
for three or four days. It should never be used at a higher temperature than
120° Fahr. In the case of children who are too young to inhale, the croup~tent
should be employed; but adults should use an inhaler every hour for ten or
ﬁfteen minutes at a time. The draught steam-kettle, which delivers a constant
quantity of steam, answers extremely well both for adults and children, and
saves the fatigue of inspiration. The use of steam is especially indicated when
laryngeal diphtheria has become thoroughly developed—in a great measure
only, however, because the comparatively inaccessible situation of the disease
renders its treatment by other and more active remedies less feasible than when
the false membrane is situated in the pharynx or nose. I am not, however,
prepared to assign to hot vapour the high value which is accorded to it by
Oertel, but consider it chieﬂy in the light of a valuable vehicle for conveying
remedies to the diseased surface.
The real remedies we have to consider are the solvents, the disinfectants,
and the antaerics. Oaustics, once so largely used, are now happily seldom
employed. Before proceeding to state my experience as to the value of
different local remedies, I may remark that I have only noted the effects in
those cases in which I have been able to direct the treatment throughout from
near the commencement of the attack. It has often happened to me to be
called in consultation to cases that were already doing well, and with these I
have interfered as little as possible. Still more often it has been my lot to be
summoned to patients at the point of death, and such cases have not appeared
to be suitable for testing particular methods of treatment.
Amongst solvents, lime-water and lactic acid have proved the most ser-
viceable in my hands. My experience of the action of lime-water is limited
to the treatment of thirty-seven cases. Of these, twenty-three were severe,
and fourteen mild; of the former, ﬁve died (17'?) per cent), in three of the
fatal cases the air-passages having been extensively involved. I have employed
lactic acid in forty-ﬁve cases, of which thirty—six were severe and nine mild,
the mortality amongst the former having been six (16'6 per cent). In ﬁve
of the fatal cases, the air-passages were involved.
In pharyngeal diphtheria these solvents can be applied either in the form of
spray or as pigments. The former is the preferable method, but the latter may
be found requisite in the caseﬁof young children and infants. Both in nasal and
in laryngeal diphtheria I depend mainly on lactic acid. In the former affection,
DISEASES OF THE THROAT. 201
from the commencement, I use a spray of lactic acid every two or three
hours; and after the disease has existed for three or four days, I wash out the
nasal passages daily, or,on alternate days, with a douche, or collunarium, of
carbolic acid (gr. @- to gr. 2 ad oz.) Careful examinations, however, should be
made from time to time, as it is better not to use the collunarium more often than
it is absolutely required—that is to say, only when the false membrane is under-
going separation. In laryngeal diphtheria I likewise employ lactic acid sprays,
and at the same time persevere in the use of steam, whilst it is needless to observe
that tracheotomy remains as a resource which ought not to be too long postponed.
Several of my medical friends tell me that they have been disappointed in
their trials of lactic acid; but on inquiry I have almost invariably found that
the lactic acid has been too much diluted. The commercial acid varies greatly
in strength, and I now use the preparation contained in the American Phar-
macopoeia,* which has a speciﬁc gravity of 1-212. Thirty minims of this acid
in an ounce of water will form a solution of suitable strength. I have again
to repeat here what I have already stated, that I have never seen any of the
had local effects of this agent described by Kiichenmeisteni‘
Antiseptics may be used either for the purposes of destroying the germs
of the disease, or for arresting the putrefactive process, or they may be employed
with the view of effecting both these objects. If the remedy be used as a
germ-destroyer, its administration should be commenced from the outset; but
otherwise it may be deferred till changes begin to appear in the false mem-
brane. For many years I have used both carbolic acid and permanganate of
potash. The best mode of administering these remedies consists in the use of
sprays. During the last three years I have also seen syrup of chloral hydrate
employed locally in several cases with such great advantage that it has appeared
to me to possess greater antiseptic properties in diphtheria than either carbolic
acid or permanganate of potash. The chloral hydrate should be applied very freely
with a brush every two hours until the false membrane ceases to reform.
Anta'e'rics, or varnishes (71.0., remedies which exclude the air from the false
membrane), appear to me to be particularly valuable. I have now employed
these remedies for three years and a half, and I never use any other local agent.
I claim for this class of remedies that they fulﬁl the conditions which I laid down
as being requisite. Here, perhaps, I may be permitted to remark incidentally
that Whilst I do not consider the bacterioid theory of the origin of diphtheria
as proved, yet there is a vast amount of evidence as regards the conditions
under which the diphtheritic poison ﬂourishes, and as to the manner in which
it is diffused, to show that its life-history is intimately connected with the
evolution of germs. Be this, however, as it may, it is a well-known clinical
fact that diphtheria can only develop on surfaces accessible to the air. It was
this circumstance that led me to the idea that a remedy which could cut off
the atmosphere from the diphtheritic membrane would prevent its further
extension, and cause retrograde changes to take place in that already formed.
I accordingly commenced a series of experiments in the year 1877, with a
view of ascertaining which varnishes would dry most quickly, form the most
impermeable coating, and at the same time cause no irritation of the throat.
A long series of trials, in which benzoin, tolu, mastic, and resin were dissolved
in rectiﬁed spirit, or in ether, and in which tinctures of the gums or resin were
afterwards mixed with ether, convinced me that tolu dissolved in ether in the
proportion of 1. to 5 was the best of these agents. In 1878 I commenced

* The German Pharmacopoeia gives the speciﬁc gravity as 1'240, but I believe that any
increase above the American standard is due to the presence of impurities.
1‘ “ Jahrbuch f. Kinderheilkunde,” 1870.
202 DISEASES OF THE THROAT.
treating patients suffering from diphtheria with this local remedy, and since
then I have constantly used it to the exclusion of every other medicinal agent—
that is to say, I have entirely given up the use of solvents and disinfectants, though
I still make use of heat and cold as valuable auxiliaries. I have now applied tolu
varnish in forty-seven cases, of which thirty—one were severe and sixteen mild.
In only two out of the thirty-one cases—that is, in 6'4 per cent.—did a fatal result
ensue, and in these cases the disease was of very malignant character. In neither
case was there any extension of the disease to the air-passages. In making
these comparisons, perhaps I may be permitted to remark that it is doubtful
whether the statistical method can ever be satisfactorily applied to modes of
cure carried out by different practitioners; and even when a series of cases has
been treated by the same physician, there are many sources of fallacy. In my
own sets of cases, to have made the comparisons completely satisfactory, it
would have been necessary either to have used local treatment only, or to have
employed absolutely the same constitutional remedies in each series of cases.
Neither of these courses has been adopted; but nevertheless the general treat-
ment has been of a certain uniform character—viz, tonic and analeptic, iron
having been the medicine most frequently administered. .
It will be seen that I do not claim for this treatment anything approaching
universal success; but only that it has yielded far more favourable results than
any method hitherto employed. It will be noticed that in all cases I have
calculated the mortality in relation to the severe cases only. Had I based my
statistics on all my cases, the results of treatment in each series would have
appeared much more favourable. It must not be forgotten also that, except
for prompt treatment, many slight cases may become severe.
The treatment should be carried out in the following manner:-Directly
any false membrane is seen, both it and the surrounding mucous membrane
should be carefully dried with blotting-paper, and immediately afterwards the
varnish should be freely applied with a camel ’s-hair pencil. It is of the ﬁrst
importance that the remedy should be very thoroughly applied around the
pharynx below the false membrane, as this procedure prevents the extension
of the deposit downwards towards the larynx. The application need only be
made twice a day. This is in itself a great advantage, relieving the patient, as
it does, from the serious annoyance of frequently repeated local treatment.
In the early stage of the disease, should there be much inﬂammation, the
patient should be directed to suck ice. On the other hand, when the false
membrane covered with its varnish begins to separate, the inhalation of steam
will be found to promote its detachment. I have observed, however, several
cases in which the false membrane was thick before the varnish was applied,
and that it has almost entirely disappeared under repeated applications of the
remedy, so that only a very thin membrane has subsequently come away.
Here I think it right to state that after I had been using varnishes for some
months, a paragraph was published in one of the daily journals, in which it was
alleged that Dr. Nicati had found that the exclusion of the air to a great extent
prevented the development of the diphtheritic membrane on the conjunctiva of
fowls. I gather from the original report* that the treatment consisted in sewing
the eyelids together. I am not aware that any attempt was made by Dr.
Nicati, or any other physician, to use remedies with the view of effecting the
exclusion of air.

* Société de Médecine de Marseille, Seance du 26 Janvier, 1878:—-“ On doit des main~
tenant conclure des experiences faites ; 1° que la diphthérie de la volaille est inoculable ; 2°
qu’elle est inoculable a l’oeil d’un individu atteint déja de la meme maladie (auto-inoculation) ;
3° que le développement (1e l’affection est sinon arrété, du moins enrayé par l’ocelusion her-
DISEASES OF THE THROAT. 203
Caustics were largely used in this country in the great epidemic which com-
menced in 1855 ; and during the years 1856, 1857, and 1858, I had many
opportunities of witnessing the eﬁects of strong nitrate of silver and hydrochloric
acid. The results, however, were so uniformly unsatisfactory that l have never
felt justified in applying them in the case of patients under my own care.
Astringents, especially tannic acid and alum, were used in a few cases in
1859 ; but when employed in mild strength they seemed to have no effect, and
when strong, they certainly acted injuriously. Hence, I have never felt inclined
to use these agents myself. .
In conclusion, and for fear lest any practitioner should think that I trust too
implicitly to local treatment, I must remind my audience that by the terms of
the subject assigned to me, the value of constitutional remedies in diphtheria is
excluded from consideration. Perhaps, however, I may be permitted to observe
that I attach quite as much importance to suitable constitutional treatment,
including medicine, food, and stimulants, as I do to the most skilfully selected
topical agents.
Locale Be/zmzd/zmg der Dz'plzz‘lzerz'z‘z's.
Dr. ToBoLD, Berlin.
Dr. Tobold was not present; the members were referred to the following
abstract of his views :—
Diphtherie unzweifelhaft eine durch ein speciﬁsches Contagium erzeugte
Allgemeinerkrankung, vergesellschaftet mit pseudomembranosen Entz'iindun gen
der oberen Luftwege. N othwendigkeit den localen Processen besondre Aufmerk~
samkeit zuzuwenden, w‘ahrend selbstverstandlich gegen die Allgemeinerkran~
kung der ganze I-Ieilapparat in Anwendung gezogen wird.
Geschichtlicher Ruckblick. Ehemals Zerstorung der Membranen mittelst
aller denkbarer Caustica empfohlen. Unbefriedigende Erfahrungen. Sp'a'ter
locale Application auﬁosender Mittel in Form von Gargarismem, Inhalationen,
etc. Geringe Wirksamkeit des viel empfohlenen Kalkwassers. Energischer
wirkt Milchs'aure, ohne indessen die ihr zugeschriebene heilende 'Wirkung Zn
besitzen. Bestes gegenw'a'rtig bekanntes Resolvens ist feuchte Wiirme in Form
von Dampf-Inhalationen mit Zusatz antiseptischer Mittel.
Schwefelbluthen und Adstringentia wenig niitzlich.
Eis innerlich und ausserlich empfehlenswerth.
Schlussfolgerungen :
1.-—Im Anfangstadium Eis innerlich, Isolation, Ventilation.
2.--Bei hoher Kcrpertemperatur nasskalte Einwickelungen des Ko'rpers,
Halses oder Halbb'ader dringend nothwendig.
3.—Bei diphtheritischen Auﬂagerungen behufs Reinhaltung der oberen
Luftwcge locale Application resolvirender und desinﬁcirender Mittel. Bei
erwachsenen Kranken Gargarismen, warme Inhalationen; bei Kindern Ein-
spritzungen mittelst Spritze. Bei geschickter Handhabung auch Application
mittelst weichen, graden, ﬁngerdicken Pinsels, der jedesmal sorgfaltig zu reini~
gen und zu desinﬁciren ist.
4.—Anwendung der Caustica ebenso absolut zu verwerfen, wie
5.——Die mechanische Entfernung der Pseudo-Membranen.

métique, en d'autres termes, que la culture de la diphthérie a besoin d‘air, d’oxygene. Cette
derniére conclusion est la. consequence d’une experience dans laquelle l’atfection inoculée n’a
fait de grands progres qu’aprcs l’éloignement des sutures qui maintenaient l’oeil clos.” I
have never seen the original article, and am indebted to Dr. Nicolas-Duranty, of Marseilles,
for the above extract.
204 DISEASES OF THE .THROAT.
Local Twain/zen! of Diphtheria.
Mr. LENNox BROWNE, London,
The ﬁrst point in the local treatment of diphtheria is, naturally, how to
detach the membrane with least irritation to the parts beneath it, and how to
best prevent its re-appearance.
I am not of opinion that we yet have at our command any drug which
actually, or even materially, dissolves the membrane ; but, as the result of
many repeated experiments, I arrive at the conclusion that lactic acid—not
diluted to the high extent hitherto in use, but applied pure by the surgeon at
least once or twice a day, and only moderately diluted (1 to 6 or 1 to 8), at
frequent intervals, by the nurse—has some considerable inﬂuence in loosening
molecular cohesion ofthe exudation, in a manner more favourable to separation
than lime solutions, which, in my hands, have proved quite valueless. I am
quite in accord with Drs. Tobold and Mackenzie, that caustics are harmful; and
I agree with the latter that astringents are useless. Sprays, gargles, &c., are
equally futile; but in cases in which the disease extends to the nose, frequent
syringing of the wound with disinfectants, and direct application of the lactic acid,
should be diligently pursued. Of disinfectants, I give preference to boracic acid,
on account of its non-irritating qualities, even when used in Saturated solution.
I do not myself understand how it is possible to apply “varnishes” to the damp
surface of the fences with any hope of cohesion, nor how they can dry while moist
air is constantly passing over the painted surface. Could these difficulties be
overcome, I should Still feel inclined to be sceptical of their therapeutical utility.
Coming to the best method of removing the membrane, or at least of
applying the lactic acid solution, I of course agree that tearing away the exu-
dation is as useless and injurious as would be similar treatment of the eruption
of small-pox; but some degree of friction, with a soft instrument well charged
with the solution, is a necessity of success in its application. For this purpose,
in the case of children, I employ—and instruct the nurse also to use—the index
ﬁnger, well swathed with lint, and soaked in the solution. For adults I
substitute a ﬁrm cotton-wool brush, the wool being burned after use, and
fresh substituted for each successive application.
Steam tents I have found very depressing, and do not employ them, even
after tracheotomy, being content with application of a double layer of anti—
septic gauze ; and I have never seen good result from an excess of moisture in
the inspired air. I have, however, had good results from the early employment
of hot-air baths on both the general and local affection.
WVe are, I suppose, all agreed as to the value of ice as a grateful and
efficient aid in reducing hypereemia, and in favouring separation of the mem—
brane. Seeing the difficulty of making children take it, I administer it in the
form of frozen milk sweetened with Sugar or Sugar of milk, or of frozen beef tea.
I recommend the same to adults, with the addition of the raw egg swallowed
whole—four or six a day ; and, with a view of giving functional rest, I advise
no other food by the mouth, preferring, if necessary, to give further nutriment
by enema. Almost the only medicine I employ has as much a local as a
general eﬂ’ect—namely, chlorate of potash in barley water, ﬂavoured with
lemon. This should be sipped cold, and may be given almost ad Zz'bilum.
Beyond a calomel purge, with or without compound antimonial powder at the
commencement of attack, I seldom give other drugs. I amdconvinced that iron
is frequently not assimilated, at any rate in the large doses often prescribed.
Externally, poultices, ice-bags, &c., are cumbersome, wearisome, and, in my
experience, unproductive of sufficient relief to compensate for their inconvenience.
From'recent experience in other inﬂammatory throat affections, I advise, with
DISEASES OF THE THROAT. 205
great conﬁdence, a trial of constant cold applications by means of Leiter’s pliable
temperature regulators, which are the perfection of simplicity and comfort.
All are aware how much more prone are those who suffer from enlarged
tonsils to be affected by diphtheritic influences, and also to what a serious
extent the existence of such a condition complicates matters and imperils the
chances of recovery. One must have seen over and over again oral and nasal
respiration each hour more impeded from this cause, and for the same reason
found inspection of the larynx impossible. I therefore, some three years ago,
in such a case removed the tonsils of a child suffering from diphtheria on the
ﬁrst occasion of seeing her. The result was an immediate improvement in the
breathing; there was no extension of the disease to the larynx. The mem-
brane was, of course, re-deposited, but it ultimately cleared. The child had
several sequelae of diphtheria, but ﬁnally made a very good recovery. I reported
the case in detail at the Medical Society of London; and I have since had a
similar case with an equally good result; and another in which I removed
from an adult, aged 23, an enormously swollen and oedematous uvula during
the acute diphtheritic state. I am quite prepared to’ hear the wisdom of this
practice questioned; but, however startling the procedure may at ﬁrst sight
appear, I think the theoretical objections likely to be raised against it will
vanish with practical experience. If one looks on diphtheritic exudation
‘primarily as a local expression of a general blood poison, I cannot think that
the fear of increasing the blood poisoning which has been advanced to me, is
other than chimerical. I claim the following advantages for the procedure:—
First, that it removes a mechanical impediment to respiration; secondly, that
it probably prevents the downward progress of the exudation; and, thirdly, that
when employed it would often render unnecessary the more dangerous measure
of opening the windpipe at a later stage of the disease.
The question of tracheotomy hardly enters into consideration under the
terms of the discussion. I would only mention that, for after removal of'
membrane from the trachea, I employ an adaptation of Siegel’s pneumatic
ear-syringe, with exhausting ball, for suction purposes; and that another
admirable instrument for the purpose is the aspirator known as “ Coudereau’s.”
This has been slightly modiﬁed for me by Messrs. Krohne and Sesemann; so
that by a very simple contrivance fresh air, or hyper-oxygenated air, can be
introduced to the lungs almost instantaneously after extraction of the exudation.
DISCUSSION.
Dr. MEYER, Copenhagen: A countryman of mine, a rural practitioner, Dr.
Nix, at Rude, Skjelskj or, Denmark, has desired me to bring forward his
experience about a local treatment of diphtheria which he devised several years
ago, and has used ever since in different epidemics. The treatment consists
chieﬂy in scraping away the membranes and eventually the subjacent softened.
inﬁltrated parts by means of a scoop and cauterizing the scraped surfaces ener-
getically with solid nitrate of silver. Before this cauterization the blood, never
being very copious, is dried off with a sponge on a piece of whalebone, whilst,
after cauterization, the superﬂuous caustic is washed away by injecting cold
water. The membranes being regenerated rather quickly, the same treatment
has to be repeated on the two subsequent days. On the following days the
membranes usually appear slower and are smaller and thinner; so the treatment
afterwards is repeated at greater intervals. The average number of scrapings
amounts to six. Besides the scraping and cauterization gargles are used of weak
carbolised water, or a half per cent. solution of quinine, and the throat is brushed
several times a day with a sponge containing a two per cent. solution of nitrate
206 DISEASES or THE THROAT.
of silver. Internally a three per cent. solution of chlorate of potash may be
taken. Stimulants are only given when the patient’s weakness requires them.
In this way Dr. Nix, during the last two years, has treated 149 cases of diph-
theria; the patients being—two in the ﬁrst year of life, thirty-four from
one to ﬁve years, ﬁfty—six from ﬁve to ﬁfteen years, ﬁfty-Seven grown—up
persons (eighteen males, thirty-nine females). The immediate result has been
that the fever sometimes sank considerably after the ﬁrst scraping; as a rule it
sank after the third one; a feeling of euphoria hereafter usually Setting in and
continuing. The ﬁnal result was this: ﬁve patients of the 149 died, all chil-
dren ; amongst them two were in a state of collapse when the treatment began.
one who was convalescent from pneumonia when diphtheria set in. A further
result, which appears to deserve full attention, is this, that none of the named
diphtheria patients were taken with consecutive croup, whilst Dr. Nix fre-
quentl y had to perform tracheotomy in former epidemics. Several other prac-
titioners have adopted the treatment, and the surrounding population has, in
spite of its being painful, not unfrequently exacted its performance in very
serious cases. My friend, who has absolute conﬁdence in this treatment, hopes
that it may be found worth your attention, and that even one or other of the
gentlemen present may give it a trial, of course in severe cases.
Professor BUROW, Konigsberg : In my opinion the most important progress
in the local treatment of diphtheria consists in the methodical employment of
inhalations, and especially in the modern use of spray apparatus. I have
experimented with solutions of lactic acid and lime water, but I think that the
chief action is to be attributed to the local effects of the steam. It is most
important to employ the steam very frequently—210., every hour, every half-
hour, even constantly. The best effects from inhalations are to be observed
after tracheotomy has been performed. Aspirations of membranes after
tracheotomy are very valuable, but they ought not to be made by the surgeon’s
mouth, as I have repeatedly done without success. Moreover, it is known that
this manoeuvre has cost the life of several surgeons. It is much better, in every
respect, to remove obstructing membranes by means of catheter and syringe.
Dr. BoCKnR, Berlin : After many trials I consider lactic acid to be nearly
useless ; at any rate, it has no advantage when compared with the results
obtained by chlorate of potash, salt water, 850. I agree with Professor Burow
that the main agent is moist warmth; and further, that systematic inhalations
are most valuable after tracheotomy. In fact, I was one of the ﬁrst to reconn-
mend them. I use for that purpose Solution of salt water, chlorate of potash,
diluted lime water, &c. ; but here also moist warmth is the active principle; and
I recommend that these solutions should be used very frequcntly, and, if possible,
constantly.
Dr. SOLIS COHEN, Philadelphia: I desire to mention some personal
experience—First, as regards solvents, the use of vapour of water in connection
with small particles of lime, as evolved from lime in process of slaking, and
inspired when respiration becomes obtruded by accumulation of false mem-
brane. This method, a purely mechanical one of facilitating detachment and
expulsion of the membrane, I have frequently seen successful in averting
apparent necessity for tracheotomy. Secondly, the local use of iced cloths
applied over the neck and up to the ears, as an exciter of the respiratory nerve-
centre—a deep inspiration usually following the immediate application of the
cloth, the application being repeated at short intervals, to excite a set of
artiﬁcially-induced respirations.
DISEASES OF THE THROAT. 207
Dr. E. FRKNKEL, Hamburg: Want of success often follows the treatment
by pilocarpine. This causes, it is true, detachment of the membranes,
but produces no alteration in the gravity of the general symptoms. I con-
sider, however, the latter to be the essential ones, the depositions only
symptomatic, and I am consequently opposed to any direct interference with
them, especially against their being scraped away. I would, on the contrary,
advise energetic general treatment (stimulants from the beginning), and seeing
that there is great want of proportion between the local deposits and the gravity
of the general affection, to which the patients often succumb—parenchymatous
myocarditis, diseases of the abdominal organs. &c.-—whilst the local deposits
are slight, I would only advise locally moist warmth.
Dr. RoTHE, Altenburg: I agree with those who consider diphtheria a consti-
tutional disease. But every practitioner knows that the local process is, as it
were, the barometer by which we judge the progress of the disease and the
degree of its severity. I have hardly ever seen a case with but slight local
affection end fatally. My object, however, was to draw the attention to a
remedy the modus operandi of which is based on the same principle apparently
as that of the pilocarpine just mentioned by Dr. Frankel. It is the cyanide of
mercury. After having tried with negative result calomel, the free use of
inunctions with blue ointment, &c., I recollected a short notice about the cyanide
by Erichsen, in 1877, who treated twenty-five cases, of which he lost three.
This is of itself nothing, for I had with the local treament with iodide of
phenol no deaths in the ﬁrst 150 cases at least, and dreamed of a “ speciﬁc ” until
the deaths came. With the cyanide I treated in short succession from November
till June, thirty-four cases, all of which recovered, although there were among
them severe cases. I gave the remedy in the following formula :—R Hydrarg.
cyanid. gr. 11,-, aq. dest. giv, tinct. aconiti, min. XX (to reduce the fever), a
tablespoonful every hour, for children under ten years; hydrarg. cyanid. gr. %-,
aq. dest. tinct. acon. min. 1:, a teaspoonful every hour for patients above
that age. The membranes when already formed (and I consider only these real
cases of diphtheria), seemed in the course of one to three days to grow thinner
and more transparent, until for several days only a ﬁne ﬁlm, like hoar frost, was
left covering the parts ; underneath this the mucous membrane soon came forth
in a healthy appearance.
Dr. PROSSER JAMES, London: I believe that the inﬂuence of cyanide of
mercury does not differ from that of other preparations of the same metal.
Mercury was largely used by British practitioners a generation ago in the
belief that it possessed the power of arresting the exudative process 5 it has,
however, been almost, if not altogether, abandoned even in those cases of
so-called sthenic croup, in which the exudation was chieﬂy, if not entirely,
laryngeal. I still rely on the use of steam as originally recommended by me
more than twenty years ago, and of late years I have combined this treatment
with antiseptics and solvents. Of the latter I have found lactic acid most
effectual. I cannot accept the conclusion that mechanical removal is absolutely
contra-indicated. There are cases in which such removal of false membrane
from the larynx can be accomplished, and in which tracheotomy may thereby
be avoided. The removal of the tonsils or uvula during the progress of
diphtheria is, I think, not unattended with risk; and therefore only to be
recommended in exceptional cases.
Dr. JOHNSON, Chicago : I can testify to the utility of the fumes from
slaking lime in certain cases, and consider that it is very difficult to come to a
208 DISEASES OF THE THROAT.
positive agreement as to local treatment, bearing in mind the difference in the
type of the disease under different circumstances.
Dr. MORELL MACKENZIE : Once more I would strongly advocate the use of
varnishes. Disastrous results attended the forcible removal of the mem—
brane, as recommended by Dr. Nix, in the hands of English medical men in
the great epidemic of 1856-57.
La pathologie de la p/zt/zz'sz'e [mg/ﬁgée.
Professor KRISHABER, Paris.
Si la phthisie laryngée est un des écueils les plus douloureux de la pratique
médicale, elle est aussi l’une des maladies sur lesquelles on a beaucoup écrit
et discuté : mémoires, articles de journaux, communications aux sociétés
savantes, &c. semblent avoir tellement épuisé le sujet, qu’au moment de
remplir la tâche que vous m’avez conﬁée, je pourrais craindre de tomber
dans les banalités.
Le seul côté du sujet qui mérite d’être porté devant vous concerne le pro-
nostic de la maladie, parcequ’il soulève incidemment la question encore
litigieuse de l’anatomie pathologique; la gravité et la fréquence de la phthisie
laryngée prêtent en ei‘Ïet un intérêt éminemment pratique au problème que je
vais avoir l’honneur d’aborder ici.
Des observateurs de valeur égale ont émis des opinions diamétralement
opposées sur l’anatomie pathologique de la phthisie laryngée, et comme la
terminaison de la maladie est en corrélation intime avec la nature de la lésion,
il me sera permis de traiter comme une seule question l’anatomie pathologique
et le pronostic.
Nous sommes loin de l’époque où l’on confondait toutes les maladies graves
du larynx sous la dénomination commune de phthisie laryngée. Déjà avant
l’apparition du laryngoscope, on avait décrit sous ce nom la laryngite ulcéreuse
des tuberculeux; on mit hors cadre les ulcérations diathésiques ou locales de
toute autre nature. Cette délimitation essentielle n’est donc pas une conquête
du laryngoscope; mais ce nouveau moyen d’investigation a soulevé la question
importante de savoir si la laryngite est tuberculeuse en elle-même, ou, pour
préciser davantage, si l’organe est envahi par le tubercule en nature, ou bien si
le larynx s’ulcère simplement et subit des altérations de tissu en dehors de la
présence de cette production morbide, ce qui constituerait la laryngite des
tuberculeux, mais non la laryngite tuberculeuse.
La question, déjà nettement posée par Trousseau et Belloc, a été résolue,
depuis, par d’éminents anatomo-pathologistes dans des sens opposés. D’un côté
nous trouvons Louis, Andral, Cruveilhier, Monneret, Rheiner, Rühle,
Rindﬂeisch ; de l”autre, Rokitansky, Lhéritier, VirchoW, Barth, Cornil et
Hérard, Isambert et je passe un grand nombre de noms.
Cette divergence d’opinion tient surtout a ce que les uns ne veulent recon-
naître comme tubercule que la matière caséeuse que l’on ne rencontre pas
fréquemment dans le larynx, tandis que les autres rattachent l’ulcération a la
présence des granulations et afﬁrment que la laryngite ulcéreuse est due à. une
tuberculose sur place, alors même que les granulations n’existent plus et que
l’ulcération est le seul vestige de leur passage.
Un fait clinique d’une importance capitale a jeté une vive lumière sur la
question; je veux parler d’une des complications de la phthisie laryngée, la
\
tuberculose du pharynx et de la langue, dont toute l’évolution est facile a
DISEASES OF THE THROAT. 209
suivre et qui a pu être observée un bon nombre de fois. On a pu conclure
que le tubercule se trouve en nature dans la muqueuse des voies supérieures.
Les partisans de la non-existence du tubercule dans le larynx invoquent en
faveur de leur opinion les autopsies d’individus morts de phthisie pulmonaire
compliquée d’ulcérations du larynx sans que la présence du tubercule sous sa
forme granuleuse ou caséeuse ait été constatée : telle est l’origine de la dénomi-
nation de laryngite des tuberculeux, c’est-à-dire d’une inﬂammation ulcéreuse
diathésique, mais non tuberculeuse in loco.
Personnellement, il ne me répugne pas d’admettre que la laryngite survenue
chez un sujet tuberculeux puisse devenir ulcéreuse sans que le produit morbide
ait existé sur place; mais je me borne ‘2. faire observer que très souvent le
tubercule existe dans le larynx, sous la forme granuleuse, quelquefois sous la
forme caséeuse, et qu’il est aisé d’en veriﬁer a l’autopsie les divers degrés
d’évolution depuis l’inﬁltration jusqu’au ramollissement compliqué de vastes
pertes de substance du tissu de l’organe.
Si la question est intéressante au point de vue purement anatomo-patholo-
gique, elle prend une importance considérable quand il s’agit du pronostic et du
traitement de la maladie.
Nous voici en face du redoutable problème de la eurabilité de la phthisie
laryngée,
Déjal’année dernière il a été posé au congrès laryngologique de Milan, mais
il n’y fut traité qu’incidemment.
Les opinions émises alors et soutenues depuis, tendraient à admettre comme
assez fréquents les cas de guérison, relative ou absolue, de la phthisie laryngée.
Au congrès de Milan, une seule dissidence se produisit ; comme elle
venait de ma part, je vous demande la permission d’exposer clairement une
opinion que l’on a dans la suite quelque peu défigurée.
J’ai soutenu et je maintiens que les individus atteints de phthisie laryngée
succombent invariablement au progrès de la tuberculose, soit que cette tuber—
culose si borne aux voies respiratoires, soit qu’elle s’étende sur d’autres organes
de l’éoonomie. L’ulcération tuberculeuse du larynx guérit quelquefois, mais
fort rarement; la cicatrisation partielle s’accomplit alors, pour ainsi dire, sous
les yeux de l’observateur ; mais, circonstance très grave, l’ulcération se produit
sur un autre point de l’organe, et alors même que cela n’a pas lieu, des compli—
cations rapprochées ou éloignées du larynx impriment à la situation le caractère
désolant des maladies marche fatale. Une érosion, une ulcération même,
peuvent se cicatriser, mais le malade n’est pas guéri, car la maladie n’en pour-
suit pas moins son évolution avec une malignité extrême. Il importe peu, en
réalité, de démontrer que chez des individus atteints de phthisie laryngée les
ulcérations ont partiellement et temporairement disparu de la muqueuse de
l’organe; je ne nie point ces faits, ayant en personnellement l’occasion de les
observer, mais ce que je n’ai jamais vu, c’est un individu atteint de phthisie
laryngée récupérer la santé; je déclare que les observations de guérison publiées
jusqu’a ce jour n’ont pas modiﬁé ma conviction.
La phthisie laryngée est une des manifestations les plus graves de la tuber—
culose qui, fort heureusement, n’est pas au même degré meurtrière lorsqu’elle
atteint certains autres organes.
Il est singulier que le poumon qui, dans la hiérarchie organique, occupe un
rang plus élevé que le lai‘ynx, puisse être atteint de tubercules sur une assez
large étendue, sans que l’affection devienne irrémédiable. Les individus
atteints de tubercules pulmonaires vivent parfois assez longtemps, tandis que
les malades atteints de tubercules du larynx sont enlevés rapidement. La
majorité meurt en moins d’un an; quelques-uns résistent deux ans, mais je
n’ai observé jusqu’ici que trois cas exceptionnels. Un de ces malades
PART III. r
.2 IO DISEASES OF THE THROAT.
n’a succombé qu’au bout de quatre ans, un autre, malade depuis quatre ans,
vit encore, mais je prévois un dénouement prochain; chez le troisième,
que j’observe depuis six ans, l’affection marche avec une telle lenteur que
j’ai conçu quelques doutes sur la réalité du tubercule malgré les complica-
tions survenues au testicule et aux pavillons des trompes d’Eustache, et malgré
l’existence depuis vingt ans d’une ﬁstule a l’anus. Ce malade est a tous égards
si extraordinaire, que son cas ne pourrait être invoqué ni pour, ni contre la
thèse que je soutiens.
Dans une communication forcément écourtée comme celle—ci, on ne peut
s’appesantir sur des faits isolés. J ’apporte devant vous l’impression générale
qui résulte pour moi d’une pratique déjà. longue et d’observations extrêmement
nombreuses ; si cette impression n’est pas Consolante, je crois du moins pouvoir
aiﬁrmer qu’avouer notre impuissance et reconnaître la nécessité de recherches
nouvelles, c’est mieux servir la science que de rendre, involontairement sans
doute et avec la meilleure foi du monde, les faits complices de ses illusions.
Conclusions—Les lésions de la phthisie laryngée dont la nature tuberculeuse
a été pendant longtemps méconnue, relèvent de la tuberculose in loco, alors même
qu’à l’autopsie la présence du tubercule dans le tissu du larynx ne peut plus être
constatée. Il est des cas dûment avérés de tubercules en nature, soit sous
forme d’inﬁltration diﬁ'use, soit sous forme de granulations grises; le tubercule
en masses caséeuses est au contraire beaucoup plus rare dans le larynx.
Il existe dans la muqueuse de cet organe des cavernules microscopiques,
suite du processus nécrobiotique dont le point de départ paraît être l’altération
des vaisseaux par des cellules embryonnaires. Ces éléments apparaissent
d’abord sur la membrane interne du vaisseau, mais ils se groupent aussi autour
de lui ; ils ﬁnissent, en l’envahissant progressivement, par oblitérer le vaisseau.
La phthisie laryngée en dehors de la tuberculose du poumon a été signalée
quelquefois, mais son existence est encore douteuse. -
Les tubercules du pharynx et de la langue sont presque toujours accom-
pagnés de lésions analogues dans le larynx.
Pendant la vie des malades la laryngite tuberculeuse se présente avec des
caractères très nettement accusés. Depuis les simple érosions de l’epithelium
jusqu’à la destruction profonde des tissus, avec ou sans formation de bourgeons
charnus qui peuvent devenir polypiformes, tout l’ensemble des lésions offre
une image frappante qui rend le diagnostic très aisé au laryngoscope. La con-—
fusion ne pourrait être permise momentanément qu’avec la laryngite syphi-
litique, alors que l’auscultation ne révèle pas de lésion pulmonaire; mais le
traitement spéciﬁque de la syphilis lève bientôt tous les doutes qui, du reste, en
dehors même de ce critérium, ne peuvent pas persister longtemps.
Le pronostic de la laryngite tuberculeuse est des plus graves. Les érosions,
les ulcérations même peuvent se cicatriser localement, mais les lésions se repro-
duisent, alors même que la cicatrisation paraît déﬁnitive, ce qui arrive très
rarement; la cause générale qui a donné naissance aux lésions du larynx
persiste, et la tuberculose évolue dans d’autres organes avec toute sa malignité.
Dz'e Paz’kologz'e der KeM/äopfpkt/zzke.
Prof. ROSSBACH, Würzburg.
Die Halsschwindsucht ist eine von den am häuﬁgsten den Laryngologen
zur Beobachtung und Behandlung kommenden Halskrankheiten und fur
ihn von um so grôsserer Bedeutung, weil einerseits die oft auf das zdusserste
gequälten Kranken in den Specialisten ihre einzige Rettungsmüglichkeit
noch erblicken und selbst in den hoffnungslosesten Fällen sich an ihn
DISEASES OF THE THROAT. 2 I I
anklammern und sich nicht abweisen lassen wollen, und anderseits, weil in
der That die allgemeine und die locale Therapie beginnt, dieser früher auch
von den Specialisten für unbesser-und unheilbar gehaltenen Krankheit eine
günstigere Prognose stellen zu lassen. Da aber über diese Erkrankung unter
den Beobachtern noch viele controverse Meinungen bestehen, und noch viele
Punkte in der That eine eingehendere Bearbeitung erheischen, so ist es mit
Recht von den verdienstvollen Leitern der laryngologischen Subsection des
Londoner internationalen medicinischen Congresses für nothwendig erachtet
worden, diese streitigen Punkte im Gebiete der Halsschwindsucht zum Vortrage
und zur Debatte zu bringen. Wegen der ausserordentlichen Schwierigkeit
vieler Fragen halten die meisten der erfahrensten Beobachter mit Recht noch
die schriftliche Mittheilung ihrer Standpunkte zurück. Im persönlichen
Verkehr und in der mündlichen Mittheilung dagegen werden dieselben wohl
weniger Grund zur Zurückhaltung ﬁnden und es mag daher der Boden des
Congresses die Früchte rascher zur Reife bringen, als es ohne diesen möglich
w‘a're. Ich habe desshalb auch mit wirklicher Freude den ehrenvollen Auftrag
angenommen, über den gegenwärtigen Stand der ganzen Lehre zu referiren
und werde suchen, mit möglichster Unparteilichkeit und Vollstandigkeit
meiner Aufgabe gerecht zu werden.
Zwar über eine der wichtigsten Fragen, nämlich die nach der Natur der
Halsgeschwüre bei Laryngo— und Tracheophthise, ist gerade in neuerer Zeit,
‘namentlich in Folge der eingehenden Arbeit Heinze’s mit seinen massenhaften
mikroskopischen Untersuchungen phthisischer Kehlkopfgeschwüre, eine
Einigkeit dahin erzielt und bereits auch von den namhaftesten Laryngologen
ausgesprochen worden, dass die gr'o'sste Mehrzahl der bei Lungen-und Hals-
schwindsucht angetroffenen Kehlkopf-und Luftrohrengeschwüre speciﬁscher,
d. h. tuberculöser Natur ist. Es wird nicht geläugnet, dass mehr oder
weniger häuﬁg auch nicht tuberculöse Halsgeschwüre im phthisischen Halse
vorkommen; aber die Ausschliesslichkeit, mit der manche altere Autoren, wie
Louis, Rheiner u. A. auf der nicht tuberculösen Natur der phthisischen Halsge—
schwüre beharrten, wird von keinem modernen Laryngologen oder pathologischen
Anatomen mehr getheilt.
Die “nicht tuberculo'sen ” phthisischen Halsgeschwüre hat man bald von
der Corrosion der Schleimhaut durch den putriden Schleim, bald von dem
Druck geschwellter Schleimhautparthien oder von der starken Reibung des
Luftstroms bei den unaufhörlichen Hustenanﬁillen abgeleitet; in jüngster
Zeit hat Schottelius die so ha‘uﬁg zwischen den Aryknorpeln sich bildenden, mit
starker Gewebeschwellung verbundenen Geschwüre auf ganz einfache physio-
logische und mechanische Momente zurückzuführen vermocht. So viel scheint
man jetzt schon sagen zu können, dass die “nicht tuberculösen ” phthisischen
Halsgeschwi'ire von den verschiedensten Ursachen und nicht von einer einzigen
der eben genannten hervorgerufen werden können; dass es “nicht tubercu-
löse” phthisische Geschwüre gibt bei Menschen, die einen einfachen katarr-
halischen, wie bei solchen, die einen putriden oder auch gar keinen Auswurf
haben, bei Menschen, welche nicht husten nnd welche von qu'alendem Husten
unaufhörlich befallen sind; und ferner, dass ganz Lungensüchtige mit und
ohne Husten, mit katarrhalischem oder putridem Auswurf u. s. w. vorkommen,
die nie Halsgeschwüre bekommen, sondern bei ganz gesund bleibendem Halse
an ihrer Lungenerkrankung zu Grunde gehen.
Wahrend für die tuberculöse Halsschwindsucht von den meisten neueren
Forschern als Ursache ein speciﬁsches infecti'oses Gift angenommen wird,
welches von Aussen kommend oder auch im eigenen Körper, z. B. in
vereiternden Drüsen selbst sich bildend meistentheils zuerst die Lungen
befallt und von da auf den Blut— und‘ Lymphbahnen zur Kehlkopfschleimhaut
r 2
212 DISEASES OF THE THROAT.
fortgeführt wird, fand Schottelius bei einer grossen Zahl von Versuchen, dass
nicht blos durch Einathmung von zerst'aubtem phthisischem Auswurf, sondern
auch von rein bronchitischem Schleim, ja selbst durch Einathmung von fein
zerriebenem K albshirn oder Kase tuberkelgleiche Knötchen in der Lunge sich
bilden und glaubt daher den Schluss ziehen zu dürfen, dass die Tuberkel
auch der Halsorgane durch ganz verschiedene Ursachen und nicht blos durch
ein einziges speciﬁsches tuberculöses Gift hervorgerufen werden könnten.
Von prima'rer tuberculöser und nicht tuberculöser Halsschwindsucht sind
zwar einzelne Falle mitgetheilt; dieselben haben aber noch keine allgemeine
Anerkennung gefunden, weil eine mögliche Täuschung und ein Uebersehen
eines bereits vorhandenen Lungenleidens nicht auszuschliessen war. Jedoch
scheint die Möglichkeit des Vorkommens einer primären Halsschwindsucht nicht
absolut verneint, sondern nur als höchst selten bezeichnet werden zu dürfen.
Es ist nicht nur denkbar, dass auch aus nicht speciﬁschen Kehlkopfgeschwi'iren
durch Einﬂiessen und Aspiriren des Eitersin die Lungen eine phthisische Erkran-
kung dieser eintritt, wie, dass auch primiir einfach katarrhalische I-Ialsgeschwüre
im Laufe der weiteren Krankheitsentwicklung tuberculös werden; sondern es
ist bereits von Sommerbrodt an Kaninchen experimentell durch künstlich
hervorgerufene und unterhaltene Kehlkopfwunden und- Geschwüre eine Peri-
bronchitis purulenta hervorgerufen worden, von welch’ letzterer wir durch
andere Beobachter wissen, dass ihre letzten Consequenzen die Zerstörung des
Lungengewebes, die Lungenschwindsucht, zu sein pﬂegt.
Wie bei der Lungenschwindsucht ist auch bei der Halsschwindsucht zur
Erklärung aller Beobachtungen nöthig, anzunehmen, dass es Individuen und
Thierarten gibt, welche besonders zu diesen Erkrankungen disponirt sind, und
andere, welche eine gewisse Immunitat dagegen besitzen.
Laryngoskopisch ist es bis jetzt noch nicht gelungen, Tuberkelablagerung,
Tuberkelknötchen im Kehlkopf als solche zu erkennen, weder vor noch w'a'hrend
der Ulcerationsperiode. Eine sichere Diagnose auf Halsschwindsucht kann
man nur bei gleichzeitig nachweisbarer Lungenschwindsucht stellen. Ist eine
phthisische Lungenaﬁection noch nicht nachweisbar und fehlen auch allgemeine
Zeichen von Syphilis, dann ist es nur möglich, tuberculöse und phthisische
Geschwüre durch ihr verschiedenes Verhalten gegen Iodnatrium von einander
zu unterscheiden. Jedoch werden alle erfahrenen Laryngologen darin überein-
stimmen, dass, oft lange bevor die physicalische Untersuchung der Lungen ein
bestimmtes Ergebniss hat, das Auftreten hartnäckiger und den gewöhnlichen
Heilmethoden trotzender IrIalsgeschw'i'ire auf ein drohendes oder verstecktes
Lungenleiden mit Sicherheit hinweist.
Halsschwindsucht ist ein ausserordentlich hartn'ackiges Leiden, doch nur in
sehr vorgerückten Stadien unheilbar. Im Beginne und selbst schon bei
ziemlich ausgebreiteten Zerstörungen hat man durch klimatotherapeutische
Haassnahmen und Einathmun g antiseptischer Substanzen entschiedene Heilungen
beobachtet. Auch in den schwersten unheilbaren Formen ist es wenigstens
möglich, durch Aethereinstüubung auf den n. laryngeus superior, durch
Morphin, Einschnitte in das ödematöse Gewebe Schmerzlosigkeit herzustellen
und das Schlucken wieder möglich zu machen.
DISCUSSION.
Dr. GEORGE JOHNSON, London : Pulmonary tuberculosis may possibly arise in
somecases from a simple laryngitis, either through absorption of m orbid materials
through the lymphatics, or through purulent secretions being carried into the
bronchi and air cells by the inspiratory current of air.
Dr. B, FRBLNKEL, Berlin : I wish to speak on two questions. 1st. Is it possible
DISEASES OF THE THROAT. 213
to diagnosticate tuberculosis from the laryngoscopic image? In this respect
laryngoscopy must take the lead, and must not admit of diagnosticating phthisis
only from the complications. For laryngoscopy works with the highest of our
senses—the eye; and in the overwhelming majority of cases the diagnosis can
be made during life quite as certainly from the laryngoscopic image as micro-
scopically after death on the dead body. This is true as well with regard to
miliary tubercles as to the ulcers originating from them (simple, con-
ﬂuent, eroding). I do not deny that there are doubtful cases, but in a very
large number of cases the diagnosis “miliary tubercle” and “tubercular
ulcer” can be made during life quite positively. As to the doubtful cases,
occasionally also laryngeal phthisis can heal under the use of iodide of potas-
sium. It is not to be forgotten, however, that large doses of the iodides
favour haemoptysis. 2nd. As regards the question whether there is a primary
laryngeal phthisis, I have seen primary laryngeal phthisis—La, cases in
which there was tuberculosis of the larynx, without the most careful examina-
tion showing anything morbid in other organs. It is true that in such cases,
without exception, later on pulmonary phthisis supervenes; the post-mortem
examination in these cases, however, shows that the larynx is the organ
most attacked. The pulmonary trouble in these cases originates from aspira—
tion, as proven in cases of carcinoma by Schech. It is necessary to take the
clinical point of view in this respect, for pathological anatomy will always
show coincidence of the disease in both organs.
Prof. SCHNITZLER, Vienna: I ‘do not agree with Professor Ptossbach’s
dictum—“ It is impossible to recognize laryngoscopically the deposition of
tubercles in the larynx before or during the period of ulceration.” I have
repeatedly observed for years past miliary laryngeal tuberculosis which I could.
laryngoscopically diagnosticate with absolute certainty. Quite recently a
microscopic examination made on a specimen removed from a living person has
corroborated my diagnosis ( T'Vz'e'ner ﬁled. Presse, 1881). My experience leads
me to believe in the curability of the disease. I do not think it is possible to
say positively whether there is a primary laryngeal phthisis, but it is
undoubted that in many cases tuberculosis can be already diagnosticated in the
larynx whilst no pathological change can be demonstrated in the lungs.
Prof. VOLTOLINI, Breslau: I doubt very much the occurrence of a primary
laryngeal phthisis. We see every day countless cases of pulmonary phthisis die
without the association of the same disease in the larynx, but I have not seen a
single case of laryngeal phthisis die Without concomitant pulmonary affection.
Prof. CADIER, Paris : with Professor Krishaber I recognize the gravity of
laryngeal phthisis, but I do not admit that a cure cannot be obtained ; at any
rate, if not a deﬁnite cure, an improvement of considerable duration might be
achieved, by associating an energetic local treatment to the general one. I
have seen this year four patients who had been under my care and that of my
late teacher, Professor Isambert, in 1873—74, and who had shown at that time
unmistakable signs of laryngeal and pulmonary phthisis. When re-examined
now they presented traces of the former laryngeal disorder, but no ulceration,
whilst the arytenoid cartilages remained a little swollen ; the state of the lungs
had also a little improved, so that one could speak of a decided amelioration
since 1873. The treatment employed consisted in the local application, made
twice a week, of the following solution ; creosote 1, alcohol 20, and glycerine
30 parts, in addition to an appropriate general treatment.
Dr. E. FRANKEL, Hamburg: I would make the historical remark that
214 DISEASES OF THE THROAT.
Reinher had already positively demonstrated, in the ﬁfth volume of Virchow’s
Archives, the origin of ulcers in the larynx from tubercles. The great
majority of ulcers found in the larynx of a phthisical patient originate, no‘
doubt, from circumscribed or diffused inﬁltrations, or from disease of the
numerous mucous glands of the mucosa. I think that it is impossible to decide
whether a primary laryngeal tuberculosis exists, inasmuch as even the absence
of changes in the lungs does not give a proof of a real immunity of these
organs. On the other hand, I do not doubt that tubercular laryngeal ulcers
can heal. Clinical observation, as well as the anatomical evidence of cicatrices
in the larynx, speak in favour of this possibility.
Professor GERHARDT, Wiirzburg : I advocate the theory of a mechanical and
infectious origin of laryngeal phthisis, in the sense that frequently ulcers which
were originally sin1ple—i.e., produced by attrition, &0., could become, if occurring
in a phthisical patient, foci of infection and metamorphosed into tubercular
ulcers. Differential diagnosis from luetic ulcers is often difficult, a transforma—
tion of typhoid ulcers into tubercular ones also occurs. A primary tubercu~
losis of the larynx seems probable in some cases. Laryngeal phthisis cannot
any longer be regarded as incurable. Pulmonary phthisis having taken a more
favourable position as regards treatment, the therapeutics of tubercular ulcera—
tions of the larynx now ought to become the subject of the most strenuous
and methodical curative efforts.
Professor KRISHABER, Paris : The thesis which I maintained last year at the
Laryngological Congress at Milan, and which I again defend to-day, is not
based upon a mere theoretical view. I have drawn up rigorously prepared
statistics; I have followed it for many years, and I have brought forward to-
day its results. I have employed against laryngeal phthisis all known topical
remedies—nitrate of silver, sulphate of zinc, sulphate of copper, iodine, chromic
acid, acetic acid, the galvano-cautery, scariﬁcations; and all these remedies have
remained absolutely inefficacious. I have ﬁnally adopted the method which
consists in making local applications of a narcotic solution for the sole purpose
of relieving suffering; this is all that I have been able to obtain up to the
present day. I will not say that tubercular- laryngitis is incurable; I maintain
only that the local therapeutic means in use are without action, and they are
rather damaging than useful; we require something else and something better.
Professor ROSSBACH,WiiI‘Zb11Tg: In opposition to Professor Krishaber, I beg to
say that one positive case is more decisive than a thousand negative ones, and that
for me the cure of laryngeal phthisis in several cases was so positively estab-
lished that no doubts of other observers are capable of shaking my conviction.
Dz'e Zmfyngoscopz'sch wa/zwze/zméarevz V w/Zimz’emmgm 2'12 Foége'
2/012 Evf/év/cmlzzmg oder Vev/Zez‘zzmg a’er moz‘ov/z'sckevz Kekl»
kopfizev/i/en.
Professor GERHARDT, Wurzburg.
Zerstorung des Accessorius-Ursprungs oder des Vagusstammes am Halse
bewirkt regungslose Cadaverstellung des Stimmbandes.
Zersto'rung des oberen Kehlkopfnerven oder seines ausseren Astes hat
geringe Aenderungen in Form und Bewegung des Stimmbandes zur Folge, die
nicht ganz tibereinstimmend geschildert werden. Sie beziehen sich auf den.
DISEASES OF THE THROAT. 2 15
Phonationsact, und zwar vorzugsweise auf Form, Ho'henstand und sichtbare
Schwingungen des Stimmbandrandes, ferner Verhinderung der activen Senkung
des Kehldeckels—abh'alngig von Lahmung der Mm. crico-thyreoidei, ary- und
thyreo-epiglottici.
Zerstorung des unteren Kehlkopfnerven versetzt das Stimmband in
Cadaverstellung. Durch Thierexperimente ist es erwiesen, dass Durchschnei-
dung des oberen nach dem unteren Kehlkopf'nerven die Form der Glottis noch
Weiter andert. Am Menschen ist der Unterschied zwischen Vagus- und
Recurrens-L'alhmung, d. h. der Einﬁuss, den nach L‘ahmung aller andern
Stimmbandmuskeln der Cricothyreoideus noch auszutlben vermag, noch
festzustellen. Langsam wirkender Druck auf die unteren Kehlkopfnerven
lahmt zuerst die Erweiterer. Ausschliessliche L'ahrnung des Cricoarytaenoideus
posticus bedingt hochgradige Adductionsstellung des Stimmbandes, noch
vollst'andigere Adductionsbewegung bei der Inspiration, normale Phonations-
schwingungen des Stimmbandes.
Es ist einiger Grund vorhanden zu der Annahme, dass auch die Absonde-
rungsvorgange der Kehlkopfschleimhaut von den Kehlkopfsnerven beeinﬁusst
werden.
Lanyngoseopz'e Signs in connection wit/z Injuries 01/ Diseases
of Me M 0501/ N err/es 0f Z/ze Lanynx.
Prof. G. M. LEFFERTS, New York.
\ That the entire subject of the motor neuroses of the larynx, as it to-day
stands and in the light of our present knowledge concerning it, admits of a re-
arrangement and of more simpliﬁcation, will not, I think, be denied ; that a better
classiﬁcation is needed, not only for our present purposes of clear and pointed
discussion, but likewise in view of the needs of the present and future student of
laryngeal pathology, is evident; that it can be made, I believe.
Why should we still adhere as closely as of old to the arrangement of all
laryngeal neuroses, purely upon the basis of the physiological and anatomical
nature and character of the nervous supply of the larynx, or to that adapted to
the arrangement of its muscular apparatus? Why commingle purely
neuropathic cases with those of undoubted myopathic origin, and lose sight in
the hazy atmosphere of doubt and uncertain statement of the sharp line of
distinction that can be proven to exist between them? The answer would be
a diﬁicult one, but that the question of the motor neuroses of the larynx is
complicated to an unnecessary degree, my researches in literature, my studies
of text-books, and my experience as a teacher, do not allow me to doubt.
If you agree with me that this statement is true, our ﬁrst efforts should be
to place the whole matter upon a new, good, substantial, and with due allowance
for future amendment in questions concerning pathology—permanent foundation;
and in pursuance of this purpose I submit the following new classiﬁcation
for your consideration.
I divide all motor neuroses of the larynx into ﬁve great classes. They
are :—
(1) Motor paralyses of the larynx, the result of complete, usually acute,
morbid implication of the nerve centres, or of the main nerve trunks, the
lesion being either unilateral or bilateral, and the vocal cord or cords
assuming the “ cadaveric ” position.
. (2) Motor paralyses of the larynx, the result of incomplete, usually slowly
progressive lesion of either the nerve centres or, more commonly, of the nerve
trunks in their course; certain nuclei of the former or certain ﬁbrils of the
latter alone being implicated, certain muscles alone are paralysed. The

2 1 6 DISEASES or THE THROAT.
abductor muscles of the glottis possessing a peculiar proclivity in this respect,
and practically being the only ones thus affected, the lesion may be unilateral
or bilateral.
(3) Motor paralyses of individual muscles of the larynx, the result of
implication of certain peripheral nerve twigs by local or intra-laryngeal lesion.
(4) Motor paralyses of single or groups of laryngeal muscles, the result of
simple myopathic change in said muscles of a degenerative character.
(5) Motor paralyses functional in their nature, the adductor muscles being
the ones commonly affected, the abductors very rarely.
Upon the ﬁrst class of cases, if I now occupy a few moments in considering
each in some detail, it is not necessary that I should dwell. Acute, complete,
recurrent paralysis, be it unilateral or rarely bilateral, whether it have its origin
in organic disease of the brain, at, or in the neighbourhood of, the ﬂoor of the
fourth ventricle, or be due to complete degenerative lesion from pressure or
disease of either the pneumogastric or spinal accessory nerves, in their course
through chest or neck, as well as of like lesions of the recurrent branches of the
former, or morbid implication of the anastomotic connections of the latter—con—
stitute a division of my subject upon which there exists little or no difference
of opinion, either as regards causation or ultimate laryngeal effects. The
clinical facts have been repeatedly demonstrated and surely proven upon a
purely physical basis. Aside from acute causes, such as traumatic inﬂuences,
or the rare occurrence of haemorrhage or purulent extravasation into the ﬂoor of
the fourth ventricle, as well as acute poisonous inﬂuences—locomotor ataxy,
with ﬁnal participation of the medulla oblongata, progressive bulbar paralysis,
multiple sclerosis, play their progressive disease-producing r616 ,' cerebral
syphilis and malignant tumour exert their baleful inﬂuence; apoplexy or
softening occurs, tumours and aneurism within the skull press upon the spinal
accessory nerve, and in either may lie the source of the ultimately complete
paralysis of all of the muscles of one or both vocal cords. The commoner
causes are even more familiar to us—the implication of the main nerve trunks,
of the pneumogastric or recurrent nerves in their course by aneurism of the
carotids, of the arch of the aorta, or of the right subclavian; by the pressure
of bronchocele, of enlarged cervical or bronchial glands, or tumours of the same
regions, be this external cause or internal retrogressive metamorphosis
unilateral or more rarely bilateral. Finally, the ravages of cancer of the oeso—
phagus, pleuritic adhesions at the apex of the right lung, and pericardial exudation,
all give rise-—if not immediately, certainly within a limited time, if the lesion be
progressive—to certain ultimate physical results, which, pictured in the laryngeal
mirror, cannot be mistaken nor misinterpreted. The motionless vocal cord, motion- '
less except for slight spasmodic movement imparted to it by the only partially
paralysed arytaenoideus proprius muscle, ﬁxed in the “ cadaveric’7 position,
bespeaks at once to the practical eye both cause and result. The lesion is charac-
teristic; the diagnosis easy and conclusive; and the class of case which it so
plainly typiﬁes may be set aside in our discussions with the verdict of proven.
To one point alone do I here call your attention. Pressure on one pneumo-
gastric or recurrent nerve has been known in more than one instance to be
accompanied by paralysis, not only on the side on which the side was implicated,
but also on the opposite side of the larynx, the abductor muscles being the
ones affected. Will the theory of a reﬂex paralysis, the different ﬁbres of the
nerve carrying the irritation back to the nuclei of the spinal accessory, suffice
to account for the phenomena? Do you accept Lockhart Clarke’s demon-
stration of the decussation of the nuclei of the spinal accessory nerve, which
would theoretically explain the condition; or do you hold to the more tenable
theory that, in the reported instances, the nuclei of the spinal accessory must
DISEASES OF THE THROAT. \ 217
have been diseased? A case of my own, elsewhere reported, certainly does
not bear out this latter view. I submit the question for- your consideration.
Cases belonging to the second class possess a peculiar and pressing importance,
having been, until recently regarded as isolated, rare, and, when met with, as un-
explainable. Though many hypotheses have been invented to account for their
existence, they must now be regarded as ﬁxed clinical facts. Experience cannot
be controverted. Instead of a general paralysis of all of the muscles supplied by
the recurrent nerve following its lesion, isolated paralysis of the abduction muscle
alone can, and does, occur in a large proportion of cases. There is then a dis-
tinct proclivity on the part of the abductor ﬁlaments of the recurrent laryngeal
nerve to become affected sooner than its others, or even exclusively, in cases of
undoubted central or peripheral injury or disease of the roots or trunks of the
pneumogastric, spinal accessory, or recurrent nerves (Semon). The question prac-
tically concerns the abductor ﬁlaments and the abductor muscles alone; for iso—
lated paralysis of the adductor muscles, which receive, I believe, and, as I shall
state, in a manner, their motor—force from the spinal accessory, mainly, if not
wholly, from organic disease or pressure, is extremely rare (a case is reported by
Tiirck, p. 437, of bilateral compression of this nerve in its passages through
the foramen laceruni, by cancerous inﬁltration, in which hoarseness was the
prominent symptom), and individual paralysis of the other laryngeal muscles
(tensors and laxors) is, perhaps, invariably of myopathic origin. I deal here,
then, with isolated paralysis of the abductor muscles of the glottis, unilateral
or bilateral, the cause lying in central or peripheral lesion of the motor nerve-
supply of the larynx. (These causes have been enumerated above.) The
clinical fact is, as I have said, proven; the reason is now to be sought. The
theory of the homogeneousness of the recurrent laryngeal nerve generally held
is no longer tenable in the face of the fact just stated. As Semon truly
remarks, were all its ﬁbres identical, but different stimuli, coming either from
the same or different centres, could be transmitted through them in every case
in which there was an incomplete impairment aﬁecting the roots or trunks of
the spinal accessory pneumogastric or recurrent nerves, one and the same
sequence only could be reasonably expected—via, diminution of all the func-
tions of all of the laryngeal muscles supplied with motor ﬁlaments by the
recurrent laryngeal nerve, and this diminution in proportion to the number
and strength of the ﬁbres disabled by the disease-producing cause. But clinical
facts and observation have proven that this is not the case; that even if such
incomplete impairment does affect them, root or branch, certain ﬁbrils, and
therefore certain muscles alone, can be affected, to the exclusion of others; and
we are forced by these facts to the conclusion that in order to produce such a
result, the ﬁlaments of the recurrent nerve must be strictly differentiated
throughout their course, surrounded by a common neurilemma, and even
possess independent ganglionic centres of their own. In this view, it may be
added, we are in entire accord with modern physiological investigation. Ac-
cepting it, we may discuss the cause of the curious proclivity which these
ﬁlaments of the recurrent which go to the abductor muscles, show, in ﬁrst,
perhaps exclusively, yielding to a morbid condition, which apparently affects
the whole nerve trunk or centre. This cause must lie in an inherent weakness
to resist degenerative change; in a peculiar susceptibility to pathological
inﬂuences; a speciﬁc vulnerability, if you choose, due to the feeble supply of
motor force derived from external sources, and received by the adductor ﬁla-
ments of the recurrents; or in the fact that their centres, single and isolated,
are ﬁrst and most easily overwhelmed and destroyed by any central lesion.
N 0 other explanation which has been advanced covers the ground. Section of
the spinal accessory nerve, usually regarded as the great source of motor power
2 1 8 DISEASES or THE THROAT.
supplied to the recurrents, is stated to be followed by paralysis of the adductor
muscles alone, as shown in Bernard’s experiments upon animals, loss of voice
alone following its division. Hence it may be regarded as the particular and
peculiar source of motor innervation of the adductor ﬁlaments. To paralyse the
abductor muscles, section of the facial hypoglossal and ﬁrst and second cervical
nerves is necessary. The relations and anastomoses of the latter, with the recur-
rents, are by no means as large nor as extensive; nor is the relation as intimate
as that of the former. Reasoning from these facts alone, we are led to believe
that the abductor ﬁlaments of the recurrent must be the least powerful, being
the most poorly supplied by motor innervation, and therefore more readily dis-
posed to yield to any pathological cause which gives rise in the centres or course
of the recurrents to degenerative change.
One of the explanations heretofore advanced to explain these cases—viz,
that the adductor ﬁlaments receive an increment of nerve-force from the
superior laryngeal, it will be seen is based essentially upon the same idea—viz.,
the superior motor and resistent power of one set of ﬁlaments of the recurrent
nerve (the adductor) over the other. Such reinforcement can be but slight;
but still it lends its aid in establishing the above described condition.
I cannot accept the view olfered in explanation of these cases, that the
arrangement of the ﬁbrils in the recurrent nerves is a concentric one,
and that the abductor ﬁlaments are situated in the periphery of the nerve,
thus earliest and most directly exposed to injury from pressure or lesion.
There is no precedent anatomically for assuming such an arrangement
of a nerve. A series of ‘microscopical sections of the recurrent nerves that I
have had made does not show it, nor, indeed, any deviation from the well-
known picture of the cross section of a nerve. Nor can I understand how any
pressure, even the most discriminating, could just touch the peripheral ﬁbres,
destroy their conductivity, and leave others intact. I can see how it might set
up degenerative changes in the'weakest. It must be remembered likewise
that the recurrent laryngeal nerve is a very small one, and that the character
and nature of all the lesions above enumerated (aside from the central, which
involve the roots) are such as not to press upon any limited point, but rather
to stretch the nerve-trunk for some distance. Furthermore, such an explana—
tion, were it true, would hold good only in cases of the lesion of the
recurrent _nerve alone; it would not be sufficient in cases of cerebral
disease, nor in lesion of the pneumogastric or spinal accessory nerves.
The theory of the morbid implication of an independent ganglionic centre—-a
respiratory centre situated in the brain and said to preside specially over the
abductor ﬁlaments—being invariably the cause of isolated paralysis of the
abductor muscles is at once overthrown, as an invariable rule, by the clinica
fact that in a large number of the reported instances of paralysis and degenera-
tion of the abductor muscles the lesion has occurred in the course of the
recurrent nerve, and not at its centre. The seat of the morbid change which
produces the isolated paralysis of the abductors lies in the nerve trunk, and
has been here demonstrated. It may lie in its centre in certain instances, but
in either case has not progressed far enough to destroy the conductivity of all
of its ﬁbres. It attacks, primarily at least, only those most disposed to yield
to its inﬂuence. Furthermore, no such independent ganglionic centre has ever
been located. It is useless, therefore, to discuss the point further. Facts
supplant theory.
The whole question may be summed up thus: The proclivity of the
abductor ﬁlaments of the recurrent nerve to undergo an internal retro-
gressive metamorphosis—becoming ﬁrst, or even exclusively, diseased in
cases of peripheral injury or disease involving the nerve trunk—depends upon
DISEASES OF THE THROAT. 219'
a speciﬁc vulnerability of these ﬁbres or their centre to degenerative changes
and ultimate loss of conducting power. This in truth is due to the feeble
reinforcement of motor power which they receive from their centres or from
supplementary sources. The proclivity of the isolated and unsupported
centres for the abductors to yield to disease-producing causes is due
to the greater resistance offered to the latter by the mutually co-opera-
tive and anatomically connected adductor centres, for certain centres being
affected others stand ready to take their place ; certain ﬁbrils of the recurrents
being destroyed, the united force of the centres is thrown into the remaining
healthy ones. This proclivity is, moreover, analogous to the similar one of the
extensor muscles of the extremities to become affected sooner than the flexors,
or even exclusively in diseases of central origin. This explanation, it will be
seen, covers the same ground and leads to the same results as the foregoing.
In other words, aside from acute, complete lesion of the brain substance, are
certain points which, affecting all routes of the recurrent and its supplemen-
tary sources of motor power, involving necessarily both adductor and abductor
ﬁlaments, lead to complete paralysis of all laryngeal muscles 3 the nature and
tendency in all the forms of lesion met with in the peripheral course of the
nerve, and even in certain instances at its centre, is to incompletely affect it
—-certainly at ﬁrst—and to gradually implicate those ﬁlaments which possess
the least power of resisting the morbid impulse. These, as has been shown,
are the abductor ones; isolated paralysis of the abductor muscles, unilateral
or, more rarely, bilateral, according to the nature and location of lesion, is thus
clearly established.
I ask your attention now to the third division of my classiﬁcation. Cases
of paralysis of individual muscles of the larynx exist of non-myotic origin,
and independently of any lesion of the nerve centres, or of the nerve
trunks in their course. The fact is, I believe, established ; why should we ignore
it in our present (with one exception) works upon the subject? The cause
if sought for in the larynx, will be found to be a local one, and to lie in the
implication of single nerve twigs by certain local lesions, such as ulcerations,
gummy tumours, cicatricial contractions specially, the pressure of enlarged
glands, and other such conditions which will suggest themselves, with degenera—
tion and atrophy of the single muscle to which it or they are distributed.
Anatomically, such a result is not difficult to explain, for you remember that
the individual muscular branches of the inferior laryngeal nerve are only given
off as the nerve itself enters the larynx. The deduction is obvious—in default
of a demonstrable nerve lesion, exterior to the larynx, although the laryngo-
scopic signs of a paralysis exist, diagnostic refuge should not at once be taken
in the hypothesis of the myopathic nature of its origin. That paralysis of a
muscle may arise from intrinsic causes, that it may undergo idiopathic change
of a degenerative character independently of any nerve lesion, modern
microscopical, clinical, and post-mortem investigation and study have proven.
Inﬂammation of any muscle may be either acute or chronic. The former,
which it is true is rare, begins with parenchymatous swelling, and passes thence
into suppuration and abscess. The latter is due to long continued and
oft-repeated hyperaemia, and results in an overgrowth of the interstitial con-
nective tissue and in changes in the muscular fasciculi. These vary; some
retain their striation, and the nuclei of the sarcolemma are more numerous
than normal. Others undergo cloudy swelling or fatty degeneration; and
ﬁnally, in a few cases, most of the muscular fasciculi present the
lesions of vitreous degeneration. Fibroid metamorphosis is well exempliﬁed in
the muscular changes seen after repeated rheumatic attacks, the mechanical
irritation produced by continuous over-use or abuse of the voice, and in
220 DISEASES OF THE THROAT.
syphilis of the larynx, aside too from such ﬁbroid degenerations inﬂammatory
in their origin. Others have been shown to exist that are certainly passive.
Let me pass now to speciﬁc examples. It is only necessary to remind you
that muscles undergo certain idiopathic changes in typhoid fever, acute
tuberculosis, cholera, and small-pox. Fatty degeneration is usually a chronic
process, but acute fatty degeneration has been known to occur in at least one case
of poisoning by phosphorus. Like instances are upon record from the toxic
effects of arsenic and antimony. Again, syphilis is not unfrequent in the muscles,
and is found to Show characters varying according to the degree of its intensity,
the stage of the inflammatory process, as well as the amount or extent of structure
implicated—the same is true of malignant tumour and primary cancer of muscle.
Another phase of the question interests us. Modern neurology has
demonstrated that many diseases, formerly regarded as neuropathic, are
primarily myopathic. Thus, we are told that progressive muscular
atrophy is due to a fatty degeneration of the muscular ﬁbres; that pseudo—
hypertrophic paralysis in early life is not a disease of the spinal cord, but
rather a primary one of the muscular tissue, “a congenital nutritive and
formative weakness of the striated muscle substance,” and that in infantile
paralysis the muscular fasciculi may in part completely disappear from a fatty
degeneration. Examples might easily be multiplied, but those here given are
sufficient to sustain the truth of the doctrine of myopathic change; and let me
here adduce another curious and suggestive fact—via, the analogy that may be
shown between the well-known idiopathic degeneration of the heart muscle
and perhaps a like change in the abductor muscles of the larynx, both muscles
resembling each other closely in their involuntary and unremitting action.
If these changes can thus be shown to occur in the muscular system generally,
it is easy and proper to apply the laws which govern them to that of the larynx,
not only because we have in it an organ peculiarly susceptible to many of the
morbid conditions which are elﬁcient factors in the production of degenerative
lesions of muscle, but likewise because its muscular apparatus is wonderfully
delicate in its construction, exposed in its situation, the subject of constant
activity, and therefore readily involved by direct injury (Ott) by over—
muscular exertion (specially exempliﬁed in the case of the thyro-arytaenoid
muscles), by exposure to cold, and like causes. The immediate effect of the
use of the laryngeal muscles, under these latter conditions, is to produce over-
strain of the muscular ﬁbre and temporary loss of contractile power; the
remote, the cause persisting, is to bring about pathological change of a
degenerative character. From the foregoing it would appear that the occur—
rence of idiopathic degenerative change in the laryngeal muscles can be
established as beyond question; the fact that the seat of the disease lies in the
muscle itself, that here it causes myotic change through which contractility is
destroyed and consequently function abolished, is proved by intrinsic evidence.
And though, as has been elsewhere said, it is possible that microscopical
research may at a future period discover histological changes in the nerves
which are beyond our present means of detection, it is not probable, and we are
justified in basing our conclusions upon the premises of which we are to-day
cognizant. The view then held above completely harmonizing, as it does, with
clinical observation, commends itself as the correct one. Such cases cannot be
regarded as neuroses, even in the widest acceptation of the term, and their con-
sideration, conjointly with those of undoubted neuropathic origin, as is almost
universally done, leads but to misconception and confusion. Rather let us con—
stitute them a separate and distinct class, the fourth to which I call your attention.
The ﬁfth class of case needs but a passing notice. It includes that form of
paralysis which we designate as functional—dependent, it is true, upon deﬁcient
DISEASES OF THE THROAT. 22I
S
muscular action; it is in no wise due to pathological lesion of nerve centre or
trunk, nor interstitial myotic metamorphosis; but takes its rise in that curious
psychical condition which we term hysteria. The one point concerning it upon
which we would do well to seek an explanation is the reason of the curious
predilection that the functional neuroses show for affecting the adductor muscles,
for the number of cases in which hysterical paralysis of the larynx has affected
alone the abductor muscles are so few and so doubtful that they only go to prove
the rule.
Finally, I hardly regard it as necessary in the presence ot this distin—
guished audience of experts to dwell upon the laryngoscopic signs met with
in connection with the motor diseases of the larynx that I have described ;
although I should like, did time permit, to call your special attention to the
diagnostic necessity of distinguishing between paralysis of the vocal cord and
immobility due to mechanical impairment of the crico-arytaenoid articulation.
The matter is an important one; but I am all the more ready to leave it
untouched, though to my regret, because a most excellent essay which has
recently appeared (Semen) fully covers the ground.
The laryngoscopic signs of the paralysis are familiar to you all. Do the reve~
lations of the laryngoscope need any exposition at my hands? Surely not. IVe
recognize without difficulty the “ cadaveric ” position of the vocal cord, and its
signiﬁcance at once attracts our attention and bespeaks further investigation as
to causation. So, too, of the varied positions and appearances of the vocal cords in
the different paralyses due to lesion of individual muscles ofthe larynx. Does not
the ﬁxture of the vocal cords near the median line on attempted inspiration, their
non-approximation on attempted phonation, indicate clearly the special muscular
derangement? \Vill not the triangular opening between the vocal cords, pos—
teriorly, in paralysis of the central adductor, the elliptical opening between them
in paralysis of the internal tensors, and the wavy glottic line in paralysis of the
external, all tell their own story clearly to the expert eye. And even if the
paralysis do not occur in the simple forms here described—~although the com-
bination vary, and even spasm be associated with paralysis—will not the
experienced observer be able to solve the combination from the variations in the
shape of the glottis, and decompose, notwithstanding its difficulty, the permu-
tations of which the laryngoscopic image is capable (Mackenzie). It would ill
become me, gentlemen, in your presence, to think otherwise; and I, therefore,
now leave my work in your hands for your discussion and judgment. The
suggestions that I have made are tendered with a feeling of good will and
strong desire to aid in our common work—would that they were more worthy of
your acceptance.
DISCUSSION.
Dr. GEORGE JOHNSON, London: One of the many points of interest connected
with this question is the curious fact that occasionally a bilateral paralysis ob-
served during life depends on a lesion of the trunk of one vagus only; and
here I may refer to a case of my own in which a bilateral paralysis of the
abductors was found post-mortem to depend on an aortic aneurism involving
the left pneumogastric nerve only. The only possible explanation of these cases
is that the irritation conveyed by the afferent ﬁlaments to the centres sets up
such disturbance there as passing along the efferent ﬁlaments to both sides causes
paralysis. In my case the nerve centres were not examined, and I would urge
on the members in such cases in future to examine especially the nerve centres of
the spinal accessory, vagus and other nerves implicated. It is an acknowledged
‘fact that a primary disease of the nervous centre may cause bilateral palsy
222 DISEASES OF THE THROAT.
‘of the laryngeal muscles, and it can scarcely be doubted that a central disease,
the result of peripheral irritation, may have the same result.
Dr. OTTOMAR ROSENBACII, Breslau : From a case of bilateral paralysis of the
recurrent laryngeal nerve, which I communicated to the Brcslauer Acrztlz'chc
Zeitschrift of 1880, the following conclusions can be drawn :—-1. In all cases
of total paralysis of the recurrent nerve, the abductors suffer ﬁrst, in the same
manner as in all other cases of paralysis of nerves or nerve centres, ﬁrst the
extensors and abductors are paralysed. The sphincters to which, in the larynx,
the adductors correspond are only attacked, it is well known, quite at the last
by paralytic affections. 2. The stridor and the approximation of the vocal
cords in paralysis of the crico-arytenoidei postici are produced by a perverse
rhythmical innervation of the glottis-closers; it cannot be produced by dif—
ferences in the pressure of air above and below the vocal cords, for in the case
from which the conclusions are drawn, the stridor and the approximation of
the vocal cords ceased when the vocal cords assumed the cadaveric position
-(the same conditions were present here as in the production of contractions in
the extremities). 3. Paralysis of the recurrent nerve and cadaveric position
are not identical ideas, if one does not admit that the crico-thyroid muscle is
also innervated by the recurrent laryngeal nerve.
Dr. FELIX SEMON, London: I am very pleased that my own observations on
the proclivity of the abductor ﬁbres have been so fully accepted by both the
gentlemen who introduced the subject; but though I have recently had the
opportunity of corroborating by a good many new observations my previous state-
ments, I would, with Professor Gerhardt, advise that we should at the present
refrain from attempts at explaining, at any price, the curious fact. It is certainly
not yet time to rush into hypotheses when the fact itself of the occurrence of
an isolated paralysis of the abductors is doubted. I hope that after the public
demonstration, on the previous day, of ﬁve such cases, which only form a
part of the sixteen I have observed during the past ﬁve years, these doubts
will cease. The practical gain already accruing now for the general prac-
titioner, if the fact of the proclivity of the abductors to submit earlier, or even
exclusively, to all forms of organic disease, whether central or peripheral, is
established, will be the following dictum : Position of an immovable cord
in the median line (if not occasioned by myopathic or mechanical disorder)
points to organic disease, central or peripheral; position at the side of the
larynx to functional or local disorder.
Professor SCHNITZLER, Vienna: I agree with Professor Gerhardt that
hysterical paralysis of the vocal cords is due to a functional disease of the
‘central nervous system, a proof for which is that I have sometimes been
successful in such cases when using central galvanization, in which long-con-
tinued local use of electricity had been without avail. I have made observa-
tions similar to that of Dr. Johnson (see IVz'ewer Klim'lc, 1878). I am
disposed to believe that bilateral paralysis of the recurrent laryngeal is scarcely
so frequent as one is induced to believe from the description of the many
cases recorded in literature. Some of them would hardly withstand a severe
scientiﬁc criticism.
Dr. BOSWORTH, New York: We are told that there is a distinct proclivity
on the part of the abductor muscles to paralysis ; that the most common lesion
found is pressure on the recurrent nerve; therefore, that we must attribute
the disease of bilateral paralysis to pressure on the recurrent nerve, and that
DISEASES OF THE THROAT. 223
this pressure so far differentiates the nerve ﬁbres as to press upon those
passing to the abductor muscles. Dr. Johnson, in the interesting case narrated,
has given, to my mind, a truer explanation, and one which I adopted some time
ago in writing on the subject. Recurrent laryngeal paralysis—unilateral or
bilateral—gives rise to a totally different condition from abductor paralysis.
Pressure on the recurrent must necessarily implicate the ﬁbres passing to the
adductor. The serious feature of bilateral paralysis of the abductors is in the
integrity of the adductors producing that glottic closure which gives rise to
the peculiar dyspnoea which oharacterises abductor paralysis. The abductor
muscles are closely analogous to the heart, in that they are in a state of
constant functional activity. Like the heart muscle, then, they are liable to
degenerative change, and in this then we ﬁnd an explanation of what is called
their proclivity to paralysis. This is, I think, precipitated by disease or
pressure implicating one or both recurrent nerves in asmall proportion of cases.
In a majority of cases, however, we must look for a lesion involving that portion
of the respiratory centres which presides over the glottis opening function of the
larynx.
Professor BUROW, Konigsberg: Apart from the unilateral cases, I have
observed nine to ten bilateral total paralyses of the glottis-openers. Two of
them were examined post-mortem; in the ﬁrst there were two large masses of
glands found in the neck, and total macroscopic and microscopic atrophy of the
posterior crico-arytenoid muscles, whilst the brain was quite healthy; in the
second case there was bilateral compression of the recurrent nerve by an
oesophageal carcinoma. The explanation hitherto given for the proclivity of
certain ﬁlaments of the recurrent nerve to succumb ﬁrst to a compression of the
whole nerve trunk, seems to me to be less of the nature of explanation than of
that of a circumscription; the really essential factor is as yet unknown to
us. In opposition to Dr. Rosenbach I wish to state that the prepon-
derance of the adductors explains the approximation of the vocal cords
during inspiration, as it becomes plainly visible in extreme cases that they become
simultaneously arched downwards, which is evidently a consequence of the
positive atmospheric pressure from above and the negative from below.
Professor GERHARDT and Professor LEFFERTS brieﬂy replied, urging the im-
portance and necessity of a further study of the subject.
Dz'e Sensz'éz'lz'z‘iiz‘s-Nennosen a’es Se/zlnndes nna’ Ke/zZ/Eopﬁs.
Prof. SCHNITZLER, Vienna.
Empﬁndungs-Anomalieen dieser Theile sehr hauﬁg. Gewohnliche Erschei-
nungsformen der Sensibilitatsneurosen (Hypaesthesie, Anaesthesie, Hyperaes—
thesie, Hyperalgesie, Paraesthesie) auch hier beobachtet. Bisweilen keine
strenge Trennung zwischen den einzelnen Formen moglich. (Ungenauigkeit
subjectiver Angaben ; Uebergehen einer Form in die andre etc.) Oft diese
Neurosen vergesellschaftet mit solchen in benachbarten Organen; oder
Ausgangspunkt resp. Theilerscheinung von allgemeiner Sensibilitatsneurose.
Charakteristik der subjectiven Symptome der einzelnen Formen. Association
von Krampfhusten, Stimmlosigkeit, Schlingbeschwerden. Objective Symptome
meist ganz negativ oder doch gering und ausser Verh‘alltniss zu subjectiven
Beschwerden. (Hyperamie, Anamie, Katarrh, Reste abgelaufener Entzun-
dungen etc.)
224 DISEASES OF THE THROAT.
Ursachen theils central, (Erkrankungen des Gehirns und Riickenmarks,
I-Iysterie, Hypochondrie—beide letztere aber hauﬁg auch Folgen der N eurosen)
theils peripher (Erkrankungen des Pharynx und Larynx). Zwischen beiden
steht die Diphtherie.
Therapie in erster Linie gegen Grundleiden zu richten. Local: beruhi-
gende Inhalationen und Pinselungen, subcutane Injectionen, Adstringentia,
Oaustica. Detaillirung der einzelnen Indicationen. Vorzuglichs es Mittel in
den meisten Formen: Electricitat, besonders constanter Strom.
New/ores 0f Sensaz‘z'mz 0f Z/ze P/zm/ynx and Lam/12x.
Professor ELSBERG, New York.
Alphabetically arranged literature of the subject.
Deﬁnition .--—Disordered sensibility of the throat, functional and not merely
symptomatic. (The word “functional” does not imply with the author that
there is no physical basis for the particular derangement of function, but that
the structural change is either remote from the organ, the function of which
is deranged, or that it is not discernible with the means of observation at our
command.) The deﬁnition excludes, on the one hand, cases of neuritis and
observed alteration of nerve tissue of the throat; and on the other, throat
neuroses, which have no other than a symptomatic signiﬁcance, as the increased
sensibility and painfulness in inflammatory affections, the diminished sensibility
in connection with the failure of all the powers, such as during an epileptic ﬁt,
in cholera, and in approaching death from any cause, and the perverted sensi-
bility of conﬁrmed insanity, or that occasioned by the actual presence of foreign
bodies, tumours, &c.
Anaz‘omz'co—physz'0logz'cal basis : Many questions relating to the normal
and pathological sensibility of the larynx, pharynx, and other constituents of
throat not yet definitely settled. What normal sensation involves. The
deviation and distribution of the sensory nerves of the throat. Hypothetical
sensory nucleus of Spitzka; his reasons. Variations of normal sensibility in
different persons, and different portions of the throat. Pieniaczek’s experi-
ments. Investigations with “throat aesthesiometer.” Krishaber’s distinction
between common or general sensibility and reﬂex or special sensibility.
The author’s discrimination between tactile, dolorous, and reflex sensibility ;
the ﬁrst appreciating temperature and pressure, the second pain, and the third
leading to muscular contraction and vascular and secretory action, each of which
may be either diminished, increased, or perverted.

Classiﬁcation :—
Complete Anaesthesia
(I. Diminished l. Anaesthesia. %Anaesthesia Dolorosa
Sensibility : Analgesia
Hypaesthesia '2. Tactile I-Iypzesthesia
A. In reference 3. Reﬂex Hypaesthesia
1. Tactile Hyperaesthesia
to the Quantity
111 response to external im-
or Degree of

Sensation pression
2. Algesia Constant
II. Increased isl§gfﬁlegg§ Intermittent(or
Disordered Sensibility: ( ‘ g trueNeuralgia)
Sensibility: lHyperaesthesia Muscular Contractions
Dyszesthesial 3. Reﬂex (cough,gagg1ng,spasm,&c.)
Hyperaesthesia ﬂushing, paling, hyperse-
cretions
B. In reference
- III. Perverted
1” the Quahty Sensibility:
or Kind _
of Sensation Paraesthesia

’§’(
DISEASES OF THE THROAT. 225
Explanations .'—-Reasons why neuralgia is considered under the second sub—
division of hyperasthesia.
Occurrence :—Frequency. Diseases in which sensory neuroses of the throat
have been observed. *
Causes and Pathogeny:—Remote and immediate causes. Suggestions of
Andrew H. Smith. Central and peripheric origin.
Symptoms and Diagnosis :—Subjective and operative. Various auxiliary
means for diagnosis. Care necessary, on the one hand, not to overlook local
lesions; and on the other, not to mistake for the latter what is the reﬂex effect
of the dysaesthesia.
Prognosis .-—In many cases very grave, in others duration uncertain. Com-
plete cure occurs, but not frequently.
Treatment .- —Instrumental, medicinal, electrical.
DISCUSSION.
Dr. B. FRANKEL, Berlin: I am of opinion that it is absolutely necessary to
differentiate between hyperaesthesia and paraesthesia, because paraesthesia also
occurs associated with anaesthesia. I would further urge the causal connection
between hypochondriasis and pharyngeal diseases, especially those of the retro-
nasal region. The abnormal sensations which originate here, and which are
associated with the feeling of pressure and heaviness in the head, produce
mental depression and well-marked hypochondriasis, which again can be cured
from the pharynx.
Dr. TORNWALDT, Danzig: I have seen a considerable number of cases in
which, by hyperaesthesia originating from diseases of the pharynx, or of the
naso—pharyngeal cavity, a reﬂex cough was produced. It is especially in cases
of granular pharyngitis, still more so in the lateral form of this disease, as
described by Schmidt, in which, by touching the granulations, cough is pro-
duced, and in which, by getting rid of the granulations, the cough is perma-
nently abolished.
Dr. BAYER, Brussels: With regard to the remarks which have just fallen
from Dr. Tornwaldt, my paper to be read in the afternoon contains communi-
cations concerning this point.
Professor SCHNITZLER: In a clinical point of view, the ﬁner diﬁerentiations
of the individual forms of the sensory neuroses cannot always be strictly
carried out, the less so because most of the forms frequently occur combined
with one another. As regards the relationship between neuroses of sensation
and those of mobility, especially of paralysis and spasm of the glottis, I would
refer for details to my paper on this subject shortly to be published.
Les z'mz’z'eaz'z'ons pom’ [e z‘mz'z‘emem‘ exz‘m 02¢ z'm‘mZm/yngé
des polypes a’u larynx.
Dr. Ch. FAUVEL, Paris.
11 est bien entendu que la question que vous m’avez fait l’honneur de
me donner a résoudre ne comporte que l’étude des operations relatives aux
polypes du larynx et non aux tumeurs du larynx.
PART III. Q
226 DISEASES or THE THROAT.
A la page 224 de mon traité des maladies du larynx—en 187 G—j e disais que
l’operation d’Ehrmann devait être regardée a juste titre, en 1844 comme une
des plus belles de la chirurgie, mais ‘passerait maintenant pour une opération
barbare.
Je n’ai pas changé d’avis, et je déclare aujourd’hui comme alors que presque
toujours l’on doit et l’on peut opérer les polypes du larynx par la voie, par le
chemin que nous offre la nature.
Il ne faut suivre une autre route que si la voie naturelle est obstruée, barrée,
encombrée, infranchissable, impracticable.
Laissez-moi, messieurs, vous faire une comparaison: Si un voyageur a
deux routes à suivre pour arriver a son but, l’une un peu longue mais sûre,
exempte de dangers, l’autre plus courte mais dangereuse, pleine de périls,
quelquefois mortelle, laquelle préférera-t-il?
La première évidemment. Nous devons donc faire comme le voyageur
prudent, nous y sommes d’autant plus obligés, qu’il s’agit non pas de notre
propre existence, mais de celle du malade qui s’est conﬁé à. nous, et dont la vie
doit nous être sacrée.
Un de nos confrères, spécialiste très-distingué de la ville de Lyon, nous a
raconté à ce propos qu’un jeune malade de Lyon, chez qui il avait diagnostiqué
un petit polype d’une corde vocale, qui aurait pu être facilement enlevé avec
les pinces laryngiennes, avait été opéré par un des premiers chirurgiens de la
ville par les voies artiﬁcielles, et ce malade est mort trois jours après l’opération.
Le spécialiste s’appelle le docteur Blanc, vous connaissez ses travaux ,' je
regrette qu’il ait été empêché de venir prendre part a notre congrès. Le chir—
urgien qui a fait l’opération—permettez—moi de ne pas vous le nommer.
Jamais e n’ai vu d’accidents après l’oblation des polypes du larynx par les
voies naturelles, et souvent il en est arrivé par la méthode extra—laryngée.
Les indications pour le traitement intra—laryngé sont donc très-fréquentes.
Dans la presque généralité des cas l’indication du traitement intra-laryngé
est formelle, évidente, indiscutable. Chaque fois que le médecin pourra intro-
duire par les voies naturelles jusque dans l’organe vocal à la rencontre des
polypes les instruments nécessaires à la destruction de ces tumeurs, il devra
le faire sans conteste ; ce n’est que dans le cas où l’introduction de ces instru-
ments est impossible que l’opérateur devra se résigner à ouvrir une voie
artiﬁcielle, c’est-a-dire extra-laryngée.
Ces cas me semblent excessivement rares; il faudrait supposer une défor-
mation ou une malformation congénitale acquise ou accidentelle traumatique de
l’entrée du larynx ou du pharynx ou de la base de la langue.
Il serait trop long de passer ici en revue tous les obstacles apportés à
l’opération intra—laryngée. Je ne les ai jamais rencontrés, il faudrait supposer
une des maladies suivantes :
1.—Une glossite ou une maladie quelconque de la langue ayant amené une
telle hypertrophie de cet organe qu’il remplit la bouche, et empêche le
passage des instruments par la cavité buccale.
2.—Ou encore une ankylose des mâchoires ou une maladie ou des articu-
lations temporo—maxillaires empêchant le malade d’ouvrir la bouche malgré ses
plus grands efforts.
3.—-Une tumeur ou gonﬂement de la voûte palatine, du voile du palais, de
la luette, des amygdales.
4.——Une maladie de l’épiglotte obstruant le vestibule laryngien.
5.—Une affection de la région susglottique, des replis ary-épiglottiques, de
la région aryténoïde, des cordes vocales supérieures ou des ventricules.
Les indications pour le traitement extra—laryngé sont très-rares; en
résumé—ne se résoudre, ne se résigner à. l’opération extra-laryngée que
DISEASES OF THE THROAT. 227
lorsqu’il est absolument, matériellement impossible de ne pas introduire
l’instrument dans la glotte par la voie naturelle, et lorsque le malade est
menacé de Suffocation, d’asphyxie, pouvant entraîner rapidement la mort.
Encore même : dans ce cas il sera toujours mieux de procéder d’abord a la
trachéotomie.
Ce n’est que lorsque la trachéotomie, par extraordinaire, serait regardée
comme dangereuse, impossible, dans un cas particulier, tout—à—fait spécial,
comme dans le cas de goitre, de déviation de la trachée, de déformation ou de
maladie quelconque du conduit trachéal qu’il faudrait pratiquer la cricotomie,
la crico—thyrotomie, la thyrotomie ou la thyro-hyotomie.
J ’ai fait une fois la thyrotomie chez un malade atteint de papillomes nom-
breux, volumineux, repullulant sans cesse malgré des arrachements journaliers.
Craignant de le voir étouffer, je pratiquai d’abord la trachéotomie ; j’étais donc
certain de ne. plus le voir s’asphyxier, et je pris le parti de fendre le cartilage
thyroïde en avant dans toute sa hauteur; je fus obligé de pratiquer plus de
trente ligatures de petites artères, car vous le savez, quand un organe est atteint
de tumeurs anciennes végétantes, les tissus du voisinage s’hyperémient con—
sidérablement. Après avoir pratiqué toutes ces ligatures et avoir séparé les
deux plateaux du cartilage thyroïde, j’eus beaucoup de peine a les écarter
l’un de l’autre de quelques millimètres seulement, c’est a peine si l’intervalle
permettait d’introduire les deux pointes d’un ciseau fermé. Je passais alors à.
travers chaque plateau du thyroïde, un gros ﬁl d’argent, et j’espérais ainsi et tirant
fortement les ﬁls de chaque côté en arrière du cou obtenir une ouverture assez
grande pour manœuvrer librement les branches des ciseaux, la boutonnière
interthyroïdienne fut toujours trop étroite, et je ne pus pas enlever toutes les
végétations polypeuses. Je craignais plusieurs fois de voir fracturer les ailes
‚du cartilage thyroïde en tirant sur les ﬁls d’argent qui servaient par leur tension à,
obtenir l’écartement des bords de mon ouverture extra-laryngée. Vous voyez
«combien 1’ opération fut longue, douloureuse, difﬁcile.
Si vous comparez d’une part ainsi que le fait, très-bien observé notre honor-
able confrère M. le Professeur Burow de Königsberg, les dangers que présentent
les opérations extra-laryngées à. la parfaite innocuité des opérations intra-
laryngées ; si vous songez que dans le premier cas le malade est exposé a tous les
accidents primaires et secondaires d’une grave opération, qu’il est obligé
d’interrompre ses occupations; tandis que dans le second cas il ne court aucun
risque, n’a même pas de ﬁèvre, peut boire, manger, aller à, ses aﬂaires, continuer
ses travaux sans interruption, vous donnerez la préférence au traitement intra—
laryngé.
Indz'cczz‘z'onen für exz‘mz— oder z'm‘y/alaryngeale Be/mnd/zmg
gutam‘zlg‘er N euéz'ldzmgen 2'772 Ke/zZ/wpf
Professor BUROW, Königsberg.
Hochgeehrte Versammlung l—Wenn ich es heute versuche der ehrenvollen
Auﬁorderung unseres Comités nachzukommen, und durch einige Worte in
‘Gemeinschaft mit Herrn Collegen Fauvel die Discussion über den fünften Punkt
unseres Programms “die Indicationen fur extra-oder intralaryngeale Behandlung
gutartiger Neubildungen im Kehlkopf” einzuleiten, so muss ich bekennen, dass
ich mich einigermassen der geehrten Sektion gegenüber in Verlegenheit beﬁnde.
Denn obgleich ‘ich Anfangs, als ich dieser Frage nahe trat, eigentlich
zweifelhaft war, ob nicht die Ansichten über die Antwort auf dieselbe in den
letzten Jahren bereits sich so Weit gekl'a'rt und geeinigt hätten, dass in der That
sein Zweifel kaum mehr obwalte, fand ich im Gegentheil bei genauerem Studium
Q2
228 DISEASES OF THE THROAT.
der Literatur so überaus verschiedene, strikte entgegengesetzte Meinungen
vertreten, dass es mir nun kaum möglich schien mit wenigen Worten eine Aus-
gleichung der Differenzen, eine Beilegung des Streites zu erzielen.
WVir ﬁnden nicht nur die Laryngologen von Fach und die Chirurgen von
sehr verschiedenen Meinungen über die in Rede stehende Frage occupirt,—-das
wäre ja ziemlich natürlich,—sondern auch selbst die Laryngologen unter sich sind
so sehr uneins, dass wahrend einzelne den grösseren Procentsatz ihrer Neu-
bildungen durch die Thyrotomie entfernen, andere unter keinen Umständen
diese “ barbarische Operation” für indicirt halten.
Und ich will hier gleich offen Farbe bekennen und eingestehen, dass, wenn
ich auch die Thyrotomie für eine bei Weitem gefährlichere Operation zu halten
veranlasst bin, als allgemein angenommen wird, und wenn ich auch fest glaube,
dass in der überwiegenden Mehrzahl der Falle sowohl bei Erwachsenen, als bei
Kindern die Entfernung gutartiger Neubildungen vom Munde aus möglich ist,
ich doch zugeben muss, dass in einigen wenigen Kategorien die Laryngofission
nicht zu umgehen sein wird.
Diese Kategorien nun möglichst zu ﬁxiren, und wie ich wohl sagen kann,
möglichst einzuschränken, soll ja eben heute der Zweck unserer Discussion sein.
Ganz genau pr‘a'cisirte Indicationen, die keinem Zweifel, keiner Verschiebung
unterworfen sind, zu stellen, halte ich heute noch für zu früh l Es wird noch
viele Jahre des Beobachtens und Forschens erfordern, ehe wir mit voller
Sicherheit werden sagen können: in diesen Fallen muss oder darf thyrotomirt
werden, in jenen nicht!
Bei genauerer Sichtung des‘Materials ﬁnden wir, dass in letzter Zeit die \
Vorliebe für die Thyrotomie immer mehr abgenommen hat, und es ist ein nicht
geringes Verdienst von Bruns jun., durch die Zusammenstellung und rationelle
Sichtung der hierhergehörigen Operationen in seiner Arbeit “die Laryngotomie
zur Entfernung intralaryngealer Neubildungen” wesentlich zur Klärung der
Situation beigetragen zu haben.
‘Wenn wir nun der Frage naher treten, so glaube ich über die Zweckmassig—
keit, Ausführbarkeit, Technik und Ungefahrlichkeit der intralaryngealen
Methode wohl nicht viel anführen zu dürfen, denn darüber sind wir ja alle einig,
dass es stets wünschenswerth sein wird, alle gutartigen Neubildungen vom
Munde aus zu entfernen.
Es wird sich gerade darum drehen, festzustellen, wie weit wir der extra—
laryngealen Methode das Terrain streitig machen können; und um das zu
können, müssen wir uns über die verschiedenen Arten dieser Methode, ihre
Gefahren für das Leben und für die Funktion des Organs, den Grad der
Sicherheit gegen Recidive u. s. w. klar werden.
Vor Allem möchte ich die Thyrotomie von den anderen extralaryngealen
Operationsmethoden strenge scheiden, und zuvörderst nur von der ersteren
handeln; denn ich bin der Meinung, dass sowohl die Lebensgefahr, als die
Berechtigung für diese verschiedenen Arten der Eröffnung der Luftwege eine
wesentlich differente ist. Bruns stellt in seiner bis Ende 1877 reichenden
Statistik circa hundert Falle von Thyrotomie etwa tausend Fallen von endo-
laryngealen Operationen entgegen, und kommt, auf Grund seiner statistischen
Berechnung zu dem Schluss, dass diese Operation zu den “grösseren Opera-
tionen von der allergeringsten Lebensgefahr zu rechnen sei,” da er im Gegen-
satz zu früheren Autoren auf diesem Gebiet, durch Ausschaltung mancher
zweifelhafter Falle nur 3 per Cent. Todesfalle (in Folge unmittelbarer Opera—
tionsfolgen) herausrechnet, wahrend z. B. .Macken'zie 8 per Cent annahm. Seit
jener Zeit ist ein Fall von J ohnson* in Chicago mitgetheilt worden, in Welchem

* Archives of Laryngology, 1880, N 0. 1, page 58.
DISEASES OF THE THROAT. 229
ein dreijähriges Kind acht Tage nach der wegen eines wahrscheinlich conge—
nltalen Papilloms ausgeführten Thyrotomie an Pneumonie starb.
Wie viele tödtliche Falle sind wohl aber unpublicirt geblieben! Dieser
Einwurf Ielenffy’s scheint mir volle Berechtigung zu haben. Denn es haben
gewiss viele Operateure keinen zwingenden Grund eingesehen, ungünstige
Erfolge nach dieser Operation sofort mitzutheilen, da sie ja an und für sich
keine so sehr interessante oder schwierige ist, dass in diesem Umstande eine
Aufforderung zur Publication zu ﬁnden wäre. Ich selbst beﬁnde mich in dieser
Lage. Denn ich habe dreimal die Thyrotomie gemacht, und alle drei Pa—
tienten starben mir an unmittelbaren Operationsfolgen, und zwar eine 62jährige
Dame am dritten Tage, nachdem bis dahin Alles gutgegangen, plötzlich, in
welchem Falle leider die Section verweigert wurde; eine 26jalhrige Frau, in
Folge von Erstickung durch einen secundaren Abscess, der sich an dem nekro—
tisirenden Ringknorpel gebildet hatte, und consecutivem Glottisödem,* und ein
46j ahriger Mann am vierten Tage, in Folge einer Nachblutung aus der Umgebung
der Wunde, für welche die genaueste Section keinen Anhalt bot. Wenn wir
aber nur diese vier Todesfalle zu den von Bruns nach scharfster Sichtung des
Material angegebenen hinzufügen erhalten wir 7 per Cent., und haben wir dann
noch ein Recht zu behaupten, dass die Thyrotomie eine sehr wenig gefährliche
Operation sei ? '
Und ich glaube nicht zu irren, wenn ich behaupte, dass manche der hier
anwesenden geehrten Oollegen im Stande sein werden, aus ihrer operativen
Praxis diesen Procentsatz noch wesentlich zu verschlechtern.
Auch ﬁnden wir bekanntlich “fast tödtliche Blutungen wahrend der Ope-
ration” selbst von den eifrigsten Vertheidigern der Laryngoﬁssion notirt.
Hierbei möchte ich erwähnen, dass in den von mir operirten Fallen die Tren—
delenburg’sche Tamponkanüle so absolut den Verschluss bewirkte, dass ich die
Larynxhöhle nach Auseinanderziehen der Schildknorpelhalften wiederholt und
energisch mit Eiswasser irrigiren konnte, ein Umstand, der nicht nur die Ge-
fahr von Seiten des hinunterﬁiessenden Blutes ausschliesst, sondern auch die
Operation sehr erleichtert, weil nach jedem Schnitt oder Abquetschen eines
Stückes der meist breitbasig aufsitzenden Papillome, auftretende Blutungen die
Vollendung und exakte Durchführung der Excision bedeutend erschweren.
Die von manchen Seiten betonte Behinderung durch Starrheit der Schild-
knorpelplatten, so dass sie nicht genügend auseinander gezogen werden können,
war in meinen Fallen nicht wesentlich. Nur muss man nicht gar zu viel
erwarten, da die in der Nahe der oberen Apertur der Cartilago thyreoidea
inserirende Epiglottis nur zum Theil gespalten wird und mit ihrem unge-
trennten rl‘heil wie eine Feder einer beträchtlichen Dilatation entgegenwirkt.
Auch ist es ein Fehler Rückschlüsse von Uebungen an Leichen zu machen, da
am Lebenden wohl in Bezug auf Muskelspannung, Turgescenz der Theile,
u. s. w., völlig diﬁerente Verhaltnisse obwalten.
Die Thyrotomie (ale. die totale) muss, meiner Ansicht nach, zu den gros-
seren Operationen von nicht zu unterschätzender Lebensgefahr gezahlt werden.
Ihre ungünstige Prognose in Bezug auf Recidive bei Papilloinen ist von
allen Seiten sicher gestellt worden.
Indessen nur bei Mackenzie ﬁndet sich der Umstand ins Bereich der
Erwahnung gezogen, dass doch schliesslich mit seltenen Ausnahmen der Thyro-
tomie gerade die schwersten Falle unterworfen werden, gerade die Falle, in
denen multiples Vorkommen breitbasig aufsitzender Papillome (i priori grosse

* Es war die Kaniile bereits entfernt, und Patientin hatte die Klinik verlassen; sie
verweigerte auf das Positivste die Wiederöffnung der Trachealﬁstel, trotzdem ihr die sicher
eintretende Snﬁ‘ocation vorhergesagt war.
230 DISEASES OF THE THROAT.
Chancen für Recidive darbieten ; wir dürfen nicht in den Fehler verfallen der
Operation ungünstige Erfolge zur Last zu legen, die in dem Charakter des
Falles bedingt sind.
Wenn wir ein den grössten Theil der Kehlkopfsschleimhaut einnehmendes
Papillom operiren, so werden wir in der Regel Rückfälle erleben, mögen wir
eine "Operationsmethode w'a‘hlen, welche immer wir wollen l
Es kommt nun dazu, dass wir bei der Thyrotomie die Ausrottung in einem
Ackte vollenden müssen, also um so leichter ein kleines Stellchen übersehen
können, das spater Anlass zu einem continuirlichen Recidiv giebt, während bei
der endolarygealen Methode wir in der Zeit und beliebigen Wiederholung
der Operation unbeschränkt sind.
Aehnlich wie für die Wahrscheinlichkeit der Recidive sind die Erfolge
der Thyrotomie in Bezug auf Wiederherstellung der Funktion des Organs
ungünstig. Und hier verhält sich die Sache noch in so fern anders und
schlimmer, als nicht nur die an und für sich ungünstigere Form und Sitz der-
jenigen Tumoren, welche vorzugsweise die Thyrotomie indiciren, die Schuld an.
häuﬁg zurückbleibender Stimmstörung tragen, sondern die directen Operations‘
folgen selbst dieses ungünstige Ereigniss bedingen.
Denn nicht nur, dass zuweilen eine geringe Abweichung des Schnittes von
der Mittellinie schwer zu vermeiden sein dürfte, zumal bei Ossiﬁcation der
Knorpel im höheren Alter, sondern es kann auch Aphonie herbeigeführt
werden, selbst bei ganz genauer medianer Schnittführung, in Folge “nicht
ganz genauer oder nicht ganz fester Wiederverwachsung des Schildknorpel-
Winkels durch Veränderung der Insertionspunkte und Spannungsverh‘altnisse
der Stimmb'alnder.”‘*'
Desshalb sollte man nie eine Thyrotomie machen zum Zwecke der Ausrot-
tung benigner N eubildun gen, wenn nur die Stimmstörung die Indication abgiebt,
da man nie Garantie leisten kann, ob nicht trotz Entfernung des Tumors eine
ebenso starke—und dann unheilbare—Heiserkeit fürs ganze Leben zurückbleiben
wird. Y
Aber auch mit der Erleichterung für die Entfernung der Tumoren steht es
für die Thyrotomie keineswegs so günstig, wie man im ersten Augenblick
denken sollte. Es sind manche Falle mitgetheilt, so von Beschorner, Pe'an,
Laroyenne, Cutter u. A., in denen die Operation unvollständig blieb, weil die
zu geringe Breite, bis zu der die starren Schildknorpelh'alften das Auseinander-
federn gestatteten, die Blutung und die Reizbarkeit der Schleimhaut trotz Nar-
kose, eine totale und reine Exstirpation unmöglich machten.
In anderen Fallen sind ausdrücklich die grossen Schwierigkeiten betont, die
sich der totalen Exstirpation entgegenthurmten. Das gilt von der totalen
Thyrotomie.
Ganz zu verwerfen ist aber meiner Ansicht nach noch die partielle. Aus—
gehend von der Idee die ungenauere Wiedervereinigung der Platten dadurch
unmöglich zu machen, schlug man vor und versuchte es vielfach die Spaltung‘
nicht bis zur oberen Incisur zu führen, sondern hier einige Millimeter stehen zu
lassen. Aber, wie es jedem, der die Thyrotomie am Lebenden ausgeführt
hat, ci pm'orz' klar sein musste, war hierdurch nur ein ungenügender Raum zu
beschaffen und auch nur das Gebiet unterhalb und bis dicht an die Stimm—
b‘a'nder zu berühren, was übrigens durch eine andere absolut ungefahrliche
Operation: die Eröﬁnung des ligament. conoideum viel besser zu erreichen ist.
Die partielle Thyrotomie ist also ganz zu verwerfen.
Auch die längere Dauer, ein gewöhnlicher Einwurf gegen die endo-
laryngeale Methode erscheint uns in wesentlich anderem Lichte, wenn wir der‘

* Bruns, l. 0., p. 99.
DISEASES OF THE THROAT. 23 I
Sache auf den Grund gehen. Es ist zwar nicht zu l'augnen, dass die Fälle, in
denen es möglich ist N eubildungen schon in den ersten Sitzungen zu entfernen,
zu den Seltenheiten gehören, dass vielmehr durchschnittlich drei Wochen hierzu
erforderlich sind. (Eine Ausnahme von dieser Regel scheint die Anwendung
des Voltolini’schen Vorschlags in manchen besonders günstigen Fallen zu
gestatten, mit einem Schwämmchen gleichsam ohne Spiegel die Polypen wegzu-
wischen.)
Indessen, wie lange ist denn ein Kranker dem wir die Laryngotomie
gemacht haben, ans Bett und Zimmer gefesselt? Doch jedenfalls mehrere Wochen
und hier kommt noch dazu, dass die endolaryngeale Methode nicht am Herum-
gehen, resp. der Ausübung seiner Geschäfte hindert.
Das Ware nun in Bezug auf die Würdigung der Thyrotomie im Allgemeinen
das Wichtigste. Betrachten wir nun einmal umgekehrt die gewöhnlich als
Contraindicationen gegen die endolaryngeale Methode angeführten Eigenschaften
der Tumoren !
Hier muss ich constatiren, dass die meisten noch vor wenig Jahren auf"
gestellten Behauptungen sich als hinfallig erwiesen haben, so dass auch hier
die endolaryngeale der thyrotomischen Methode den Boden unter den Füssen
fortzieht.
Denn wenn noch vor acht Jahren Hüter in seiner Bearbeitung dieses Capitels
im “ Pitha-Billroth’schen Handbuch ” sagen konnte: “ die kleinen und schmal-
gestielten Polypen am freien Rande der Stimmbänder seien das einzige berech—
tigte Gebiet der endolaryngealen Methode, alle übrigen Geschwulstformen
müssten eigentlich der extralaryngealen Methode anheimfallen,” so müssen wir
nach den seither gesammelten Erfahrungen unser Urtheil heute wesentlich
anders formuliren. Eine breite Basis der Schleimhautpolypen kann wohl die
vollständige Entfernung derselben per vias naturales erschweren, aber keines-
Wegs verhindern. Es stehen uns die verbesserten Instrumente, namentlich
auch die Galvanocaustik, hier hülfreich zur Seite und viele Krankengeschichten
illustriren die erfolgreiche Bekämpfung dieser Schwierigkeit.
Fibröse Beschaffenheit der N eubildung, selbst hohe Grade der Härte, wie sie
derbe Fibrorne oder Enchondrome darbieten, lassen sich durch Guillotinen über-
winden. Das Wurzeln der Tumoren in der Tiefe der Morgagni’sohen Ven-
trikel scheint ebenfalls keine lndication für die Thyrotomie; denn sind die
Geschwülste noch sehr klein, so sind die durch sie hervorgebrachten Beschwer-
den zu gering, um eine so eingreifende Operation zu rechtfertigen ; bei stärkerem
Wachsthum aber dr'a'ngen sie sich aus den Ventrikeln hervor, werden gewisser-
massen geboren, und lassen sich dann entfernen.* Auch selbst der Sitz der
Tumoren unterhalb der Glottis ist an und für sich keine absolute Indication
für die Laryngoﬁssion. Es sind mehrfach erfolgreiche Onerationen an subglot<
tischen Tumoren auf dem natürlichen Wege mitgetheilt worden. Hohe Dyspnoe'
erfordert die sofortige Tracheotomie ; man saume mit derselben nicht und ver-
suche namentlich keine Eingriffe per os vor Ausführung derselben, damit nicht
consecutive Erstickungsanfalle diese Versaumniss rächen; aber eine absolute
Indication für die Thyrotomie geben sie ebenfalls nicht. Der tracheotomirte
Kranke kann jetzt mit Ruhe und Sicherheit auf dem natürlichen Wege geheilt
werden.
Bedeutender Umfang der Tumoren kann uns nicht veranlassen der Laryngo—
ﬁssion den Vorzug zu geben, ebenso wenig, wie Multiplicitiit der Papillome.
Denn im ersten Falle können wir nach vorausgeschickter Tracheotomie vom
Munde aus arbeiten, und wir sahen auch, dass gerade die Spaltung der Schild-
knorpel für sehr grosse Geschwülste nicht genug Raum schafft, und die letzte

*1‘ “ Mein Atlas,” Taf. vi. Fig. 6.
232 DISEASES OF THE THROAT.
Schwierigkeit ist bei Erwachsenen, wie auch bei Kindern durch Ausdauer zu
überwinden.
Noch auf dem letzten Chirurgencongress in Berlin theilte Böcker einige Falle
mit, in denen er per vias naturales operirend es ermöglichte Geschwülste so rein
zu entfernen, dass die Kanüle fortgelassen werden konnte, die die Patienten
nach früher ausgeführten Radicaloperationen (Laryngoﬁssion und Pharyngotomia
subhyoidea) hatten Jahre lang tragen müssen.
Also nicht jede der hier genannten erschwerenden Eigenthümlichkeiten der
Kehlkopfsneubildungen giebt an und für sich eine Contraindication gegen die
Operation auf natürlichem WVege ab, sondern erst das Zusammentreffen mehrerer
derselben wird. uns zur Thyrotomie drangen.
Von andern extralaryngealen Methoden haben wir noch der Spaltung des
ligamentum crico-thyreoideum, der Pharyngotomia subhyoidea und der neuen
Rossbach’schen sogenannten “ subcutanen" Methode* zu gedenken.
Die erstere Operation, die Laryngotomie nach Vicq d’Azyr, ist bekanntlich
zuerst von meinem Vater und dann von mir mit Erfolg zur Entfernung von
Kehlkopfspolypen ausgeführt worden. Es sind dann noch Mackenzie, Bruns
und einige Andere gefolgt; im Ganzen sind, soviel mir bekannt, dreizehn Opera-
tionen der Art gemacht. Es ist einleuchtend, dass durch die ausgiebigste
Spaltung dieses Ligaments eine immerhin nur kleine Oeffnung geschafft werden
kann, dass andrerseits aber die Operation, da das Ligament ganz oberﬂächlich
liegt, ein ganz unbedeutender Eingriff ist. Man kann sich durch dieselbe sehr
leicht Zugang zu Tumoren schaffen, die unterhalb der Stimmbänder liegen,
aber, wie ich gezeigt habe, kann man auch Tumoren, die am Rande der Stimm—
bänder, ja selbst solche, die auf der Oberfläche sitzen, gut exstirpiren, so ferne
sie nur mit einem genügend langen Stiel versehen sind, und durch den Inspi—
rationsstrom nach unten gezogen werden können. Für solche Falle ist die
Methode sehr zu empfehlen; sie wirkt hier cito, tuto, und gewissermassen auch
j ucunde, und ich glaube ihr in Zukunft eine grössere Verbreitung prognosticiren
zu können. ß
Endlich die Pharyngotomia subhyoidea ist eine Operation die zwar den
Larynx nur indirect eröffnet, oder zuganglich macht, die aber doch schon
wiederholentlich zum Zweck der Entfernung der Larynx-Tumoren ausgeführt
ist. Die Operation scheint nicht gefahrlich zu sein, und ist von keinem Risiko
für die Stimmbildung gefolgt. Sie schafft Zugang zu Tumoren der oberen
Larynxapertur, und namentlich zu denen der Epiglottis an der oberen, wie
auch an der unteren Flüche derselben.
So habe ich bei einer Operation der Art die Stilreste eines wallnussgrossen
Sarcoms der Innenfl‘ache der Epiglottis, das ich einige Monate zuvor vom Munde
aus mit dem Drahtecraseur entfernt hatte, mit gutem und bleibendem Erfolge
zerstört. Ich fand allerdings den Raum bei ‘Weitem nicht so genügend, wie ich
es erwartet hatte; das Vorausschicken der Tracheotomie mit Einsetzen der
Tamponkanüle halte ich für nothwendig.
Ueber die Rossbach’sche Methode, der bekanntlich vorschl‘a'gt ein 22 Mm.
langes, starkes Lanzenmesserchen vorn durch die Schildknorpel zu stossen und
mittelst desselben unter Leitung des Spiegels im Larynxinneren zu operiren,
müssen noch weitere Erfahrungen gesammelt werden, ehe ein Urtheil möglich
sein wird. Ich selbst habe die Methode noch nicht ausgeführt.
Bisher sprach ich von Operationen bei Erwachsenen; anders liegt die Sache
bei Kindern; die Altersgrenze, bis zu der erfolgreich auf natürlichem Wege
Geschwülste bei Kindern entfernt werden können, hat sich in letzter Zeit we-
sentlich erweitert. Man hat bis zu dem jugendlichen Alter von zwei und

a
* Berl. klin. Woch., 1880. No. 5.
DISEASES or THE THROAT. 233
einem halben Jahre Geschwülste sowohl auf natürlichem Wege, als auch nach
Spaltung der Schildknorpel entfernt, aber leider sind, im Ganzen genommen, die
Erfolge keine befriedigende. Wir haben es bei Kindern fast ausnahmlos mit
Papillomen, und zwar mit multipeln Papillomen zu thun, und in diesem Um—
stande und den kleinen räumlichen Verhältnissen liegt wohl die Erklärung für
die geringen Erfolge. Je jünger die Kinder, desto grösser die Wahrscheinlich-
keit auf Papillom, und gerade die ersten drei Lebensjahre disponiren besonders.
Von 40 Kindern, bei denen per os operirt wurde, konnten in 1?) Fallen
vollständige und dauernde Heilung erzielt werden, 6 Falle recidivirten und in
7 Fallen blieb die Operation unvollständig.
Auf der anderen Seite 25 Thyrotomien (bei 21 Fallen) mit 8 Heilungen
und 9 Recidiven.
Es steht uns die Wahl frei zwischen der endolaryngealen Operation, der
Laryngoﬁssion, und dem Mittelweg, bei eintretender Dyspnoe zu tracheotomiren,
mit der Absicht zu warten, bis bei zunehmendem Alter und Verstand die endo-
laryngeale Operation möglich wird. Ich selbst habe auf diese Art mit ein—
jähriger Pause bei einem achtjährigen Kinde mit Erhaltung der Singstimme-
vollkommene Heilung erzielt. Meine Meinung ist nun diese:
-Unter allen Umständen versuche man, auch bei Kindern, endolaryngeal
vorzugehen, und lasse sich nicht zu schnell durch missglückte Versuche ab-
schrecken, denn man kommt mit Ruhe und Ausdauer bei Kindern viel weiter,
wie man Anfangs glauben sollte. Ist auf diesem Wege die Heilung unmöglich,
tritt Dyspnoä ein„„‚und-ist das Kind so alt, dass man in einigen Jahren auf den
zunehmenden Verstand rechnen kann (also 6 bis 8 Jahre) so tracheotomire
man und warte ab. Bei ganz kleinen Kindern, bei denen die endolaryngeale
Methode unausfuhrbar sich erwiesen hat, wird es misslich sein, das Kind nach
ausgeführter Tracheotomie den immerhin doch vorhandenen Gefahren eines
Jahre langen Tragens der Kaniile auszusetzen, und hier tritt dann die Laryngo—
tomie in ihr Recht; natürlich mache man aber den Angehörigen und sich selbst
die zweifelhafte Prognose der Operation in Bezug auf Recidiv, Functions-
erhaltung und Lebensgefahr klar.
DISCUSSION.
Professor KRISHABER, Paris: Intra-laryngeal operations are easier on the
infant than on the adult, as they can be executed without a laryngeal mirror.
Last year Professor Verneuil did me the honour to consult me in his clinic of
the Höpital de la Pitié, of Paris, about a child, six years old, in whom the
existence of multiple polypi in the cavity of the larynx had been diagnosticated.
I at once operated in the following manner: I introduced the index ﬁnger of‘
the left hand into the mouth until I touched the epiglottis and drew it upright.
I then pushed my ﬁnger nearly into the cavity of the larynx, and sliding the
forceps along the index ﬁnger, I caught hold of the tumours and removed them.
The whole operation was executed with extreme rapidity, and yielded an
immediate result. The child left the hospital breathing normally.
Dr. HOPMANN, Cologne : I agree fully with Professor Burow’s proposition that
benign neoplasms ought, if possible, to be always removed endo—laryngeally,
and I have myself followed this practice whenever I could, but on the other
hand, I cannot consider thyrotomy an operation so dangerous to life as it would
appear from the statements of the gentlemen who have introduced the subject.
Amongst the eight cases of laryngeal tumours which I have treated by laryngo-
ﬁssion, there is not a single fatal result which can be directly assigned to the
operation itself. The two patients in whom the operation has not had the
desired result, died, the one six, the other fourteen, months after the operation,
234. DISEASES OF THE THROAT.
from the constitutional disease which had led to the operation. A third
patient died a long time after the operation, in childbed. The remaining ﬁve
cases are still alive. The ﬁrst of these, a clergyman, was operated upon twice
(in 1876 and 1877), for what was probably a soft tubercular granulation in the
anterior commissure and neighbouring parts. He is now well and able to follow
his ecclesiastical duties. In the second case the operation had to be repeated
three times. The patient was a child aged four, suffering from multiple papil-
lomata; in the end a permanent cure has been obtained, the operation having
‘ been performed in 1876. The third successful operation was made for a
lupoid granuloma on a female, aged forty—three, who presented on nose, cheeks,
pharynx, and larynx the characteristic signs of lupus. The operation was
performed in May, 1878; the cure continues perfect to the present time. The
fourth case was that of a workman, aged thirty, suffering from a granuloma on,
andbeneatlnthe anterior commissure. Thyrotomy was performed at thebeginning
of last year, and the patient now speaks clearer than before, no recurrence
having occurred to necessitate a new operation. The ﬁfth successful case is
that of a female, with formation of a traumatic adhesion between the vocal
cords and ankylosis of the left arytenoid cartilage, who was shown, in 1879,
to the Medical Society of Cologne, and whose case has been described in Dr.
Felix Semon’s Paper on Ankylosis of the Crico-Arytenoid Articulation
(Med. Times and Gazette, vol. ii. 1880). Attempts at improving the
whispering voice by excising a part of the membrane through the external
opening, in the middle of last year, were only successful in a limited degree.
The immediate reason why in all cases the operation was performed was, in cases
2 and 3, danger of suffocation; in case 5 the cause stated; in the remain-
ing ﬁve, the desire of removing tumours which apparently predisposed to laryn-
geal tuberculosis, and which were, at any rate, of a suspicious character. It was
thus hoped that the possible development of pulmonary phthisis might be pre-
vented. None of the cases showed distinct signs of a deeper affection, but
in all catarrh of the apices was present. In a paper to be published shortly I
intend to show that during the operations in all cases, facts became apparent
which corroborated my anticipations, that in these cases endo-laryngeal proce—
dures would not have led to the desired end. I wish, however, to declare
distinctly that amongst many hundreds of cases which could not be regarded
other wise than as tubercular tumours or ulcerative proliferations of the larynx,
besides these eight cases, scarcely four or ﬁve have occurred in which I should
have considered the attempt justifiable to prevent, by a very thorough extirpa-
tion of the new formation by means of laryngotomy, the development of
laryngeal or pulmonary phthisis.
Dr. BooKER, Berlin: I wish to direct attention to an incident which may
occur when Trendelenburg’s canula is used. In a case of mine, in which, after
tracheotomy had been performed, this tampon canula was introduced and
inﬂated, the patient suddenly became cyanotic, the pulse irregular, and the
respiration impeded. A catheter was introduced through the tube, and the
breathing became freer; as soon, however, as the catheter was removed, the
former symptoms returned. Now the tube itself was withdrawn, and it became
evident that a bulging of the inﬂated tampon downwards had occurred, which
by passing over the lower end of the canula had completely occluded the’
trachea. As to the question of recurrence of tumours, this happens after
laryngo-ﬁssion quite as frequently as after the operation per vias natumles. In
speaking of recurrences, in strictness, those cases ought to be excluded in which
new tumours form in parts other than those in which the removed new
formations have had their seat. I have operated upon a case in which the
DISEASES or THE THROAT. 235
whole of one vocal cord was surrounded by papillary new formations; laryngo-
ﬁssion had been advised by some one else. I succeeded in removing the
tumours in one week’s time. No recurrence ever took place on this vocal
cord, but later on excrescences formed on places which had originally been
quite free. Had this patient been subjected to laryngotomy, this operation
would have had to be repeatedly performed. In the end he was completely and,
lastingly cured by endo-laryngeal operations. As to the possible consequences
of laryngotomy, I would refer to my observations made at the last Congress of
German Surgeons, on which occasion I also showed the case referred to by
Professor Burow. I will here mention another case in which a patient was
operated on extra-laryngeally in a hospital for a fibroma ofa vocal cord the size
of half a pea. After the patient had been discharged from the hospital,
swelling and thickening of the anterior portions of the ventricular bands, and
thickening between the anterior parts of the vocal cords, which prevented their
approximation, were visible. The patient was entirely aphonic, and it required
a galvano—caustic treatment extending over a period of three months to restore
to the patient the use of his voice. I am firmly convinced that this patient
might have been operated on through the mouth, and been cured within eight
days.
Dr. SOLIS COHEN, Philadelphia: I am afraid that laryngologists sometimes
convert innocent papillomas into epithelioma by protracted manipulations con-
tinued too long. The indication for extra-laryngeal operations presents itself,
in my opinion, as soon as three or four trials under a skilled manipulator fail
to procure prompt relief, intra-laryngeally. Fourteen years ago I had occasion
to perform two thyrotomies in close succession, and twelve years elapsed before it
became necessary to perform another, and then I had to do two at short intervals
again. This shows how individual experiences differ, and how wrong it is
to draw conclusions entirely from one’s own practice. In none of these cases
was there any trouble in performing the operations or anything untoward after
them, and in none of them was the patient necessarily conﬁned to bed—I can
testify to the value of the digital removal of growths in small larynges, as
mentioned by Professor Krishaber. The prolonged retention of a tracheal canula
sometimes produces paralysis of the posterior crico-arytenoid muscles, Whether
from inaction or myo-degeneration, and therefore tends, in some instances, to
unnecessarily submit the patient to the permanent use of the canula, when an
extra-laryngeal operation might have relieved him from his growth, and thereby
of the necessity of the tube. Sub-hyoid pharyngotomy in one case of a child,
opened by myself, failed to give sufficient access to the growth.
Mr. LENNox BROWNE, London : It cannot be too explicitly laid down that
the more facile the operator the less frequent will be extra-laryngeal operations.
An axiom, therefore, to this effect can be enunciated as the result of this dis-
cussion. It should also be clearly understood that whenever an extra-laryngeal
operation is decided on, it is useless to compromise with partial division;
for at best the space at command is small, and the more thorough the
division, the greater will be the amount of success.
Dr. MAX SCHKFFER, Bremen : I have a new fatal case of thyrotomy, which has
occurred in my practice, to communicate. In a patient seventy-three years of age,
thyrotomy was indicated by the presence of large masses of tumour in the
larynx. The operation was begun on account of suddenly occurring dyspnoea,
but could not be completed, because severe haemorrhage set in. I therefore
extended the wound downwards, splitting the crico-thyroid ligament, the
2 36 DISEASES or THE THROAT.
cricoid cartilage, and the superior rings of the trachea, so that a high
tracheotomy was eﬁected. In spite of the length of the incision, the extirpation
of the tumour-masses was very difficult on account of the ossiﬁcation of
the thyroid cartilage, and the removal was not a complete one. The patient
progressed favourably for the first three days after the operation, but died on the
ﬁfth day, with pulmonary symptoms.
Professor SCHNITZLER, Vienna: I fully agree as to the preference given to
intra-laryngeal operations within the limits deﬁned by Professor Burow. I have
often had occasion to operate endo-laryngeally on cases of papilloma, in which
recurrences had taken place after the performance of extra-laryngeal operations.
I fully abide by the dictum that the more dangerous extra-laryngeal operations
are only to be adopted after an actual attempt, made by a skilled laryngologist,
at proceeding endo—laryngeally has failed.
Dr. FELIX SEMON, London: I beg to state that this question, which seems
to most laryngologists to be completely settled, was not intended for the
laryngologists proper, but to give the opportunity to the medical public, and to
the surgeons especially, to discuss it. This is still necessary. It was—to
give but one instance—publicly stated only two years ago, that extra-laryngeal
operations had been repeatedly performed on a patient only for the reason that
it was really not easy to perform endo-laryngeal ones. Such a moral cannot be
condemned strongly enough. The good of the patient is the ﬁrst thing to
be considered; and if it is admitted that, without special training, it is
impossible, or at any rate dangerous to the patient, to adopt a method which
is undoubtedly the preferable one, then it follows, with absolute logical
necessity, that such cases ought to be transferred to those specially trained.—
The subject was further chosen to enable gentlemen to substantiate the
dangerous and unproven statement that endo-laryngeal interference was
frequently productive of a transformation of a benign into a malignant growth;
a statement made some time ago in Mr. Lennox Browne’s Textbook, and now
reiterated by Dr. Solis Cohen. I am now exceedingly surprised to hear from
Mr. Browne that he has changed so completely the views concerning this
question which he, only three years ago, submitted to the profession in his
Text-book.
Professor LEFFERTS, New York : I cannot agree in the extreme view of this
question taken by Dr. Fauvel, but would incline rather to the more temperate
opinions expressed byProfessor Burow. The extra-laryngeal methods of removing
laryngeal growths undoubtedly have an important-—an often necessary—place
among the means of operating at our command. I regret, then, to hear the
operation so condemned, as it has been done, by some of the speakers, and
must offer my personal experience in justification of it. We are all agreed
that the intra-laryngeal means should be employed in all cases where they are
possible—attempted in all instances; but failing, as they must at times, there
is no other resource open to us. The operation of thyrotomy has not, in my
hands, been the dangerous and bloody one represented, and my results have
been good: voice has been restored—mo recurrence of the growths. I do not
agree that a partial thyrotomy is entirely to be repudiated. On the contrary,
I regard the preservation of the cricoid cartilage intact as important, and as
having an important inﬂuence on the accurate co-aptation of the wings of the
thyroid after the operation. Upon this accurate co-aptation depends the
result as regards voice. Too often is it neglected. The division of the crico—
thyroid membrane, in order to reach growths, I have twice seen utterly fail.
DISEASES OF THE THROAT. 237
Finally, I cannot agree with Prof. Burow that in little children a tracheotomy
should ﬁrst be done, and the surgeon then wait for some years before perform-
ing any operation, by the natural passages, for the removal of the growths.
Regarding the ﬁrst opening of the air passages, the tracheotomy, as the
dangerous operation, I should rather follow it up at once by a thyrotomy—
complete the operation—than by waiting as advised, expose the child to an
opportunity for the growths to increase, with the dangers attendant upon such
a development.
Dr. C. FAUVEL, Paris: It results from our discussion that the removal of laryn-
geal polypi must remain the domain of the specialist, and that We are unanimous in
rejecting, as long as possible, extra-laryngeal operations. I cannot do better in
this respect than accept Dr. Felix Semon’s conclusions. It is to be hoped
that even surgeons who do not devote themselves especially to the subject will
see the force of the arguments in favour of the intra-laryngeal method.
Prof. BUROW, Konigsberg : I should have mentioned Prof. Voltolini’s sponge
operations. I would further ask why Dr. Hopmann did not remove the
excrescences in laryngeal tuberculosis through the mouth, as, according to his
own statement, they were soft. I confess that Dr. Hopmann’s cases do not seem to
me to offer an urgent indication for thyrotomy. With regard to Dr. Bocker’s
remarks on the use of Trendelenburg’s tampon—canula, I would urge that the
tampon should be doubly and very ﬁrmly tied to a piece of drainage tube
inserted between it and the canula, and that it should be inﬂated only after
narcosis has been fully established.
Sur les e/jw‘ez‘s a’u z‘yaz'z‘ezizem‘ memrzz'gue [les sz‘e’noses
Zmjnzgzemzes.
Dr. KOCH, Luxemburg.
Les rétrécissements laryngiens peuvent surgir subitement, ou bien leur
début et leur parcours sont plus ou moins chroniques. C’est surtout dans
l’intention de combattre ces derniers que You a préconisé et employé avec plus
ou moins de succes le traitement mécanique.
Les sténoses aigu'es s’olfrent a nos yeuX le plus souvent comme symptome
predominant de quelques affections aigues de l’enfance; ce sont surtout la
diphthérie et le croup, moins souvent l’oed‘eme, les abces, les paralysies aigues de
la glotte qui en sont la cause; plus rarement elles se présentent comme compli—
cation de certaines maladies générales ohez les adultes. C’est contre ces espéces
de rétrécissements aigu‘els que Loiseau a préconisé le premier le cathe'térisme
laryngien. Desault, en 1e pratiquant d’abord malgré lui, en avait démontré la
possibilité. Apres Desault, un certain nombre de chirurgiens ont pratique' le
cathe'térisme avec un succes plus ou moins douteux ; et si l’on en avait prouvé
1a possibilité, on en avait démontré en meme temps la diﬁiculté, l’insuﬂisance
et meme le danger. Plus tard Bouchut étendit l’emploi de la sonde laryngienne
en ce sens qu’il conseillait a la laisser en demeure et a la rendre inamovible en
ﬁxant son extrémité ante’rieure. C’était par ce “ tubage de la glotte” que l’on.
voulait éviter la trachéotomie sous prétexte que oette derniere était plus dan-
gereuse, plus difﬁoile et plus cruelle. Déjz‘i apres les premieres expériences
malheureuses ce tubage de la glotte fut caractérisé par Trousseau comme “ une
operation tres-belle en théorie, mais diﬁ‘icile et a condamner en pratique;”
:238 DISEASES OF THE THROAT.
c’était a l'occasion de l’enquête qui eut lieu quand les sept premiers enfants
soumis au tubage de la glotte avaient succombé.
Nous savons tous que le tubage n’est pas une opération si facile ; la sonde une
fois bien introduite, il nous est presque impossible de la ﬁxer convenablement
par son extrémité antérieure; des plaies et du décubitus de la muqueuse malade
sont les suites presque inévitables de cette opération; en cas de diphthérie ces
nouvelles plaies deviennent couenneuses elles-mêmes; la sonde laryngienne
s’obstrue très-facilement, et un simple mandrin ne suffit pas pour la rendre
perméable a l’air respiratoire; pour la nettoyer il faut la sortir et répéter ainsi
un certain nombre de fois une opération laborieuse et cruelle, répétition à
laquelle les petits malades et l’entourc ge ne se soumettront que très difficilement.
Les simples cathéters anglais employés autrefois sont trop facilement rongés
par les dents aiguës des enfants; Weinlechner de Vienne les remplaça par les
tubes en caoutchouc vulcanisé, et par précaution, il mettait un coin dans l’angle de
la mâchoire inférieure du malade.* Depuis les chirurgiens ont construit un certain
nombre de tubes laryngiens, parmi lesquels nous ne voulons citer que celui de
Labus de Milan comme le meilleur. J ’aurais bien voulu voir le cathétérisme
‘pratiqué des temps d’Hippocrate et de Paul d’Egine, alors qu’aujourd’hui avec
nos connaissances anatomiques parfaites, le miroir laryngien comme guide
a la main, il nous faut encore avoir acquis une certaine adresse pour le
pratiquer tant soit peu convenablement. L’enfant, forcé déjà a lutter contre
une dyspnée suffocante, se debat moyennant le reste de ses forces musculaires
pour s’opposer à. .cette opération assez barbare; ce dernier reste de forces
musculaires dépensées, le petit malade ne pourra plus faire les efforts si
nécessaires pour respirer et pour expectorer les fausses membranes. De plus,
pour pratiquer le tubage, le médecin a besoin d’une assistance au moins aussi
instruite qu’il la faut pour pratiquer la trachéotomie. Sceparowskij a vu deux
fois survenir une mort subite parsuite de la poltronnerie bien explicable des
enfants et de l’inadvertance de l’entourageT Quand le larynx et la trachée sont
revêtus de fausses membranes, il n’arrive que trop facilement que le tube les
pousse devant soi jusqu’a la bifurcation, endroit où elles constituent alors une
nouvelle entrave à la respiration; les forces de l’enfant a moitié asphyxié ne
sufﬁsent pas pour expectorer ces conglomérats de membranes, la trachéotomie
vient trop tard et la mort est inévitablei Dans la littérature nous
trouvons deux exemples de croup où cet accident fâcheux est arrivé.
Avant le cathétérisme la dyspnée était exclusivement laryngienne; après
l’opération la dyspnée prit subitement un caractère tout-a-fait différent; l’air
passait facilement par le larynx et la trachée, les mouvements respiratoires
étaient normaux aux points supérieurs du thorax, tandis qu’à la plus grande
partie inférieure de ce dernier on observait le type respiratoire inverse ; la mort
survint sans que la dyspnée laryngienne ne se soit déclarée de nouveau.
Plus encore: dans la majeure partie des cas le cathétérisme et le tubage
pratiqués selon les règles de l’art se sont montrés insuffisants, il fallait avoir
recours à. la trachéotomie consécutive; naturellement les manipulations
antérieures et l’état d’asphyxie avancé diminuaient les chances de réussite de
cette dernière opération.
Si, d’un autre côté, nous considérons que la trachéotomie faite sur l’enfant
est une simple opération qui avec moins de douleur et moins de danger remplit
exactement le même but que le tubage, que la pratique de ce dernier est une
opération assez difficile qui d'après le conseil de I-Iack de Fribourg ne devrait

VVeinlechner, Jahe'buch fùr Kinclerhcillcunde, 1876. 4 J obi-gang. Heft i. S. 69.
1‘ Centralblatt fur Chirurgie, N o. 26.
I Observations du Dr. Hüttenbrenner de Vienne.
DISEASES} OF THE THROAT. 239
jamais se faire sans l’emploi du laryngoscope f‘ si nous pensons que la répétition
souvent nécessaire du tubage est une cruauté, tandis que le nettoyage et même
le changement d’une canule trachéale ne sont qu’un jeu; si, de plus, nous
songeons que le traitement local exigé par l’affection primitive se fait plus
facilement et avec plus de succès par une ouverturextrachéale que par la bouche,
on conviendra ce tainement que dans tous les cas sans exception aucune il faut
préférer la trach otomie au cathétérisme et au tubage.
Les sténoses laryngiennes chroniques sont ordinairement occasionnées par
‘des retractions cicatricielles, par l’élimination, le déplacement ou l’hyperchondrose
des cartilages du larynx, plus rarement par des épanchements sanguins et séreux
Eu par des foyers purulents d’ancienne date. Le traitement mécanique dans
ces cas a pour but d’augmenter le calibre de la glotte à. un degré tel que la
trachéotomie puisse être évitée complètement ou que le malade puisse se passer
de la canule quand cette dernière opération a dû être pratiquée antérieurement.
Ce traitement a été préconisé et mis en usage par b‘chrütter, qui le pratique
suivant la méthode connue des bouleaux en zinc et des sondes en caoutchouc
durci; les différents dilatateurs imaginés par les auteurs, tels que ceux de
Navratil, de Dupuis, de Labus, de Mackenzie, les bouleaux en ivoire de Paul
Bruns, l’olive en ivoire de Rose servent au même but. Les statistiques ainsi
que l’expérience journalière nous démontrent que cette méthode d’élargir
les premières voies met à. l’épreuve le bon vouloir du malade et la patience
du médecin; elle n’est pas innocente; pratiqueé par les mains les plus
habiles et avec le plus grand ménagement possible, elle n’est que trop sou-
vent suivie de douleur, d’inﬂammation, de ﬁèvre, d’abc‘es; la durée du
traitement prend des mois et même des années; après cette époque on n’a atteint
ordinairement qu’une amélioration, les guérisons réelles sont rares, les récidives
sont a l’ordre du jour. C’est le résultat ﬁnal auquel Mackenzie, Paul Bruns,
E. Burow et Ganghofner sont parvenus depuis longtemps et auquel les statis-
tiques nous mènent. Les exemples que j’ai observé m’ont conduit aux mêmes
conclusions. Les statistiques générales vous seront soumises tout a l‘heure, je
veux seulement citer quelques exemples l’appui. Le premier concerne un
ancien cocher parisien, âgé de 45 ans, affecté d’un chancre dur en 1864, lequel
n’a été traité que localement; en 1872 les premiers symptômes laryngiens
consistant en aphonie et légère dyspnée se déclarèrent; l’amélioration survint
sans traitement; plus tard l’aphonie et une plus grande dyspnée se déclarèrent
de nouveau; cette dernière atteignit un degré inquiétant aux grands mouve-
ments. En ce moment le malade montre les glandes cervicales engorgées et des
cicatrices rétrécissant le calibre du larynx; le traitement mécanique longtemps
prolongé restait sans eﬁÛet. Le malade prit de grandes doses d’iodure de
potassium et la trachéotomie put être évitée. Ainsi malgré la date reculée de
l’infection syphilitique il existait encore quelque engorgement, soit de la
muqueuse soit du périchondre, affection qui cèda {t l’iodure de potassium.
Le second cas concerne un garçon âgé de 18 ans, qui pendant une ﬁèvre
typhoïde très-intense fut atteint d’un laryngotyphus; après la guérison de la
maladie générale les cordes vocales se touchèrent par leur tiers antérieur,
et par leurs deux—tiers postérieurs ils formaient les deux côtés d’un triangle
isoscèle dont la base mesurait a peine quelques millimètres, triangle qui
représentait la glotte. Le traitement par les bouleaux en zinc était resté sans
effet; l’introduction facile des plus gros bouleaux était en contradiction avec la
dyspnée qui survint chaque fois que l’on bouchait la canule et ﬁt admettre
l’ankylose des deux articulations crico-aryténo‘idiennes contre laquelle le
traitement mécanique restait nécessairement sans effet. Le malade portait la
* Volkmann’s “ Klinische Vorträge,” Baud ii., Chirurgie.
240 DISEASES OF THE THROAT.
canule pendant trois ans, époque pendant laquelle le traitement mécanique fut
répété de temps en temps. Enﬁn, en 1880, ainsi quatre ans après l’invasion du
laryngotyphus, un abcès se forma au dessous de l’ouverture trachéale et s’ouvrit
en laissant écouler une grande quantité de pus sans grumeaux cartilagineux; le
malade, de son propre chef, avait ôté la canule et ne s’est présenté qu’après
la guérison de l’abcès et après que l’ouverture trachéale ét it fermée. La
respiration s’effectue normalement par les voies naturelles, Ê. voix est celle
d’une basse profonde, les cordes vocales sont d’une teinte rosâtre, le cartilage
de Santorini droit a disparu, les excursions des aryténoïdes sont réduites à. la
moitié de leur grandeur normale. Ainsi cette guérison spontanée, pour ainsi
dire, peut avoir été hâtée dans sa marche par le traitement mécanique, mais nous
sommes loin de vouloir prétendre que ce dernier a guéri le malade. Ce fait
nous apprend qu’après une marche lente et insinuante ces périlaryngites
typhoïdes et avec elles les rétrécissements laryngiens peuvent marcher vers la
guérison après des années encore et qu’il n’est pas permis d’entreprendre une
opération radicale avant que la terminaison de ces aﬁections si lentes ne soit un
fait accompli.
Un troisième cas de rétrécissement laryngien chronique concerne un robuste
garçon, âgé de 19 ans, atteint d’un laryngotyphus. La trachéotomie n’avait
pas été pratiquée par négligence de la part de l’entourage ; néanmoins le malade se
tira d’affaire après avoir expectoré de grandes quantités de pus et de sana.
Quelques semaines après le malade était guéri en ce sens que la voie était voilée
et que la dyspnée combinée au cornage se faisait sentir aux grands mouvements.
L’examen laryngoscopique ﬁt voir les cordes vocales légèrement rougies, un
mouvement incomplet de la corde vocale gauche au moment de la phonation, un
écartement incomplet du deux cordes vocales pendant une inspiration profonde.
Impossible d’apercevoir des cicatrices. Il fallait diagnostiquer une myopathie
des deux muscles crico—aryténo‘idiens postérieurs, du crico-aryténoïdien latéral
gauche et du muscle inter-aryténo‘idien. Naturellement le traitement mécanique
restait sans effet. On avait tort de ne pas pratiquer la trachéotomie à. l’apogée
de la maladie; mais le traitement mécanique ne peut rien faire contre les
myopathies quand même ces dernières sont de nature cicatricielle.
Un quartième exemple nous est représenté par un robuste campagnard, âgé
de 22 ans. Atteint d’une ﬁèvre typhoïde intense les symptômes d’un laryngo—
typhus survinrent la septième semaine de l’aﬁection générale ; la trachéotomie
devint inévitable. Quinze jours après cette opération le miroir laryngien ﬁt
voir l’épiglotte tuniéﬁée et injectée; au dessous de cette dernière on n’apercevoit
qu’un cône dont la base correspondait à, l’entrée de la glotte et dont le sommet
se trouvait au niveau du cricoïde; on ne pouvait pas distinguer les cordes
vocales. La muqueuse laryngienne était d’un rouge foncé et d’une sensibilité
extrême. En bouchant la canule on provoquait un accès de Suffocation. Sans
aucun doute le procès morbide n’était pas ﬁni, mais en vue de changements
pathologiques aussi développés nous nous attendions à. un rétrécissement
laryngien consécutif énorme. La canule fut laissée a demeure et l’aﬁ‘ection fut
abandonnée à. son cours naturel, sauf a faire plus tard un essai par le traite-
ment mécanique. Le malade refusa le traitement, prétendant que son état
s’améliorait de jour en jour. Il avait raison : trois ans après l’opération de la
trachéotomie la canule a pu être ôtée déﬁnitivement, la respiration s’effectuait
normalement par les voies naturelles, la voix était a peine voilée; le laryngo-
scope ﬁt Voir l’image laryngienne correspondante à. un simple catarrhe chronique
sans cicatrices. Si nous avions employé le cathétérisme nous lui aurions attribué
à. tort un succès qui ne lui revenait pas. _ Cet exemple nous prouve donc encore
une fois la marche lente des périlaryngites des périchondrites et des ulcérations
chroniques, et montre la possibilité de leur guérison ﬁnale spontanée et tardive.
DISEASES OF THE THROAT. 24.1
Dans les hôpitaux et dans les cliniques particulières des grandes villes il est
rare de pouvoir suivre les sténoses laryngiennes depuis leur début jusqu’à
leur dénouement; c’est pourquoi j’ai tenu a observer ces exemples à, partir
de leurs premiers symptômes alarmants jusqu‘a leur guérison spontanée relative.
Sans ce contrôle continu et sévère on n’aurait été que trop porté à admettre
l’eﬂicacité du traitement mécanique.
Si d’un côté on a revendiqué au traitement mécanique des effets salutaires
que ne lui reviennent pas, il n’est pas à nier d’un autre côté qu’il a eu des succès
bien mérités; il s’agit seulement de limiter ces derniers consciencieusement. C’est
notamment en cas d’œdème chronique avec ou sans périchondrite, en cas
d’épanchement sanguin sousmuqueux, d’hypertrophie partielle de la muqueuse
laryngienne, en cas d’adhérences partielles des cordes vocales, en cas de simples
cicatrices transversales que son emploi est indiqué. Mais dès qu’il y a le moindre
danger en demeure c’est de notre devoir de pratiquer la trachéotomie prophylactique;
c'est une petite opération qui conjure de grands dangers. Quand de cette façon
la respiration est garantie, on peut attendre tranquillement la ﬁn de la maladie;
un traitement local et notamment le traitement mécanique peuvent être essayés,
leur pratique est d’autant plus facile; mais la canule trachéale doit rester en
demeure jusqu’à. la guérison la plus complète. Nous trouvons dans la littérature
des faits déplorables qui nous engagent à observer cette règle sans exception
aucune; je citerai quelques exemples survenus tous dans‘la même clinique
viennoise: sur un jeune homme âgé de 20 ans on avait dû pratiquer la
trachéotomie a cause d’une chorditis vocalis inferior hypertrophica; a la suite
du traitement mécanique on le croyait guéri; mais le malade étouffa deux
mois plus tard. Une servante âgée de 16 ans fut traitée moyennant le
cathétérisme sans trachéotomie préalable ; pendant la nuit il survint un accès de
Suffocation, la malade étouffa, la trachéotomie vint trop tard; il s‘agissait
d’une simple périchondrite laryngienne contre laquelle la trachéotomie aurait été
le spéciﬁque. Le même accident fâcheux s’est produit sur une servante âgée de
22 ans. Pendant le cours du traitement mécanique institué pour une simple
affection syphilitique du larynx, un cordonnier, âgé de 20 ans, étouﬁa de la
même façon sans que la trachéotomie n’avait été faite; nous voyons donc que le
raisonnement aussi bien que les statistiques nous prouvent qu’il existe un bon
nombre de sténoses laryngiennes ou le simple cathétérisme ne saurait jamais
remplacer la trachéotomie; et si quelques succès temporaires semblent
contredire a cette règle, ces succès ne doivent pas nous rendre aveugles
vis a vis du nombre relativement grand de catastrophes fâcheuses qui plaident
«en sa faveur.
Si la trachéotomie a été pratiquée préalablement, si de plus nous sommes
convaincus de l’insufﬁsance du traitement mécanique, il faut avoir recours a
la laryngotomie qui a souvent ses avantages non douteux. Cette dernière opéra-
tion rentre dans ses droits quand il y a déplacement des cartilages laryngiens, suite
de fracture, de blessures par armes à feu, de tentatives de suicide, surtout si
dans ce dernier cas le rasoir avait séparé complètement les cartilages thyroïde et
crico‘ide. Si Billroth a prouvé que les deux bouts d’un cartilage costal fracturé
se réunissent moyennant un cal osseux, si Schottelius a démontré qu’après l’âge
de la puberté il se forme normalement dans les cartilages laryngiens des
foyers vascularisês suivis de formations osseuses, la formation de grands cals
osseux dans des larynx fracturés n’a rien de surprenant (Max Schüller); il n'y
a pas a penser a un traitement mécanique dans les cas d’hyperchondrose,
surtout si nous voyons que dans ces mêmes cas la simple laryngoﬁssure est
très—difficile et que nous possédons des exemples où après la pratique laborieuse
de la laryngoﬁssure le chirurgien, n'ayant pu écarter le deux moitiés laryn-
giennes malgré les plus grand efforts, a dû recourir a la résection partielle
PART III. R ‘
242 DISEASES OF THE THROAT.
de la paroi laryngienne antérieure. Cette résection partielle avec conserva—
tion du périchondre a été pratiquée pour la premiére fois par Heine. Immédi-
atement après cette résection on place une simple canule laryngienne ou mieux
encore une canule en T, en attendant la guérison de la plaie. La possibilité‘
de la perte de la voix n‘est pas une objection sérieuse contre l’indication de la
laryngotomie et de la résection laryngienne: la voix est le plus souvent dé-
truite par l’affection primitive et le malade pourra porter un larynx artiﬁciel.
Dans les cas rares où la voix n’était pas perdue primitivement, les cordes
vocales peuvent ordinairement être ménagées et quand après un certain temps
la consolidation du larynx s’est opérée, le malade pourra se passer de la canule
et du larynx artiﬁciel.
Conclusz'ons.—l.—Le cathétérisme et le tubage de la glotte sont à rejeter
en cas de sténoses laryngiennes aiguës dès que ces dernières menacent la vie ;.
le cathétérisme et le tubage ne peuvent, sous aucune condition, remplacer la
trachéotomie.
2.-Quand il s’agit de sténoses laryngiennes chroniques on examinera
d’abord si le procés morbide est arrivé à, sa ﬁn; si non, il faut instituer le
traitement général correspondant, et attendre que l’aﬁection laryngienne ait
atteint son dénoûment ﬁnal.
3.—Dans les cas de rétrécissements chroniques le traitement mécanique
peut être employé de primabord; mais dès qu’il existe le moindre péril en
demeure, il faut faire la trachéotomie préventive.
4.-11 faut pratiquer chaque fois la trachéotomie profonde.
5.——Quand la respiration est ainsi garantie ou par les voies naturelles ou
par l’ouverture artiﬁcielle, on peut faire emploi du traitement mécanique, soit
par les voies normales, soit par l’ouverture trachéale.
6.-Quand dans ces cas le traitement mécanique fait défaut, il faut
avoir recours a la laryngotomie suivie de d’excision, de cautérisations, &c. &c.
7.-—Quand la laryngotomie avec son traitement consécutif ne suﬁisent
pas a elle seule‘; il faut la faire suivre par la résection partielle, par l’introduction
d’une canule en T, et éventuellement d’un larynx artiﬁciel.
Die Resulz‘az‘e der mee/zmez'se/zevz Bekema’lzmg der Kekl/eepf-
sieezoseez.
Dr. T. HERING, VVarschau.
Die bisher nicht genügend pr'alcisirten und zum Theil widersprechenden
Ansichten über den Werth der mechanischen Behandlungen der Larynxstenosen,
veranlassten unser hochverehrtes Präsidium, dieses Thema in das Programm der
zu discutirenden Fragen aufzunehmen und dadurch Klärung und Verst'aln dniss
der fraglichen Punkte zu bewirken. k
Die Larynxstenose bildet unstreitig einen der qualvollsten Zustände, sowohl
für den Kranken, wie für seine Umgebung. Auch der Arzt war noch his vor
Kurzem dem Leiden gegenüber machtlos und nach bald erschöpften thera-
peutischen Versuchen, trat die Tracheotomie in ihre Rechte. Wohl beseitigte
sie den drohenden Erstickungstod, aber sie schuf neue Gefahren und blieb, da
gewöhnlich die Stimme verloren oder unverständlich war, ein palliatives, einen
elenden Zustand verl'angerndes Mittel. Der Kranke war verdammt das ganze
Leben die Canüle zu tragen, und war von der Welt durch den peinlichen
Eindruck den er weckte, wie abgeschlossen.
Bevor ich der Versuche, die Canüle entbehrlich zu machen, erwähne, möchte
ich einige Worte der Eintheilung der Stenosen und ihren Ursachen widmen.
Die Kehlkopfstenose bildet vom pathologischem Standpunkte aus keine
DISEASES OF THE THROAT. 24.3
selbstständige Krankheitsform, sondern nur einen durch verschiedene Processe
bedingten Zustand. Wir unterscheiden im Allgemeinen acute und chronisch
verlaufende Formen. Die acuten Larynxstenosen werden meistentheils durch
entzündliche Processe als da sind: Croup, Diphtheritis, acute Perichondritis,
chemische und mechanische Lasionen bedingt. Die chronischen Formen sind
das Resultat von hypertrophischer Entzündung der Schleimhaut, des sub-
mucösen Gewebes, oder des Perichondriums. Narben und Verwachsungen, als
Residuen ulcerativer Processe, wie solche im Verlaufe der Variola, des Typhus,
der Syphilis gesetzt werden, sind die häufigsten Ursachen der Verengerung.
Von allen Einzelheiten dieser Processe absehend, da sie Ihnen, meine
Herren, ja allen gut bekannt sind, werde ich mich bemühen, die Resultate
einer Statistik von 100, von mir gesammelten Fallen mitzutheilen und je nach
der in Anwendung gezogenen Behandlung von einander zu scheiden.
Die Schwierigkeiten einer solchen Zusammenstellung waren grösser als ich
es anfänglich vermuthete, weil die bisher Publicirte Casuistik keine vollständige
Garantie bietet, ob die als geheilt angegebenen Falle, sich als solche bisher
bewahrt haben, ferner da die Diagnose nicht immer pr'aoise gestellt werden
konnte, besonders aber die Anamnese nicht genügend in allen Füllen berück—
sichtigt worden war. Ich war also angewiesen, um ein möglichst sicheres
Material zu sammeln, mich an die Herren Collegen, welche auf diesem Felde
gearbeitet hatten, zu adressiren und um Angabe über den weiteren Verlauf zu
bitten.
Der Liebenswürdigkeit vieler dieser Herren verdanke ich nicht nur genaue
Angaben über den weiteren Verlauf, sondern auch eine Bereicherung der Casuistik,
durch bisher noch nicht publicirte Beobachtungen und ich ergreife die Gelegen-
heit ihnen hiermit meinen verbindlichsten Dank auszusprechen. Arbeiten, welche
ohne Angabe der Casuistik publicirt worden sind, konnte ich nur in Kürze
berücksichtigen, da sie kein brauchbares Material zur Statistik bieten. Um
eine leichte Orientirung in dem angehauften Material zu erlangen, ist die
Casuistik in Tabellen, deren Rubriken die wichtigsten Punkte jeder Beobach-
tung enthalten, aufgenommen worden.* Von der Beschreibung jedweder
Methoden werde ich ganz absehen, den Catheterismus beim Croup nur ﬂüchtig
berühren und in möglichster Kürze meine Schlussfolgerungen zu Präcisiren ver-
suchen. Obwohl der grösste Theil der Casuistik den Originalarbeiten entnom-
men wurde und nur einige Beobachtungen aus Referaten stammen, sind mir
die Mangel dieser Statistik wohl bekannt. Von Ihnen, meine Herren, hängt es
ab zu ihrer Vervollkomnung beizutragen und wird jede Angabe über unbe—
rücksichtigt gelassene Beobachtungen, oder etwaige Ungenauigkeiten in der
Bearbeitung des Materials, mit grossem Danke angenommen werden.
Bei der mechanischen Behandlung der Larynxstenosen sind zwei Methoden
zu unterscheiden :
1) Einfuhren in den Larynx von Hohlrohren vor der 'I‘racheotomie;
2) Methodische Dilatation nach bereits ausgeführter Tracheotomie.
ERSTE METHODE.
(V 01‘ der Traclzeotomz'e.)
Die ersten Versuche durch Einführung von Rohren der Larynxstenose vor—
zubeugen und dadurch die Tracheotomie zu umgehen, stammen von Desault.
Bei Croup wurde der Catheterismus von Bouchut in sieben Fallen angewandt,
doch immer mit lethalem Ausgang. Trousseau, welcher von Seiten der franzö-

'X‘ Die Tabellen werden von dem Autor in den Archives of Laryngology veröffent-
licht werden. Die Verweise auf dieselben sind beibehaltenword en, um spatere Vergleiche
zu erleichtern. Anm. der Herausgeber.
n 2
244 DISEASES OF THE THROAT.
sisohen Akademie zum Referenten einer Commission zur Prnfung dieser
Methode berufen war, konnte sie nioht empfehlen und betonte unter anderen
Gri'mden das experimentell naohgewiesene Zustandekommen von Deoubitus-
Geschwtiren, welche duroh Druok der R‘o'hren erzeugt wurden. Auoh der
Vorsohlag \Veinleohners, der im Jahre 1871 das Einfnhren von Rohren ans
Hartgummi als symptomatisohes Heilmittel bei Group und Diphtheritis empfahl,
fand Wenig Beobaohtung. Es sind von H'Littenbrenner, Rauohfuss und Hack
begrtindete Bedenken gegen diese Procedur erhoben Worden, w‘zihrend Monti
den Catheterismns zwar bei Group verwarf, ihm dagegen bei asphyotischen
Zustiinden als symptomatisohem Mittel Geltung zu sohaﬁ'en versuohte. War
auoh die Idee von Weinleohner im Allgemeinen von den Aerzten nioht accep—
tirt Worden, so muss es ihm dennooh als Verdienst angesehen Werden, den
Catheterismus zur methodischen Behandlung der Larynxstenosen Vorgeschlagen
11nd ausgefiihrt zu haben. ~
Erst Sohrotter War es vorbehalten, diese Methods weiter auszubilden und
duroh striote Beobaohtungen und Versuohe ihr das Bnrgerrecht zu versohaffenz
Statt der elastisohen Bougies oder Catheter sind von Schrotter dreieckige,
dem Larynxinnern entspreohend geformte und gebogene Hartgummir'ohren von
versohiedener Dicke zur Dilatation angewandt und der Grundstein einer Heil-
niethode, die mit vollem Reohte den Namen ihres Begriinders tr‘a'gt, gelegt
Worden.
A. Der Caz‘lzeterz'smus laryngz's aZs lebensrettende Operation bei acut auftre—
tenden Larynxstennsen.
Dieses Verfahren hat sioh bei aouten Stenosen sogar als 1ebensrettende
Operation erwiesen, die in einigen Féillen die Tracheotomie gé'tnzlioh ersetzen
konnte. wiihrend in anderen Ftillen Zeit zur Vorbereitung fur die Tracheotoniie
gewonnen Wurde.
Hierher gehoren die Beobachtungen von LaJous, Hack, Mao Even, O. Chiari
und Szepairowicz.
Der Catheterismus Wurde vorgesohlagen aber so Viel mir bekannt, nioht
angewendet bei :
1) Bluterg'nssen in das submuoijse Gewebe, in Folge von Verletzungen
oder Fracturen der Kehlkopf'knorpel (Sohrotter).
2) Bei Laryngospasmus (Hack).
Er wurde bisher angewandt bei folgenden durch Larynxodem bedingten,
mit drohenden Suffooationsanﬁillen einhergehenden Zustiinden:
Phthisis laryngea . . . . . . . 2
AoutesLarynxoedem . . . . . . . 2 ,
Periohondritis mit Oedem . . . . 1
Pdstious—L‘alhmung . . . . . . . . 1
Laryngitis hyperplastica . . . . . . 1
Syphilitisohe Stenose . . . . . . 1
8
Die Tubage ist im Allgemeinen indioirt bei alien acut auftretenden Ste-
nosen, welche, sei es duroh Oedem, sei os duroh Lahmung der Glottiserweiterer
entstanden, zu lebensgeﬁihrliohen Erstiokungsanﬁillen Veranlassung geben. Sie
kann in Ermanglung von Sohro'tter’sohen Rohren mittelst eines elastisohen
Catheters (Labus) oder einer Sohlundbougie (Szeparowicz) mit Erfolg aus-
geﬁihrt werden. Obwohl prinoipiell das Einftihren von Instrumenten in den
Larynx nnter Beihiilfe des Spiegels ausgef'nhrt werden soll, kann und muss in
gewissen Fiillen das Rohr unter Leitung des Fingers eingefiihrt werden.
Die speoiellen Angaben 'L'lber die Resultate dieser Methode sind in der
DISEASES OF THE THROAT. 245
Tabelle I., N. 1-7 (and T. VIL, N. 37) aufgenommen Worden. Wir ersehen
aus derselben, dass die giinstigen Resultate
2 Mel bei acutern Larynxb'dem (N. 3, 4)
l Mal bei luetischer Stenose (N. 2)
1 Mal bei Posticus-Léihmung (N. 37, T. VII.)
erzielt Worden sind, d. 11., die Tracheotomie ersetzt batten. Die Tracheotomie
~Wurde auf'geschoben :
2 Mal bei Phthisis laryngea. (N. 1, 6)
1 Mal bei Perichondritis (N. 5).
Verschlimmerung des Zustandes (subcutanes Emphysem) ist in einem Falle
(No. 7) von Szeparowicz bei einem 1.} j'ahrigen Kinde beobachtet Worden.
Die Sehrb'tter’schen R'dhren, resp. Catheter, Wurden entweder kiirzere Zeit von
5 Minuten bis 1 Stunde, oder 2t demeure, bis zu 8 Tagen, ohne Unterbrechung
im Larynx gelassen (N0. 37).
Eine Durchsieht der vorliegenden Ftille, fnhrt uns zu folgenden Schl'tissen
ﬁber den VVerth des Catheterismus bei acut auf'tretenden gefahrdrohenden
Stenosen :
1) Der Catheterismus kann die Tracheotomie in gewissen F‘a'llen ersetzen,
ist aber bei kleinen Kindern mit grb'sster Vorsicht und nur in der dringend-
sten Noth auszufiihren.
2) Das Einf'uhren und léingere Liegenlassen im Larynx von Hohlbougies
(‘a demeure) kann zu Deeubitusgeschwiiren, sogar zur Blosslegung der
Knorpel Veranlassung geben und ist bei kaehektischen Zustiinden direct als
schﬁdlich zu bezeichnen (No. 33, 35, 39).
3) Diese Behandlungsweise darf nicht ambulatorisch ausgefiihrt Werden;
sie fordert grosse Vorsicht und stetige Ueberwachung des Kranken von Seiten
des Arztes, da nach unvorsiehtiger Entfernung der Riihren tiidtliche Er-
stickungsanﬂille vorgekommen sind (No. 36).
4) Beim forcirten Catheterismus (bei Erwachsenen) sind alle Vorbereitun-
gen zur Tracheotomie zu treﬁ'en, die Versuehe mit diinnen R'dhren und nicht
zu lange vorzunehmen, und falls keine Besserung eingetreten ist, die Tracheo-
tomie auszuﬁihren.
5) Bei tubercul‘o'ser Phthise und bei Carcinoma laryngis ist die Tracheo-
tomie der Tubage vorzuziehen (N 0. 29, 30).
B. Der Catlzeterz'smus Zaryngis behufs der graduellen Erwez'temng von
chronz'schen Lavynwstenosen und seine Resultate.
Diese Behandlungsweise Wurde mittelst Catheter, Schlundbougies,
vorwiegend aber mit den von Schr'o'tter angegebenen Hartgummirehren
ausgefuhrt. Eine Reihe von 47 Beobachtungen ist in den letzten Jahren
publicirt Worden und in den Tabellen 2 bis 9 (No. 8-54) enthalten. Diese
Art der Behandlung wurde angewandt bei :
Chorditis hypertrophica . . . . .
Blenorrhcna. Stoerkii . . . . . . . .
Perichondritis ehronica . . . . . .
Stenosis ex lue . . . . . . . .
Narbige Strictur ('3) . . . . . .
Posticus-Liihmung . . . .
Stenosis ex hyperplasia membranze mucosae '.
Perichondritis tuberculosa. .
Lupus l.aryng1_s . . . . . . .
Eplthehalcarcmom . . . . . .
Abscessus laryngis . . . .
PP.‘ l—l
\]|)-1)-H—ll—4N.>C>DH>G'>UDCDN)
246 DISEASES or THE THROAT.
In Anbetracht der Natur des Leidens, welches sich in Störungen der Respi-
ration und des Sprachvermögens manifestirt, ist unter Heilung die Erweiterung
der Glottis bis zur Norm und dem Verschwinden der stenotischen Erscheinungen,
sogar bei forcirter Körperbewegung‘, zu verstehen.
Als vollständig geheilt betrachte ich diejenigen Fälle, wo, ausser der frei
gewordenen Respiration auch die Stimme in Bezug auf Starke und Klang ihren
normalen, oder nahezu normalen Charakter wiedererlangt hatte.
Als gebessert sind diejenigen F‘a'lle zu betrachten, in welchen bei forcirter
Bewegung sich leichte Dyspnoe einstellte, und die Stimme laut, wenn auch
etwas unrein blieb.
Die Tabelle A. ergiebt folgende Resultate :
Respiration und Stimme normal . . . 12 Falle
Respiration normal, Stimme unrein . 15 ,,
Respiration gebessert, Stimme unrein . ll „
Resultat unbekannt . . . . . . . 3 „
Negatives Resultat . . . . . . . 6 „
4:7 Falle
Sie ersehen, meine Herren, aus dieser Zusammenstellung, dass auf 47 Falle
von hochgradiger Larynxstenose in 27 Fallen die normale Respiration wieder
erlangt wurde,——wahrlich ein schönes beherzigenswerthes Resultat.
Und nun, meine Herren, le revers de la medaille!
Unter den sechs mitgetheilten mit negativem Resultate behandelten Fallen
ﬁndet sich fünf Mal lethales Ende verzeichnet.
Diese fünf Todesfalle verlangen eine nähere Betrachtung, da gerade die
Misserfolge am meisten belehrend sind, und uns vor Fehlgriﬂ‘en in der Zukunft
schützen. (Hierher gehören die Beobachtungen Nr. 33, 34, 35, 36 und 39
[Tafel 6 und
Wir ﬁnden Exitus lethalis bei
Perichondritis acuta . . . . . . . 2 Mal
Perichondritis chronica . . . . . . 2 Mal
Posticus-Lahmung . . . . . . . . l Mal
Der Tod war in einem Falle (Nr. 36) verschuldet durch Entfernung der
Röhre aus dem Larynx seitens des Patienten, die a demeure belassen war ; in
einem Falle (Nr. 33) entstand, nach zu schnellem Dilatiren in einer Sitzung,
starke Dyspnoe, und in der Nacht Tod in Folge von Lungenödem.
In drei Fallen erlagen die Patienten ihrem Leiden, welches nur einmal durch
Recidiv der Stenose bedingt wurde; in den übrigen zwei Fallen als Myelitis
und Pneumonie bezeichnet ist. Aus dem bisher Angeführten können folgende
Schlusssatze formulirt werden :
1) Die besten Resultate sind von dieser Methode bei der sogenannten
Chorditis vocalis hypertrophica inferior erzielt worden (8 Falle).
2) Das zu schnelle Vorgehen bei der Dilatation ist absolut zu meiden, und
als schädlich zu bezeichnen.
ZWEITE METHODE.
Mechanische Dilatation der Larynxstenosen nach ausgeführter Traclzeotmm'e.
Der erste, der das Einfuhren solider Metallbougies von conischer Form und
allm'alig steigender Dicke vom Munde aus versuchte und in einem Falle prac—
tisch verwerthete, war Trendelenburg. Unabhängig von ihm hat Schrötter
seine Versuche, mittelst dreieckiger Zinnbolzen die Stenose von Oben zu dila-
tiren, an einer gewissen Anzahl von ‘Kranken verfolgt, das Verfahren weiter
DISEASES OF THE THROAT. 247
.ausgebildet, entspreohende Instrumente angegeben, und seine Erfahrungen in
der bekannten Brochiire : “ Beitrag zur Behancllung cler Larynxstenosen ”
nieclergelegt.
Vier versohiedene Behancllungsmethoden sind zur Hebung der Stenosen
naoh ausgeﬁihrter Tracheotomie bisher in Anwendung gezogen Worden.
a) Meohanisohe Dilatation naoh der Laryngotornie (Spaltung des Kehlkopf's)
‘(lurch Einlegen von Zinnstabchen oder entspreohenclen Caniilen, von dem
Munde ans.
6) Dilatation duroh die Trachealﬁstel mit verschiedenen Instrumenten.
c) Dilatation von Oben, durch den Mund (Schrotter’s Methode).
d) Laryngotomie, partielle Kehlkopfresection.
A. Metlzodz'sche Dilatation nach Spaltung des Kehllcopfes clarclz Einlegen
won Zinnstéibchen ode?’ entsprechender Camden, von der Wunde aas.
Versuche dieser Art sind von Trendelenburg mit relativ giinstigem Res ultate
versuoht Worden; doch konnte die Caniile deﬁnitiv nicht entfernt werden. Dies?
Versuohe Weiter verfolgt, bildeten den Grundstein des schon angegebenen Ver-
fahrens die Dilatation vom Munde aus mit conischen Zinnstabchen zu erwirken.
Aehnliohe Versuche sind von Dupuis, mittelst der bekannten T-formigen Candle
in einem Falle von Narbenbildung im unteren Kehlkopfabschnitte, die zur
Stenose ﬁihrte, mit gutem Resultate ausgefiihrt Worden.
B. Dilatation von Unten darch die Trachealﬁstel mittelst Sonden, C'atheters
Schraubendz'latatorien, G’ummz'tampons.
Die Sohwierigkeiten der Einﬁihrung von Instrumenten vom Muncle aus hatte-
eine Reihe von Aerzten zu Versuclien angeregt die Erweiterung von Unten
(lurch die Traohealﬁstel zu probiren. Diese Methode Wurde angewanclt von
Liston, Czermak, Busch, Victor von Bruns und vielen Andern, doch mit relativ
geringem oder ungnnstigem Resultate.
Eine zWeite Reihe von Versuchen mittelst specieller Schraubendilatatorien
oder Gummitampons die Stenose von Unten zu heben, war von besserem Erfolge
gekrijnt.
Hierher gehoren clie Beobachtungen von Parona, Stoerlz, Braun, cleren
Resultate aus der Tafel 10 Z11 ersehen sind. In Zwei Fallen wurde damit.
Heilung erzielt, und die Caniile entfernt; in dem dritten Falle der Patient mit
dem Dilatationsapparate geheilt entlassen. Die Details dieser Apparate konnen
Zhier nioht berncksiohtigt werden.
Ausser diesen positiven Resultaten sincl noch (lie Versuche mittelst eigener
Instrumente die Strictur zu dilatiren von Seiten Gerhardt’s, Paul Bruns’,
Professor Burow’s uncl meine eigenen zu verzeichnen, deren Resultate als un-
Igeniigend bezeiohnet werden mnssen, oder nicht n'a'her bekannt geworden sind.
Eine DLll‘CllSlCllt der hier in aller K'i'irze skizzirten Fiille ergiebt, (lass iiber
diese Methode der Dilatation nioht zu voreilig cler Stab gebroehen werden soll,
Wie dies bisher einige Mal gesohehen. ObWOlll clie anatomischen Verhiiltnisse
des Kehlkopfs die Dilatation vom Munde aus als die rationellste erscheinen
lassen, so sind dooh Wiederum gewisse Umst'ande, welohe fiir die Erweiterung
von Unten aus sprechen. Vor Allem ist hier die Thatsache in Betracht zu
ziehen, dass, w‘a'hrend die Methocle der Dilatation vom Munde aus eine perfekte
Teohnik aller endolaryngealen Behandlungsmethoden erforclert, und daher nnr
'von Speoialisten geleitet werden kann, die Behandlung von der Trachealﬁstel
Won jedem Ghirurgen, der mit dem Spiegel zu untersuohen versteht, versucht
werden kann. Die guten Resultate, die J elenﬁ‘y auf diesem Vvege mittelst
Cauterisationen mit Wiener Pasta in einem Falle von Larynxstenose erlangte.
die positiven Resultate von Stoerk, Parona und Braun forclern es, clieser Me—
fthode, trotz manoher ungiinstiger Erfolge, grossere Ber'ncksiohtigung zu wiclnlen
mind dieselbe in entsprechenden Fallen zu versuohen.
248 DISEASES OF THE THROAT.
G. Dilatation der Larynmstenosen von Oben, dw'ch den Bland, mit Gatlzetern,
illetallsonden, Schranbendz'latatorien und Zz'nnbolzen (Schre'tteﬂs M elf/rode).
Dreieokige, gebogene Eisenst'n'he versohiedener Dioke wurden von Oertel im
Jahre 1863 zur Dilatation in einem sehr interessanten Falle von Larynxstenose
naoh Typhus benutzt, und bedeuten'de Besserung erzielt. Sohrotter hat seinen
Zinnbolzen die prismatisohe Form, als die entspreohendste, verliehen, 11nd diese
Behandlungsweise ist nun heute als das N ormalverfahren naoh ausgefiihrter
Traoheotomie anzusehen. Paul Bruns hat sioh in einer vor Kurzem publi-
oirten Arbeit 'nber Resection des Kehlkopfes 'nber die Schr'o'tter’sohe Methode
dahin ausgesproohen, dass sie naoh seinen aus flinf Fallen gewonnenen Er-
fahrun gen allerdings im Stande ist, eine allmiilige Erweiterung selbst in sohweren
Fiillen bis zu dem Grade zu erzielen, class die Athmung bei gesohlossener
Caniile duroh den Larynx moglich sei. Allein unter allen Umstanden ist die
Behandlung langwierig, Monate und J ahre in Anspruoh nehmend, mit grossen
Besohwerden ﬁir die Kranken verkniipft und nioht ganZ gefahrlos, da bei ener-
gischer Dilatation zuweilen entziindliohe Ersoheinungen mit Sohmerzhaftigkeit,
Oedem, Absoessbildung und Fieber beobaohtet Worden sind.
Aus einem Privatsohreiben, Welohes ioh der Giite des Professor Burow
verdanke, entnehme ioh folgende Siitze nber die mechanisohe Behandlung naoh
von Sohr'o'tter’s Methode.
“ Ich habe diese Methode wiederholt ausgeiibt, sowohl die Einf'nhrung von
Zinnbolzen, als die der durohbohrten I~Iartgummirohren, habe aber nie einen
zufriedenstellenden Erfolg gesehen. Die Stenosen bessern sioh wohl etwas, aber
es war mir in 'vorgesohrit-tenen Fallen, in denen dio Patienten traoheotomirt
waren, nie mo'glioh die Cantile zu entfernen.”
1n demselben Sinne hat sioh auoh in letzter Zeit Professor Roser ﬁber diese
Methode ausgesproohen.
Uebersehon wir nun die von mir gesammelten 36 Féille von mechanisoher
Behandlung der Stenosen naoh Sohrotter’s Methode, das heisst, mit Zinnbolzen,
resp. spater mit Hartgummirohren, so ﬁnden wir, dass die Verengerung duroh
naohstehende Krankheitszust'ande bedingt war:
Periohondritis idiopathioa . . . . . l6 Féille
Periohondritis naoh Typhus . S ,,
Periohondritis naoh Lues . 5 ,,
Periohondritis naoh Variola 2 ,,
Entz'i'lndliohe Stenose . . . . 2 ,,
Membranbildung . . . . . . 1 ,,
Chorditis hyper. inf‘. . . . . . . 1 ,,
Catarrh. ohron. Papillomata . . . 1 ,,
36 Falle
Von diesen 36 Fallen sind 31 wegen Periohondritis behandelt Worden. In
8 Fallen, deren Einzelheiten in der Tabelle II. aufgenommen Worden sind,
konnte die Cantile entfernt Werden; die Stimme ist als normal oder nahezu
normal bezeiohnet Worden. In 10 Fallen Wurde in Folge der Behandlung die
Glottis bis zur Norm erweitert, die Stimme gebessert, dooh konnte die Caniile
nioht deﬁnitiv entfernt werden. In 4 Fallen, wo die Stenose so weit behoben
wurde, dass die Cantile entfernt Worden war, musste Wegen Recidiv’s des
Uebels naoh einer gewissen Zeit die Traoheotomie in der Narbe wiederholt
Werden. Die ‘nbrigen 14 Falle erguben entweder ein ganz negatives Resultat,
oder eine unbedeutende Besserung.
Ferner ersahen wir aus den 8 geheilten Fallen, dass das Alter der Kranken
zwischen 4 11nd 26 Jahren sohwankte; dass die Stenosen vor der Behandlung
DISEASES OF THE THROAT. 249
schon drei Monate bis zwei Jahre bestanden; dass die Dauer der Behandlung
drei Wochen bis zwölf Monate in Anspruch nahm, und nur ausnahmsweise bei
Labus im Durchschnitte drei Monate betrug. In den 18 durch Perichondritis
erzeugten, mit negativem Resultate behandelten Fallen, betrug die Dauer der
Behandlung durchschnittlich 1 bis 1-,1, Monate, und scheint dieser Umstand der
Hauptgrund der mangelhaften Erfolge zu sein.
Im Ganzen sind zu constatiren, auf 36 Fälle:
Vollständige Heilung und Entfernung der Canüle. 8
Erweiterung der Stenose bis zur Norm, doch Ca-
nüle gelassen . . . . . . . . . . . . 10
Negatives Resultat. . . . . . . . . . . 18
36
Die Entfernung der Canüle konnte in vielen Fallen auf Grund einer 'Wei—
gerung der Kranken nicht ausgeführt werden, trotzdem der Larynx seine normale
oder nahezu normale Weite erlangt hatte, und die Stimme laut, wenn auch
unrein, war. 5
Ausser den 36, nach Schro'tter’s Methode behandelten Fallen sind noch in
der Tabelle 8 drei Beobachtungen verzeichnet, wo die Dilatation mit Bougies,
Metallsonden oder Guttaperchazapfen erlangt worden war.
Hierher gehören die Beobachtungen von Stoerk, Asch, Weinlechner und
die interessanten Versuche von Reyher, die es verdienten ausführlicher be-
sprochen zu werden. In drei Fallen konnte die Canüle deﬁnitiv entfernt
werden. Endlich finden wir noch in der neunten Tabelle vier Beobachtungen,
wo mittelst specieller Instrumente die Dilatation vom Munde aus vorgenommen
war, nämlich ein Fall von Navratil, einer von Oertel, zwei von IVhistler.
Es wurde damit erzielt:
Heilung . . . . . 3 Mal
Besserung . . . . l Mal
In einem Falle von Whistler konnte die Canüle entfernt werden.
Verzeihen Sie, meine Herren, wenn ich Ihre Zeit und Geduld so lange mit
trockenen Ziffern und statistischen Tabellen in Anspruch genommen habe. Die
mechanische Behandlung der Larynxstenosen lasst sich nicht mit wenigen
‘Vorten abfertigen, und verdient Beobachtung, als eine der schwierigsten
laryngochirurgischen Behandlungsweisen, die, wenn gelungen, den Arzt mit
gerechtem Stolz erfüllen kann. Selbstverständlich kann diese Methode nur bei
gewissen Formen von Larynxstenose von gutem Erfolge gekrönt sein, ange-
nommen, dass die Cur von einem mit der laryngochirurgischen Technik voll—
kommen vertrauten Arzte geleitet wird. Sie wäre vorwiegend bei massig alten,
nicht cylindrischen Stenosen zu versuchen, und zwar nach dem Verschwinden
der entzündlichen Symptome und jeder Spur von Fiebererscheinungen. Ihre
Resultate lassen sich in folgenden Schlusssützen formuliren:
1) Das bisher relativ gering ausfallende positive Resultat hat seinen Grund
in dem Mangel an Geduld und Ausdauer von Seiten der Kranken, manchmal
der Aerzte.
2) Die positiven Fülle, so unter anderen die Beobachtungen von Labus be-
weisen, dass bei einer energischen, aber trotzdem vorsichtigen Behandlung sogar
in veralteten Füllen von narbiger, im Gefolge von Typhus oder Variola entstan—
dener Perichondritis dauernde Heilung, das heisst, Entfernung der Canüle
erzielt werden kann.
3) Die durch zu rasches Dilatiren erzeugten entzündlichen Symptome
fordern eine Unterbrechung der Cur.
4) Bei Anwesenheit von Narbenwülsten, Verwachsungen, Granulations—
250 DISEASES OF THE THROAT.
wucherungen, ebenso im Larynx, wie in der Trachea, mussen dieselben clurch
entsprechende chirurgische Eingriffe beseitigt werden, uni mit Erfolg die Ste-
nose dilatiren zu k'o'nnen. Diese Eingriﬁe konnen sowohl endolaryngeal wie
auch von der Trachealﬁstel vorgenommen werden; doch verdient die Behandlung
von Oben den Vorzug. Die mangelhafte Beriicksichtigung dieser Punkte
scheint in vielen Fallen der Grund der negativen Resultate zu sein.
5) Hochgradige cylindrische Stenosen, die durch mit Necrosis einher—
gehender Perichondritis entstanden sin d, eignen sich nicht fur diese Behandlungs-
weise, und sollten durch Laryngotomie resp. partielle Kehlkopfresection beseitigt
werden.
6) In Ermangelung von Schrotter’schen Zinnbolzen, k‘o'nnten Beniques von
verschiedener Dicke mit Erfolg benutzt werden. Falls die Einfuhrung von
Zinnbolzen vom Munde aus auf Schwierigkeiten st'o'sst, lassen sich dieselben
mittelst einer diinnen Belloc’schen R‘o'hre durch die Stenose von der Tracheal-
ﬁstel aus dirigiren.
7) Die mechanische Behandlung der Larynxstenosen ist als ein bedeutender
Fortschritt der Laryngochirurgie, und als ihr Begriinder, mit vollem Rechte,
Schrotter zu bezeichnen.
DISCUSSION.
Dr. TORNWALDT, Dantzig: The main difficulty of the treatment consists in
the slight toleration of hard instruments by the larynx. In order to obviate
this, I have had an instrument constructed of soft india—rubber, consisting of an
inner thick tube with an opening at the top and an external thinner rubber
tube, balloon-shaped. The balloon is inﬂated with water by means of a
syringe. The introduction is made from the tracheotomy wound and through
the opening of the canula, the proper form having been given to the instrument
by means of a ﬂexible pilot.
Dr. GRossMANN, Vienna: To-day, thanks to the work of my esteemed
teacher, Professor von Schrotter, we can promise, in all cases in which the
exciting cause does not render the disease incurable, full success. To obtain
such result, ‘however, we must not be satisﬁed by simply dilating, but treat
also the morbid process which has caused the stenosis. I consider tubage
indicated in diphtheria and croup in those cases only in which it is desired to
gain time for the performance of tracheotomy, otherwise, I think, it is a 72012’ me
tangere.
Dr. MAX SCI-IliFFER, Bremen : I am able to add to the reported cases ﬁve new
ones, in which the ideal end of obtaining improvement, or even cure, without
previous tracheotomy was obtained. The ﬁrst two cases belong to the class
of acute, the three others to the class of chronic stenosis. 1. The patient, a
gentleman, with numerous tumefactions in the larynx caused by syphilis,
nearly aphonic, began to suffer from attacks of suffocation in consequence of
oedematous swelling of these new formations. The impending danger to life
was got rid of by the introduction, twice daily, of Schro'tter’s hard caoutchouc
tubes. Time was gained for the endo—laryngeal removal of the tumours. The
patient died two years later from pulmonary tuberculosis, most likely caused
by syphilis which had existed for ten years. The voice had been greatly
improved. 2. A syphilitic woman suffered from attacks of suﬁfocation in con-
sequence of acute rapid inﬁltration of the laryngeal mucosa and submucosa;
she was sent to me to have tracheotomy performed. By constant tubage,
however, so much time was gained that an energetic mercurial treat-
ment could be instituted. This, in turn, produced retrogressive change in the
DISEASES OF THE THROAT. 2 5 I
inﬁltration, and in a short time complete cure, with restitution of the normal
voice. 3. The patient was a woman with a stenosis caused by perichondritis
thyroidea. There was an external abscess extending down to the cartilage
without, however, producing sequestration, which healed with a puckered-in
cicatrix. The voice was completely aphonic. Daily tubage for several
minutes has been continued up to the present time. The patient now—5.6., one
year after the beginning of the treatment—speaks with a rough, deep voice,
which, it is hoped, will still further improve. 4. A woman was attacked with
pneumonia after erysipelas of the face, and in the course of this perichondritis
thyroidea supervened. One night she thought that she would have been
choked. After violent efforts something in the larynx seemed to burst, and a
large quantity of badly-smelling pus was evacuated. Half a year” after this
she consulted me, as since that time a gradually increasing dyspnoea had
made its appearance. The woman was much emaciated. Examination of the
lungs, however, yielded no positive result. The laryngoscopic examination
showed that there was a stenosis at the level of the ventricular bands. The
vocal cords were scarcely visible, and were later on seen to be defective in their
anterior parts. Speech was entirely inarticulate; respiration very laborious,
and associated with a loud stridor. For four weeks tubage was made twice
daily, each time for ﬁfteen minutes. The lumen of the larynx became normal,
and the voice almost good. The woman has had a child since the operation.
Now—216., one year later—feels quite well. 5. Man, still under treatment. The
stenosis is caused by chronic inﬂammation of the mucosa and submuscosa of the
larynx at the level of the ventricular bands. Tubage. The voice, which in the
beginning was almost absent, is already good and respiration. nearly free, so
that the man can work for hours.
[miz'caz‘z'oas for Z/ze Complez‘e 01/ Pam‘z'al Exz‘z'rpaz‘z'oa of Z/ze
Lam/ax.
Dr. FoULIs, Glasgow.
Advances in surgery, as in other arts, commonly meet with obstruction,
which they must overcome before they are recognized as genuine or safe;
and even then a certain period of probation is necessary to deﬁne clearly
the path in which the new methods may be followed. It is this period
of probation and scrutiny through which the operation of excision of the larynx
is now passing; and the object of this discussion is to point out the cases in
which, according to present experience, excision may be practised.
First performed in man by Patrick Heron Watson, of Edinburgh, in 1866,
this operation was only introduced to the profession in 1873, by Billroth, in
Vienna; but since that date it has made so much progress in the favour of
surgeons, that I am able to present to you a list of thirty- two cases in which
the larynx has been completely removed. It has become one of the standard
operations of surgery, and doubts as to its feasibility are now replaced by
a desire to improve its details and to deﬁne its proper place. This may
be assisted by examination of the cases of complete excision on the roll.
These may be divided into three groups, according to the causation_
1.———Cases of complete excision for non-malignant disease, two in number.
The ﬁrst of these cases was also the ﬁrst in which the operation was ever
resorted to in man; and I may, therefore, relate it brieﬂy in the words of the
operator, Dr. Heron Watson, of Edinburgh, who, in a letter to me, dated April
1, 1881, saysz—“The ﬁrst case (in 1866) was a gentleman, aged thirty-six,
2 52 DISEASES OF THE THROAT.
suffering from tertiary syphilis, with destruction of the laryngeal cavity. I had
previously, about a year before, opened his trachea to relieve him from the
ulcerative condition. The larynx then healed, but the puckering gave rise to
a condition of matters by which some portion of all fluid nutrinient and saliva
made its way into the trachea, and occasioned ﬁts of spasmodic cough. Feed—
ing by the tube did not prevent the saliva from passing down, and in almost
every instance on its withdrawal some fluid regurgitated, and some part of it
passed into the trachea, &c. I operated by a linear incision, and clearing the
trachea ﬁrst above the tracheotomy opening, I out it right across, introduced a
gum elastic tube (a full-sized lithotomy tube), and tied the trachea upon it by a
piece of silk ligature. I then cleared the soft parts from the larynx by means of
the points of probe-pointed scissors, using them to pull away the structures when
one could, and clipping with them when this was necessary. The patient
rallied from the operation, but died some weeks afterwards from pneumonia.”
The second case in this group is one in which Rubio, of Madrid, removed
the larynx, owing to necrosis of the laryngeal cartilages, in a man aged forty—one,
the case ending fatally in ﬁve days by marasmus. In both of these instances there
was great debility before the operation, and this rendered them less hopeful.
2.—Oases of sarcoma of the larynx, ﬁve in number. The result in these
ﬁve patients was very good. One of them (by Bottini) is alive and well six
years after operation ; one (by Oaselli) is alive and well nearly two years after
removal of larynx, pharynx, tonsils, and soft palate. Three of the ﬁve patients
have died ; but of these, one (by myself) lived seventeen and a half months,
and succumbed, not to a recurrence of the sarcoma, but to phthisis; another
(by Ozerny) lived ﬁfteen months, and died from recurrence of the sarcoma;
while the third patient (by Lange), an old man of seventy-four years, died from
asthenia nearly seven months after the operation.
This group of cases, then, is a brilliant one, all the patients in it having
decidedly beneﬁted by the surgical procedure.
3.——Oases of cancer of the larynx, twenty-ﬁve in number. The death-rate here
is very high, partly because of the debility and advanced age of the patients, and
partly owing to the infiltrating nature of cancer, which necessitated, in some of
the cases, extensive cutting operations wide of the larynx, and favoured in all
a speedy recurrence of the disease in the vicinity. Only three out of this
group of cases are not recorded as having died at longer or shorter periods
after operation—namely, one (by VVegner) in which I have not received any
details after the seventh month, at which time there was no recurrence; and
two (by Czerny and by myself) operated on three months ago, and both now
alive and well. Not one of the patients in this group has been reported as
alive at the end of a year after operation, and only two of them have lived even
nine and ten months respectively.
This is a gloomy account; but it loses some of its forbidding aspect when
more closely examined. In order to avoid repetition of details, let us consider
the three groups together, and try to discover the more prominent causes of
the formidable mortality. I say formidable, for out of the thirty-two cases,
sixteen (or one half) died in or near the ﬁrst fortnight; nine terminated fatally
within ten months; two within one and a half years; and only ﬁve are alive-—
one of these being not reported on after the seventh month, and two others only
dating as yet three months from operation. This leaves two patients alone who
have lived fairly past the two years succeeding the operation. Why have so
many of them died?
(a) The heaviest factor in the death-rate is the immediate risk after
operation; and analyzing it, we ﬁnd that of the sixteen cases dying in or near
the ﬁrst fortnight, eleven are set down as due to pneumonia, two to pyaemia,
DISEASES or THE THROAT. 253
and three to collapse. The danger of lung complications, therefore, must, in
the ﬁrst place, be carefully guarded against. I am convinced that two chief
exciting causes of the lung mischief are—(1) trickling of ﬂuid into the air
passages by the side of the tracheal tube, and (2) variations in the temperature
of the air; and, therefore, I would advocate the use of a very wide tracheal
tube, quite ﬁlling the trachea after operation, and the maintenance, night and
day, of a temperature of say 70° Fahr. _
Another source of danger is pyaemia; and here our safety lies in the free
use of zinc chloride solution to the raw surface at the completion of the opera—
tion, avoidance of all and every form of dressing to the wound surface, very
careful removal of ﬂuids accumulating in it, and syringing with Condy’s ﬂuid
at regular intervals.
Last among the immediate dangers is collapse, best warded off by care-
ful feeding through a permanent gullet catheter.
(6) Later on the recurrence of the disease increases the death-rate,
seven patients succumbing to it. This is intimately connected with the
question of the extent to which the disease has been allowed to advance.
From an exaggerated fear of the operation, and also owing to the limited use
of the laryngoscope, the disease has run on until neighbouring parts were
involved, rendering the operation, when at length undertaken, both extensive
and severe. Not the larynx only, but parts of the tongue, pharynx, and gullet,
as well as enlarged lymphatic glands, have had to be removed, and thus the
chances of recurrence were greater. It is to be hoped that a more general use
of the laryngoscope will bring such cases earlier under notice; and also that
improvements in the operation itself may render it less feared and more readily
resorted to.
(0) Then we must not forget the inﬂuence of age on the mortality. In the
cancer group the average age is ﬁfty-four and a half years, two patients being
over seventy years old. In the sarcoma group the age is thirty-eight years,
one patient being over seventy. In the non-malignant group the average age
is thirty-eight years. Need we wonder at the high mortality in the cancer
group when we reﬂect on the advanced age and extensive disease in ‘its
members? It is not too much to expect that earlier operation will yet improve
the statistics in cancer cases.
Bearing in mind, then, the experience gained in the past, what are the
cases in which the larynx may be extirpated in the future?
I think it will be conceded that the sarcoma group has been so successful as
to render the operation admissible at once on recognition of the disease, and in
this group I would include papillomata which recur after fair and clean
removal, for we know that they have a strong malignant tendency in many
cases.
The cancer group also I consider as within the scope of the operation-—
excluding cases of very advanced age, for I do not regard a patient over seventy
as a proper subject of operation for cancer; and excluding also cases in which
the lymphatic glands of the neck are involved, for then the disease is practically
not within our reach. It may be true that eventual recurrence in the best
selected cancer case is always to be looked for, but the scanty lymphatic supply
of the larynx renders recurrence slower, and we give to our patient at all
events a period of relief from suffering, and, if the artiﬁcial larynx is well
ﬁtted in, a term of comfortable and useful and hopeful existence. And is that
not a good result? It will be contended that a simple tracheotomy operation
ensures as long, or a. longer, continuance of life as the much more dangerous
operation of extirpation. But the quality of the life so prolonged must be
weighed also ; and in the absence of pain, ease of swallowing, freedom from the
2 DISEASES OF THE THROAT.
terrible burden of an ever-present malignant disease, we have advantages
which are only secured by the removal of the part affected.
But what are we to say about the group of non-malignant cases? May we
excise the larynx as we would a knee-joint when it is hopelessly thickened and
ulcerated? When the breathing and the voice are impeded, and the parts are
no longer capable of distension by dilators, it appears to me that the diseased
larynx may properly be removed and replaced by an artiﬁcial one. That
there are such cases, especially in old—standing catarrh of syphilitic origin-—
cases in which dilatation is useless—no one will deny. In such patients I
would not hesitate to remove the larynx.
This brings up the subject of partial extirpation of the larynx, for it is in
such stenosed non-malignant cases that partial removal might have advocates. _
By partial extirpation I understand the removal of part of the laryngeal
cartilages. I exclude mere thyrotomy. No doubt such cases as that in which
Lister split the larynx and cleared out the vocal cords, &c.—-an operation
which I have lately repeated with excellent results—is a partial excision in a
sense, but the term seems to me rather to refer to the excision of part of the
cartilages.
Of such operations my list contains six examples. In four the larynx was
split in the middle line, and one-half of it taken away—an operation introduced
by Billroth in 1878. Two of the cases were for cancer, one (by Billroth)
dying of recurrence in six months; and the other (by Reyher) alive and free
from recurrence at the end of fourteen months. In one case (Gerster) of
sarcoma, the right wall of the pharynx, right half of the larynx, right tonsil, right
half of hyoid bone, whole of epiglottis, and part of the base of the tongue, were
taken out, and a year later the patient died of pleurisy, without recurrence of
the sarcoma. The remaining case (Oaselli) was one of a large chondroma in
the neck, in the excision of which one-half of the larynx had to be removed;
this case ended fatally in two days. Two more cases I may quote from my
own practice, in both of which there was old and extreme stenosis, owing to
catarrhal thickening. In both I cut out a disc of the anterior part of the
cricoid and lower edge of thyroid cartilages, and inserted a large vulcanite
trachea tube—purposing, later on, to use a dilator-larynx through this
opening. One of these cases died of diabetes and cellulitis of the leg, two
months after operation; the other developed perichondritis of the larynx,
refused further operation and returned home, where he died in three months.
The result of these six cases is then indecisive, but not very encouraging.
From a study of them, and keeping in view the good result of complete excision,
I do not hesitate to recommend complete in preference to partial excision in any
case where the latter seems to be necessary. By complete excision we avoid
the risk of perichondritis, and we get the disease more thoroughly out, while I
cannot see that it is much, if at all, more serious.
In conclusion I would sum up, thus :
1. Total is better than partial excision of the larynx.
2. The extirpation of the larynx for malignant disease is required as
soon as the diagnosis is clearly made; but
(a) When the cervical glands are involved, these may be a
barrier to the operation ; and
(6) Very old people—(2.9., above seventy years of age, are not
ﬁt subjects for this operation.
3. The larynx may be excised in certain intractable cases of advanced
thickening and stenosis, even though this be of non-malignant
orlgin.
DISEASES OF THE THROAT.
255
Table of Cases of Complete Eatirpation of the Larynx.
To Illustrate Dr. D. Foulz's’ Paper.
Based on and extending the Table in MORELL MAcKExzIE’s Work.
Patient’s
Name of - Parts Immediate Further -
Operator- Date‘ Dlsease‘ Removed. Result. Remarks. Recorded m
Age. Sex.
Patrick'Heron 1866. 36 M. Syphilitic. Larynx and Patient ral- Patient was Letter from
Watson Scarred con- one ring of lied, but died in in a very weak Dr. Watson to
(Edinburgh). tracted state of trachea. three weeks state, andthere Dr. Foulis.
' larynx, especi- from pneumo- was pneumonia
allyatitsupper nia. suspected be-
end. fore the opera-
tion.
Billroth 1873, 36 M. Carcinoma of Part of the Recovery. Death from Archie fur
(Vienna) 3131; the larynx, two upper tra- recurrence of Ktin. Camr-
Dec, cheal rings, the carcinoma, gie, Band xvii.
cricoid,thyroid, seven months Heft p. 343.
‘both arytenoid after operation.
cartilages, and No RM.
lower third of
the epiglottis.
Heine 1874, 50 M, Carcinoma of Larynx in Recovery. Deathfrom re- Archiv fur
(Frag). 28th the larynx. toto. currencc of the Ktin. C'kiru'r-
Apn disease six gie, Band xix.
months later. p. 584.
M. Schmidt 1874, 56 M. Carcinoma of Cricoid. thy- Death °I1 the Archie‘ fur
(Frankfurt). 12th the larynx, mid, and both ﬁfth day after in. Ckirur- "
Aug, arytenoid car- operation from, gie, Band xviii.
tilages. collapse. Heft i. p. 189.
Maas Frei- 18 M, Adeno-ﬁbroma Larynx in Death two Archie fur
burg). (Mt that 13?, 57 carcinomato- toto. weeks_ after Kltn. C'lzirztr-
time in Bres- June. Sum. operation from gie, Band xix.
lau). pneumonia. p, 507,
' P. H. Watson 1874. 60 M. Epithelioma Larynx. Death in two Letter from
(Edinburgh). of larynx ex- weeks _from Dr. Watson to
tending to left pneumonia. Dr. Foulis.
vocal cord.
Scho’nborn 18 , 2 M. Carcinomaof Larynxin Death a few Beeline,-
(Kdnigsberg). zziid 7 the larynx. toto. days after ope- Klinische
Jan. ration. Wockensclzrt'fh
1875, No. '
xxxviii. p. 525.
' ' 2 M. Sarcoma of Larynxin Cure. This This is the “Communi-
Botll'llliirin), 168$’ 4 the larynx, toto. patient in May, most successful cazione letta
Feb_ partly round- 1878, was per- case on record, Innanzi, La R.
celled, partly fectly _ well, the patient Academia di
spindle-celled. working in the having been Medicine. di
ﬁelds, and act- able to undergo Torino” dal
ing as a post- considerable Prof. E. Bot-
man between bodily labour tini, Seduta
Miazzina and after the opera- del 30 Aprile,
Trabaro. ‘on. 1875.
(Letter from (Well on April
Signor Dome- 19, 1881. Let-
nico Barozzi, ter from Prof.
Sindaco of Bottini to Dr.
Miazzina.) Foulis )
. an cnbeck 18 M. Carcinoma of Larynx in Recovery. Death four Berliner
v 1(JBeiglin). 2173:’ 57 the upper part toto, hyoid months after Klinische
July of the larynx, bone, part of the operation Wochensc/zrift,
the epiglottis the tongue, from recur- 1875, Nro. 33,
and the hyoid pharynx, and rence of the p. 453; and
bone. oesophagus. carcinoma in Archie fur
the lymphatic Klin. Chirar-
glands of the qie, vol. xxi.
neck. Supplement-
band, p. 136.

256
DISEASES OF THE THROAT.

Name of

No Operator. Date’
10 Billroth 1875,
(Vienna). 11th
Nov.
11 Mihiws b ) 1881?,
u-ei urg . 5
Feb.
12 Gerdes 1876,
(J ever). 30th
Mar.
13 Reyher 1876,
(Dorpat) . May -
14 P. I-LWatson 1876.
(Edinburgh).
15 Kosinski 1877,
(Warsaw). 1 5th
Mar.
16 Foulis 1877,
(Glasgow). 10th
Sept.
17 Wegner 1877,
(Berlin). 16th
Sept.
18 Bottini 1877,
(Turin). 29th
Aug.


Patient’s
- Parts Immediate Further , -
Dlsease‘ Removed. Result. Remarks. Recolded m
Age Sex.
54 M. Carcinoma of Larynx in Death on the Information
the larynx toto. second day communicated
(diagnosed by after operation by Dr. Mulhall,
Prof. Schroet- from eroupous in reply to in-
ter) aﬁecting pneumonia. quiries madein
the organ Vienna in
generally. March, 1879.
50 M. Epithelioma Larynx in Recovery. About three Archie fur
of the larynx. toto, with ex- months later, Klin. Chiral/r-
ception of the recurrence of gie, Band xx.
epiglottis and the disease in p. 535; and
of a small piece the posterior private com-
of the cricoid part of the munication by
cartilage. tongue. No Prof. Maas.
operation al-
lowed. Death
six months
after the ﬁrst
operation from
hacmorrhage
from the ulcer—
atedearcinoma.
76 M. Carcinoma. Larynx in Death on the ‘Archie ﬁlm
toto. fourth day from Klin. Chimer-
collapse. ie, Band xxi.
i-Ieft ii. p. 473.
60 M. Carcinoma of Larynx in Death on the St. Peters-
the vocalcords. toto, with ex- eleventh day burger Medi-
eeption of the after operation cimsche I/Voch-
epiglottis. from hyposta- enscimlft,1877.
tie pneumonia. Nro. i7 and 18.
60 F. Epithelioma Larynx and Death in one .. Letter from
of larynx, some enlarged week from pul- Dr. Watson to
adjacentglands glands cutting monary embol- Dr. Foulis.
enlarged. the lingualand ism.
facial veins.
36 F. Epithelioma Larynx in Recovery. The patient Centralblatt
of the larynx, toto. died nine fur Ohi/rurgie,
with perfora- months after Nro.xxvi.1877,
tion of the the operation, p. 401, and
skin. recurrence of private com-
ihe disease munieation by
having taken Dr. Kosinski.
place.
28 M. Partly papil- Larynx in Cure. Death from Lancet, Oct.
loma, partly toto, with ex- tracheal and 13, 1877, and
spindle-celled ception of the pulmonary Marchzg,1879.
sarcoma. superiorcornua phthisis,March
of the thyroid 1, 1879.
cartilage and
half the arytze-
noid cartilages.
52 F, Careinomaof Larynx in Cure. At the Exhibited at Private com-
the larynx, toto, with epi- time of com- theCongressof munication by
originating glottis and munieation German Sur- Dr. Wegner.
from the right upper half of (seven months geons, Berlin,
ventriculus the cricoid car- after opera- 1878, on the
Morgagni, size tilage. tion) no recur- 12th of April.
of walnut. rence'.
48 M. Epithelioma Whole of Death on the Bloodless Annales des
of the larynx. larynx andpor- third day from operation, hav- Maladies cle
tion of ms0~ double pneu- ing been en- Z’Oreille et du
phagus. monia. tirely carried Lm'yuw, July
out with the 1,1878.
galvanocautery
knife.


DISEASES OF THE THROAT.
257


Patient’s
Name of - Parts Immediate Further -
N0 Operator- Date’ Disease’ Removed. Result. Remarks. Recorded m
Age. Sex.
:9 V. Bruns, sen. 1878, 54 M. Epithelioma Entire larynx. Recovery. Preliminary WienerMecl.
(Tubingen). 29th of the larynx. tracheotomy Presse, Nov.
Jan. was not per- 17,1878. Fur-
formed. Died the: communi-
Nov. 1, 1878, cation from
from recur‘ Professor Paul
rence. Bruns.
20 Rubin 1878, 41 M. Necrosis of Entirelarynx. Death on the “0bservacion
(Madrid). 11th the cartilagcs ﬁfth day after Clinica,” 850.
May. ol'the larynx. the operation Real Academia
from maras- deMed.Mad.rid,
mus. 1878.
21 Czerny 1878, 46 M. Sarcoma in Larynx and Recovery. Repeated re- Letter from
(Heidelberg). 24th and undervucal glands. moval of recur- Geh. Hofrath
Aug. cords, and per- ring masses. Czerny to Dr.
forating the Death Nov. 30, Foulis.
thyroid carti- I879, ﬁfteen (See also
la e, also in- months after Schuller in
v0 ving the operation. Billroth and
neighbouring Luecke’s
glands. Dezttsche
Chirurgt'e.
22 Billroth 187 , 43 F. Epithelial Entire larynx, Recovery. Death from Private com-
(Vienna). 27t cancer of the with part of passage of munication by
Feb. pharynx, la- pharynx and bougie into Professor Bill-
rynx, and thy- (esophagus. mediastinum roth.
l'OId gland. after six weeks.
23 Wm. Macewen 1879, 56 M. Cancer of Larynx, part Death in Case-books of
(Glasgow). 31st larynx and of the gullet, three daysfrom Glasgow Royal
J uly. upper end of andtheglandu- pneumonia. Inﬁrmary.
gullet, also a lar mass.
glandular mass
at left side of
neck.
24 Cav. Azzio 1879. 19 F. Sarcoma of Larynx,pha- Recovery. Well and ﬁt Bullel‘ino
Caselli (Reg- zoth larynx, ha- 1-ynx, base of for work in delta IS'cie/zze
gio-Emiha). Sept. rynx, pa ate,‘ tongue, soft April,1881,i.e., Matdi Bolog-
and base of palate, andton- twenty months na,vol. v. 1880;
tongue. sils. after operation. and letter from
Dr. Caselli to
Dr. Foulis.
25 F. Lange, 187 . 74 M. Sarcoma 0f Larynx,right Recovery. Recurrence Archives of
(New York). 121: larynx, mvolv- horn of hyoid of anodule of Laryngology,
Oct. ing the gullet. bone, part of the sarcoma. to]. i. p. 3b.
gullet. Death six
months and
twenty-four
days after the
operation from
asthenia.
26 Carl Reyher 1880. 48 M Carcinoma. Larynx. Death at the Letter from
(St. Peters- seventh day By, Reyher to
burg). from broncho- Dr, Foulis, and
pneumoniasep- Wolner’s llIed.
tica. Joma, 1880,
Heft i.
27 Czerny 1880, 47 M. Epithelioma Larynx and Recovered. Glands aﬁ‘ec- Letter from
(Heidelberg). 11th of larynx and soft tissues in ted in Jan. 7, Geh. Hofrath
Oct. soft parts over front of it. 1881. Death Czerny to Dr.
. from exhaus- Foulis.
tion and hi!!-
morrhag'e on
25th March,
1881.
PART 111. s
258
DISEASES OF THE THROAT.


Patient’s
Name of - Parts Immediate Further .
N0 Operator. Date‘ Dlsease' Removed. Result. Remarks. Recorded m
Age. Sex.
28 H. Bircher 1880, 49 F. Scirrhus of Thyroid Death in Letter from
Aarau). 3rd the thyroid gland excised; sixteen days Dr. Bircher to
Dec. gland, involv- six months from pneu- Dr. Foulis.
ing the larynx. later the cancer moniaandgan-
recurred, and grene of lung.
the larynx was
excised with
part of the
gullet.
29 Pick (London). 1881, 39 M. Epithelioma Larynx and Deathin ﬁve Lancet, April
16th of larynx (pre- epiglottis. days from 2, 1881, p. 541.
Jan. ceded by papil- pleurisy and
lomata). pericarditis.
30 Foulis 1881. 50 M. Epithelioma Larynx. Recovery. _ Went home Brit. Med.
(Glasgow). 30th of larynx (pre- in ﬁve weeks, is Jowr. May 7,
April. ceded by papil- now well and and June 11,
lomata). strong. 1881.
31 Czerny 1881, 47 M. Epithelioma. Larynx and Recovered. Went home Letter from
(Heidelberg). 12th twoupperrings in six weeks, is Dr. Czerny to
May. of trachea now well and Dr. Foulis
strong
32 Carl Reyher 1881, 57 M. Carcinoma. Larynx. Deathat ﬁfth .. Letter from
(St. Peters- 14th day from bron- Dr. Reyher to
burg). May. cho-pneumonia Dr. Foulis
septica.
Cases of Partial Excision of the Lam/ma. \
Patient’s
Name of - Parts Immediate Further .
N0’ Operator. Date’ Dlsjease‘ Removed. Result. Remarks. Recorded m
Age Sex.
1 Foulis 1878, 59 M. Old catarrhal The front Recovery. DeaﬂlintWO Case - book.
(Glasgow). 29th and extreme part of cricoid months from GlasgowTrain-
Jan. etenosis of cartilage. sloughing cel- ing Home for
larynx. lulitis of leg. Nurses.
(Diabetes).
2 Foulis 1878, 60 M. Old and ex- The front Recovery.‘ Death in two Case - book,
(Glasgow). 30th treme stenosis part of cricoid and a half Glas ow Train-
May. of larynx, ma- cartilage. months. Ex- ing ome for
lignant. haustion. No Nurses.
exact details.
3 Billroth I878, 50 M. Epithelioma The left half Recovery. Death from Morell Mac-
(Vienna), 7th of larynx, left of larynx. recurrence in kenzie’s work;
July. vocal cord, and six months. Table of Cases
under. in vol. i.
4 Arpad Gerster 1880, 50 M. Sarcoma of Right half of Recovery. Died 9th Archives of
(New York). 5th right part of hyoid and la- March. 1881, of Lanyngology,
Mar. harynx and rynx and pha- pleurisy. No vol. i. p. 124,
arynx, and rynx,rightton- recurrence of and letterfrom
base of tongue. sil, epiglottis, the sarcoma. Dr. Gerster to
and part of base Dr. Foulis;
tongue.
5 Carl ReyherO 1880, 57 M. Carcinoma. Left half of Recovery. No return of Letter from
(St. Peters- 9th larynx. the disease at Dr.- Reyher to
burg). Mar. , iourteenth Dr. Foulis.
month.
6 Cav. Azzio 1880, 27 M. Enchondroma A lar e tu- Death in two Pamphlet by
Caselli (Reg- 9th 01 neck. mour an right days. Dr. Caselli:
gio-Emilia). Nov. ala of thyroid ’
cartilage .


DISEASES OF THE THROAT. 259
Die Indicationen für die gänzliche oder z‘keilweise
Exsi‘izpaz‘ime des KekZ/äopfs.
Dr. PHILIPP Sonnen, München.
Die Entwickelung der Laryngoskopie zu einer selbständigen Disciplin
brachte es mit sich, dass manche früher vom Chirurgen geübte Operation in
die Hände des Laryngoskopikers überging. So ist es, um nur ein Beispiel
anzuführen, allgemein anerkannt, dass die Entfernung der Kehlkopfneubildungen
auf endolaryngealem Wege den Vorzug verdient, und jedenfalls zuerst versucht
werde, ehe man zu andern Methoden schreitet. Dass aber die endolaryngealen
Encheiresen trotz der hohen Vervollkommnung, die sie in den letzten Jahren
erfahren haben, nicht in allen Fällen ausreichen, wird Jeder mit der Sache
einigermassen Vertraute gerne zugestehen.
Es wäre aber ebenso kritiklos, den Werth der endolaryngealen Methoden.
verdächtigen, als die Berechtigung anderweitiger blutiger Eingriﬁe in den
Kehlkopf von der Hand weisen zu wollen. I
Desshalb erscheint es nöthig, präciser als es bisher geschah, die Bedin-
gungen abzuwägen, unter welchen das eine oder das andere Verfahren den
Vorzug verdient; zur Discussion dieses Themas Anlass gegeben zu haben, ist
das grosse Verdienst der geehrten Herren Präsidenten und Secretaire dieses.
Congresses. WVenn wir wünschen, dass die Errungenschaften der Laryngologie,
die sich ihres jetzigen Standes wahrlich nicht zu schämen braucht, bei dem
modernen Arzte Berücksichtigung ﬁnden mögen, so ist dies sicherlich kein
unbilliges Verlangen, wir werden aber auch andrerseits nicht zögern, dem
Chirurgen da das Messer in die Hand zu geben, wo unsere Hilfsmittel ungenü-
gend erscheinen.
Dies ist nun meistentheils der Fall bei den bösartigen N eubildungen des
Kehlkopfes, die wegen ihres raschen VVachsthums in Fläche und Tiefe, und
ihrer ausgesprochenen Tendenz zu Recidiven für die zeitraubenden und deli-
caten laryngoskopischen Manipulationen sich wenig eignen. Nachdem Czerny
und Billroth die Möglichkeit der vollständigen, Heine der theilweisen Exstir-
pation des Kehlkopfes demonstrirt hatten, folgte eine Reihe von Mittheilungen
welche bei der Ohnmacht anderweitiger Heilmethoden die Berechtigung
obengenannter Operationen ausser Zweifel stellten. Das bis jetzt vorliegende
Material ist freilich noch zu gering, als dass man nach allen Richtungen hin
erschöpfende Antworten erwarten könnte, doch dürften sich nach den bisher
gewonnenen Erfahrungen die Indicationen und Oontraindicationen der in Rede
stehenden Operationen zur Zeit etwa in folgender Weise formuliren lassen.
I.
Die gänzliche Exstirpation des Kehlkopfes ist indicirt:
l) Bei allen bösartigen N eubildungen, die grosse Strecken oder mehr als
die Hälfte des Kehlkopfes befallen, die N achbarorgane aber verschont haben.
Wenn ich zur Bedingung mache, dass die Neubildung grössere Strecken
oder mehr als die Hälfte des Kehlkopfes befallen habe, so geschieht dies mit
Rücksicht auf die Indicationen für die theilweise Exstirpation die, wie wir
später sehen werden, aus mehr als einem Grunde günstigere Chancen bietet.
Wenn ich ferner verlange, dass die Nachbarorgane des Kehlkopfes gesund, d. h.
noch nicht von der Neubildung occupirt sind, so stütze ich mein Postulat auf
die Erfahrung, dass in jenen Fällen, in welchen die Neubildung auf den
Larynx beschränkt war, die relativ besten Resultate erzielt wurden. Wenn
aber auch in diesen Fällen noch häuﬁg Recidive auftraten, so ist zu bedenken,
dass bisher die Operation erst in einem sehr späten Stadium vorgenommen
wurde, also zu erwarten steht, dass bei möglichst frühzeitigem Eingreifen die
s 2
26o DISEASES OF THE THROAT.
Resultate sioh giinstiger gestalten Werden. Dass 'nbrigens die Sarcome eine
viel bessere Prognose gestatten, als die eigentliohen Caroinome oder malignen
Papillome, geht ans den bisherigen Beobachtungen mit Sicherheit hervor.
Die Totalexstirpation des Kehlkopf'es ist ferner angezeigt:
2) Bei den durch excessive Hypertrophie des Ring- und Aryknorpels und
deren Schleimhauttiberzug bedingten Schlingbeschwerden, bei denen die
Ernahrung durch das Sohlundrohr unmoglioh und die Ernahrung per anum
ungentigend ist.
Ich habe in erster Linie j ene Aﬁ’eotion im Ange, die man nach Dr. Whist-
ler’s Vorgange als chronisohes syphilitisches Fibroid des Kehlkopfes bezeiohnet.
Wenn auch meist nur die Weichtheile, besonders Mueosa und Subrnucosa an
der Volumzunahme theilnehmen, so kommt es doch anoh gar nioht selten
zu reiohlicheren Proliferationsvorgangen an Knorpel und Periohondrium.
In der Regel mag die theilweise Exstirpation zur Hebung der dringliohsten
Besohwerden ausreichen, ja selbst die Tracheotomie; Wenn aber der Kehlkopf
ﬁir Respiration, Phonation und Deglutition ganz unbrauchbar geworden ist,
dann erscheint es angezeigt, denselben total zu entfernen. Hieher geh'ciren
ferner die Ecchondrosen, Enohondrome und Knorpelwueherungen mit nach—
folgendem Zerfall, wie Turk in seiner Klinik der Kehlkopfkrankheiten einen
derartigen Fall (Nr. 80) beschrieben hat, vorausgesetzt, dass ihre Entfernung
auf anderem Wege mittelst Enucleation* oder theilweiser Resectionj‘
unmoglieh ist. Auoh bei complioirten Knorpelfractnren, besonders den Zer-
malmungen der Knorpel diirfte die Totalexstirpation eine Zukunft haben. End-
lich mijohte ich Schtiller beistimmen, Wenn er in seinen] vortrefﬁichen ‘Verke
pag. 202 sagt, dass die Schlingbeschwerden der Krebskranken sehon mit Ruck-
sioht auf die das lethale Ende beschleunigenden Schluokpneumonieen die Total-
exstirpation als Indicatio vitalis rechtfertigten.
Die Totalexstirpation lialte ich ﬁir contraindioirt:
1) Bei allen gutartigen Geschwiilsten und multiplen Papillomen, Wenn
Sie auoh nicht vollsta'ndig auf andere Weise entf'ernt werden konnen und Ufter
recidiviren.
Ioh begriinde diese These mit der Behauptung, dass man immer im Stande
sein Wird, dnroh endolaryngeale oder laryngotomische Eingrifle die bedroh—
lioheren Symptome fur langere Zeit vollst‘alndig zu beseitigen. Ferner lehrt die
Erfahrung, dass man Selbst nach Wiederholten Recidiven die Hoffnung auf
Radicalheilung nioht aufgeben d'urfe. Ich halte es demnach fur unverantwort-
lioh, in derartigen F'a'llen eine Operation ausfiihren zu wollen, Welche die
Kranken nicht nur in die augenscheinlichste Lebensgefahr bringt, sondern auch
fur das ganze Leben zum Tragen einer Caniile verurtheilt.
Ioh halte ferner die Totalexstirpation fur contraindioirt:
2) Bei Periohondritis und N ecrose der Knorpel.
Wenn Federigo Rubio Wegen Periohondritis die Totalexstirpation ausftihrte,
so lassen sich dagegen sehr gewichtige Grunde geltend machen. Die Peri-
ohondritis ist meistentheils eine secundare, d. h. eine durch ein dyskrasisohes
Allgemeinleiden hervorgerufene Lokalaﬁection. Gibt die Dyskrasie Aussioht
auf Heilung, wie dies bei Syphilis in der That oft der Fall ist, so wird sioh die
innerliche Medication auoh in Bezug auf das Lokalleiden geltend machen; der
Process wird entweder stillestehen, es wird naoh litngerer oder kiirzerer Zeit
relative Heilung eintreten, oder die Zersto'rung wird fortsohreiten; letzteren
Falles gen'ugt in der Regel die Vornahme der Tracheotomie oder nach

* Vergleiche die jiingste Mittheilung von Ehrendorfer in Langenbeck’s Aq'chi'v, Bd. , xxvi.
pag. 578.
'T Vergl. die Mittheilung von Prof. Azzio Caselli, Reggio Emilia, 1880.
DISEASES or THE THROAT. 261
geschehener Vernarbung eine endolaryngeale Operation oder die Thyreotomie
oder Resection zur I-Iebung der zuriickgebliebenen Beschwerden. Ist aber
die Perichondritis tuberculo'ser Natur, so erscheint es umsomehr geboten, sich
auf die gewo'hnlichen operativen Eingriife zu beschr'zinken, als die Erfahrung
lehrt, mit welch’ erschreckender Regelm'a'ssigkeit derartige Kranke selbst nach
I-Ieilung des Lokalleidens ihrer Lungenaifection erliegen. In den ausserordent—
lich seltenen Fallen von prim'alrer Perichondritis endlich wird man gleichfalls
im Stande sein, durch Tracheotomie, endolaryngeale, oder thyreotomische Ein—
griffe Abhilfe zu schaffen.
Die totale Entfernung halte ich endlich auch fur contraindicirt:
3) Bei allen bosartigen Neubildungen, die entweder schon Zu krebsigen
Affectionen benachbarter oder entfernterer Organe gefiihrt haben oder mit
anderen schweren, nicht krebsigen Krankheiten combinirt sind.
Die Erfahrung hat gezeigt, dass Recidive dann am hauﬁgsten und
raschesten auftraten, je mehr die Nachbarorgane, Zunge, Pharynx oder Oeso—
phagus von der N eubildung in Mitleidenschaft gezogen waren. Lymphdriisen-
schwellung allein diirfte jedoch keine absolute Contraindieation abgeben.
Anders verh'a'lt es sich jedoch dann, wenn noch anderweitige unheilbare
St'o'rungen vorhanden sind, wie Z. B. Affectionen des Herzens, Lungenphthise,
Morb. Brightii. Ich selbst habe einen derartigen Fall beobachtet und im
Bande xxiii. des Archivs fu'r klz'nz'sche rlfedz'zz'n. beschrieben; der Kranke starb
an Pneumothorax, bevor noch das Larynxcarcinom stenotische Erscheinungen
erzeugt hatte.
II.
Die theilweise Exstirpation des Kehlkopfes, nach ihrem Begriinder, Heine,
Resection oder subperichondrale Resection des Kehlkopfes genannt, ist indi—
cirt:
1) Bei allen hochgradigen, unnachgiebigen und r'ohrenformigen Larynx—
stenosen.
So grossen Werth auch die von Trendelenburg-Schrotter in die Praxis
eingeftihrte Methode der successiven Dilatation hat, so geniigt sic doeli nicht
fur alle Falle. Ganz ungenugend aber erscheint sie bei jenen sehr derben und
starren, r'o'hrenﬁirmigen Verengerungen, die einestheils einer ossiﬁcirenden
Perichondritis, Knorpelwucherungen und unnachgiebigen callosen Binde—
gewebshypertrophien, anderntheils dem Einsinken des Kehlkopfes nach Elimi-
nation ganzer Knorpel oder grosserer Knorpelstiicke, constringirenden N arben
und umfangreichen Verwachsungen ihre Entstehung verdanken. Fracturen der
Knorpel und Sehussverletzungen geben hiezu weniger Anlass, als bis auf den
Knorpel dringende Ulcerationen bei Typhus und Syphilis. Die Mittheilungen
von Heine, P. Bruns und Foulis, sowie Schuller besta'tigen i'ibereinstimmend
nicht nur den eclatanten Erfolg der partiellen Resection, sondern auch die
Nutzlosigkeit der Dilatationsmethode. Auoh darin stimme ich Schiiller und
P. Bruns bei, wenn sie die Resection bei jenen Stricturen vornehmen, bei
welchen zwar die successive Dilatation ausreichen wiirde, die Stimmorgane aber
derartige Veritnderungen erfahren haben, dass eine Phonation ohne Kunsthilfe
unmijglich ist. Ohne den Werth der allmahlichen Dilatation auch nur im
mindesten bezweifeln zu wollen, kann ich doch, gestiitzt auf eigene Erfahrung,
nicht verschweigen, dass diese Methode wegen ihrer unverhaltnissmassig langen
Dauer sehr oft die Kranken abschreckt und diese dann in kategorischer Weise
rasohe Abhilfe verlangen, zumal unendliche Geduld nicht eben Jedermanns
Sache ist. Beriicksichtigt man ferner, dass in Folge von mechanischen Hin-
dernissen, die von F. Semon in einer ausgezeichneten Arbeit zum erstenmale
ausfiihrlicher beschrieben wurden, in Folge von Substanzverlusten und N arben
262 DISEASES on THE THROAT.
die Stimme sehr oft vollständig zu Verlust gegangen ist, so muss man unbe—
dingt demjenigen Verfahren das Wort reden, das mit de‘r Schnelligkeit auch
die ‘Möglichkeit der Wiederherstellung oder wenigstens Verbesserung der
Stimme mittelst Einlegen eines Phonationsapparates verbindet.
Wenn ich ferner die Resection für angezeigt halte:
2) Bei jenen gutartigen Neubildungen, bei denen die Thyreotomie oder
Laryngotomie indicirt Ware, diese aber wegen Verknöcherung der Knorpel und
Gefahr der Knorpelfractur nicht ausgeführt werden kann, so bedarf dies wohl
keiner weiteren Begründung.
Wenn ich aber endlich die partielle Exstirpation für angezeigt halte :
3) Bei jenen bösartigen Neubildungen, die bei circumscripter Insertion den
Knorpel ergriffen haben oder bei ﬂachenförmiger Inﬁltration auf eine Kehl—
kopfhalfte beschrankt sind, so muss ich ausdrücklich betonen, dass bis jetzt
noch zu wenig Erfahrungen vorliegen, als dass diese Indication immer und
überall stricte aufrecht erhalten werden könnte. Dass die theilweise Ent-
fernung des Kehlkopfes insoferne günstigere Resultate gibt, als dieselbe den
Gebrauch der natürlichen Stimme mittelst eines Stimmbandes ermöglicht und
das trotz aller Verbesserungen immer noch lastige Tragen eines Phonations—
apparates überﬂüssig erscheinen lasst, hat der von Billroth operirte Kranke
sicherlich bewiesen. Ob aber die partielle Entfernung des Larynx zur Ver-
hütung der Recidive genügt, und ob dieselbe doch nicht besser durch die
Totalexstirpation ersetzt wird, muss, wie auch Schüller hervorhebt, erst die
Zukunft lehren.
Eine Ausnahmestellung scheinen die derben Fibrosarcome des Kehlkopfes
einzunehmen, da in manchen F'a'llen die Entfernung durch Thyreotomie*
und wie ich selbst erlebt habet sogar die endolaryngeal-galvanokaustische
Methode genügte, deﬁnitive Heilung ohne Recidive herbeizuführen.
Für contraindicirt halte ich die Resectio laryngis: ‘
1) Bei den einfachen dehnbaren Larynxstenosen, besonders bei den mem-
branösen Verwachsungen der Stimmbänder oder anderer Kehlkopftheile.
Hier ist das Feld der successiven Dilatation, hier feiert die endolaryngeale
Behandlung, Spaltung mittelst Messer oder Galvanokaustik, ihre schönsten
Triumphe. Für den Fall aber, dass genannte Methoden nicht ausreichen,
führt die Discision der Narben oder Entfernung hypertrophischer Schleimhaut-
wülste auf laryngotomischem Wege sicher zum Ziele.
Die Resection des Kehlkopfes halte ich endlich für contraindicirt:
2) Bei Papillomen, auch wenn sie wiederholt recidiviren, und
3) bei jenen bösartigen Neubildungen, welche bei einseitigem Sitze
benachbarte oder entferntere Organe in Mitleidenschaft gezogen haben.
Die Gründe hiefür sind dieselben, wie ich sie bereits früher gelegentlich
der Contraindicationen der totalen Exstirpation auseinandergesetzt habe.
DISOUSSION.
Dr. SOLIS COHEN, Philadelphia :——I am afraid that there is a tendency to
the operation being overrated, if we do not appreciate the usually miserable condi-
tions of the patients, who have undergone it successfully, for there is an important
difference between “ recovery ” and mere “ survival after the operation.”
Professor CASELLI, Reggio Emilia: In the course or a year I have twice
excised parts of the larynx, which were involved in large tumours of the neck;

* Vergleiche P. Bruns, “ Die Laryngotomie zur Entfernung intralaryngealer N eubil-
dungen.” ‚ -
'I' Vergleiche meine Mittheilung im Bande xvi. des Archivs für klinische M edizin.
DISEASES on THE THROAT. 26 3
but my results have not been so happy as in the case I showed last year at the
Congress at Milan. In one case there was an enormous myxomatous ﬁbrochon—
droma of the hyoid bone and larynx; but the exhausted state of the patient led
to his death in three days after operation. In the other case there was a
diffused epithelioma of pharynx and epiglottis, involving part of the thyroid
cartilage. This patient succumbed to acute oedema of the lungs, induced by
the entrance of particles of food into the respiratory tract even before the
operation. If I were to draw any conclusion from my own experience, I would
be inclined to prefer complete to partial extirpation; or, at least, I would
remove the whole of the thyroid cartilage even where a part of it seemed to be
sound, and leave the cricoid only. My chief reason would be the liability to
inﬂammation from rubbing of the anterior part of the remaining half of the
larynx in contact with the cicatrix after the operation. This friction might
easily induce a submucous oedema, which, spreading along the trachea, might
cause suffocation, in spite of the presence of a tracheal canula.
Dr. MORELL MACKENZIE, London: Dr. Foulis’ table seems to indicate a
higher rate of success than that published by myself. I am glad to see this,
but it must be remembered that many unsuccessful cases may not be recorded.
Comparing the opinions of Drs. Foulis and Schech, I find that they differ as to
the adoption of extirpation in recurrent papilloma. I would in this respect
agree with the latter rather than the former, who recommends the operation.
It ought to be remembered, also, that the condition of a patient after extirpation
of larynx is usually one of great misery. The case of the American patient has
certainly made a great impression in this country, and must have made most
laryngoscopists less disposed to recommend the operation. On the other hand,
we must not forget the case of Bottini, in which a patient has continued to act
as a postman, walking eight miles a-day for several years since the operation.
With reference to the position of resection, I am inclined to agree with Dr.
Schech, in opposition to Dr. Foulis, that there are many cases in which re—
section can be performed and extirpation avoided.
Professor CZERNY, Heidelberg: The question of extirpation of the larynx
presents such difﬁculties that I have come here not to teach but to learn. Fully
as I recognize the right of existence of the sceptical party which has to separate
the chaff from the grain, yet I must pertinently claim for my less sceptical
party the recognition that we ask, quite as conscientiously as the other side, in
every individual case : “What would you wish to be done unto yourself under
the circumstances of the case?” If we look at Dr. Foulis’ tables, it is true
that we should come to the conclusion that the extirpation of the larynx was
but of little value, only ﬁve of all who had been operated on being aiive now.
But let us be true to ourselves, and confess that of all patients operated on for
‘carcinoma but few have been permanently cured. As long as we do not possess a
treatment as efficient against malignant tumours as the knife, we really must
be consistent, and not refuse to the patient, who is irreparably lost through his
laryngeal carcinoma, the possible advantage of the operation. As to the
permissibility of the extirpation of the larynx, the state of the patient after the
operation is, it is true, of decisive importance, and we have just heard that an
American patient was very, very miserable after its performance. I have
performed the operation three times on men, and do not consider it so very
dangerous; but the after-treatment is one of the most difficult tasks that could
be given to the surgeon, and the functional results vary very much according
to the stage of the disease. But even in my ﬁrst two cases, in which I was only
.able to operate late, as the diagnosis was for a long time uncertain, yet there
264 DISEASES OF THE THROAT.
was the advantage that the pains, which before the operation rendered the
taking of food almost impossible, ceased afterwards. If it is necessary to remove
much skin, the circatricial contraction is not suﬁ‘icient to cover completely the
space round the artiﬁcial larynx; under these circumstances, taking food,
especially fluid, is often impeded. In my last case, which unfortunately is
only of three months’ date, the state of affairs is so favourable, and the artiﬁcial
vocal apparatus answers so admirably, that the patient is about to resume his
duties as a superior judge (Oberlandesgerz'chisrath). Let us hope that he may
fulﬁl them for a long time I--The question, in functional respects, as_to the
preservation of the epiglottis, is not yet decided. The results vary very much
according to the case and according to the patient’s individuality, which has
the greatest influence upon the functional success. For all this it follows
that the whole question is a most difficult one, and which will not be ripe
for decision for a long time to come. I believe that extirpation of the
larynx, apart from other indications, is demanded as soon as the diagnosis
of a malignant new formation, be it by means of the laryngoscope or by
microscopic examination of removed particles, is attained, and as soon as it
becomes visible that after failure of other remedies the malady irresistibly
progresses, and unquestionably endangers the life of the patient.
Dr. FELIX SEMoN, London: I fully feel the diﬁ‘iculty of speaking in an adverse
sense immediately after the man who has ﬁrst practically shown the possibility
of removing the larynx during life without killing the individual. But I cannot
help thinking that in the whole question one important fault is committed by
a good many members of the profession—viz, that of confounding the two very
different ideas of the “possibility” and of the “justiﬁability ” of an operation.
I am astonished to hear that both Dr. Foulis and Prof. Czerny simply take it for
granted that as S0011 as the diagnosis of carcinoma of the larynx is established,
under all circumstances extirpation should forthwith he proceeded with. Now,
I cannot help asking myself, when looking at Dr. Foulis’ own tables, are the
results hitherto obtained in cases of carcinoma, and recorded in these tables,
really of so brilliant a character as to justify the laying down such a dogmatic
rule ? It will be found there that of the twenty-six cases in which total extirpa-
tion of the larynx has been performed for carcinoma, not less than fourteen died
-—one may fairly say from the immediate consequences of the operation itself—-
216. , within a fortnight of the operation. Of the remaining twelve, nine died from
recurrence, one having survived just nine months, and the majority having died
from within four to six months. The fate of one is unknown after the seventh
month, and only two are alive at the present moment; but it must be remembered
that one was operated upon on the 30th of April, the other on the 12th of May of
this year; thus, in neither of the two only surviving cases does the operation
date back more than three months. Are these results encouraging? And especially
when compared with those of tracheotomy in the same complaint in which statistics
show that the average duration of life after the operation is rather more than a
year ? Moreover, how different is the life after tracheotomy from that, according
to almost all descriptions, miserable existence after extirpation of the larynx!
1 know what objection will be made to these conclusions—viz., that the majority
of the cases hitherto operated on were already in so late a stage of the disease
that no general conclusions ought to be drawn from these instances. But I am
ready to answer this objection at once. Who, in a large proportion of these
cases, will take upon himself to diagnosticate early and positively carcinoma; and
who again, if carcinoma is diagnosticated, Will say positively whether it is in an
early or more advanced stage ?--With regardto the ﬁrst question, I wish to say that
the differential diagnosis of carcinoma from tertiary syphilis, and its consequences,
DISEASES or THE THROAT. 265
;
is often really not the easy thing one might be induced to believe from the con-
venient descriptions in the textbooks. Not only is the laryngoscopic differ-
ential diagnosis often exceedingly difficult for a long time, but I wish to state
here that it is necessary to be guarded in making the diagnosis and giving out
a prognosis ex juvantz'bus; for having had the opportunity of seeing and carefully
observing an unusually large number of cases of laryngeal and oesophageal
carcinoma, in which I have given iodide of potassium to avoid any possible
error, I am able to state distinctly that in a large proportion of them (though
not in all) the administration of this drug has produced a subjective improve—
ment, and in some of them apparently even a temporary arrest of the progress
of the disease, for a period varying from eight days to four weeks. With regard
to the second question—viz., “Is it always possible to decide whether the
carcinoma is in an early or advanced stage—i.e., has or has not an infection
of the neighbouring parts already taken place ?”———I cannot do better than com-
municate a case of carcinoma which is still under my observation, and which
gives much subject for thought. It is that of a gentleman aged sixty, who had
twenty years ago secondary syphilis, and who began to suffer from his throat in
October, 1880. The diagnosis remained for a long time doubtful between
speciﬁc Perichondritis on the one hand and carcinoma on the other, iodide of
potassium yielding by no means the decisive results which are generally
anticipated from its use. Particular attention was paid from the very beginning
to the condition of the lymphatic glands, which were found in repeated exami—
nation not to have undergone any perceptible change. It was not till the
beginning of March, 1881, that the diagnosis of carcinoma could be actually
established, at this time the posterior cervical lymphatics becoming slightly
hardened, but not perceptibly enlarged. The question of extirpation of the
larynx was carefully taken into consideration, and a consultation was held with
Sir James Paget, who entirely corroborated the diagnosis including the state of
the lymphatics, but who was as little in favour of extirpation as myself. The
posterior surface of the cricoid cartilage, and with it the muscles opening the
glottis, becoming affected at that time, I had to perform tracheotomy on the 9th
of March; exactly one week after the operation a swelling of the size of a
hazel-nut, which quickly increased, and was painful on touching, appeared on
the right side of the neck immediately behind the posterior belly of the sterno-
mastoid muscle !—If in this case extirpation had been performed instead of
tracheotomy, there would have been a recurrence within one week after the
operation I—‘l'his case, I think, is suﬂiciently instructive to show the difficulties
of deciding at an apparently early date whether constitutional infection has not
yet taken place. In conclusion, I desire to say that I have no theoretical
objections against the operation as such, and that I agree with many of the
indications laid down by my friend Schech, but that I consider it a duty to
protest against its indiscriminate recommendation in all cases of carcinoma,
a recommendation which, I think, is with difﬁculty theoretically justiﬁable, and
which is certainly practically not justiﬁed. I wish to protest still stronger
against the operation in cases of recurrent papillomata, a subject 011 which I
shall have to say more on a future occasion.
Prof. BURow, K'o'nigsberg: In my opinion it is better not to perform total
extirpation on patients with carcinoma of the larynx, but if the case be a
suitable one, to make endo-laryngeal, even if only partial, excision, and to
tracheotomize if dyspnoea makes its appearance. Such patients live on the
average two and a half years from the beginning of the affection, and one and
a half after tracheotomy, and are frequently able to follow their vocation for a
considerable time. If the operation of extirpation is to be performed at all in
266 DISEASES or THE THROAT.
such cases, it certainly ought to be done at a very early period; but will we,
in such an early period, when the symptoms are still slight, get the patients’
permission, unless we tell them the malignant nature of their affection? By
doing so, we make the rest of their existence miserable, and deprive them of
the desirable self-deception in which we can keep them for a long time if we
only temporize—iaa, tracheotomize. These are my present views, but it
is, of course, possible that new observations in coming years may lead me to
modify them.
Dr. PROSSER JAMES, London : The question of operation is to be con-
sidered in reference to—(a) the disease, (b) the patient. In malignant disease
it is clear that the earlier the operation be undertaken, the greater is the prospect
of success; in recurrent growths we should delay as long as possible. Although
some have advocated the operation in benign cases, I have not yet seen an
example in which I could bring myself to recommend it. Recurrence of growth
can be met by repetition of less serious procedures. As to the patients, much
depends upon their individuality. Up to the present the patients to whom I
could recommend the operation have either declined the risk or postponed the
decision until complications have arisen to forbid it.
Prof. LEFFERTS, New York: The one American case of extirpation of the
larynx has been alluded to several times to-day as the extreme example of the
bad moral effects that may follow the operation. The main reason for the patient’s
subsequent discomfort, not unusual however in like cases, was the impossibility
of closing the large defect in the neck, by any form of artiﬁcial apparatus, so as
to permit of perfect deglutition. The moral effects of this operation was not
as bad as has been represented; the patient lived cheerfully for some months,
naturally however discouraged by a result (in deglutition) which he had
hoped would be better. The other facts of the case are known to you. He
did not, let me say, commit suicide.
Dr. JOHNSON, Chicago: The patient just referred to was under my care.
I performed cricotomy. The canula gave him some discomfort, and he was
extremely anxious for a radical cure. I refused, after consultation, to perform
extirpation of the larynx. The operation, however, was performed elsewhere,
and I heard from members of his family that he was in a state of great despon—
dency, but I do not believe that he ever attempted suicide.
Dr. FoULIs, Glasgow : With regard to the class of cases of recurring papillo-
mata, it will be, of course, necessary to be quite sure that the recurrence is
complicated by sarcomatous elements; and therefore one would not think
of extirpation until signs of such complication made their appearance.
Dr. Semon’s remarks as to the relation of the desirability of any operation
are, of course, true, but in every operation these considerations occur to
the mind of the operator, and extirpation is no exception to the rule. In
each case I am accustomed to tell the patient the whole facts, and let him
decide. The American case, about which so much had been said, is, I think,
not in court, for the advanced state of the disease, and the great age of the
patient. make it a very unfair case on which to found an opinion in other and
more favourable cases.
DISEASES OF THE THROAT. 267
Dzlegalwﬁoéausz‘z'sc/ze Metkoa’e 2'12 N ase, Sc/zlzma’mm’ Kehlkopf
Prof. VOLTOLINI, Breslau.
Die von Middeldorpf in Breslau erfundene Galvanokaustik hatte Anfangs
no’ch nicht diejenige Verbreitung gefunden, die sie verdient; zum Theil ‘war
hieran Schuld die Construction der Batterie von Middeldorpf, welche mit den
stärksten Sauren gespritzt wurde. Ich kann wohl, ohne unbescheiden zu sein,
sagen, dass meine neue Batterie viel dazu beigetragen, dass die Galvanokaustik
nunmehr eine grössere Verbreitung gefunden und habe ich diese Batterie so
eingerichtet, dass sie auch zum InductionsStrome, zum constanten Strome, zur
Electrolyse und zum Electromagnetismus verwendet werden Rann.
Die Galvanokaustik habe ich in den genannten drei Höhlen nur in der Form
der galvanokaustischen Schlinge und des Galvanokauter in Anwendung gebracht,
sehr selten als Porzellanbrenner. Letzterer, resp. das Porzellan kühlt sich zu
langsam ab und man kommt deshalb in Gefahr beim Zurückziehen des Instru-
mentes nach dem Brennen die gesunden Theile zu verbrennen, wenn der Raum
nicht weit genug ist.
Die vielen unzweckm'alssigen Batterien und Instrumente, die bis etzt in der
Welt circuliren, verdanken ihren Ursprung lediglich den Mechanikern oder
Instrumentenmachern, ohne dass diese Sachverständige Aerzte bei der Construction
zu Rathe gezogen haben. Der Mechanikus allein hat aber keine Ahnung von
der zweckmassigen und richtigen Construction der Batterie und Instrumente,
wie sie der Arzt nöthig hat. Daher die plumpen Operations—Instrumente,
unpraktischen Batterien mit Galvanometer—eine unnütze Spielerei u. s. w.
Es ist ein grosser Irrthum, wenn man glaubt, dass die Galvanokaustik
an sich vor Blutungen schütze; im Gegentheil: man kann durch dieselbe
lebensgefahrliche Blutungen hervorrufen und es soll namentlich der Zweck
dieses Vortrages sein, zu zeigen, wie man mit Galvanokaustik operiren soll, um
Blutungen zu verhindern und die grossen Vortheile der Galvanokaustik
auszubeuten. In der Nase ist die Galvanokaustik bisher durch kein anderes
Mittel zu ersetzen, sowohl bei N asen-Polypen als bei Tumoren, Geschwüren, &c.
Bei Nasen-Polypen reicht die kalte Drahtschlinge durchaus nicht aus, sondern
man muss mit der Galvanokaustik auch den Boden zerstören, auf welchem die
Polypen sassen. WVenn die Polypen sehr massenhaft in der Nase vorhanden
sind, so erleichtert man sich die Operation sehr, wenn man zunachst nur brennt,
d. h. mit dem glühenden Kauter die Polypen zerstört. Ist die Nase weit, wie
das gewöhnlich der Fall ist bei solcher Massenhaftigkeit der Polypen, so kann
man auch den Porcellanbrenner in Anwendung bringen. Wartet man nach
diesem Brennen l—-—2 Tage, so sind die Polypen so morsch geworden, dass man
ganze Convolute mit der Schlinge mit Leichtigkeit hervorbringen kann und hat
mit keiner Blutung zu schaffen.
Bei grosser Schwellung der Nasenmuscheln, wie sie besonders an der untern
Muschel und vornehmlich an deren hinterem Ende vorkommt, giebt es kein ein-
facheres und sichereres Mittel, als das Bestreichen derselben mit dem glühenden
Galvanokauter. Bei dieser Operation aber, so wie bei der mancher Nasenrachen-
Tumoren (Fibrome) muss man nach bestimmten Grundsätzen verfahren, wenn
man nicht eine lebensgefahrliche Blutung hervorrufen will. Die Nichtbeachtung
dieser Regel hat Veranlassung gegeben, hier der Electrolyse "or der Galvano—
kaustik einen Vorzug einzuräumen; aber die Electrolyse ist viel langwieriger,
umständlicher, unbequemer für den Arzt und Patienten, da das Operations—
Instrument mindestens 10—15 Minuten im Rachen des Patienten still gehalten
werden muss; ausserdem erreicht man auch mit der Galvanokaustik in 5
Minuten mehr, als mit der Electrolyse in 5 Tagen. Man muss mit der Galvano-
268 DISEASES OF THE THROAT.
kaustik nach folgenden Regeln verfahren, wenn‘ man einen Tumor vor sich hat,
welchen man für sehr blutreich hält (was bei gewöhnlichen sogenannten.
Schleimpolypen nicht der Fall ist) :—
1) Man dringe niemals mit der Spitze des Kauter direkt in den Tumor
hinein, weil sonst ein Blutstrom hervorstürzen kann, welcher den Tod des
Patienten herbeizuführen vermag.
2) Man ‚bestreiche solche Tumoren also nur mit der ﬂachen Klinge des
glühenden Kauters und zwar in der ersten Sitzung nicht zu häuﬁg. Man bringe.
so zu sagen, durch dieses Bestreichen den Tumor erst zur Kochung, Gerinnung,
was nach der Bestreichung nach mehreren Tagen eintritt, alsdann kann man
dreister vorwärts gehen, d. h. aber nur mit der ﬂachen Klinge.
Aber auch selbst, wo man blos die Fläche der Klinge wirken lässt,
gebrauche man niemals zu starke Glühhitze, nicht Weissglühhitze, weil diese
auch bei der ﬂachen Klinge zu tief eindringt; deshalb wähle man bei frischer
Säure die Combination der Elemente, welche schwächeres Glühen erzeugt. Da
beim Betupfen der Kauter leicht an den Tumor anbackt und man beim
Zurückziehn des Instrumentes leicht Stücke des Tumor abreisst und dadurch
ebenfalls eine Blutung erzeugen kann, so vollfuhre man das Zurückziehn in
dem Momente, wo man das Instrument wieder verglühn lässt, es löst sich dann
vom Tumor leichter ab.
Bei Operationen im Kehlkopfe ist Galvanokaustik bis jetzt ebenfalls nicht
zu ersetzen. Ich spreche hier nicht von der Entfernung gewöhnlicher Polypen,
diese magjJeder nach seinem Geschmack, nach seiner Methode entfernen,
aber es giebt Gewächse, wo die Galvanokaustik nicht zu ersetzen ist. Diese
sind jene ﬂächenhaften l/Vucherungen über einen grossen Theil der Innen—
ﬂäche des Larynx; wer Aetzmittel anwenden will, kann den Patienten in
Gefahr bringen, weil diese zerﬂiessen und ihre Wirkung nicht begrenzt
werden kann. Ich bin nach Erfahrungen, die ich gemacht habe, auch der
Meinung, dass die Galvanokaustik allermeist auch die Dilatations-Instru—
mente (Bougie, Röhren) bei Stenose des Larynx entbehrlich machen kann, ja
ihnen weit vorzuziehn ist. Die Dilatations-Instrumente geben selten eine
volle Sicherheit, dass die Stenose nicht wieder eintritt—und dann manchmal
plötzlicher Tod. Man vergleiche hierüber die Abhandlung von Sceparowski.a6
Ausserdem wird durch die Bougies das noch Gesunde des Larynx schwer
geschädigt, wie ich jetzt eben einen solchen Fall in Behandlung habe und von
den Bougies zur Galvanokaustik übergegangen bin. Wenn eine Schwellung
von einer Seite des Kehlkopfes in das Lumen hineinragt und die andere Seite
noch relativ gesund ist, so giebt diese Schwellung dem Bougie oder der harten
Röhre immer beim Einführen eine Direction nach der gesunden Seite und diese
wird jedesmal mitgetroffen und schwer geschädigt, während bei dem
Galvanokauter ich eben nur die kranke Seite treffe und verkleinere. Mit dieser
brenne ich die Schwellung oder Schwiele, fort, bis diese Seite der andern gleich
ist, oder wenn die Schwiele sich auf beiden Seiten beﬁndet, so wurde hier zwar
die Bougie oder Röhre nicht jene vorhin angegebene Gefahr mit sich bringen,
die Galvanokaustik nimmt aber sicherer und dauernder die Schwellung hinfort,
und zwar geschieht dieses Alles ohne jede Blutung, während Scariﬁcationen
durch das herabﬂiessende Blut den ohnehin nach Luft ringenden Patienten
noch mehr belästigen.

Przeglad Ckarski, 1880, N o. 14-20, Centralblatt für Chirurgie, N o. 26 ; M onatsch'réfé
für Oln'cnheillczmda, &c., N0. 3, 1881.
DISEASES or THE THROAT. 269
GaZz/mwcausz‘z'c Mel/20d 1'12 1V05e, P/zm/ynx mm’ Lew/yin.
Dr. J. SOLIS-COHEN, Philadelphia.
While not using the galvano-cautery with anything like the frequence with
which it is employed by many of my covgj'reres, I have used it sutﬁciently to
test its comparative utility in the treatment of various affections of the nasal,
pharyngeal, and laryngeal cavities. My own resort to the galvano-cautery is.
almost entirely conﬁned to one or other of two purposes: ﬁrst, to destroy
tissue; and second, to produce an alterant effect upon the nutrition of deep—
seated tissues by superﬁcial cauterization of the overlying mucous membrane.
There is little doubt in my mind that the galvanic cautery is often unneces-
sarily employed to perform work which can be more easily accomplished—and
more satisfactorily, too, for that matter—by less severe means.
In the Nose—Complete or partial stenoses of the nasal passages, whether
due to hypertrophied mucous membrane, sub-mucous inﬁltrations, or morbid
growths of various kinds, furnish frequent occasion for the use of the galvano-
cautery. I-Iypertrophied tissue, when it cannot be subdued by the ordinary
application of astringents, or more or less systematic compression with tents of
compressed sponge or tubes of laminaria, or progressive dilatation with metallic
bougies, may sometimes be forced to undergo absorption by superﬁcial scoring
of the mucous integument. _
Even scoring deep enough to destroy linear portions of the mucous mem-
brane itself, though this effect is by no means necessary, will rarely be
productive of harm; because the cicatricial tension of the adjacent surfaces
will tend to draw the membrane more tightly upon subjacent tissue, and thus
keep up a salutary compression. Care is necessary in the execution of these
procedures to avoid touching sound tissues with the cautery itself, or even
with the wires, insulated though they may be, to which the platinum cautery
is attached. Disagreeable burns and permanent disﬁgurement may be the
penalty for neglect of this precaution.
While acknowledging the value of the galvanocaustic loop in the removal
of pedunculated neoplasms from the nasal passages, or even hypertrophied
masses of tissue that protrude into these cavities neoplasm-like, I am satisﬁed
that resort to it is unnecessary 3 and that with a little care, and a little more
time occupied in the operation itself, these masses may be removed with the
unheated wire with equal facility, with less pain, with much less hazard of
subsequent haemorrhage, and without the almost inevitable cauterization of
adjacent healthy tissue.
It too often happens that the incautious use of the galvano-cautery in the
nasal passage is followed by inﬂammation not only of the nasal tract itself, but
of the nasal duct and the conjunctival mucous membrane. Thence the inﬂam-
matory process may even extend to the eyelid, the cheek, and the face. Severe
erysipelas has likewise followed the manipulation, involving not only the
structures ust named, but even intercranial tissues. -
Inﬁltrations of the posterior surfaces of the vomer, so often occluding the
posterior nares, are sometimes removable by means of the galvano-cautery
more easily than by any other surgical procedure. The galvano-eautery blade
should be introduced by the nostril and passed along the septum until it
reaches the exuberant tissue, when, inoandescence being excited, it may be
pushed through this tissue into the pharynx, thus detaching a portion. Or the
ﬂat blade may be pressed upon the growth, so as to destroy it by actual cauteri-
zation. The position of the instrument should, wherever practicable, be
veriﬁed in the rhinoscopic image before the incandescence is excited. The
270 DISEASES OF THE THROAT.
manipulation described, though often difficult, is much easier of execution, and
far more accurate, than when the attempt is made to attack the growth by a
curved cautery introduced through the mouth.
In the Pharynm—The galvano-cautery has been used freely in some portions
of the United States at least, for the purpose of destroying hypertrophied
adenoid tissue at the vault of the pharynx. Having always been able to free
this region from this exuberant tissue by means of cupped-shape cutting forceps,
I have never had any occasion to resort to the cautery for the purpose. The
reaction, as I have heard, is sometimes equally severe with that encountered
in like operations within the nasal passages.
N aso-pharyngeal growths, especially ﬁbromas, appear to me to ﬁnd in the
galvano-caustic loop the safest and most satisfactory method of removal. The
advantage of the heated wire over the cold one in these operations is not only
the greater rapidity of the operation, and the consequent avoidance of inspira-
tion of the fetid exhalations of the decomposing masses during the period—-
often several days—which is required for the wire to cut through the base of
the growth; but the searing of the attached surface of the growth leads to a
destructive action, which is apt, in some instances, at least, if not in many, to
involve the entire remnant of the neoplasm, which is eventually discharged by
slough. When we recall the dangers of imminent death, in unfortunate cases
of naso-pharyngeal tumour of unknown extent, wrenched away with violent
tugs of the forceps, the galvano-cautery seems to point out a means of security
from such untoward complications.
In those cases of folliculous pharyngitis which seem to require absolute
destruction of the little masses of enlarged follicles, which have resisted or are
likely to resist all treatment less severe than their actual demolition, the
galvano-cautery certainly presents the most ready, effectual, and least annoying
method for accomplishing that result. At periods varying from three to ﬁve or
more days, successive cauterizations of from two to ﬁve of these little masses
can be made without producing pain of any consequence at the moment, or
sufficient discomfort of any kind to interfere with the immediate resumption of
ordinary employment. The cauterized masses will slough out in the course of
a few days, and as this process continues with each successive batch of them,
a few weeks will suffice to effect permanent riddance of the source of long-
protracted suffering.
Slight clefts of the palate may sometimes be united by cauterization of the
angle of the cleft. As soon as the adhesion is ﬁrm, cauterization of the edges
immediately below is effected in the same manner. When this adhesion becomes
ﬁrm, another cauterization is made immediately below it, and these processes are
continued until the parts become adherent along the entire line.
Perforations of the palate can sometimes be closed up in a similar manner
by superﬁcial cauterization with the galvano-cautery.
Hypertrophied tonsils may either be excised with the loop or burned down
with the surface cautery. When time is not an object and the patient can
remain a number of weeks under treatment, the latter operation is, in my
opinion, much to be preferred.
The difficulty of securing a wire loop around the ,tonsil, and of protecting
the tongue, lips, and angle of mouth from cauterization, either by the heated
wire or even the heat of the insulated portion of the electrode, and the absolute
necessity of at least one assistant in order to perform the operation effectively,
often render the procedure an awkward one, and unsatisfactory as a surgical
manoeuvre. The cauterization of the surface, on the other hand, is compara-
tively easy, and can be readily performed without the presence of an assistant.
The broad surface of a ﬂattened wire can be pressed over successive POI":-
DISEASES OF THE THROAT. 27 I
tions of the surface of the tonsil at each interview, and the process be repeated
until the organs are burned down to the most suitable shape and dimensions.
Enlarged glands at the base of the tongue sometimes require destruction, for
which purpose the galvano-cautery point may be used; but great care is
requisite to avoid cauterizing the undiseased tissue of the tongue on one side
and the epiglottis on the other.
Retro-pharyngeal tumours, if not extending into the cervical region, may be
removed by the galvano-cautery, after due exposure of the morbid mass, by
means of an incision through the overlying mucous membrane and other
investments.
Extensive tumours in the palate, or in the palate and pharynx, when the
pharyngeal attachments are apparently circumscribed, may be removed with
the galvanocaustic knife without risk of haemorrhage, such as interferes so
seriously with due performance of the operation by cutting instruments. The
secondary haemorrhage, however, is apt to be greater and more imminent, and
the presence of the sloughing tissues renders it difﬁcult to keep the patient’s
health from undergoing deterioration during the after-treatment.
Pharyngeal stenoses, due to adhesions between the palate and the pharynx,
often tempt the use of the galvano-cautery: but the difficulty of keeping the
parts from apposition usually prevents success from following it.
In the Larg/nm—Small neoplasms which evade removal with forceps may
sometimes be advantageously cauteri’zed with the galvano-cautery. Web-like
cicatrices, such as follow section of the larynx from the exterior, are more readily
severed by the galvano-cautery than by any other means; but it behoves the
manipulator to be sure of his hand, his instrument, and his patient. Other-
wise, in the spasmodic action which almost inevitably ensues before the part
has been sufficiently burned, he will be sure to do injury to sound tissue.
Laryngeal stenoses of cicatricial origin are more likely to yield to galvano-
caustic treatment than to incisions, although the tendency to re-cicatrization is
often so great as to render the treatment practically useless.
In performing these operations it is best‘ to do but little at a time, and to
interpose frequent dilatation so as to prevent re-cicatrization as far as possible.
Conclusions.-~1.--The galvano-cautery is often used unnecessarily.
2.—'I‘he galvano-cautery is often inferior to the cold wire in the treatment
of intra—nasal neoplasms and neoplasmic-like hypertrophic protrusions of normal
tissue.
3.-—The galvano-cautery is valuable both as escharotic and alterant in
hypertrophied nasal mucous membrane impeding respiration.
4.——The galvano—cautery is unnecessary in the treatment of hypertrophied
adenoid tissue at the vault of the pharynx.
5.—The galvanocaustic loop presents one of the safest and most satisfac-
tory appliances for the removal of naso-pharyngeal growths and of pharyngeal
tumours, for the destruction of masses of hypertrophied follicles in chronic
folliculous pharyngitis, and for the destruction of enlarged follicles at the base
of the tongue, and in adjacent localities. .
6.-—Hypertrophied tonsils may be readily burned down with the surface
cautery; the inconveniences attending excision with the wire loop render the
method inferior to ordinary excision with cutting instruments.
7 .——Extensive tumours involving the palate, or the palate and the
pharynx, are often subject to satisfactory removal with the galvano-caustic knife.
8.—-The galvano-cautery is inadequate to the satisfactory treatment of
pharyngeal stenosis.
9.——Small laryngeal neoplasms, readily reached, may be destroyed with
the galvanocaustic point.
2 7 2 DISEASES OF THE THROAT.
10.--VVeb-like cicatrices between adjacent structures are best destroyed by
the galvano caustic knife, and with less certainty of subsequent re-adhesion.
]1.—In the employment of the galvano-cautery great care is requisite to
avoid cauterization of healthy tissue adjoining the diseased structures.
La War/Mode ga/vaﬂocausz‘z'gue dans le 7262‘ [e p/zarynx ea‘ [c
larynx.
Professor CADIER, Paris.
Depuis que la découverte de la pile sécondaire de Planté a permis de graduer
d’une façon mathématique l’élévation de température des ﬁls de platine du
galvano-cautère, j’ai fait de nombreuses applications de cet instrument pour le
traitement de différentes affections de l’appareil vocal. J e me propose de lire
au Congrès de Londres le résumé de mes observations à. ce sujet. L’analyse de
ces observations nous permet de tirer les conclusions suivantes, que e vous
adresse comme résumé de ma communication.
Conclusions—L—Dans la période tertiaire de la laryngite syphilitique, lors—
qu’elle est caractérisée par des végétations papillaires polypiformes assez nom—
breuses, j’ai vu employer et j’avais recours autrefois à. l’arrachement avec la pince,
suivi d’une application de caustique (nitrate d’argent ou acide chromique) ; mais,
malgré cette médication, les végétations répullulaient rapidement. En présence
de l’insuccès de cette médication, ’ai employé la cautérisation avec le galvano—
cautère, mais en ayant soin de ne porter le ﬁl de platine qu’a la température du
rouge sombre. Par ce moyen j’ai obtenu le double avantage d’arrêter immé—
diatement l’hémorrhagie occasionnée par l’arrachement a la pince, et de détruire
en même temps les végétations trop peu saillantes pour être saisies avec la
pince. Sous l’inﬂuence de ce traitement j’ai pu obtenir dans trois jours une
guérison assez rapide de ces végétations. L’une de ces trois observations a été
publiée et lue a la Société de Médecine.
2.——Dans l’hypertrophie chronique des amygdales, au lieu d’avoir recours à.
l’ablation avec l’amygdalotome, qui peut quelquefois provoquer des accidents
graves, j‘emploie une igni-puncture galvano-électrique, en ayant soin d’enfoncer
ma pointe de platine de 4 a 7 millimètres environ dans le tissu de l’amygdale, et de
porter cette pointe à. la température du rouge blanc. En pratiquant à. chaque
séance 4- a 6 pointes d’igni-puncture, il suffit le plus souvent, dans les cas ordinaires
de deux ou trois séances pour arriver à diminuer considérablement le volume
de l’amygdale hypertrophiée. Cette opération n’est pas douloureuse ; j‘y ai eu
recours dans quatorze cas chez des enfants de huit à. quinze ans. Dans dix cas
j’ai obtenu un succès complet, et dans quatre cas il n’y a eu qu’une résolution
partielle de l’amygdale.
3.——Dans les granulations volumineuses du pharynx, souvent les caustiques
ordinaires ne donnent aucun résultat bien appréciable, j’ai alors recours a des
cautérisations localisées avec la pointe d’un galvano-cautère. Ces granulations
sont ainsi détruites instantanément, et en ayant soin de ne toucher qu’avec
légèreté la partie la plus centrale de la granulation, on peut répéter un assez
grand nombre de fois cette opération, sans craindre de déterminer une inﬂam—
mation trop nrûre. A la suite de cette cautérisation, il se produit une petite
ulc'ération qui se guérit rapidement pendant que la totalité de la glande paraît
s’atrophier. Sept ou huit jours après cette cautérisation, on n’aperçoit plus
qu’une petite cicatrice blanchâtre, et la granulation a entièrement disparu.
4.—Dans les polypes du nez, lorqu’ils ne sont pas trop volumineux ni
trop profonds, je les enlève, avec l’anse galvano-caustique qui présente l’avantage
DIsEAsEs OF THE THROAT. 273
d’éviter les hémorrhagies. Pour introduire cette anse j’ai fait construire a
Aubry une pince spéciale queje me propose de présenter au Congr‘es. Lorsqu’il
m’est impossible d’introduire l’anse galvanique je pratique l’arrachement avec
la pince, mais en ayant soin de pratiquer ensuite une cautérisation galvano-
électrique qui arréte l’hémorrhagie et enleve les polypes d’une facon beaucoup
plus complete et de plus présente le grand avantage de rendre les récidives
beaucoup moins fréquentes.
Galvmzomusz‘z'e Met/10a’ in N are, P/zm/yhx, mm’ Lay/31122:.
Mr. LENNOX BROWNE, London.
The large number of contributions offered on this subject is sufﬁcient
evidence that the galvanocaustic treatment is largely employed, and the
general tone of the abstracts shows also that its value is pretty generally
recognized. Except on one point—that of its application to the larynx,
trachea, and msophagus—differences are essentially those of individual
experience, but it is just on these little matters of detail that success in
my opinion depends. Having regard to the large amount of work still
before the section, I have reduced my paper to the smallest limits, and will
content myself with stating, in the briefest terms, the conclusions to which I
have come. I am entirely with Dr. Solis Cohen that the galvano-cautery is
inferior to the cold wire in the treatment of intra—nasal polypi and other
neoplasms, though I have only come to this conclusion within the last year, for
it is certain that the cold wire can be adapted more accurately to the base of a
polypus, and the pedicle removed more completely by a cold wire snare, evul-
sion being slowly performed, not suddenly or with a jerk, than is the case with
the galvanocaustic loop. 1f the latter be employed, connection should not be
made until the growth is nearly out through, otherwise strangulation will be
imperfect, only partial removal will be effected, and a greater risk of htemor-
rhage will occur. For this plan of treatment it is also necessary to have some
kind of hook to draw down the polypi, such as Dr. Thudichum has today
described. It is to be regretted that this author has not ﬁgured and detailed
these instruments, to which he justly attaches importance, in his various com-
munications to the public on the merits of his operation. For the treat-
ment of non-pedunculated or false growths due to hypertrophy of the normal
tissue I give preference to the cautery, on this point differing from Dr.
Cohen, as I do in reference to its use for destruction of hypertrophied
adenoid tissue at the vault of the pharynx, for which condition I prefer the
cautery as less painful, more thorough, and less likely to lead to haemorrhage
than either forceps or curette. In these cases I do not employ a loop, but
a porcelain point, and apply the cautery with considerable friction against
the surface to be reduced. We are all agreed, I think, as to its value as
an escharotic and alterant in all conditions of ulceration of the nasal mucous
membrane, as well as in those in which the secretion is altered, and in my
experience I have found the method equally valuable in those cases in
which the secretion was excessive and limpid as in those in which it was
inspissated and retained, probably because the latter is but an advanced
stage of the same pathological condition. In all such conditions I agree with
Professor Voltolini that the galvano caustic is the method par excellence.
Professor Voltolini has spoken of the great importance of the thorough
excellence, and efficiency of a battery, and this is a point on which too much
stress cannot be laid. In my battery I have always employed a foot con-
PART III. T
274. DISEASES OF THE THROAT.
nection, so as to leave the hand at liberty, and at the same time to keep
so important a matter within my own control. The foot-piece I formerly
employed was in the course of one of the cords, and often acted imperfectly
on account of the unnecessary amount of resisting force caused by the
distance of the connection from the plates. I now employ a direct connec-
tion, much more effective and equally simple. Another point is to have the
instruments as delicate as possible, and the cords pliable. In these matters I
think I have succeeded in obtaining something like perfection; and I have to
thank Mr. Ooxeter for the great pains he has taken to act on my instructions in
these respects. Of the form of battery, I certainly prefer, on account of
convenience and economy, the Bichromate. Professor Voltolini has spoken of
the question of haemorrhage, and by the abstract, I see that he considers “the
belief that the galvanocaustic method, per se, prevents haemorrhage is erro-
neous.” I think that, provided the cautery power be properly regulated, there is
no fear of haemorrhage, and the only way to ensure regularity is to employ a
rheostat to measure exactly the heat of the wire. All danger of haemorrhage
arises from having the wire too hot—a black heat often answers for all that is
required; a dull red heat is seldom needed, and by me never exceeded; abright
red heat is quite unnecessary, and anything like white heat absolutely to be
avoided as dangerous. Another caution, not noticed by any of the contributors
to this subject, but one of considerable importance, is that purulent median
otitis is sometimes set up as a result of galvano-cautery in diseases of the nose.
The following are the measures I observe for prevention of this complication:
(1) To have as little heat as is absolutely necessary; (2) To use ivory nasal ,
specula, which form non-conductors; (3) To syringe thelnostrils with a rather
strong solution of carbonate of soda directly after application of the cautery, and
then to apply oil on wool to the nostrils so as to keep the air from the charred
surface; and (4) To apply, in case pain is complained of, to the ears some warm
atropine drops. In case of continuance of this pain, the ears should be examined
and watched carefully, and a puncture of the membrane be made without delay
if fluid be seen in the tympanum. This accident of extension of inﬂammation
has three times occurred to me, and in two it has been necessary to perforate the
membrane. In all, however, no permanent injury has resulted. It is mentioned
because no good is done to any operation by ignoring risks against which, being
forewarned, the surgeon may be forearmed. N ot to make this paper tedious, I
would say that I agree with all that has been said as to the value of the galvano—
cautery in ulcerations in the pharynx and palate; but while I would never
employ it for enlarged tonsils, as an unnecessarily tedious and painful substitute
for excision by guillotine, it is of great value, as pointed out by Dr. Cohen, for
destruction of diseased follicles in unenlarged or atrophied tonsils, and I employ
it in cases of enlarged papillae of the tongue and enlarged veins. In the latter
condition, especially whether of pharynx, base of tongue, or epiglottis, it is
invaluable, and in my opinion superior to every other method. For convenience
and efficiency, it certainly surpasses electrolysis, of which I have but a limited
experience. Its great claim over the actual cautery is that the instrument can be
introduced and withdrawn cold. The same advantage holds good over the Paquelin
or other form of thermo-cautery. Moreover, the after-pain of galvano-cautery is,
in my experience, much less than either of these methods, certainly much less
than in the case of acid nitrate of mercury, or nitrate of silver, in which there
is diffusion of the caustic and unnecessary irritation of healthy surrounding
tissue. I have employed galvano-cautery in one case of pharyngeal tubercu—
losis with beneﬁt, and in one case of lingual tuberculosis with negative result.
I have often used it in malignant disease of the epiglottis, and in one case of
lupus, but have never yet ventured to apply it lower in the larynx, nor beyond
DISEASES OF THE THROAT. 275
the upper limit of the superior constrictor of the pharynx. I have not yet
employed it, nor am I inclined to recommend it for tracheotomy. In conclusion,
while without galvano-cautery in diseases of the nose, pharynx, mouth, and
tongue, I should feel deprived of, at least, one—half my power to help the con-
ditions for which I use it, I have a strong conviction that were I to employ it
in such regions as the larynx below the epiglottis, or to the pharynx below the
same level, or the oesophagus, I should introduce into my practice a new and
a grave element of danger.
T he Aez‘ual Cemiery in Certain Forms 0fPka1/y1egea! Disease.
Dr. FoULIs, Glasgow.
In 187 7 9* I published the results of my experience of the use of the
actual cautery in chronic thickening of the pharynx in thirty-ﬁve cases.
I now bring before you the further experience gained in treating over two
hundred cases by this means. This method of treatment was suggested
to me by the paper on the galvanocaustic treatment, introduced by Carl
Michel, in 1873. Following his example, I was soon convinced that the
(cautery cures the troublesome symptoms of this affection more surely, and with
less inconvenience to patient or operator, than any of the other methods in use.
‘The galvano—cautery, however, is an expensive instrument, and it is apt to get
out of order. This led me to seek for a simpler means of cauterizing the
pharynx than is afforded by the battery; and I naturally turned to the plain
actual cautery. A few trials made it apparent that patients did not seriously
object to its use, even when it was heated before them in the ﬁre. To obviate,
however, any occasional alarm from this cause I resorted to the use of a small
gas-heater, which is now before you. The heater’r costs from 45. (id. to 88. 6d.
The cautery is a piece of thick wire, fourteen inches long, with a pear-shaped
Tloulb at one end, and any blacksmith can make it for a shilling or two. Placed
*in the noiseless heater, which is concealed by a small box or screen from the
patient’s view, the cautery may be got ready in less than one minute. The
cautery bulb is used at a dull red heat. The patient’s tongue being depressed
by a spatula, the cautery is passed straight into his mouth in a line from the
right ear of the operator, steadily held for two seconds against the spot of the
pharynx selected for its application, and then withdrawn in the same line in
\which it entered. If the cautery is hurriedly used, or if it is entered or with-
drawn ob1iquely, it is apt to touch other parts of the mouth or the lips, and then
it gives pain; but if deliberately used only to the thickened nodules on the
pharynx or tonsils, the pain caused by it is triﬂing and transitory. During the
following day there is always a- period of swelling and uneasiness, but this
rarely lasts beyond twenty-four hours; and it may be greatly relieved by the
use of marshmallow lozenges, or by the simple expedient of swallowing a small
piece of fresh butter. The eschar separates in a few days without further pain,
and the cautery may be used, therefore, once a week. N 0 other treatment is
necessary during its use in most cases; but, of course, it need not interfere
with other treatment, nor need the patient depart in any way from his usual
course of life. I am satisﬁed with the efficiency of this mode of treating cases

'* Brit. Med. Journal, Sept. 22, 1877 ; and Glasgow Med. Journal, Oct. 1877.
1" Made by Fletcher, of Warrington.
T 2
276 DISEASES or THE THROAT.
of nodular and granular thickening of the pharynx and tonsils. Enlarged
tonsils, which are not suitable for removal by the knife or guillotine, may be
reduced completely by successive applications of the actual cautery. Patients
have assured me that they wouldwvillingly bear the slight pain of the burning
ten times over in order to get rid of the annoying symptoms of the disease; and
experience shows that after the unhealthy tissue of enlarged tonsils has been
removed by the cautery, the tendency to recurring acute attacks of tonsillitis
is almost, if indeed not quite, abolished. In using the cautery, the points
to be remembered are :-—( 1) To select carefully beforehand the individual
places to be touched. (2) Not to apply it indiscriminately, or to more than
two, or at most three, places at one sitting. (3) To avoid haste, and not to
touch the lips or tongue. As compared with the galvano-cautery, it is cheaper;
it is more handy ; it is more rapidly got ready ; and it can practically never get
out of order. It presents advantages also over the London paste, recommended
by Morell Mackenzie. From comparative trials it has been found less painful
than the paste; it is entirely free from the distressing hawking of abundantly
secreted mucus, which follows on the use of the paste; and, in fact, I have
never seen any patient require to expectorate or to gargle after the cautery was
applied. The eschar, after the cautery, is dry, distinct, and limited to the spot
selected. Gratifying results are sure to follow its use in the proper cases, and
I have brought this instrument before you in the wish to gain for it a wider
trial in your hands.
0% Z/ze Use of Z/ze Ga/va'ieoeausz‘z'e Method in Nose and
Pﬁm/yezx.
Dr. V. LANGE, Copenhagen.
Galvanocaustic method is to be regarded free from danger in diseases of
the nose and pharynx.
(a) Diseases of Nose.
1. As a rule unnecessary in operation for pedunculated nasal polypi, the
cold wire being sufficient in almost all cases; on the other hand, useful and
preferable to all other caustic methods in after-treatment—z'.e., the destruction of
the remnants of polypi.
2. Best plan for treatment of hypertrophies of the mucous membrane and
polypoidal excrescences.
3. Often indispensable in lupus of the nose, especially where sharp spoon
or Scariﬁcation is impracticable on account of a certain inﬁltration of the soft
parts.
4. May be useful in punctiform haemorrhages of the nose, but is quite
inadequate in profuse haemorrhages.
(5.) Diseases of the Pharynx.
1. As a rule unnecessary in hypertrophy of the tonsils.
2 and 3. Best plan in granulations and swollen mucous folds.
4. Not to be regarded as the chief remedy in adenoid vegetations.
DISCUSSION.
Dr. LoWENBERe, Paris: I attribute the general excellent action of galvano-
cautery to the antiseptic action of the high temperature, 130'0° 0., a germ-
killing means not to be equalled by any other one. The nose is a receptacle
for bacteria, drawn in by inspiration. The galvano-cautery destroys them, and
the eschar (scab) covers and protects the burned place from infection. As to
haemorrhage, I believe the action of red-hot platinum prevents bleeding; white-
DISEASES OF THE THROAT. 277
hot causes it by destroying the walls of the vessels as well as the clots, thus
preventing stasis of blood. I use as a battery Planté’s e'le'menz‘s secondaz'res.
Nose: I have invented a nasal galvano-cautery, only burning laterally, thus
avoiding cauterization of the septum, and allowing of the localization of the
galvano-cautery to the sides of the nose. I have just published a paper on the
treatment of chronic coryza,* where I extol the galvano-cautery as the treat-
ment for the nose the same as in mucous polypi. It is excellent, too,
for tonsils, where these new instruments protect palate and pharynx. The
best treatment for mucous polypi is the cold snare and the subsequent use of
the galvano-cautery. I prefer snaring to Voltolini’s beginning by burning clans
Ze tas. I protest against the idea that the galvano-cautery can provoke
dangerous inﬂammations. I have never seen any, and I believe this is due to
the antiseptic action I described above.—Pharynx: Excellent, under certain
precautions, to be given to-morrow in my paper on “Adenoid Vegetations.” I
think, in opposition to Dr. Solis Cohen, that galvano-cautery is indispensable
for lateral adenoid growths. I do not approve of Dr. Foulis’s system of using
actual cautery in the throat. The advantage of galvano-cautery is that it can
be applied cold, so as to act only when in contact with the part desired to be
destroyed.
Dr. THUDICHUM, London, described his method of dealing with all the
different forms of tumours, hypertrophic changes, polypoid degenerations,
exostoses, &c., found—sometimes associated with one another—in the nose.
He also gave a description of the instruments he had invented for this purpose.
Dr. BOSWORTH, New York: The highly-tempered steel-wire snare aﬁords a
means of removing pharyngeal ﬁbromata. For the treatment of enlarged
follicles in the pharynx, a strong wire, heated in a spirit lamp, is better than
either galvano-cautery or the formidable cautery irons of Dr. Foulis. With
reference to Dr. Thudichum’s remark, that the hypertrophy of the lower tur—
binated bones, anteriorly and posteriorly, had not been described, I wish to
call attention to a full description of this feature of nasal catarrh in my recent
book on “The Throat and Nose.” As regards Dr. Thudichum’s transﬁxion
needle, I have long used it in connection with the snare.
Dr. RUFUS LINCOLN, New York: I fully indorse Dr. Solis Cohen’s views;
but regret that he has not described the method more in detail. I recommend
that after the removal of pedunculated nasal polypi, either by the galvano-
caustic method or by the cold wire, the stump should, at any rate, be repeatedly
touched by the galvano-cautery until it is completely destroyed; this will
effectually prevent recurrence. As a proof of this statement, I should like to
refer to two most desperate cases of this sort which I showed two years
ago to the American Laryngological Association. They had been operated
upon before repeatedly, inasmuch as recurrence had taken place several times;
but, by observing the plan recommended above, I ﬁnally succeeded in effecting
lasting cures.
Dr. W. MEYER, Copenhagen: The thermo-cautery, which has not been
mentioned, is certainly very useful for removing granulations from the pos-
terior wall of the pharynx.
Professor VoLToLmI brieﬂy replied.

* Union Médz'cale.
278 DISEASES or THE THROAT.
Adenoid V qg‘ez‘az‘z'om in #26 V aulzf of Me Pkarymait
Dr. W. MEYER, Copenhagen.
The considerable and increasing interest which adenoid vegetations in the
vault of the pharynx have elicited during the comparatively short time since
their discovery, appears by no means to be due only to their connection with
affections of the ear. Three circumstances seem in this respect to have been
of greater importance: First, the frequency of their occurrence: whenever,
both in Europe and elsewhere, they have been sought for, they have been
found. Next, the fact that well—marked cases, once known, are so very
easily recognisable: you meet them in saloons, in public conveyances, nay,
even in the remembrances of your childhood. Last, not least, deserves to-
be mentioned the facility with which, again, in well-marked cases, vegeta—
tions may be removed, and the striking immediate effect, which in such cases
even a partial removal may exert upon the symptoms, These circumstances,
no doubt, account for the great interest taken by specialists in these operations,
for the innumerable methods and instruments devised, as well as for the
literature to which these operations have given rise.
Before proceeding to the pathological part of this introduction, which because
of the shortness of time compared with the vastness of the scheme, will claim
your forbearance for being treated in an aphoristical way, I beg permission
for a remark about the name of the growths in question. 'I should say that the
affection, being a thoroughly international one, deserves likewise a name
which is the same in all languages. About the adjective there can hardly be
any doubt, the microscopical structure being eminently characteristic; as to
the substantive the name of “ vegetations” may be found preferable to the others
proposed in this respect: that it admits of no proper translation into any of
the modern languages. I, therefore, propose to this Section to ﬁx upon the
name of “adenoid vegetations ” for the growths we are to treat upon.
As to their anatomy, so well known by you, a few remarks will suﬁ'ice.
Of their two prevalent forms, the cristate and the cylindrical, the ﬁrst
frequently, the second are never to be considered as representing a hyper-
plastic state of physiological prominences. The place of election of the
cristate vegetations is the posterior wall of the pharynx, especially its upper
curved part, the cylindrical ones mostly occupying the lateral walls. Another
practical distinction of even more importance is their difference of consistence.
They may be soft, brittle, or hard and tough—in the latter cases they are
mostly covered with a thick mucous lining. In spite of these differences they
are all composed of the same adenoid tissue, which lines the greater part of the
vault of the pharynx, and from which they only differ in their greater
vascularity and, as far as my experience goes, in their showing a certain.
erectility. The mucous secretion from the adenoid vegetation is commonly
abundant, and the tissue around them is always in a state of chronic catarrh.
Also the neighbouring organs lined with mucous membranes are mostly found
in an abnormal state ; thus the middle ear, the turbinated bones, the soft palate,
the tonsils, and the oral part of the pharynx. The latter is often affected with
granular inﬂammation. Now, if these vegetations entirely ﬁll up the vault of '
the pharynx--~which rarely occurs, or if they are less in number, but partly
situated in a manner to ﬁll up the split between the edge of the soft palate and
the opposite posterior wall of the pharynx, it is obvious that in both cases the
passage of air through this cavity must be intercepted from both sides. This-
obstruction will give rise to a series of characteristic symptoms, amongst which.

at ‘Nith a plate showing the instruments described in the paper.
DISEASES OF THE THROAT. I‘ 27 9
the expression of the face, and what I propose to call the “ dead” pronunciation
are the most prominent. The characteristic face shows itself by the mouth
being constantly kept open, and the nose, by its long inactivity becoming
collapsed, pinched, further by a vacant expression of the features and a dim
look of the eyes, the orbicular muscle of the mouth no longer giving support
to the other facial muscles. The “ dead” speech is composed of two consti—
tuents: firstly, the impossibility of pronouncing the nasal sounds m, n and azg;
secondly, by the loss of resonance in the anterior and posterior nares. Another
series of symptoms is owing to the vascularity of, and copious secretion from,
the vegetations as well as to the catarrh of the environing mucous membrane.
To this series belongs the occurrence of blood in the mouth after awaking from
sleep, an habitual headache, and 'the complicating affection of the ear. The
latter forms a frequent concomitant of the growths in question, and may be
transient or lasting, varying in degree from a slight want of acuteness in
hearing after taking cold, to a chronic dry catarrh in the tympanum, chronic
discharge from the ears and insupportable noises. It will easily be understood
that vegetations grouped around the apertures of the Eustachian tubes are
particularly apt to produce complications in the shape of affections of the ear.
In well-marked and uncomplicated cases, the symptoms'by themselves will
commonly suffice for establishing a correct diagnosis. But complications being
frequent, and the. characteristic symptoms sometimes wanting in cases (for
instance, affections of the ear) where it may be desirable to know whether
vegetations are present, physical means of diagnosis must be had recourse to.
Three ways of investigation are here available—via, posterior and anterior
rhinoscopy and digital examination. If possible, all of them ought to be
employed combined; for it must be remembered that in this affection, as in
all others, a thorough diagnosis of the case is indispensable for securing a suc-
cessful treatment. If only one method can be employed, digital examination
is preferable. The practised ﬁnger used gently will, without giving real pain,
reveal with sufficient clearness the number, situation, size, shape, consistence,
and vascularity of the growths. Moreover, digital examination is applicable
under all circumstances; Yet, it-is but fair to state that the application of
either of the two other methods, particularly of posterior rhinoscopy in certain‘
cases, is indispensable, and that-results of a high diagnostical and therapeutical
value may be obtained by them, which digital examination is unable to
ield.
y It may not be superﬂuous to add that if, in spite of physical diagnosis, any
doubt should occur as to the nature and character of the growths found, the
microscope is the only infallible means to solve it.
Regarding the etiology, we know that youth is the most important of
the predisposing causes. Of 295 patients of which I have taken accurate
notes, only twenty-three were above twenty—five years, whereas 165 were
below ﬁfteen. According to my experience, the affection is more frequent
with boys than with girls. Some children appear to be born with vegetations.
Another predisposing cause is family disposition. I have eleven times found
two, seven times three, once four children of the same family affected; and in
not a few cases one or both parents were, or had been, suffering in a similar
way. As to scrofula its inﬂuence is doubtful: recent observations of Dr.
Wiesener, of Bergen (Norway), seem to show that (by emigration of lymphatic
cells) adenoid vegetations do not unfrequently give rise to so-called scrofulous
inﬁltration of lymphatic glands. Adenoid vegetations are met with in all
classes of. society, from the lowest to the highest, as well as in all climates, in
which they have been sought for. Amongst the ﬁrst patients who presented
themselves to a medical friend of mine, after his arrival at Bangkok, in the
280 DISEASES OF THE THROAT.
Tropics, were two sisters, with numerous adenoid vegetations, and whose
mother had suffered from the same complaint. From Chicago and New
York I possess information about their rather frequent occurrence; and in
different parts of Europe medical authorities agree more and more as to their
frequency. A damp and cool climate, however, appears especially to favour
their development. This we may conclude from some statistics which we
possess about the frequency of vegetations amongst school-children. Amongst
about 700 children in public schools in Florence, my brother, Dr. Adolph
Meyer, found not quite 1 per cent. with the characteristic faces and “ dead”
pronunciation; I arrived at nearly the same result by examining a similar number
of school-children at Stockholm. At Copenhagen I found 1 per cent. of 2,000
children'suffering in this way. In England (Haverstock Hill Orphan School)
I met with 2 per cent ; while my friend, Professor Doyer, among 4,000 school-
children at Leyden, found 5 per cent. with characteristic faces and pronunciation.
Considering, then, the universal frequency and the damage done by the
vegetations, not only to the appearance but to one of our highest senses, it
appears most desirable that not only specialists, but medical men in general,
should pay particular attention both to their diagnosis and treatment.
Of occasional causes, we know colds, measles, and local irritation. Measles
appear to produce, colds to develop them; and, as to the inﬂuence of local irri-
tation, it may be adduced what already has been stated in the Lancet, of 1869,
by the English dentists, Coles and Smith, that people with cleft palate are par-
ticularly liable to hyperplasia of the adenoid tissue in the vault of the pharynx;
which statement I fully conﬁrm, in accordance with my experience, with
the addition that the larger the cleft, the more numerous and the larger will
the vegetations be.
Regarding the prognosis, we shall have to consider both the prognosis of
the vegetations themselves and that of the concomitant affection. It is an
acknowledged fact that vegetations left to themselves will shrink and disappear
in mature age. Consequently they might be left alone if they did no mischief
before their disappearance. This, however, they are very apt to do. _It has
been observed that by way of inﬂammation they may occasion retro-pharyngeal
abscesses (Wiesener); they may further give rise to glandular swellings and
inﬂammations; but by far the greatest and most frequent damage is that done
to the ear and to the hearing. Therefore, when vegetations are known to be
present, they should be removed.
And I can conscientiously assert that. this may be done with perfect safety
in any case‘. Unless organic complications be present, the Symptoms will dis-
appear with the growths that had given rise to them, and will never return if
the treatment has been a thorough one. I have recently had the opportunity of
examining several cases upon which I had operated many years ago, and I
have found the vault absolutely free from growths, and no symptoms. Nay,
even the most important of complications, the affections of the car, will, in a
surprisingly great number, be beneﬁted by the removal, disappear, or become
more tractable. Of 198 patients whom I treated for defective hearing in com—
bination with adenoid vegetations, upwards of 42 per cent. regained their full
power of hearing.
Some remarks may here be added about the prognosis of measles and scarlet
fever, as influenced by the presence of vegetations. Experience has shown that
a comparatively great number of patients whose ears are affected in consequence
of these eruptive fevers, present adenoid vegetations in the vault of the pharynx;
and it is obvious that vascular growths, with abundant secretions in proximity
of the middle ear cannot but influence these organs if the surrounding mucous
membranes are inﬂamed.


DISEASES or THE THROAT. 281
From a satisfactory treatment of adenoid vegetations, we will have to
exact :-—- ‘
1.----That it should remove all the growths.
2.—-That it should prevent their recurrence.
3.——That it should do away with the concomitant catarrh in the vault of the
pharynx.
Several methods may serve this end.
If the vegetations are soft, few, and small, I have several times seen them
‘disappear after long-continued injections of medicated ﬂuids through the nose.
For these injections I recommend, as Weber’s douche is not without danger, a
slender metal tube, whose closed extremity is perforated by two splits, forming
a + , and which is attached to a valve syringe.
If they are soft, but more copious, cauterization with solid nitrate of silver,
mixed with two parts of saltpetre, will be found useful. A metal stem, the
slender and curved end of which is covered with platinum, appears to be a
convenient instrument for this purpose. Cauterization should be continued
about once a week, until all vegetations have disappeared. As long as any,
even slight, bleeding is caused by the application of the caustic, cauterization
should not be discontinued. Injections of salt water wash away the superﬂuous
caustic, and similar injections should be continued long after the cauterization,
the catarrh of the vault of the pharynx being always obstinate.
A third method of destroying soft vegetations is that of bruising them with
the pulp of the exploring ﬁnger, and scraping them off with the nail. To ensure
a lasting result, this crushing should be followed by the above cauterizations
and injections.
WVhenever the vegetations are hard or covered with a tough lining, an
operative procedure with cutting instruments is indicated, unless galvano-
cauterization be employed. Many methods of operations have been devised
within the last seven years, and the published results prove that adenoid
vegetations may be successfully treated in several ways—at least, as to the
immediate result. In order to judge the ﬁnal result, I will state that a year
must have elapsed after the termination of the treatment. Not having had
occasion myself to use any other methods than my own, except galvano-
cauterization, I am not qualiﬁed to judge them. The only remark concerning
them which I shall venture is this, that any method, in the performance of
which the cutting instrument is guided neither by the ﬁnger nor the eye, will
have to be abandoned as dangerous.
I will now shortly describe the method which I have used for upwards of
thirteen years, and which has proved so satisfactory to me that I have felt no
desire to change it. Besides the two instruments named, I use two others : a
ring knife, consisting of a small transverse oval ring, with one sharp though not
.absolutely cutting edge,- and ﬁxed on a slender but ﬁrm steel stem, whose
other extremity is attached to a wooden handle ; next a. gag, which consists of
a triangular piece of ebony, armed on either side with a larger metal plate, and
attached to a curved stem, which bears a wooden handle.
The patient being seated, an assistant, standing behind him, holding his
slightly bent head, the operator, who stands in front of the patient, begins with
introducing the gag between the patient’s left molar teeth. 1Whilst the assistant
takes hold of its handle, the surgeon passes his left foreﬁnger over the patient’s
tongue into the vault of the pharynx, and immediately after he passes the ring
knife—the axis of the ring being kept perpendiciliar—through the widest side
of the nose. The ﬁnger and the ring having met behind the posterior nares,
the ring is moved in a downward direction, so as to scrape off the vegetations
at their base, the point of the ﬁnger serving as a point d’appui for the instru~
282 DISEASES or THE THROAT.
ment. In this way the operator works gradually on from above down-
wards, the finger all the time controlling the movements of the ring, until
everything necessary has been removed. In case the operation cannot be
ﬁnished through one nostril, the instrument has to be removed, the ﬁnger re-
maining in its place, and introduced through the other nostril in order to
complete the removal.
The bleeding is commonly considerable, but it soon stops. To facilitate
this, as well as to wash out blood-clots and remains of vegetation, a strong stream
of cool salt water with some carbolic acid is next injected over the bleeding
surface by means of the metal tube. This injection is followed by a cauteriza-
tion with solid mitigated nitrate of silver. Finally, the superﬂuous caustic is
neutralized by a second injection.
The operation is never a very painful one. I remember even having per-
formed it on a timid boy, 11 years old, without his being aware of it. He had
for some time previously been prepared by daily introducing both the ﬁnger
and the ring knife into the vault of the pharynx.
Commonly the operation is followed by some headache, sometimes by a
slight stupor : both usually disappearing on the same day after a short sleep.
In former years I have (in ﬁve cases) seen an acute inﬂammation of the
tympanum follow the operation. The like has not occurred for the last four years,
and this is due, so far as I can see, to the fact I have not meddled with the
wounded surface at all in the ﬁrst week after the operation. After the lapse of
a week, the after-treatment has to begin. Formerly I was not unfrequently
obliged to repeat the operation. Improved technicality, however, and the
introduction of a more methodical after-treatment, have of late years made the
repetition almost absolutely unnecessary. In some very rare cases in which
tough vegetations were situated on the side-walls a second operation has occa—
sionally been indicated—for which I use a special instrument (called duck’s
bill), curved like an ear-catheter and shaped like a small lithotrite, but with
spoon—shaped cutting ends.
The after-treatment I have found to be of the very greatest importance,
experience having taught me that if any remains of the adenoid vegetation are
left, they will inevitably grovtr again. In thirteen of my cases I have found the
growths to have recurred ; in some of them the treatment had been interrupted
before the after-treatment was completely ﬁnished, in others the after—treatment
had been conﬁded to unpractised hands. What accidentally will remain, in
spite of a thorough after-treatment, are small wart—shaped prominences on the
walls of the vault, easily known by their not bleeding when pressed by the
ﬁnger: they are the remains of the tough mucous linings of the destroyed
vegetations.
In several cases I have with beneﬁt begun the after-treatment with
galvano-cauterization. As a rule, however, the above-described cauterizations
' with mitigated nitrate of silver are employed, along with daily injections. I
would impress upon you not to become tired of cauterizing as long as any soft
and bleeding remains of the vegetations can be discovered. The douche is to
be continued long afterwards; bicarbonate of soda or chlorate of potash, or
both in combination, dissolved in the injected water, will, in obstinate cases,
serve the purpose.
Another kind of after—treatment is what I would term the gymnastic one.
It consists in accustoming the parts which have been out of use (the nose,
the soft palate) to their proper functions.
I conclude with wishing that the treatment of adenoid vegetation in the
vault of the pharynx may afford to many of you the same satisfaction and
pleasure which I have derived from it.
DISEASES OF THE THROAT. 283.
Les végétations aa’énoz'des dams [a z'oziz‘e du p/zarymr.
Dr LOEWENBERG, Paris.
I.
Le sujet que je vais avoir l’honneur de traiter devant vous possède une
portée qui dépasse de beaucoup le domaine d’une spécialité de Part de guérir.
L’affection qui nous occupe, siégeant au pharynx supérieur, carrefour important
des voies nasales et auriculaires, entraîne des conséquences pour la santé et
l’avenir social ‘des malades, et s’impose, par là, à l’attention de tous les médecins.
Malheureusement nous constatons tous les jours des faits qui prouvent
combien les notions importantes concernant cette affection sont loin d’être sufﬁ-
samment connues. Je crois donc devoir saisir l’occasion de faire proﬁter ce
sujet du retentissement exceptionnel d’un congrès international. Grâce à. lui,
en effet, ces notions éminemment utiles dépasseront le cercle restreint des
spécialités et se répandront davantage dans le monde médical.
L’ensemble des phénomènes provoqués par les tumeurs adéno‘ides du pharynx
nasal a dû se révéler, de tout temps, non seulement aux médecine, mais encore
aux personnes étrangères à notre science. En effet, ces symptômes: bouche
entr’ouverte, nasonnement, surdité plus ou moins prononcée, se réunissent pour
former un type physionomique très-caractéristique. Mais ce n’est qu’à une
époque récente, lorsque le miroir rhinoscopique a été découvert, que leur véri—
table signiﬁcation a pu être reconnue: on a compris alors que cet ensemble
de phénomènes morbides reconnaissait pour cause un obstacle dans la région
supérieure de la cavité pharyngienne. Bientôt après, mon savant collègue,
M. Meyer de Copenhague, est venu nous montrer, dans un excellent travail,
que les végétations formant cet obstacle, sont simplement le produit de
l’hyperplasie du tissu adeno‘ide, qui entre pour une si large part dans la com-
position des parois du pharynx.
Une fois le siège et la nature de l’aﬁection reconnus, l’enchaînement de ses
conséquences devenait évident. Le rétrécissement que les végétations consti-
tuent aux arrière-narines, interdit à la respiration le parcours du nez et l’oblige
à emprunter la route buccale, de sorte que la bouche reste constamment entre-
bâillée. Le malade ne peut plus former les consonnes et les voyelles nasales
dont l’émission exige que le nez soit libre. Obligé de les remplacer par d’autres,
il nasonne en parlant. En obstruant l’ouverture gutturale de la trompe
d’Eustache, ou bien en lui communiquant un état inﬂammatoire, les tumeurs
adéno‘ides provoquent souvent en outre une otite catarrhale ou suppurative, et
constituent ainsi une source fréquente de surdité chez les enfants.
Une aﬁection qui entraîne les conséquences pathologiques que je viens
d’énumérer mérite certes de ﬁxer l’attentipn. Son étude est d’autant plus
fructueuse que, la cause du mal reconnue à temps, il est possible, par des
moyens chirurgicaux exempts de tout danger, d’enlever l’obstacle mécanique
et tout l’enchaînement de ses effets pathologiques. Si, au contraire, l’abla-
tion n’est pas faite en temps utile, tous les accidents consécutifs deviennent
incurables, et c’est a cette négligence que sont dues beaucoup des surdités
graves qui, datant de l’enfance, se prolongent pendant la vie adulte. Il en est
de même pour la respiration buccale et l’expression particulière de la
physionomie due a l’entre—bâillement de la bouche, conséquences de l’affection
en question qui s’enracinent, à. moins qu’ on ne pratique a temps l’ablation des
végétations.
Le moment me semble donc propice pour insister sur la responsabilité
qu’on encourt en privant les malades des bienfaits de ce progrès important de
284 DISEASES OF THE THROAT.
notre science. J e vais, Messieurs, vous soumettre mes observations sur ce sujet
et les résumer dans une série de conclusions pour lesquelles je serais heureux
d’obtenir l’appui de votre haute autorité scientiﬁque.
Voici la première de ces conclusions :
Conclusion N o. 1.——La suppression de la respiration nasale et le nasonne-
ment, accompagnés généralement de troubles auriculaires, forment un ensemble
symptomatique fréquent dans l’enfance et l’adolescence. Il est dû, non pas a une
affection nasale ni amygdalienne, mais a l’existence, dans le pharynx nasal, de
tumeurs composées, dans l’immense majorité des cas, de tissu adénoïde.
La dernière partie de cette conclusion se rapporte au diagnostic différentiel
de ces végétations. Il se peut, en effet, que des tumeurs bien‘ autrement re-
doutables, des polypes pharyngo-nasaux, ne présentent, à leur début, que de
simples phénomènes d’oblitération nasale, et qu’il soit possible, pendant un
certain temps, de les confondre avec des végétations adénoides. Mais, outre
que la première de ces affections est inﬁniment plus rare que la prolifération
adénoïde, elle s’accompagne de très-bonne heure de désordres sérieux carac—
téristiques, tandis que les tumeurs qui nous occupent ne sont nullement
destructives ni envahissantes, et qu’on parvient facilement a les détruire d’une
façon déﬁnitive.
Mais il y a des confusions que nous voyons commettre plus fréquemment, et
je voudrais ajouter quelques mots pour faciliter le diagnostic différentiel à nos
confrères moins versés dans ce chapitre spécial.
Je ne m’occuperai pas de l’erreur qui consiste à attribuer tout cet ensemble
symptomatique au lymphatisme ou a la sorofule, sans se dire qu’une cause
mécanique seule peut provoquer des phénomènes d’obstruction aussi manifestes.
Il est plus compréhensible, par contre, que ceux qui ne sont pas au courant
des procédés spéciaux d’exploration, exigeant, comme la rhinoscopie par exemple,
une grande habitude, se trompent sur le siégé de l’obstacle et le placent soit
dans les fosses nasales, soit dans les amygdales.
Quant a celles- ci, un savant du pays qui nous offre en ce moment une si
gracieuse hospitalité, Harvey, a combattu victorieusement l’opinion générale qui
attribuait des troubles auriculaires à l’action directe des amygdales engorgées.
Convaincu qu’il faut en faire autant quant a leur prétendue inﬂuence sur les
cavités du nez, j’ai déjà fait ressortir autrefois qu’il me semblait inadmissible
que l’hypertrophie tonsillaire puisse rétrécir, non pas seulement la voie bucco-
pharyngienne, ce qui est incontestable, mais également, en refoulant le voile du
palais en haut, la route nasale, au point de la fermer.
En dehors de toute considération théorique, l’examen attentif de beaucoup
de personnes atteintes d’engorgement des amygdales m’a conﬁrmé dans cette
manière de voir, et m’a appris, en outre, que lorsque cette aﬁection s’accompagne
de symptômes d’obstruction nasale, ceux—ci sont dûs à des végétations adénoïdes
existant simultanément. J ’ai observé un certain nombre de cas qui présentaient
en même temps ces deux affections, cas nullement surprenants, car le tissu
adénoïde (ou lymphoïde) dont l’hyperplasie est si caractéristique pour la diathèse
lymphatique, abonde aux amygdales comme a la muqueuse du pharynx nasal
et peut proliférer dans les deux endroits en même temps. J ’ajoute que les
symptômes de gêne respiratoire n’en sont qu’augmentés, l’engorgement tonsillaire
rétrécissant la voie buccale, les végétations pharyngiennes obstruant les arrière—
narines. Dans ces cas, l’ablation des amygdales était impuissante à faire dis-
paraître les phénomènes d’obstruction, qui cédaient, par contre à l’extirpation
des tumeurs adénoides.
La confusion avec la simple hypertrophie des amygdales écartée, on ne peut
hésiter qu’entre les tumeurs adénoïdes et le coryza chronique. Outre que celui—ci
appartient plutôt à. l’âge adulte qu’à l’enfance, la question est tranchée aisément
DISEASES OF THE THROAT. 285
par un procédé facile a apprendre : la palpation. Il suffit de s’être exercé par
l’examen d’un petit nombre d’enfants pour pouvoir reconnaître immédiatement
l’existence d’une hyperplasie adénoïde assez avancée pour encombrer les arrière-
narines. Dans l’immense majorité des cas dont nous nous occupons, on la con-
statera et on trouvera les fosses nasales indemnes; je n’ai vu le contraire que
dans des cas excessivement rares. D’ailleurs les troubles auriculaires man-
quaient chez les quelques enfants oùj’ai vu le coryza chronique simple (non
spéciﬁque); lorsqu’un enfant présente des phénomènes d’obstruction nasale et de la'
surdité, il y a donc une présomption, pour ainsi dire, absolue en faveur des
tumeurs adénoïdes.
II.
L’inﬂuence des végétations adénoïdes ne se borne pas toujours au pharynx,
aux fosses nasales et aux oreilles, mais peut s’étendre au-dela de ces cavités.
J ’ai décrit, en 1878, une déformation particulière du thorax qui s’est rencontrée
chez les deux tiers environ des malades atteints d’hyperplasie adénoïde du
pharynx.
Bien que cette déviation de la conﬁguration normale montre des degrés
divers chez différents individus, elle présente toujours un même type caractér—
istique, dont les traits saillants peuvent se résumer ainsi: Les côtes sternales
sont déprimées vers le poumon ; leurs cartilages, au contraire, bombés en
dehors, forment une série de saillies, sans cependant offrir le chapelet noueux
du rachitisme. Le sternum, au lieu c’être projeté en avant, comme dans cette
dernière maladie, est notablement déprimé, surtout vers l’apophyse xiphoïde
qui est souvent profondément repoussée en dedans.
Cette déformation atteint quelquefois un degré considérable, ainsi on m’a
présenté un jeune malade comme portant une tumeur a l’épigastre; or la tumeur
n’était autre chose que la déformation que je viens de décrire, parvenue, il est
vrai, à. un développement extraordinaire.
Depuis ma publication, quelques observateurs ont émis des doutes quant à.
l’exactitude du fait signalé par moi. En présence de ces négations, j’ai continué
mes recherches sur un grand nombre de sujets, et je ne puis que maintenir mon
affirmation. Je dois dire, ‘a ce propos, que la symptomatologie de l’affection,
en dehors des grands traits caractéristiques, est présentée d’une façon un
peu divergente par diﬁérents observateurs. Ainsi on cite, parmi les signes
caractéristiques, des maux de tête fréquents et opiniâtres, qu’il m’a été impossible
de constater chez mes malades, malgré une investigation d’autant plus scrupu-
leuse que l’afﬁrmation émanait d’auteurs compétents.
Quant a l’étiologie de la déformation thoracique, nous pouvons écarter le
rachitisme, car, outre que la forme du thorax est tout autre dans cette maladie,
comme je viens de le prouver, je me suis assuré par l’examen de beaucoup de
sujets vivants et par l’autopsie d’un certain nombre de rachitiques qu’il n’y a
aucun rapport entre cette affection et l'hyperplasie adénoïde du pharynx.
Il ne nous reste donc qu’il chercher l’origine de la déformation de la poitrine
dans la gêne respiratoire due à, l’encombrement de la voie naso—pharyngienne.
Mais comme la respiration buccale a laquelle les malades ﬁnissent par avoir
recours, ouvre à. l’entrée de Pair un chemin suffisant, il faut invoquer les con»
ditions particulières dans lesquelles s’opère le changement du mode respiratoire.
C’est dans ce sens que j’ai proposé d’expliquer la genèse de la malformation
thoracique par ce qui se passe pendant la période de transition entre les deux
manières de respirer. Ce changement a lieu, sans doute, a une époque très-
reculée de la vie, alors que les tumeurs, en grandissant, commencent rétrécir
les arrière-narines, sans que l’enfant ait encore appris bien pratiquer la respi-
ration par la bouche.
286 DISEASES or THE THROAT.
On sait que, pendant l’inspiration, a mesure que les muscles tendent à dilater
le thorax, la tension du contenu gazeux intra-pulmonaire diminue, et que
l’équilibre se rétablit par l’entrée' de Pair a travers les fosses nasales. Lorsque
‘celles-ci s’obstruent, l’air ne peut plus entrer en quantité sufﬁsante, et alors la
pression de l’atmosphère sur les parois du thorax prédomine pendant l’inspira-
ration et la poitrine s’aﬁîaisse sur elle-même. L’élasticité du tissu pulmonaire
favorise cet affaissement. Comme ces troubles se manifestent chez des enfants
en pleine croissance, ils peuvent, à, la longue, entraîner des effets durables et
imprimer à la cage thoracique l’affaissement déﬁnitif en question.
Mais il reste à expliquer la voussure des cartilages costaux. Peut-être
résulte-t-elle de ce que l’enfoncement de leur deux points d’insertion, la côte et
le sternum, a pour effet de bomber, par une pression latérale, ces cartilages en
sens opposé, c’est-a-dire, vers l’extérieur.
Depuis Dupuytren, on attribue à l’hypertrophie des amygdales l’origine d’une
déformation du thorax qui présente, d’après la description des auteurs, quelque
analogie avec celle dont je viens de traiter. Or, ce grand chirurgien dit lui-
même* que, dans ses cas, la résection des amygdales ne faisait pas cesser la
difficulté de respirer, ce qui s’accorde parfaitement avec ma manière de Voir, qui
attribue cette difficulté à la coexistence de tumeurs adénoïdes. Il est vrai que
la déformation que j’ai décrite diffère par quelques détails de celle causée,
d’après les auteurs, par l’hypertrophie des amygdales, mais je ne puis faire
autrement que d’attribuer cela a des examens incomplets, témoin la confusion
manifeste que Dupuytren lui—même fait entre cette déformation spéciale et le
thorax rachitique.
Conclusion N o. 2.-Chez un certain nombre d’enfants atteints de cette
affection, la gêne respiratoire entraîne une déformation particulière de la cage
thoracique.
III.
Les végétations dont nous venons d’étudier l’inﬂuence, sont le produit de
l’hyperplasie du tissu adénoïde si abondamment représenté dans la muqueuse
du pharynx nasal. Aussi atteignent-elles le plus grand développement la où
se trouve la plus forte agglomération de ce tissu, à. savoir la région supérieure
et postérieure de l’organe, occupée par la tonsilla pharyngea de Luschka. Dans
tous les cas de végétations adénoïdes que j’ai examinés, celle-ci s’est trouvée
hypertrophiée, souvent seule, d’autres fois simultanément avec des parties plus
ou moins étendues des parois latérales.
La forme la plus commune est celle où l’hypertrophie porte exclusivement
ou principalement sur l’amygdale pharyngienne. Dans le premier cas, l’affection
se trouve conﬁnée au siége de celle-ci, a la région supérieure et postérieure du
pharynx nasal. L’image frappante d’une crête de coq donnée au rhinoscope
par cette forme nous a révélé l’existence de l’affection. C’est cette découverte
qui a attiré l’attention sur la région pharyngo—nasale, terrain 'si peu exploré
avant Czermak, qu’on aurait pu l’appeler, en variant un peut le mot d’Albert de
Haller : dg'ﬁcz'llz'ma particulapathologz'æ.
Les dentelures de cette crête correspondent aux lobes antéro-postérieurs de
la tonsille pharyngienne, vus en raccourci au miroir rhinoscopique.
Cette forme présente, chez différents malades, les degrés de développement
les plus divers, d’une légère hypertrophie, ne gênant en rien le fonctionnement
du pharynx ni de ses annexes, à une prolifération qui remplit absolument les
arrière-narines. Prononcée à ce dernier point, elle trouble profondément le

* Dupuytren, Mémoire sur la dépression latérale des
' parois de la poitrine, in Réper-
toire Gén. d’Anat. et de Physzol. Pathol, p. 112. 1828. '
DISEASES OF THE THROAT. 287
passage de l’air par le nez, la prononciation et le jeu physiologique des trompes
d’Eustache.
J ’ai remarqué que les cas où les désordres auriculaires faisaient défaut,
étaient justement ceux d’une hypertrophie modérée de l’amygdale de Luschka
seule, hypertrophie suffisant pour rendre par son épaisseur l’ouverture nasale
postérieure trop étroite, mais ns’atteignant pas en largeur la partie gutturale de
la trompe d’Eustache. Par contre, l’oreille souffre, lorsque la tonsilla pharyngea
grossie arrive en contact avec celle—ci, ou qu’il existe des tumeurs latérales qui
l’affectent directement.
Parmi les cas où les parois latérales des arrière-narines étaient également
malades, j’ai quelquefois observé une forme particulière; c’était une hyperplasie
diffuse et uniforme du tissu adénoïde du pavillon de la trompe d’Eustache, qui
ressemblait vaguement, par son épaissement général, à un petit col utérin.
Quelquefois les tumeurs se montrent dans tout le pharynx nasal à. la fois ;
c’est la que le miroir rhinoscopique nous révèle des images confuses, très-
difﬁciles à. interpréter. C’est un chaos de bosses, de crêtes et de pointes, où il
est impossible de reconnaître les points de repère habituels, le bord postérieur
de la cloison nasale et les saillies des pavillons tubaires.
La tonsilla pharyngea hypertrophiée ne présente pas toujours l’aspect lobulé
dont j’ai parlé, mais revêt quelquefois la forme d’une tumeur compacte et unie.
Je citerai a cet égard le cas d’une jeune ﬁlle de quatorze ans, où cet organe
hypertrophié possédait la conﬁguration et la grosseur d’une forte cerise, à laquelle
il ressemblait de plus, par sa surface tout-a-fait lisse. En bas, la tumeur était
un peu étranglée par une rainure verticale. Il existait, dans ce point, une
ouverture dans laquelle les instruments pénétraient profondément ; c’était
évidemment l’entrée de la bursa pharyngea de Mayer. La tumeur se montrait
bien isolée au milieu d’un pharynx d’apparence normale d’ailleurs et n’en
touchait pas les parois latérales ;'aussi n’y avait-il aucun trouble auriculaire et
n’eXistait-il que la gêne dans la respiration nasale.
Je résume ce chapitre dans la
Conclusion N o. 3,-——L’aﬁ’ection porte toujours sur la tonsilla pharyngea et
souvent, en même temps, sur les parois latérales du pharynx.
IV.
Les tumeurs adénoïdes constituent, à mon avis, une manifestation fréquente
et importante de la diathèse lymphatique. Je ne crois pas que l’on puisse les
imputer a une autre cause générale, par exemple la syphilis congénitale. J ’ai
constaté par plusieurs nécropsies d’enfants, auxquels était échu ce triste héritage,
qu’elle n’a aucun rapport avec les végétations en question.
Comme d’autres manifestations du tempérament lymphatique qui portent
également sur le tissu adénoïde (ou lymphoïde), ces tumeurs sont susceptibles
de rétrograder d’elles—même a une certaine époque de la vie, mais trop tard pour
permettre aux fonctions entravées par elles de recouvrer leur activité normale.
Or, nous savons que les perversions fonctionnelles s’enracinent particulièrement
vite dans l’enfance; il faut donc intervenir de bonne heure pour empêcher
qu’elles deviennent irrémédiables.
Aucun traitement général ne parvenant à faire disparaître ces végétations, il
faut les attaquer chirurgicalement. De petits enfants même supportent facile—
ment l’ablation de ces tumeurs, quand on a. soin de n’employer que des méthodes
prudentes et des instruments appropriés.
Le succès de l’opération est rapide, quant à certains symptômes; aussitôt
les tumeurs enlevées, la respiration nasale redevient possible, mais les autres
troubles demandent du temps et souvent des soins spéciaux pour disparaître.
Le succès est en outre durable, car, une fois enlevées ou seulement entamées,
288 DISEASES or THE THROAT.
ces végétations ne repoussent plus. L’eHet de l’opération peut même augmenter
par la suite, car souvent les restes des végétations qu’on a laissés s’atrophient
d’eux—mêmes, comme je l’ai constaté maintes fois. On sait qu’une pareille
atrophie secondaire arrive souvent après l’ablation des amygdales palatines,
organes également riches en tissu adénoïde.
L’ensemble des faits que je viens d’exposer indique la ligne de conduite à.
observer. Il faut opérer le plus tôt possible, mais se borner à diminuer le
volume des tumeurs dans une mesure suﬂisante pour rendre la respiration nasale
possible et débarrasser la trompe d’Eustache. L’inspection rhinoscopique démon-
trera si ce dernier résultat est atteint; le libre passage de l’air par les deux
narines prouvera que la voie nasale est suﬂisamment dégagée.
S’obstiner a vouloir enlever tout ce qui est hypertrophique serait inutile,
pénible pour le malade et même dangereux. ‘
Ce qui s’est passé postérieurement à. l’opération dans le cas que j’ai cité
tout-a-l’heure, prouve qu’il suffit d’enlever le strict nécessaire des excroissances,
en comptant sur l’atrophie consécutive a l’opération. Après avoir détruit a peu
près les deux cinquièmes de la tumeur bilobée, le seul symptôme présent, la gêne
de la respiration nasale, avait cessé. J ’ai revu la jeune ﬁlle un an après l’opé-
ration et j’ai constaté, au rhinoscope, que le reste considérable du produit
morbide que j’avais laissé, avait disparu sans la moindre trace. En même
temps, le développement de la jeune personne avait pris un essor remarquable.
D’autres cas m’ont présenté des phénomènes du même genre.
Ces faits se résument dans la conclusion suivante :
Conclusion N o. 4.—L’ablation de toutes ces tumeurs doit être pratiquée le
plus tôt possible ; on se bornera toutefois à. enlever des portions suffisantes pour
rétablir la perméabilité des fosses nasales et de la trompe d’Eustache.
V.
La nécessité d’opérer réconnue, il s’agit de choisir les procédés a suivre.
Ici, il me semble indispensable d’établir des règles différentes pour les végéta-
tions qui résultent de l’hyperplasie de l’amygdale de Luschka et que d’après
leur siége j’appellerai “ médianes,” et pour celles implantées aux côtés du
pharynx nasal et que je désignerai sous le nom de “latérales.”
1.-Quant aux tumeurs médianes, je pense que la plupart des procédés
recommandés par les auteurs peuvent être employés à leur ablation. Il faut
citer, parmi les instruments en usage, le galvano—cautère utilisé par M. Voltolini,
le couteau annulaire de M. Meyer, et la pince tranchante que j’ai décrite, en
1878, dans la Gazette des Hôpitaux, et qui a été modiﬁé à. son avantage par
plusieurs auteurs, surtout par notre distingué confrère, M. Woakes. Je
mentionnerai de plus l’adénotôme de mon savant ami M. Delstanche, l’anse de
ﬁl de fer, employée comme écraseur et, en dernier lieu, la curette ou cuiller
tranchante. Tous ces instruments peuvent être employés dans la région supéro—
postérieure des arrière—narines, car la muqueuse qui la tapisse ne renferme
aucun organe important que les manœuvres instrumentales puissent léser.
On ne saurait nuire au malade qu’en dépassant cette muqueuse en profon-
deur, ou bien en empiétant sur les parois latérales de la cavité. Le premier de
ces dangers n’existera pas si l’on reste ﬁdèle au principe posé plus haut de ne
détruire que ce qui obstrue en faisant saillie dans le pharynx. Il est prudent
également d’employer de préférence des instruments comme le couteau annulaire,
les pinces tranchantes et l’anse qui agissent parallèlement à la surface interne
de la cavité et ne sauraient pénétrer perpendiculairement dans les tissus comme
cela peut bien arriver avec la curette trop fortement appuyée.
On sera sûr de ne pas empiéter sur les parois latérales si l’on n’opère que
guidé par le miroir pharyngoscopique ou par le doigt, qui palpe en même temps
DISEASES OF THE THROAT. 289
qu’il dirige et maintient l’instrument. Mais on n’insiste pas suffisamment sur
le nombre considérable de malades qui tolèrent seulement l’exploration digitale
rapidement faite ou le simple examen rhinoscopique, mais ne supportent nul-
lement ces procédés combinés avec l’introduction d’un instrument quelque peu
volumineux. Il est vrai que des exercices patiemment répétés amènent souvent
une tolérance inespérée, et j’ai trouvé surtout chez les enfants une grande facilité
à supporter l’examen rhinoscopique prolongé—mais il n’en subsiste pas moins
des personnes réfractaires chez lesquelles il faut agir sans l’aide de l’œil ni du
doigt. Dans ces cas, qui ne sont pas très-rares, on fera bien de suivre strictement
mon conseil de n’employer que des instruments agissant parallèlement à. la
surface de l’organe et de se borner à opérer sur le milieu du pharynx. C’est
dans ces circonstances aussi que les entonnoirs de M. Zaufal peuvent être très-
utiles lorsque les fosses nasales permettent leur introduction, parce qu’ils nous
dispensent de la rhinoscopie et permettent le passage d’un petit galvano-cautère
ou d’une anse, guidés par l’inspection. 1
Quant au galvano—cautère, son usage est peu ou pas douloureux, pour peu
qu’il soit contrôlé a l’aide du miroir pharyngoscopique. Comme le volume de
l’instrument est minime, on peut souvent l’employer là. où d’autres plus encom-
brants ne sont pas utilisables, soit que leur contact provoque des nausées, soit
que leur volume cache une trop grande partie du miroir.
Je me sers de galvano-cautères courbés selon l’aXe bucco-pharyngien et
formés d’une tige de quatre millimètres d’épaisseur seulement, qui porte au bout
une spirale de platine, large de deux à. quatre millimètres. Rien de plus facile,
même chez de petits enfants, que d’introduire ces instruments et de les porter,
guidé par le rhinoscope, sur la partie à brûler. On évite ainsi de toucher les
amygdales, la luette, le voile du palais et les parties saines du pharynx 5 par
conséquent, pas de constriction ni de cautérisation déplacée.
En opérant d’après ces principes, le galvano-cautère ne donne lieu à aucune
irritation sérieuse; je proteste donc contre l’idée que son usage soit dangereux.
Il va sans dire qu’il n’en est plus ainsi lorsqu’on agit sans précaution, qu’on
brûle à. l’aveugle, c’est-à-dire sans rhinoscope, qu’on ne localise pas strictement
l’action de l’instrument en profondeur et en étendue, ou que l’on emploie des
instruments d’une taille et d’une puissance hors de proportion avec le but à
atteindre, tels que le brûleur de porcelaine.
En cas de très-grande irritabilité de la gorge, on peut quelquefois introduire
un galvano—cautère ﬁn, droit et bien isolé par le nez et brûler ensuite, après
avoir placé rapidement le miroir rhinoscopique.
2.——Si des procédés variés me paraissent applicables au traitement des tumeurs
médianes, je ne saurais en dire autant pour les végétations placées latéralement.
Vu l’exig‘uïté de l’espace sur les côté du pharynx, des instruments encombrants
ou des manœuvres opératoires’pratiquées sans rhinoscopie ni palpation, risquent
de blesser gravement l’extrémité pharyngienne proëminente de la trompe
d’Eustache qui occupe le côté de la cavité et vient se placer, pour ainsi dire
d’elle-même, dans la sphère d’action de l’instrument. A cette occasion, je ne
saurais trop louer l’esprit de franchise vraiment scientiﬁque des auteurs qui
avouent que pareil accident leur est arrivé, avec des instruments inventés,
pourtant par eux, et dont ils possédaient naturellement le maniement mieux que
personne.
En blessant la trompe d’Eustache, on provoque souvent une otite moyenne
purulente, et je suis persuadé que cette conséquence fâcheuse—mais, à ce qu’il
paraît, fréquente—de l’ablation des tumeurs adéno‘ides ne reconnaît point d’autre
cause que des imprudences de ce genre.
A mon avis, la meilleure méthode de se mettre à. l’abri de ce danger
consiste dans l’usage du galvano-cautère avec les précautions exposées tout-à»
PART III. U
290 DISEASES OF THE THROAT.
l’heure. On respectera ainsi la trompe, tout en détruisant ce qui l’embarrasse
ou l’étreint. 11 en est ainsi non seulement pour les végétations des cotés du
pharynx, mais aussi pour les parties late'rales de la tonsilla de Luschka hyper-
plasiée, qui sont également diﬁ‘iciles a‘détruire autrement. Le procéd'é est
excellent, de plus, pour combattre la forme particuliere d’hypertrophie diffuse
du pavillon tubaire que j’ai signalée dans un chapitre précédent. i
Conclusion No. 5.-—Les tumeurs resultant de l’hyperplasie de la tonsilla
pharyngea peuvent étre opérées d’apres diﬁiérents procédés; les vége'tations
siégeant sur les parois latérales du pharynx, surtout celles qui avoisinent
1e pavillon de la trompe d’Eustache, seront détruites a l’aide d’un galvano—
cautere mince, guidé par le miroir rhinoscopique.
I
Adenoid V egez‘az‘z'om 2'12 z‘lze Vault of Me P/MZVJ/WJC.
Dr. GUYE, Amsterdam.
There are in the etiology and in the treatment of these vegeta-
tions a few points on which I would like to ﬁx attention. As regards
the etiology. The view to which my experience has brought me is that
the adenoid vegetations are caused by chronic catarrh of the mucous
membrane, and result from hypertrophy and swelling of the adenoid tissue which
in the normal state is to be found as the tonsilla pharyngea (Luschka). In
many cases it is difficult to say whether we ought to speak of hypertrophy of
the tonsilla pharyngea or of adenoid vegetations. The simple catarrhal
swelling produces a result of great importance, by impeding the nasal respira-»
tion, and the patient takes to the habit of breathing through the mouth,
especially during his sleep. This circumstance, if not prevented with great
care, becomes soon an aggravating feature of the disease. The inspired air,
which ought to be puriﬁed and moistened by the mucous membrane of the nose,
produces dryness and irritation of the pharynx, and increases the swelling of
the nose, as the normal quantity of air is no longer passed through that organ.
Therefore, the mechanical occlusion of the mouth during sleep, and in some
cases, even in the daytime, ought to be an essential part of the treatment. This
occlusion can be effected by a contra-respirator, which is simply a respirator
which does not let any air pass. This part of the treatment is important
against the development of the vegetation, and may prevent relapses after
operation. As to the operation, I wish to advocate strongly the operation by the
ﬁnger-nail, without any instruments, for the great majority of cases. The cases
where this method is insufficient are rare exceptions. This method has the advan-
tage of being always applicable even in children in the ﬁrst years of life. I wish,
in addition to these remarks, to say a few words on the frequent coincidence of
adenoid vegetations in the vault of the pharynx with chronic catarrh of the
conjunctiva. During the last two years, I have, conj ointly with Professor Snellen,
seen a number of such cases. The ﬁrst case which came to my notice was that
of a young lady from Haarlem, about ﬁfteen, who had been under Professor
Snellen’s treatment for chronic follicular catarrh of the conjunctiva. She came
to me with a swo]len nose, the mouth more than half open, her voice being both
hoarse and nasal. Professor Snellen had advised her to submit to my treatment
of her throat and nose, and had said to her that, when these were cured, he
expected that her eyes would get all right of themselves. I own that I
was rather astonished at ﬁrst, and regarded the prediction sceptically.
However, I found enormous adenoid vegetations, which I scratched out once a
week four or ﬁve times. I prescribed injections into the nose, and made her
DISEASES OF THE THROAT. 291
wear a contra-respirator at night. In a few weeks the case went on very well,
the voice was improved a great deal, and the eyes really got all right, thoroughly
in accordance with Professor Snellen’s prediction. Professor Snellen had been
struck by the frequent coincidence of the so-called follicular conjunctivitis with
the pharyngeal and nasal adenoid vegctations, and he thought it likely that the
diseased state of the nasal mucosa might have an inﬂuence on the conjunctiva,
either by producing irritation and lacrymation of the eye by reﬂex action
or perhaps through the direct connection of the lymphatic systems of both
mucous membranes. Since that time I treated a number of Professor Snellen’s
patients, generally with good results both in regard to the general health and
to the cure of the follicular conjunctivitis. I remember, 6.9., three children of
one family in Utrecht, who all three had been for the last two years under
treatment for their eyes, having a follicular catarrh of the conjunctiva. They
had all of them enormous vegetations in the vault of the pharynx, with more or
less impaired hearing. One of them, the eldest, a girl of about thirteen, had a
purulent inﬂammation of the left tympanic cavity, with perforation of the mem~
brane and otorrhoea for three or four months. She had been suffering from
earache and fever now and then during the last winter. She had not been.
much improved by a local treatment of the ear. Scratching out the adenoid
vegetations did a great deal of good to all three of the patients. Their hearing
got restored, they could again breathe freely through the nose, whilst the mouth
was kept closed by a contra-respirator at night; the general health greatly im-
proved, and in a couple of months the conjunctiva of the eldest was quite, that
of the others nearly, cured. I might record a larger number of cases, some of
which are still under treatment, but I do not wish to be tedious. I think
the subject deserves highly the attention of ophthalmic surgeons, who, more-
over, are well aware of the inﬂuence on the conjunctiva of nasal catarrh and
swelling and obliteration of the lacrymal duct. Galezowsky, for instance, devotes
a long chapter to his “ Conjonctivite Lacrymale.” In my opinion that disease
may in many cases be found complicated with, and perhaps caused by, adenoid
vegetations in the vault of the pharynx; and the thorough means of curing
dacryocystitis may require, besides local treatment, the scratching out of the
tonsilla pharyngea. Hardness of hearing is so frequent a symptom of adenoid
vegetations, that it is in most cases the reason why such patients seek treatment 5
and if the aurist whom they consult is not alive to the frequent occurrence of
adenoid vegetations as the cause of the disease, his treatment will be of little, or
at least ofno durable, result. If I am not much mistaken, when the eminent
and distinguished surgeons who treat and observe diseases of the eye have given
to the subject due attention, they will not be long in ﬁnding a large number of
cases where the adenoid vegetations of the vault of the pharynx play an impor—
tant etiological part.
072 Papz'llo-Adeazomaz‘ous Disease, 07' Pod-Nasal V egez‘az‘z’ozzx.
Dr. E. \VoAKEs, London.
The following remarks are based upon an experience of upwards of 100
cases of the disease, which have occurred in my hospital and private practice
during the last ﬁve years. I have given in a tabulated form the details of
eighteen of these. The general features of all resemble each other so nearly
that it seems unnecessary to add to this number.
Pathology—In the account of this disease which I have already publishedi"

Vide chap. iii. “On Deafness,” &c., second edition.
U :3
292 ' DISEASES OF THE THROAT.
I have stated the grounds which lead me to consider these growths to be
papillomatous in their origin, though owing to the nature of their situation and
general environment, they acquire a more pronounced mucous membrane
envelope than do papillary developments from mucous membrane in other
situations. The position which I incline to adopt on this point is as follows z----
The point of departure in the morbid process resides in the papillae, some
of which assume hypertrophic growth of very considerable proportions. This
is evidenced by the solid ﬁbrillar structure of the centre of the growth, which
immediately surrounds the artery and vein entering at its root, and which
modiﬁed connective-tissue structure is continued through the excrescence to
within a short distance of its periphery. Outside this, and passing insensibly
into it, is a thick stratum of mucous membrane proper; although proper
mucous cells are met with in this outer layer, I have never been able to trace
anything like a duct follicle, such as would imply the presence of gland tissue
proper in any specimen examined. This fact seems to imply that the starting-
point of the disease is not in the follicles or any special gland structure to be
met with in the post-nasal space.
True papillomata are met with in the adjacent regions of the throat and
larynx not infrequently; such a specimen, a, which I removed very recently
from the left arch of the palate is here exhibited, others from the vocal cords
I), 0. My contention is, that these, growing on a comparatively free surface,
develop normal papillomata; while their congeners in the post-nasal space,
which in infancy and childhood is very limited, crowd and compress each other;
and, being constantly bathed in retained secretion, they become softer and
smoother than do growths of a similar origin occurring elsewhere.
Another point of perhaps more importance in connection with the pathology
of the disease is that in quite a large proportion of my cases there was to be
found a very marked development of the mucous membrane of the locality.
This hypertrophied mucous membrane was usually found on the posterior and
lateral walls of the pharynx, immediately behind the soft palate, Where it
assumed occasionally quite a corrugated condition, the folds so caused encroaching
largely upon the oriﬁces of the Eustachian tubes. In some of these instances
the vegetations were seated high up in the vault, and in others they were
present to a very slight extent only, the chief cause of the symptoms being due
to the corrugated and thickened mucous membrane.
So far as I have been able to form any opinion of the cause of the foregoing
condition, it has seemed to be due to increased blood supply of the part, conse-
quent upon the presence of the growths, leading to the ordinary consequences of
hyper-nutrition.
Etiology—That the disease may be congenital is to be inferred from the
fact that I found them in an infant of nine months; and have operated on
another somewhat over two years of age, who had exhibited indications of their
presence from birth. In every case of so-called “ snufﬂes” they should be
looked for, as the foregoing experience indicates that this symptom is occasionally
due to their existence thus early in life. On the other hand, some of my patients
have referred the initiation of the disease to an attack of one of the exanthe-
mata—that is to say, the subject or his friends were unconscious of any
nasal trouble till after an attack of measles or scarlet fever, on recovery from
which the symptoms commenced.
Heredity is, no doubt, an important factor in predisposing to the disease.
Vaso-motor pareses in the areas of the cervical ganglia are very distinctly
transferable from parents to their offspring; but, having treated of this in
another communication, this passing allusion to it as a potential cause of
hyperplasias must suffice.
DISEASES OF THE THROAT. 293
As regards inherited syphilis, my experience points to it as evidence of a
remote sequence of the disease rather than to a recent infection.
That there is a distinct tendency for these vegetations to disappear in adult
life there can, I think, belittle doubt. I have only met with them once or
twice after the age oftwenty-five years. As I have elsewhere expressed the
opinion, this is due to the increase of spacein the naso-pharyngeal region, which
takes place here in common with the rest of the facial framework as develop-
ment approaches completion. This “implies freer access of air, readier escape of
secretions, and, consequently, greater dryness of the surroundings generally.
The soil thus drained and ventilated appears unﬁtted for the vegetations to
ﬂourish upon, and they accordingly disappear.”*
It is, however, most undesirable that the patient be left to this issue for
reasons irrespective of those immediately due to the disease, and belonging to
the locality primarily affected; because the obstruction to nasal respiration,
induced by the growths, means that the air inspired by these patients is drier,
colder, and less free from impurities than it should be, and so predisposes them
to lung affections of an inﬂammatory type. Also, from this cause, as well as
probably from reﬂex irritation of the vagus nerve, to asthma, which in children
is an occasional concomitant of the disease. Further, they maintain a low state
of vitality in the regions implicated, which predisposes to frequent sore throats
and tends to establish enlargement of the tonsils. Should these patients become
the subjects of the exanthemata, especially of diphtheria, their symptoms are
more severe, and show a less tendency to yield to treatment, than where such
complications do not exist. Thus, these subjects are handicapped against
recovery from illnesses which are the common lot of the younger representa-
tives of the race.
On these grounds, if on no other, the removal of the growths, as soon as
discovered, becomes‘imperative.
The symptoms most generally present are modiﬁcation of the voice, so that
it assumes a nasal twang, in which the letters m and n are pronounced as b and
(1 respectively; buccal respiration, obliging the patient to breathe through his
mouth, and keep it open during sleep, during which time he usually snores.
Chronic pharyngitis is commonly set up in consequence of this condition. All
these symptoms, referable to obstructed nasal respiration, have attained much
less marked degrees of intensity in the cases observed by myself, than in those
reported from the Continent. The degree of ﬂux from the anterior or posterior
nasal oriﬁces is also very liable to vary 3 in most cases some catarrh exists, and
when, as occasionally happens, the patient is unable to blow his nose, the
discharges are apt to collect in the posterior nasal space or trickle from the
excoriated nostrils, adding much to the discomfort as well as to the disﬁgure-
ment of the patient.
I have not noticed loss of taste or smell, though it is conceivable that these
senses would be interfered with where extreme occlusion of the nasal fossae
exists. Neither have I seen deformity of the chest walls as presented in a
proportion of Lowenberg’s patients. ight sweats have obtained in a number
of my cases, and may be accounted for probably by the complementary activity
of the skin acting as a set—off to the impediment of respiration.
Interference with the organs of hearing, inducing more or less deafness, is
the most frequent, and to my mind the most important, of the direct lesions
resulting from the disease. Not more than ﬁve per cent. of my cases have
escaped this complication. The severity of the ear mischief will depend
largely upon the situation of the vegetations. Thus a very extensive develop

* Op. cit. p. 38.
H 2
DISEASES OF THE THROAT.
ment of these in the vault of the pharynx interferes less with the function of
the Eustachian tubes than does a much smaller amount seated upon the
posterior wall of the pharynx. In this latter situation a single growth will be
frequently complicated with that hypertrophic thickening of the mucous
membrane already alluded to, and which must be dealt with step by step with
the primary disease, inasmuch as it proves quite as detrimental to the function
of the tubes as the latter.
As regards the nature of the ear aﬁ'ectz'ons induced by the foregoing
conditions, they offer no special characteristic by which to distinguish them
from other affections of the organs of audition, having a faucial origin—that is
to say, if catarrh is the prominent symptom of the throat aﬁection the tendency
is for this to involve the Eustachian tubes and tympanic cavities. suppuration
and perforation of the membrana tympani, with polypus or polypoid granulation,
and, in short, all the sequences of conﬁrmed otorrhoea, are most frequently seen
under these circumstances—5.6., when the vegetations affect mainly the vault. On
the other hand, when a fewer number of vegetations accompanied with extensive
augmentation of mucous membrane are seated on the posterior wall of the
pharynx, implying a complete mechanical occlusion of the tubes, the form of
ear disease ensuing hereon is more apt to assume the condition known as
chronic non-suppurative inflammation of the middle ear with collapse of the
drum membranes and severe degrees of deafness. The latter is far more
tedious and difﬁcult to treat than the former, and the chances of com-
plete recovery of hearing power are less in it than when the grosser phase of
suppuration is present.
The diagnosis of post—nasal growths is by no means difficult. If a patient
presenting the indications of nasal obstruction be inspected with reference to
the state of the faucial region, the soft palate will usually be seen to project
somewhat forwards, imparting a greater depth to the space between it and the
posterior wall of the pharynx.
In young children rhinoscopy is usually abortive, and palpation, or exami-
nation by the ﬁnger, should be employed without delay. If the examiner
possess the tactus eruclz'tus of experience, he will be able to pronounce
deﬁnitely as to the existence of the disease. If performed skilfully, the pro-
ceeding is not very painful, and occupies a few seconds only. Instead of a
clear space with its well-deﬁned landmarks, a soft irregular mass is encountered,
which bleeds on contact with the ﬁnger and more or less occupies the region.
At other times the digit encounters the obstruction immediately behind the
velum, after passing which the vault on either side the fornix is found perfectly
free.
As regards differential diagnosis, the disease most likely to give rise to
doubt is hypertrophy of the pharyngeal tonsil. Besides being a much rarer
disease than that under review, its tactile indications are distinctive, as it is
much ﬁrmer and more uniform in outline than are the mass of vegetations.
In a marked case of this kind at present under my care the rhinoscopic
evidences were conclusive. These were, a solid looking rounded mass ﬁlling up
the vault, overlapping the choanae in front for the distance of the third of an
inch, and laterally ﬁlling up Rosemuller’s fossw, so as to come in contact with,
and press upon, the protuberance of the Eustachian oriﬁces. In the median
line there was a faint indication of division, and in this line were two deep
crypt-like depressions. These latter were quite unintelligible to me at ﬁrst,
but as the mass diminished under treatment, these fossm enlarged and at
length merged in each other, showing them to be simply gaps left between the
swollen halves of the gland where the latter did not quite come into apposition.
The patient who presented the foregoing condition was an intelligent lad of
DISEASES OF THE THROAT. 295
ﬁfteen, who four years previously became subject to deafness, the starting-point
of which was a severe cold. The deafness varied considerably, but he never
had otorrhoea. A year ago he was at school at Heidelberg, where he was
treated chieﬂy by Politzer’s inﬂation, but without beneﬁt. Within the last
few months he has had frequent attacks of epistaxis, which now occur almost
daily. On examination, May 11, 1881, he presented, besides the foregoing
rhinoscopic appearances—and in his tolerance of the mirror he formed a happy
exception to the generality of young subjects—a considerable amount of
rhinitis, the mucous membrane of the inferior turbinated bones being swollen
and spongy, so as to obliterate the lower nasal channel on each side. H. D.
right $91,, left 126. He has tidal tinnitus in both ears, with occasional giddi~
noss, and both memb. tymp. are depressed and dull-looking; Eustachian tubes
impervious. The treatment consisted in application of the galvano-cautery to the
spongy Schneiderian membrane, after which the nostrils were lightly packed with
terebinth wool night and morning; nitrate of silver was applied freely to the
pharyngeal tonsil. Later on iodoform wool was substituted, being applied as
far back as possible. The bleeding was rapidly cured, the pharyngeal swelling
subsided, and after local treatment of the ears the deafness also disappeared.
In my former essay on this subject I stated that nasal polypus is scarcely
likely to be a source of confusion, inasmuch as it rarely occurs at an age when
papillo—adenomatous disease is most frequent. Since giving expression to the
above, however, I have met with two cases which necessitate a modiﬁcation of
this view. Both were somewhat peculiar, because, besides the readily per-
ceived antero-nasal polypi, there was almost uniform cystoid degeneration of the
mucous lining of the post-nasal space, a condition calculated to deceive the touch,
and which without the exercise of due care might convey the impression that the
case was one of post-nasal growths. Both these patients were between thirteen and
ﬁfteen years old, and in the elder boy the disease dated from birth. The bridge
of the nose was much ﬂattened, from spreading of the nasal bones outwards in
consequence of the pressure from within during their plastic state in very early
life. Examination revealed extensive superﬁcial necrosis of the bony structure of
the nose, and it was found necessary, in order to remove the diseased tissue, to
lay open the nasal fossae by dividing the attachment of the cartilage of the
nose through the inside of the upper lip. This gave room for- the manipula-
tion of instruments with which to remove the necrosed portions of the nasal
aspect of the superior maxillary bone and the middle turbinated bone—the
lower turbinated had already disappeared in the mass of diseased tissue that
surrounded it. Subsequently the galvano-cautery was freely applied to the
entire region dealt with—up to the present the left side only—with the result,
as yet, of completely removing the disease. I have given the above details as
well for their diagnostic value in relation to the disease under discussion as for
the interest attaching to the extensive exfoliations of bone in consequence of
the cystoid degeneration of its lining membrane, which are unique in my expe-
rience of non-syphilitic disease of this region in young subjects.
Treatment—Several cases treated in my clinic have been so far relieved by
‘the use of alkaline nasal washes that they have declined further interference.
‘These were of course only the mildest in degree. Two or three others have
recovered by the application of caustics—London paste, nitrate of silver in
the solid form, followed subsequently by solution of chloride of zinc. All the
others have been dealt with instrumentally. Since becoming acquainted
with the forceps designed by Dr. L'owenberg, I have practically rejected
every other in their favour—that is to say, in favour of his instrument
modiﬁed to meet my requirements, by adding a cutting edge to the posterior
aspect of the blades. By means of this addition one is enabled to seize
962:
‘.LVOHHL Ell-Ll} d0 SI'ISVEISICI
TABLE or Cases or ADENOID VEGETATIONS IN THE VAULT or run PHALRYNX.
Dr. E. WOAKES, London.

Name.
Archibald
'l‘reherne.
Alice
Rawe.
Mary Anne
Platt,
sister of
A lice
Rawe.
Albert
Rawe,
brother of
2 and 3.
Florence
Liddal .


Age Date of
and atten-
sex. dance.
21 1877
yrgs. Dec. 18.
M
16 1879
yr_s. June 6.
23 1879
yrs. May 16.
mar-
ried.
14 1879
yrs. May i6.
IO I879
yrs. Sept. 30.
Prior dura-
tion of
symptoms.
From birth.
Deafness 1
month, pro-
bably longer;
several chil-
dren being
deaf, not no-
ticed earlier.
Several
, years’ ear
I trouble.
2 years.

3 years.

Posterior

Deafness and
Additional
Treatment.
. 0 . tur ,
nasal space. Nasal Pqssa" es Dzﬁegtﬁfniiar symptoms.
Numerous Excoriated. .. Obstructed re- Growths crushed with long thm
growths on spiration; dis- curved drcssmg forceps. Vin. fer.,
posterior wall turbed sleep. ol. morrhute. Garg.pot.chlorat.
of pharynx, ung. zinc. benzoat. to. nostrlls.—
visible on ra‘s- Operation 0. anaesthesm.
ing velum.
Extensive Occlusion of Deafness in- Shores; dys- Several pperations; ﬁrst with
mass of right from dis- creased ot'late; pnoea on exer- cutting ring, afterwards w1th
growths, and placement of extreme de- tion, but not L6wenberg’s_ forceps; nasal
hypertrophied septum; rhi- pressmnofboth marked;buceal bougies to dilate passages; was
tissue from nitis- membrana respiration; under observation till lllay, 1880.
vault to tubes. tympani; ob- keeps her Politzer’s process, catheter. _Lot.
structed Eus- mouth open, sodee carbol. ; mist. fer. et quin.
Free from
growths at pre-
sent time ;
catarrhal.
Vault and
entire posterior
nasal space
occupied with
growths,granu-
lar pharyngitis
and enlarged
tonsils.
Extensive
growths,ehieﬁy
in vault; en-
larged tonsils.

Nasal and
posterior nasal
eatarrh.
Catarrhal.
Right nasal
bone enlarged;
nasal passages
sore, much dis-
charge ; ex-
coriated exten-
sively.

tachian tubes.
Deaf, right;
granular poly-
pus occupying
right fundus;
detached and
necrosed manu~
brium present-
ing on face of
polypus.
Very deaf ;
H 1). right,
5 inches; left,
3 inches; both
membrane.
tympani de-
pressed; ma-
nubrium and
plicze injected;
obstructed
Eustachian
tubes.
No observable
deafness; no
chest defor-
mity.

Snores; keeps
his mouth
open ; voice
but slightly
affected.
Voice, nasal.

May 28, 1879. Polypus removed
with necrosed manubrium. Gutta:
plumbi diacet.; lotio sodae carbol.
to nose and ear. Mist. fer. co.
Lotio sod. carbol. to nose and
ears; zinc. chlor. to pharynx.
Politzer’s pr. cathetcr.-—September
19, r879, admitted; ﬁrst operation,
September 2 5 .~—November 3, made
out-pat1ent. -— Second operation,
October 23, 1880.——February 6,
third operation; afterwards treated
with gut. arg. nit. gr. v; to '53;
and catheter.
Lotio sod. earbol. to nose—Ad-
mitted October 8.—-October 14,
tonsils removed and some growths.
--October 21, second operation, c.
anaesthesia.
Whether other
members of
family affected.
Result—Remarks.
2 other chil-
dren also.
2 others ; his-
tory left no
doubt of early
existence of
growths which
had disappear-
ed when seen
ﬁrst, but to
which ear
symptoms were
due.
2 others.
Other
dren free.
chil-
Cured.
Cured; recovered
good hearing power
for voice.
November, 1879;
cured, with perma-
nent perforation of
membrane. tym-
pani, and some
eafness of right
ea!‘-
Growth cured;
attended for deaf-
ness till May, 1880,
when he could hear
fairly well.
Remained under
treatment till
March, 1880. chieﬂy
for bronchial ac-
tarrh; cured.

‘.LVOHHI. HHJ'. JIO SHSVHSICI
.462

O)
Maude
Hen der-
son.
Henry
Newshain.

9
yrs.
14
yrs.

1881
Feb. 8.
1819
July 4.

2 years, after
scarlet fever.
Several
years. (Sub-
se q u en t l y
stated to
have existed
7 years.)

Very exten-
sive growths,
ﬁllingposterior
nasal space.
Entire pos-
terior nasal
space; hyper-
trophied and
inﬂamed folli-
cles on pos-
terior wall of
pharynx.

Complete
obstruction,
buccal respira-
tion.
structed.
Quite ob-
structed on
right side ;
great thicken-
ing of inferior
and middle tur-
binated bones.

Quite deaf to
conversation ;
hears only
wthen shouted
a .
Very deaf ;
Eustachian
catarrh; left
tube pervious ;
right, closed;
m.t. thickened
and retracted.

Voice, nasal ;
night sweats;
no chest de-
formity.
Buccal respi-
ration ; nasal
voice.

Lotio sodae carboL; mist. fer.
quin.—March 1 1, admitted; opera-
tion same day; very extensive re-
moval from entire space; much
hzemorrhage, requiring posterior
space to be plugged, also anterior,
with tannin wool. Made rapid
recovery. Politzer’s pr.——Mareh 12,
T. 101'6; P. 124.——Mareh 13, T.
99'4; P. 120.
Lotio sodas carbol. and pot.
chlor. to nose ; catheter.—Septem-
ber 23, 187g,admitted—September
26, ﬁrst operation; with anaes-
thesia.-Out-patient, October 2.—
Oetober 21, readmitted—October
23, second operation; with anaes-
thesia—Out-patient, November 7,
1879 ; continue lotion and catheter.
—-February 6, 1880, 2 rowths re-
appeared and remove ; no anaes-
thesia—March 9, 1880, 2 growths
reappeared and removed; no
anaesthesia—June a6, 1880, re-
admitted ; third time; ﬁfth opera-
tion; space again cleared; with
anaesthesia—July 17, 1880, out-
patient—October 15, London
paste to growths.


May 20 _ cured;
hears whispering
voice; anaesthesia.
November 19,
1880; left to join
his rather in Ire-
land. In this case
growths obstinately
recurred; was im-
proving in health
and hearing power;
left Eustachian tube
was free, right par-
tially so. Relieved.
Ellen E.
Alleock.
William
Beecroft.
yrs.
13
yrs.
1880
Sept. 21.
1880.
Jan. 23.
9 months,
probably
longer.
6 months.
Vault and
posterior wall.
Growths on
vault and
on posterior
wall.
Partially 0b-
Very deaf;
membrane.
tympani re-
traeted.
Otorrhoea ; left
membrana
tympani de-
pressed and
thickened ; ma-
nubrium rest- “
ing on promon-
tory. Right
membrane
tympani has
interstitial de-
posit, and
iront of ma-
nubrium per-
forated.
Discharge
ex coriated.
Lotio sod. carbol. for nose.—
Se tember 28, 1880, admitted.
Poitzer’s pr .——October 8, 1880,
ﬁrst operation—October 1o,second
0perati0n.-—Discharged October
26, then made outpatient. Opera-
tions eanzesthesia.
January 23, 1880, lotio sod.
carbol. to nose and ears.--January
30, some growths removed;_no
anaesthetic; zinc. s. gr. VJ to 3,] to
cars; I’olitzer’s pix—March _ 5,
second operation ; no anirsthetic.
One sister.
May 17, 1881,
cured; membrane
tympani somewhat
ﬁat; hears well.
Much better ; dis-
continued attend-
ance; the father
being a couchman
had to leave Lon-
don.

86
'LVOHHI. HHQL HO SGISV'EISICI


IO
No.
Name.
Louise
Becroft.
Louisa
Haﬁleman.
William
Hill.
Margaret
Faber.
Frederick
' Owen.
l
A ge
and
sex.
4
yrs.
9
yrs.
9
yrs.
81}
13
yrs.

yrs.
Date of
atten-
dance.
1880.
Feb. 27.
1879.
Aug. 29.
1880.
June 29.
1879.
Dec. 5.
1881.
Feb. 8.
Prior dura-
Deafness and
Whether other


- Posterior , Additional
tion of Nasal passages. nature of ear Treatment. members of Result—Remarks
symptoms. nasal space‘ affection. Symptoms. family affected.
Several Vault exten- Embarrassed Not deaf. Voice thick. March 6, 1880, admitted; ope- One brother, Cured. Passed
Weeks- SiVe- “515111 l‘espim- ration; anaesthesia; lotio sod. as above. from observation
t1011, (‘Specially carbol. to nose.-—March 11, dis- on 19th of March;
at night. charged. same reason as
above; could
. breathe perfectly.
Several Vault and Post - nasal Some deaf~ Hypertro- August 29, 1879, lotio alum. 5j, Cured.
years. posterior wall- catarrh. ness; tubal phicd tonsils, cateehu ‘5ss, aq. 5x for nose.
catarrh. right worst, Politzer’s pr.—January 13, 1880,
in-patient ; operation with antes-
thesia; right tonsil also removed.
February 15, discharged.
3 months. Vault. Post - nasal Slight deaf- Lotio sod.carbol. to nose; Polit- Greatly relieved.
catarrh. ness. zer’s pr.; mistpot. chlor. ammon.c.
cinchon.—-August 20, iii-patient ;
operation with anaesthesia—Sep-
tember 3, discharged.
Several Prominent in Very deaf, Otorrhoea December 5, 1879,10tio sod. car- April 1, 1881.
years. middle line, right chronic in both. bol. to nose and ears—January 2, Nearly well, but
with much inﬂammation 1880, guttze zinc. s. gr. vj to 5g‘. still under treat-
thickened tis- of the middle Politzer’sprr—Febiuary6to Janu- ment. Very little
sue in neigh- ear, with per- my, 1881, growths removed with beneﬁt resulted
bouihood of loration of pos- anzesthesia ; lotio alum. 3j to 3x; from removing
Eustachian terior left ditto. Politzer’s pr.; when acid. boracic. growths, but when
tubes. Eustachian insufﬂatcd; lin. ammon. c. opio the hy ertrophied
tubes pervious, behind ears—February 12, in- tissue 'rom tubes
but caiarrhal. patient; operation to remove was removed hear-
In January, thickened tissue‘from tubes; ether mg rapidly im-
1880, left and chloroform. February 25, dis- proved.
middle ear be- charged relieved. [NIL—Alter
came acutely operation in February, 1881, T.
inﬂamed. rose 102°, P. 120°. Tr. acon. mj,
col. et rhei purge; rapidly re-
duced.
1 year. Vault and pos- Displacement Not very deaf. Laryngitis; February 8, 1881, lotio sod. car-
Cured.
terior wall; of tip of nasal obstructed bol. to nose; vap. benzoin. ung.
follicular pha- septum to the nasal respira- zine.chlor. to pharynx and larynx.
ryngitis. right; posterior tion; sleeps ——March 11, in-patient; operation;
nasal catarrh. with mouth amount of growth and tissue re-


open ; snores.


moved with anaesthesia proportion-
ately small.-—March 22, breathes
freely and hears quite well.—-April
19, sleeps with mouth closed.


‘.LVOHHI. HHL r10 SEISVEISIG
66a’

15
16
18
18
Adelaide
Lanigan.
Charles
J am es
Page.
John
Belson.
J ane
Head.

yrs.
yrs.
13
yrs.
21
yrs.

1881.
Feb. 15.
£881,
Mar. 25.
1881.
May 6.
1879.
Sept. 16.

4 years.
8 years.
18 months.
2 years.

Vault and pos-
terior wall ex-
tensive.
Vault and pos-
terior wall.
Growths on
posterior wall.
Growtlis on
posterior wall;
posterior nasal
catarrli.

Catarrhal.
Obstructed
respiration.
Catarrli.
Very deaf to
ordinary voice,
manubrium
onpromontory;
Eustachian
tubes open to
P0]. pr.
Deaf; tinni-
tus at night.
Occasional
vertigo. H.D.
right, four
inches; left,
three inches,
both mem-
brane. tympani
depressed; fun-
nel-shaped '
anterior.
Very
ll. 1)., right,
three inches;
left, one inch;
both mem-
brana tympani
depressed,
rig-ht injected
anteriosly.
Slight deal‘-
ness in left ear.
deaf
Hypertro-
phied tonsil;
health delicate;
obstructed
nasal respira-
tion.
Hypertro—
phied right
tonsil; night
sweats.
Hypertro-
phied tonsils ;
sleeps badly,
and snores
loudly.
Slight 0n-
lar emcnt of
r1 g it tonsil.

February 15, 1881, lotio sod.
earbol. to nose—February 22, 01.
morrh., vin. fen, zinc. 0111. to pha-
rynx and tonsil.——March 9, in-
patient—March 1 1, operation with
anaesthesia; much tissue and
growths removed; mist. amara;
l’olitzer’s pr.——March 15, dis-
charged; out-patient.
March 25, 1881, lotio sod. carbol.
to nose and ears—April 6, opera-
tion; Politzer’s pr.; out-patient.
—~April 22. H. D both 7 in.—
May 6, improving.
Arthur
Preston.
yrs.
1881.
April 1.
2% years.
Vault ; hyper-
trophied tissue
of posterior
wall.
Posterior
nasal catarrh.
Very deaf;
otorrhoea both;
granulation
polypus oc-
cuping inferior
half’ of the left
membrana
tympani.
April 1, 1881, lotio sod. carbol.
to nose and ears—May 1, in-
patient—May 11, operation with
anaesthetics; growths and thick-
ened tissue removed from posterior
wall of pharynx.
May 6, 1881,10ti0 sod. carbol. to
nose, g'arg. alum. fer. to pharynx.
—May 20, mist. fer. quin. cit.—
May 27, inpatient—May 3o, ope-
ration with anaesthesia; largish
growth removed from behind
velum, and much thickened tissue.
—June 7, out-patient; repeat.
September 16, 1881, lotio sod.
earbol. to nose; mist. fer. quin.
cit.; Politzer’s pr.--October 1.1,
right tonsil removed; zine to
pharynx—December 2, London
paste to granulations.—December
12, l’olitzer's pr., and applications
till June, 1880, when she was dis-
charged.

Cured. Under
treatment for
general health ;
hearing improves
daily.
Cured. June 24.
Hears quite well.
M embrana tym-
pani normal ;
breathes freely
through the nos-
trils; sleeps well,
and does not snore.
Treated through-
out as out-patient;
paste reduced
granulatious,whieh
were very acces-
sible. Cured.


300 DISEASES OF THE THROAT.
such of the vegetations as grow on the posterior wall of the pharynx, and
more especially to remove portions of thickened tissue above referred to as.
of frequent occurrence in this locality. I regard this latter proceeding as
equally imperative with the removal of the growths; as when this is superadded
to the latter it forms a greater obstruction to the tubal function than do the-
vegetations, and no improvement will result to the hearing power if the opera-
tion be limited to their ablation. For this latter purpose I have occasionally
used the galvano-eautery knife and have found it very efficient for the purpose.
Asa rule, Ifind it desirable to administer anaesthetics, because the operation
can be more efficiently performed, especially in young children, when the
patient is under their influence. Under these circumstances one operation will
frequently suffice for the entire removal of the disease, and it has the further
advantage, from its thoroughness, of rendering any after-treatment, by caustics,
‘$50., unnecessary. For the purpose of anaesthesia in young subjects, I prefer a
mixture of one part chloroform and three of ether to any other. In two cases
hmniorrhage occurred which required measures for its restraint, and in one of"
these plugging the posterior nares was had recourse to. Very frequently it
happens that, with the removal of the cause, the deafness gets well of itself.
But where the auditory apparatus has undergone lesion, in consequence of long‘
existing catarrh or obstruction of the tubes, this lesion will require treatment on
generally recognized principles.
DISCUSSION.
Dr. MICHEL, Cologne: I cannot agree as to the necessity of after-treatment
in order to prevent recurrence, for I myself have never seen recurrence. I
would rather believe that if digital exploration only is made, pieces remain
unobserved, are not removed, and are later looked upon as recurrences. The
use of a contra-respirator I consider only indicated after everything is removed.
I understand by “everything” all that is projecting from the posterior wall,
and is large enough to be caught. It is positively necessary to remove all that,
if it is wished'to get rid of all symptoms of impeded respiration, profuse secre—
tion, inarticulate speech, &c.
Dr. E. FRANKEL, Hamburg: I desire to speak on some etiological and
therapeutical points. In the ﬁrst place, I agree with Dr. Meyer with regard to
the inﬂuence of the climate upon the development of the disease. I have had
the opportunity of making observations on that point, having formerly lived
in Silesia, where the disease is rare, and dwelling now in Hamburg, where not
only is it much more frequent than in my former abode, but where it might
be ranked among the more common diseases. In a somewhat considerable
proportion of the cases the affection is congenital, as can be ascertained by
anatomical investigation, after Schalle’s method, of the naso-pharyngeal cavity
of children who died from other diseases. Sometimes a spontaneous retro-
gressive change takes place in these cases later on. In the smaller proportion
of the cases of adenoid vegetation the affection is, according to my observa--
tions, acquired and to be traced to catarrhal processes of the naso-pharyn—
geal cavity. The unfavourable influence of the vegetations upon certain
general diseases, especially upon diphtheria, is a fact not to be lost sight of.
Under these circumstances, very frequently the local affection becomes much
more extensive, and the false membrane has a tendency to extend into the
nose. As regards treatment, I consider the exclusive employment of the-
galvanocaustic method much too one-sided; certain forms belong, it is true,
to its domain; others can certainly be operated upon by different methods-
-—e. 9., by the cold wire, sharp spoon, &e. The galvanocaustic method
DISEASES OF THE THROAT. 301
’ does not positively prevent recurrence. In conclusion, I wish to mention the
occurrence of a disagreeable incident after the employment of the galvano—
caustic method, which consists in a tonic spasm in the region of the sterno-
cleido-mastoid muscle, which sometimes disappears after a few hours, sometimes
lasts for several weeks. I. am unable to give any explanation of this occurrence.
Dr. Bo'cKER, Berlin: I fullyagree with Dr. Heyer’s arguments, and only
wish once more to direct attention to the fact that in many cases the relationship
is not such that the enlargement of the pharyngeal tonsil is dependent upon a
chronic catarrh in the naso—pharyngeal cavity ; but that the congenital tonsil
produces and maintains the catarrh by its augmented secretion. If an oppor-
tunity be afforded of examining the naso-pharyngeal cavity of many small
children who are brought to the surgeon on account of dyspnoea, keeping the
mouth open, &0., the conviction will be arrived at that in most of these cases
the cause of this state of affairs is to be fraud in a congenital pharyngeal tonsil.
I have operated upon such vegetations i.1 children as early as the age of three
1nontlis—i.e., I have crushed them wiih my ﬁnger, and postponed the ﬁnal
operation till a later period. I think 1 hat in future more attention should be
paid to this point—via, that a congenital tonsil produces catarrh, and that
the naso-pharyngeal cavity should be properly examined in these cases.
Dr. HOPMANN, Cologne: My experience in this question is based upon an
observation of ﬁfty—eight cases, thirty-three of which were operated on. The
youngest patient was seventeen months, the oldest thirty-six years. In two-
thirds of all the cases hyperplasia of the pharyngeal tonsil in the form of
moderately sized knobs, plates, and peg-like processes was present. In the
remaining third an excessive proliferation, not only of the tonsil, but in several
cases also of the whole adenoid tissue of the superior pharyngeal cavity, quite
apart from the tonsil, was observed. Most of these cases were complicated by
considerable hypertrophy of the palatinal tonsils. I should like to propose the
name of “ adenoid tumours of the vault of the pharynx,’7 this name being more
comprehensive than the one now in use, “hypertrophy of the pharyngeal
tonsil.” As to treatment I have used wire loops, forceps, ﬁnger-nail, and sharp
spoon, according to the circumstances of the case. In 1875, in which year I ﬁrst
operated, I used the galvano caustic écraseur, in the form recommended by
Professor Voltolini, especially for the operation of the palatinal tonsil. As I
soon found, however, by experience that when the loop was simply tightened
the pieces of the growth remained in it, even before the current was passed
through the wire, I generally use only the cold wire, and employ the
heated wire only in the eicessive forms which are distinguished by the develop-
ment of ﬁbroid tissue in the bases of the tumour. In conclusion I wish to draw
attention to the fact that in the case of larger tumours, in which frequently
adhesions of the single proliferations between each other and especially between
them and the posterior wall of the pharynx exist, the operation is greatly
facilitated by a previous separation of the adhesions by means of the ﬁnger-
nail, or of an appropriately curved little knife, which is introduced parallel
and close to the posterior wall up to the base of the skull, and which is moved
from side to side. -
Dr. MEYER replied, urging the diffusion of the knowledge of so serious a
malady, and of the means of contending with it.
Dr. LOEWENBERG, in his reply, dwelt especially on the prophylactic
treatment.
DJ
O
N
DISEASES OF THE THROAT.
Die N am?’ mm’ Behandlung der 02mm.
Dr. B. FRANKEL, Berlin.
Wir nahen dem Schlusse unserer Verhandlungen und es bleibt uns
noch die Besprechung eines Leidens, durch welches die Natur in vom teleo-
logischen Standpunkt aus ungerechtfertigter Weise den Sitz eines höheren
Sinnes so entarten lasst, dass er denselben Sinn anderer Menschen in der
erhehlichsten Weise belüstigt. W'ir haben noch üben, Ozaena zu verhandeln
und werden wir wohl alle unserem Comite dankbar dafür sein, dass dieser
Gegenstand auf unsere Tagesordnung gesetzt worden ist, denn die Ozaena hat _
in der letzten Zeit im Vordergrund der Discussion gestanden, und will ich
versuchen, die Fragen,zu pracisiren, die besprochen wurden und voraus-
sichtlich auch den Gegenstand unserer heutigen Discussion bilden werden.
Da ist zunächst der Name, Ozsena, ehrwürdig durch sein Alter und klar
in seinem Begriff. Ozzena sind Nasenleiden, die stinken. Weiter aber sagt der
Name nichts. Er bezeichnet lediglich ein Symptom, wie Husten, Zahn-
schmerzen. Diarrhöe und ist an und für sich nicht geeignet in unser auf ana—
tomisch-atiologischc Gesichtspunkte gegründetes nosologisches System als
eine Krankheit suz' generis eingefügt zu werden. Es entsteht die Frage, sollen
wir nun denselben ganz aufgeben, oder durch unsere Epitheta geeignet machen,
für uns eine stringente Bezeichnung zu werden? Das ist zun‘a'chst eine
unserer Discussion unterliegende Frage!
Aus dem grossen Bereich von Krankheiten, in denen Gestank aus der Nase
beobachtet wird, verdient zunächst eine Form unsere Beachtung, in welcher
sich keine Erkrankungen der Knochen, keine Ulcerationen oder dergleichen
tiefere Erkrankungen, wohl aber der Gestank in der exquisitesten‘Weise
ﬁndet. Es gehört diese Form dem atrophischen Gatarrh an, wie die makro—
skopische Beobachtung der Schleimhaut und die sich immer mehr hüufenden
mikroskopischen Untersuchungen ergeben. Bei dieser Form ﬁnden sich dicke,
eingetrocknete Borken, welche stinken und an welchen der Gestank haftet.
Sie bestehen aus untergehenden Gewebstheilen und Micrococcen und füllen
zuweilen die ganze N asenhöhle aus. Ich glaube, es genügen diese Andeutungen,
um in diesem Kreise das Leiden zu charakterisiren. Es entstehen dabei die
Fragen: Sollen wir fernerhin nur noch diese uns am hauﬁgsten vorkommende
Form der Ozzena als solche bezeichnen, oder sollen wir sie Ozaena simplex oder
catarrhalis nennen? Ware es nicht besser zu sagen: “ Catarrhus atrophicus
ozaenicans”—denn es bleibt uns auch zu discutiren übrig, ob der Gestank bei
diesem Leiden ein so wichtiges Symptom ist, um seinetwegen ein besonderes
Leiden aufzustellen ?
Ich glaube aber, wir thun gut, uns in unserer Discussion lediglich dieser
Form der Ozaena zuzuwenden und die anderen in hohem Grade interessanten
Fragen zu verfolgen, die sich daran knüpfen. I/Volzer kommt der Gestank?
Die Antwort lautet: Aus der Zersetzung der Secrete! Aber nicht alle sich
zersetzende secrete der Nase haben den speciﬁschen Nasen-Gestank. Ist es
no'thig, dass ein besonderes Ferment hinzu komme ? Sind es besondere Formen
der Zersetzung, die sich hier ﬁnden? Genügt es, dass überhaupt in der Nase
Zersetzungen vor sich gehen, um den speciﬁschen Gestank zu erzeugen?
Weiter: ist es immer eine atrophische Schleimhaut, die diese Form der Ozgena,
bedingt? Kommt dieselbe auch beim hyperlrophisclwn Catarrh vor? Ich
glaube, es ist immer eine atrophische Schleimliaut vorhanden, denn ich denke,
dass der Verlust der Drüsen erst die Eintrocknung der Secrete ermöglicht.
Nasen mit I-Iypertrophie können auch zuweilen stinken, zeigen aber nicht
den speciﬁschen Ozmna-Gestank.
DISEASES OF THE THROAT. 30 3
ine weitere Frage ist die: Ist dieser stinkende atrophische Catarrh immer
ein constitutionelles Leiden? Welche Fehler der Constitution bedingen diese C’
Ich glaube, an und fur sich beweist er keine Dyskrasie, und unter den consti-
tutionellen Krankheiten, die hier in Frage kommen, sind diejenigen in den
Vordergrund zu stellen, die zum atrophischen Catarrh führen, sicher Scrofulose
und vielleicht Syphilis.
Wenden wir uns der Behandlung zu, so wird sich gegenüber dieser Krank-
heit kein Arzt wie ein Schöpfer vorkommen, der neues Leben schafft! ‘Vie
gern würde unser von hohem Mitleid bei diesem ekelhaftem Leiden
ergriffenes Herz hülfreich sein—aber es bleibt auch heute noch die Frage
bestehen : Können: wir diese Ozæna heilen .7 Die Antwort darauf lautet:
Die Atrophie sicher nicht, vielleicht aber das lästige Symptom: den Gestank.
Um diesen zu entfernen, dazu dienen uns zunächst Douchen, die die stinken—
den Secrete herausbefordern. Auch zeigt die Erfahrung, dass die Gottstein’sche
Tamponade die Borken auﬂöst und den Gestank vermindert. Gegen die
Eiterung der atrophischen Schleimhaut leisten Adstringentien und die Galvano-
caustik die besten Dienste. Meine Herren! Es wäre über Ozæna noch viel
zu sagen, ich habe mich aber absichtlich auf die Vorlegung der Fragestellung
beschrankt; es bleibt Sache der Discussion das Neue zu Tage zu fördern.
La nature 62‘ [e Zraztemmz‘ de Z’ozène.
Dr. E. FOURNIÉ, Paris.
‚Natura de l’ozèna—L’ozène constitue-t-il une maladie distincte? Nous
examinerons d’abord si l’ozène constitue par lui-même un état morbide
distinct, ou bien s’il est l’eXpression de plusieurs états morbides différents.
Jusqu’a ces dernières années, les mots “ozène” et “coryza chronique”
servaient à désigner la même affection. Encore, en 1869, Desnos, dans un
excellent article du “Dictionnaire de médecine et de chirurgie pratiques,”
accepte cette synonymie, et, si on cherche dans le même ouvrage le mot ozène,
on ne trouve qu’un simple renvoi. Pourtant, Trousseau, dans ses cliniques,
faisait déjà. remarquer que, souvent, l’ozène affecte des allures particulières
qui en font une maladie a part: “Lorsque, dit-il, rien ne permet de penser
qu’il existe une phlegmasie de la membrane pituitaire, une nécrose des os du
nez ; quand l’individu atteint de punaisie a les attributs de la plus ﬂorissante
santé, nous nous voyons forcé d’admettre que, dans ces cas, la sécrétion nasale
a une fétidité spéciale, et c’est réellement cette forme de l’ozène qu’il faudrait
conserver l’épithète de punaisie constitutionnelle.”*
Cette remarque, pleine de justesse, resta pendant longtemps lettre morte;
mais, quelques années plus tard, VVarrington HaWard ajouta aux trois variétés
d’ozène habituellement admises: ozène scrofuleux, syphilitique et traumatique,
un quatrième groupe, l’ozène idiopathiqueq" L’auteur anglais, il est vrai, reste
muet sur la pathogénie de cette dernière forme. Il se borne faire remarquer
qu’il a souvent _eu l’occasion d’en observer des exemples chez des enfants
récemment atteints de rougeole ou de scarlatine, et chez des jeunes femmes mal
réglées.
Plus familiarisés avec l’examen rhinoscopique, les médecins durent bientôt
reconnaître que l’ozène n’est pas fatalement lié à l’existence d’altérations
sérieuses de tissus. Restait alors en trouver la cause. Quelques—uns s'en

* Trousseau, “ Clinique médicale,” 3me édition, t. i. p. 544.
1- “St. George’s Hospital Reports,” vol. viii. 1874-76, p. 123.
304 DISEASES OF THE THROAT.
\
tirèrent a bon compte; ils prétendirent que, dans l’ozène, les désordres ana-
tomiques sont constants, mais que les ulcérations, cachées dans la profondeur
des cavités nasales, échappent aisément à l’examen. l‘vîalheureusement pour
la théorie, des autopsies, dont les résultats furent plus tard conﬁrmés par
les recherches de Hartmannfx' démontrèrent l’absence de lésions nasales
spéciﬁques.
Bien que Trousseau ait écrit que: “on voit fréquemment des personnes
dont les narines sont extrêmement étroites de telle sorte que l’air ne passe pas
par le nez en quantité sufﬁsante pour les besoins de la respiration, et chez
lesquelles, cependant, les sécrétions nasales ne prennent jamais d’odeur ;”1‘ bien
que pareil fait soit d’observation journalière, certains médecins, à l’exemple de
Sauvage, incriminent l’étroitesse des fosses nasales. Dans une note sur le
catarrhe chronique, le Dr. Tillotj: se range a leur avis et pense que “la réten-
tion du mucus au milieu dés cavités nasales rétrécies par la disposition
naturelle des os du nez suffit bien seule pour expliquer l’inﬁrmité si fréquente
chez les individus ainsi conformés.
Avec Zaufahë Michel," Gottsteinﬁl la question entre dans une phase nou—
velle, et l’ozène idiopathique se substitue dans l’attention des médecins à. l’ozène
symptomatique. Ce n’est plus l’étroitesse des fosses nasales qu’il faut
incriminer, mais bien au contraire leur ampleur. D’après Zaufal, la fétidité
trouve sa raison d’être dans une disproportion considérable entre la capacité des
fosses nasales et la force du courant d’air expiré. Cet accroissement de
capacité est dû au volume rudimentaire du cornet inférieur, lequel joue, a l’état
normal, un rôle si important dans le balayage du nez par la colonne d’air de
l’expiration. On comprend dès lors que, difficilement entraînées par un
courant trop faible, les sécrétions nasales s’accumulent, se déssèchent, et
forment des croûtes, qui conservent même après leur expulsion, une odeur
repoussante.
Mais la question n’est pas résolue complètement. Cet augmentation de
capacité des fosses nasales, cause immédiate de l’ozène, est—elle primitive?
N’est-elle Point consécutive à une lésion des sinus? Suffit-elle a expliquer
l’apparition de l’ozène ?
Si l’on en croit Michel, des causes adjuvantes sont nécessaires; il doit y
avoir en même temps, du catarrhe chronique des sinus sphenoïdaux et ethmoï—
daux.
Quant a Gottstein, il admet que l’ozène n’est que la troisième période d’un
catarrhe chronique dont les deux premiers stades sont passés inobservés; la
muqueuse, rouge, enﬂammée, s’est d’abord hypertrophiée, puis a la longue, a
l’hypertrophie a succédé l’atrophie. Celle-ci son tour entraîne l’atrophie des
cornets sous-Jacents.
Pour Zaufal, au contraire, la déformation du squelette est primitive et
congénitale. Cette théorie, soutenue également par Zuckerkandl trouve un
appoint considérable dans ce fait que, généralement unilatéral, l’ozène peut être
héréditaire ; tout comme la déformation nasale qui lui donne naissance. Cette
manière de voir a été également soutenue dernièrement dans une thèse
remarquable de M. le Dr. Martin.’H _
Il résulte de l’aperçu historique qui précède, que mieux éclairés, la plupart
des médecins reconnaissent aujourd’hui l’existence d’une ozène idiopathique

* Deutsch. med. Wochensclw'ift, 1878. + “ Clin, Méd_n t. L
I Ann. des mal. de Pareille et du larynx, t. ii. p. 112.
§ “De l’application du serre-nœud à l’opération des polypes du nez,” 1878.
|| “ Maladies du nez et du pharynx.” Berlin : 1876.
1] Brcslau. ärztl. Zeitsch. “ De l’ozène vrai :” Thèse de Paris. 1881.
DISEASES OF THE THROAT. 305
constituant par lui-même un état morbide et se distinguant par des caractères
particuliers des autres états morbides. Examinons ces caractères.
Caractères distinctifs de l’ozène.—Ces caractères nous les trouvons dans
l’odeur, dans l’altération particulière des secrétions de la pituitaire, dans cer-
taines lésions anatomiques, et, par exclusion, dans l’absence de toute autre
affection susceptible de se localiser dans les fosses nasales.
A. Odezm—L’odeur de l’ozène vrai est tout à fait caractéristique; mais ce
caractère ne peut être bien apprécié que par les médecins qui voient—il serait
plus juste de dire qui sentent—beaucoup d’affections nasales; il y a, en effet,
dans ce sujet, des nuances, des intensités, des resemblances et des différences
qu'on ne saisit bien que par des comparaisons multipliées et après une assez
longue pratique. L’odeur de l’ozène vrai ne ressemble ni à l’odeur inﬂammatoire,
ni à l’odeur de la carie, ni à l’odeur de la nécrose, ni à l’odeur de la syphilis,
elle est sur: genem's, et, pour la connaître, il faut l'avoir sentie. Elle présente
cependant des nuances qu’il n’est pas inutile d’indiquer. Dans les cas peu
prononcés elle est moins désagréable et rappelle l’odeur de la marée: c’est
cette même odeur atténuée que présentent les malades atteints d’ozène intense
après le nettoyage et le lavage des fosses nasales.
D’où provient l’odeur de l’ozène ?
Cette odeur ne peut pas provenir d’inﬂammation, puisque dans l’ozène
l’inﬂammation est beaucoup moins intense que dans certaines maladies u
ne donnent d’autre odeur que l’odeur fade de l’état inﬂammatoire.
Proviendrait—elle de la présence de certaines microbes? Nous n’ignorons
pas qu’on a trouvé le bacterium fœtidum de la sueur des pieds mais per—
sonnellement nous ne sommes pas ﬁxé sur la légitimité du rôle qu’on a fait
jouer à. cet élément organique. Cependant, l’occasion était trop belle ici pour
ne pas la saisir et nous avons étudié, avec le microscope, les produits de sécrétion
de deux malades en traitement. A plusieurs reprises nous avons retiré des
mucosités molles ou durcies que nous delayions aussitôt dans un peu d’eau dis-
tillée et nous mettions une goutte du mélange sur l’objectif.
Nos examens n’ont abouti qu’a constater la présence de débris de cellules
et celle de quelques micrococcus dans lesquels nous n’avons pu reconnaître rien
de spéciﬁque.
Ces recherches sont sans doute insuffisantes et nous ne sommes pas autorisé
à en tirer une conclusion ; mais elles offrent un trop grand intérêt pour que nous
ne les reprenions pas dès que l’occasion se présentera. Si on obtenait quelque
chose dans cette voie ce serait la justification des idées de Ziem, qui attribue
l’ozène a la présence d’un ferment.
Doit-on attribuer le développement de l’odeur a une certaine conformation
du nez et des narines favorisant l’accumulation des produits de sécrétion et
s’accompagnant d’un état inﬂammatoire plus ou moins intense? Cette manière
de voir professée particulièrement par Zaufal est plausible, mais nous ne la
partageons pas pour plusieurs raisons.
Premièrement nous avons bien des fois rencontré l’ozène vrai avec une con—
formation intérieure et extérieure du nez absolument irréprochable. En ce
moment même nous soignons une jeune femme qui résume dans ses traits regu-
liers le type de la jolie femme et qui, néanmoins, est atteinte de l’ozène vrai
avec croûtes revêtant la paroi du pharynx nasal.
Secondement, très-nombreux sont les malades qui présentent du coryza
chronique avec sécrétion abondante et qui n’ont pas d’odeur, bien que leur nez
écrasé, la dilatation hypertrophique des narines leur donne les apparences
extérieures des individus atteints d’ozène. Nous avons en ce moment même une
jeune institutrice de Mannheim, qui présente tout à. fait ce type et qui cependant
n’exhale aucune odeur.
PART III. X
306 DISEASES OF THE THROAT.
Disons enﬁn que s’il était vrai que l’odeur est engendrée par l’altération
des mucosités retenues dans le nez, il suﬁirait d’entretenir la propreté des narines.
pour empêcher l’odeur de se développer. Or, c’est un fait non douteux, le
lavage atténue l’intensité de l’odeur, mais pourquoi? 1°, parce qu’on a fait
disparaître un de ses principaux foyers, les croûtes; 2°, parce que les glandules
elles-mêmes qui fournissent les mucosités et l’odeur ont participé a ce nettoyage.
S’il en était autrement, si l’odeur était due à. la cause invoquée plus haut, elle
ne devrait se reproduire qu’après un certain temps, c’est-a-dire apres le temps
nécessaire a l’altération des mucosités. Or, ce n’est pas ce qui arrive et l’odeur
se reproduit aussi intense qu’auparavant quelques heures après le nettoyage, si
on n’a employé que de l’eau pure.
Nous ne nions pas cependant l’inﬁuence d’une certaine conformation des
narines. Nous croyons, par exemple, que la dilatation des cavités nasales
favorise le dessèchement des mucosités, mais nous ne saurions admettre
que le séjour prolongé de ces dernières dans le nez soit la cause de l’odeur
spéciﬁque.
Les auteurs qui soutiennent l’opinion que nous venons de critiquer ont
observé un fait relativement vrai, c’est la coïncidence éventuelle d’une certaine
conformation du nez et des narines avec l’ozène, mais cette conformation doit
être considérée, selon nous, comme conséquence de la cause plus éloignée qui a
produit en même temps l’ozène et non comme la cause immédiate de l’ozène.
En d’autres termes, certaines conformations vicieuses du squelette indiquent
un état constitutionnel qui se manifeste également par de l’ozène.
Voici à présent comment nous comprenons le développement de l’odeur.
Nous considérons l’odeur particulière de l’ozène comme un produit de sécré-
tion des glandes de la pituitaire. Chaque région du corps, au point de vue qui
nous occupe, a une odeur suz' generz's qui s’exhale naturellement ou que l’état
morbide met en relief, telles: l’odeur de la respiration buccale et nasale, l’odeur
des aisselles, l’odeur de la sueur des pieds, l’odeur de la tête, l’odeur des parties
génitales, l’odeur des abcès du périnée ou de l’aisselle, l’odeur de la stomatite
mercurielle, &c. .
Eh bien, les glandes de la pituitaire sécrètent elles aussi, une odeur par-
ticulière et cette odeur, dans certains cas, revêt les caractères spéciﬁques de
l’odeur de l’ozène. Ce qui prouve d’ailleurs qu’il en est ainsi c’est que les
produits de sécrétion retirés des narines présentent la même odeur. Sur ce
point il ne nous semble pas qu’on puisse dire plus.
Il est bien plus utile de chercher comment il se fait que, dans certain cas,
l’odeur naturelle de la pituitaire revêt les caractères de l’odeur de l’ozène, car
ceci nous place sur le véritable terrain de la nature de la maladie.
Si nous éloignons l’idée de toute cause inﬂammatoire aiguë ou chronique—
car l’expérience de tous les jours prouve que les inflammations les plus intenses
peuvent siéger dans les narines sans provoquer de l’odeur; si nous éloignons
également les causes spéciﬁques que peuvent donner lieu a des lésions odorantes-—
ces dernières se distinguent sufﬁsament de l’odeur de l’ozène vrai—nous restons
en présence d’une seule cause possible ; l’état constitutionnel de l’individu, état
qui provoque dans les acini de la membrane de Schneider une sécrétion d’odeur
morbide, de la même manière qu’il provoque ailleurs des sécrétions purulentes,
des altérations osseuses, &c. .
Telle est la manière de voir a laquelle nous a conduit notre expérience
personnelle, sur la cause première de l’odeur de l’ozène.
B. Altêratz'ons des sécrétions de la pituitaira—Le second caractère de
l’ozène que nous ayons à examiner est l’altération particulière des produits de
sécrétion de la pituitaire et de la muqueuse pharyngo-nasale. Ce qui frappe
tout d’abord dans l’examen de ces produits, c’est la tendance qu’ils ont à se
DISEASES OF THE THROAT. ' 30 7
concréter. Quelle que soit la forme de l’ozène, les produits de sécrétion se
concrètent toujours et plus rapidement que dans d’autres états morbides. Cela
dit, il nous paraît utile de considérer ici une forme humide et une forme
sèche.
Dans la forme humide les mucosités se concrètent en paquets, mais sans se
dessécher, elles sont entourées d’une certaine humidité due probablement à la
prédominance de l’état catarrhal. On rencontre surtout cette forme chez les
natures scrofuleuses.
Dans la forme sèche, les mucosités non seulement se concrètent presqu’im-
médiatement après leur sortie des glandes, mais encore elles se dessèchent,
prennent une teinte noirâtre ou grise et adhèrent fortement à la muqueuse.
Cette forme affecte de préférence le pharynx nasal et la partie postérieure des
fosses nasales.
La rapidité de formation de ces produits est telle que du jour au lendemain
ils recouvrent de nouveau la surface qu’on avait pris soin de nettoyer. Leur
adhérence est telle sur le pharynx nasal que souvent on est obligé de les saisir
avec des pinces, et encore ne les enlèvent-on que par morceaux.
Il est évident que ces produits ne ressemblent en rien aux produits de sécré-
tion qui accompagnent les autres états morbides, et que la rapidité de leur
formation éloigne toute idée d’une cause mécanique provenant de la trop grande
dilatation des narines. Il y a quelque chose de plus, et ce quelque chose est une
altération spéciﬁque des glandes qui fournissent le mucus.
C. Le'sz'ons anatomiques—Les lésions anatomiques qui accompagnent l’ozène
ne sont nullement en rapport, par leur peu de gravité apparente, avec l’intensité
de la maladie; un peu d’injection de la muqueuse, quelques excoriations sous
les croûtes telles sont les seules lésions qu’on rencontre dans un examen super-
ﬁciel. Cependant, en voyant de plus près les choses, et après un certain temps
d’expérience, on arrive à constater des modiﬁcations plus sérieuses sur lesquelles
Zaufal et Michel ont appelé les premiers l’attention. Nous voulons parler de
l’atrophie progressive des parties molles qui recouvrent les cornets et princi-
palement le troisième. Cette atrophie résultant d’un véritable catarrhe atrophique
aurait été précédée, selon M. Gottstein, d’un catarrhe hypertrophique et
conduirait à la guérison spontanée de l’ozène vrai quand elle a atteint le cornet
lui-même.
Quoiqu’il en soit, l’atrophie de la muqueuse et des parties sous-jacentes est
un fait généralement vrai, mais surtout dans la forme humide, catarrhale et
coïncidant avec le tempérament scrofuleux. Nous ne l’avons jamais rencontrée
dans la forme sèche.
Voici d’ailleurs les caractères particuliers de ces deux formes :—
A. Forme sèche.——Il y a des personnes qui présentent un ozène très-prononcé
sans qu’il y ait catarrhe. Mais si l’on regarde dans les narines ou dans la région
pharyngo—nasale on voit la muqueuse recouverte, par places, d’un enduit noirâtre
assez adhérent. Cet enduit s’accumule très souvent vers la partie postérieure
du plancher des narines et forme la de véritables paquets qui séjourn‘ent long-
temps si on ne les retire pas.
Au-dessous de cet enduit noirâtre la muqueuse est rouge, saignante excoriée
plutôt qu’ulcerée. Nous tenons beaucoup a cette distinction parce que l’on a
toujours fait jouer un grand rôle a des ulcérations qui n’existaient pas ou qui
ne sont pour rien dans la genèse de l’odeur. Cette forme se rencontre surtout
chez les constitutions entachées d’herpétisme.
B. Forme humz'da—C’est la plus fréquente. La muqueuse qui recouvre les
narines est plus ou moins gonﬂée, tomenteuse, excoriée par places, surtout au
niveau des parties resserrées de la cavité nasale et, en ces points, recouverte de
petits amas de matière muco—purulente, plus ou moins tachée de noir. Cette
‘ x 2
308 DISEASES or THE THROAT.
matière se présente en grande quantité sur la partie postérieure du plancher
des narines où elles se réunissent en paquets plus ou moins bruns, plus ou
moins durs, mais jamais ni aussi noirs ni aussi durs que dans la forme sèche.
Un point qui m’a paru être un siége de prédilection des manifestations morbides
estle pourtour de l’oriﬁce postérieur des narines formé par le bord postérieur du
vomer, les palatins et le spheno‘ide. C’est la surtout que l’on voit de petits
amas, comme des grains de millet, formés par du muco-pus et une matière
brune qui simulent des ulcérations à, fond grisâtre. Si on enlève ces amas
on trouve a leur niveau la muqueuse gonﬂée, saignante, mais non ulcéree
profondément.
Tels sont les caractères anatomiques que nous avons relevés dans l’ozène.
Il résulte donc de ce qui précède, que l’ozène constitue un état morbide
distinct de tout autre et caractérisé par une odeur spéciﬁque, par des pro-
duits de sécrétion altérés d’une façon spéciale, et enﬁn par des lésions
anatomiques particulières. Cet état morbide serait, à notre avis, dû a une
disposition constitutionelle et non a des causes ambiantes, mécaniques ou
autres.
2.——Traz'tement de l’ozèna—S’il est vrai que les médications nous montrent
la nature des maladies, naturam morborum ostendunt curatz'ones, il n’est pas
moins certain que, la nature d’une maladie étant connue, nous sommes en
état d’instituer un traitement sinon toujours efficace, du moins très-rationnel.
Partant de cette idée, que l'ozène est un état constitutionnel provoquant des
altérations particulières dans la membrane de Schneider, nous sommes conduit :
10 a modiﬁer la constitution; 2° à réprimer localement les manifestations
morbides. i _
Parmi les modiﬁcateurs de la constitution nous donnons la préférence aux
bains sulfureux pris par séries de douze chaque fois, trois ou quatre fois Pan,
chez ceux qui présentent la forme humide. Nous leur faisons prendre en
même temps, soit de l’huile de foie de morue, soit de l’iodure de potassium, soit
de l’iodure de fer, selon les besoins du moment.
A ceux qui présentent la forme sèche, nous leur recommandons plutôt les
bains alcalins alternés avec les bains arsênicaux, également par séries de
douze trois ou quatre fois Pan.
En même temps, nous leur faisons prendre alternativement l'arsénic et le
bicarbonate de soude a l’intérieur.
Quant au traitement local, il comprend: (1) les soins de propreté (2) les
agents capables de neutraliser l’odeur ; les agents modiﬁcateurs des parties
malades.
(1) Soins de propreté—Les soins de propreté consistent en lavages répétés
deux ou trois fois par jour avec de l’eau tiède additionée de sel marin (une
cuillerée à café par litre). Ces lavages peuvent être eiÏectués, soit avec le
syphon de Weber, soit avec la seringue anglaise. Cependant, nous devons dire
qu’avec ces appareils on s’expose a des inconvénients, qui pour n’être pas
fréquents n’en sont pas moins réels. Nous voulons parler de la pénétration
éventuelle de l’eau soit dans les trompes, soit dans la bouche.
Le seul moyen de fermer la trompe et en même temps l’oriﬁce bucco—nasal,
consiste à contracter les péristaphylins, comme nous l’avons démontré autre
part. Mais, comme il n’est pas toujours facile de soumettre ces muscles a la
direction de la volonté, nous avons cherché un acte physiologique, compréhen-
sible et facile pour tous, qui nos donnât le résultat désiré. Cet acte consiste a
soufﬁer fortement dans un tube, et, pour ne pas perdre cette dépense de travail,
nous lui faisons remplir l’ofﬁce de la poire de caoutchouc que l’on place sur les
ﬂacons pour pulvériser de l’eau. L’appareil dont nous nous servons ne
pulvérise pas de l’eau, mais il injecte l’eau avec l’énergie que l’on désire dans la
DISEASES OF THE THROAT. 309
région pharyngo-nasale.* Avec ce appareil on est a l’abri de la pénétration
de l’eau dans les trompes et de sont passage dans la bouche.
Les lavages ne suffisent pas toujours à débarraser les narines des mucosités
qu’elles contiennent. Il est indispensable alors de les détacher avec une tige
terminée par un bout entouré de coton qu’on introduit dans les narines, ou.
bien, s’il s’agit de la région pharyngo-nasale, avec une tige recourbée et des
pinces.
Parmi les moyens de pansement, nous devons signaler particulièrement le
coton introduit dans les narines.
M. Zaufal emploie le coton pour remédier à. l’élargissement des narines;
M. Gottstein l’emploie dans le but d’exercer une action irritative et sécrétoire.
Quant à. nous, nous nous en servons avec l’idée de faire du Lister, ou plutôt
dans le but que se propose d’atteindre M. Alphonse Guérin (selon les indica—
tions de Pasteur) dans le pansement ouaté des plaies. Selon nous, la ouate
introduite dans les narines empêche les germes de l’extérieur de pénétrer et
d’agir sur les mucosités, qui ont déjà. une tendance a se décomposer. Quelle
que soit d’ailleurs l’idée théorique qui préside à. l’emploi du coton, ce moyen
est excellent comme palliatif, et nous ne saurions trop le recommander.
(2) Les agents neutralisateurs de l’odeur sont très-variés depuis le perman-
ganat de potasse jusqu’à. l’iodoforme. Nous donnons la préférence à. l’acide
borique (3 gr. p. 500 gr. d’eau) et au salicylate de soude (10 gr. p. 500 gr.
d’eau).
Ces agents doivent être employés à, la dose d’une petite seringuée par narine
immédiatement après le lavage.
(3) Les agents modiﬁcateurs de la muqueuse sont nombreux ; nous employons
à. cet effet les eaux minérales sulfureuses, alcalines, arsénicales et enﬁn la solu-
tion de nitrate d’argent au cinquième et la teinture d’iode pure ou mélangée par
moitié avec de l’acide phénique.
Nous employons les eaux minérales comme eaux de lavage, à la place de
l'eau salée quand le malade prend des bains.
Quant aux caustiques, nous les appliquons au moyen d’une tige terminée
par du coton tous les deux ou trois jours et en nous servant du speculum mm‘,
Il nous est impossible, ici, d’entrer dans les détails, mais ces indications
générales adressées à des médecins qui sont comme nous au courant de ces
questions nous paraissent suﬂîre.
D’ailleurs, les moments de cette lecture sont comptés et nous ne saurions,
sans indiscrétion, aller plus loin.
Bornons-nous à, dire, en terminant, que grâce surtout aux travaux des mé-
decins spéciaux, qui manient le laryngoscope et le rhinoscope, l’ozène n’est plus,
de nos jours, une maladie désespérante et rebelle à. nos moyens. Aujourd’hui,
le médecin peut toujours pallier convenablement les inconvénients de l’ozéne et
bien souvent en triompher.
T/ze Clinical Aspects 0f Chronic Discharges from Me
N ash/ii; and 02mm.
Mr. SPENCER WATSON, London.
I recognize three typical forms of chronic rhinorrhœa, the outcome 01
which in the later stages may be ozæna: 1. The eczematous or scrofulous
form, beginning in infancy or early childhood, and being then associated with

‘ï? M. Roustan, de Montpellier, a eu une idée analogue pour l’insuﬁlation de la trompe ;
mais le principe est différent.
3 IO DISEASES OF THE THROAT.
the characteristic physiognomy of scrofula. 2. The phthisical or lupoid form,
beginning generally in youth or early adult life, in individuals of a family
other members of which are phthisical or ozaenic; the physiognomy being
in these cases such as is often associated with phthisis, and the face being
sometimes scarred by lupoid ulcers or the traces of lupus erythematosus.
3. The syphilitic form. The hereditary syphilitic physiognomy in youth and
adult life, and especially the sunken bridge of the nose and the Hutchinsonian
upper incisor teeth will enable us to recognize this form. It begins in very
early infancy. It is not necessarily or commonly associated with diseased bone.
It is often aggravated by nasal stenosis. The syphilitic ozaena of acquired
syphilis, on the other hand, is often asociated with diseased bone, and is
recognized rather by the character of the ulceration and the personal history
than by physiognomical peculiarities.
There are besides these three typical forms of rhinorrhoea mixed and
intermediate forms, but it is generally possible to classify cases of ozaena under-
one or other of these heads. The oza¢na described by some authors (6.9.,
Trousseau) as constitutional, and by others as ozaena by exhalation (6.9.,
Cozzolino of Naples), may perhaps be only cases of lupoid origin in which the
external manifestations are very slightly pronounced.
In making a diagnosis of these various forms we have to consider : l. The
age. 2. Physiognomy. 3. Family history. 4. Rhinoscopic inspection. 5. Results,
of treatment. In regard to rhinoscopic inspection I will only say that the
presence or absence of ulceration Will often determine the question as to-
acquired syphilis being the cause; and that anterior rhinoscopy gives often
more information than posterior. I gave a description of my method of anterior
rhinoscopy in No. 1 of the Specialist, September 1, 1880, illustrated by wood-
cuts. In ﬁg 4, on page 5 of that number, the patient is represented as spread-
ing out and drawing down the upper lip, while the hooks of the dilator draw
the ala outward and the tip of the nose upward. In ﬁg. 5 another method is
shown; it is somewhat simpler, and answers better in some cases.
Treatment—In no single case of ozaena can an unvarying line of treatment
be adopted throughout the case. The ozaena of to-day is an entirely different
thing from that of yesterday, and to-morrow will bring about another phase of
the disease.
Many of our failures have probably been due to our not recognizing this
extremely perplexing feature of ozaena, and to our too obstinate persistence in
some favourite method of attack, and too little regard for the protean and
treacherous character of the foe. To-day perhaps the nostrils are completely
blocked by dry greenish crusts, yesterday they were discharging pus, to-morrow
they may be ulcerated and with a ﬂow of sanious matter; we ought to be
prepared with corresponding changes in the local applications. It will be
convenient to consider the treatment under two heads.
1.-—Methods of treatment for the removal of sequestra or foreign bodies-
I believe the best method is through the natural passages, the only operative
proceeding that is necessary being a forcible expansion of the Walls, especially
of the septum, by means of a strong pair of forceps. The deeper-seated
region can then be reached, and the sequestrum, if any, removed by means of
the canula or other suitable forceps. If the passage is very narrow, and the
sequestrum small, the canula forceps offers many advantages from the circum-
stance that it can be passed through a very small passage, and when opened
occupies a very small space. Rouge’s operation is a better method in a few
exceptional cases—viz, those in the vestibular position of the meatus
rhinarius are separated from the deeper region by a narrow internal meatus
formed of a ring of thickened mucous membrane, which thus diminishes
DISEASES OF ‘THE THROAT. 3 I I
the available space at the junction of the cartilaginous and bony portions of the
alae and septum. In ordinary cases the difﬁculty of exploring and passing
instruments into the deeper parts depends upon the rigid bony constriction of
the channel at this point. Rouge’s operation merely displaces the-vestibular
portion of the meatus—the deeper bony constriction being unaffected by it—and
hence it is only when the soft parts are abnormally thickened, congenitally or by
disease, that the aperture of the internal meatus is practically widened by
Rouge’s operation. The depth from the surface is no doubt lessened, but this
triﬂing advantage is counterbalanced by the not infrequent haemorrhage, a
complication which is very embarrassing.
2.—-As methods of local cleansing and deodorization, I can strongly
recommend the use of sulpho-carbolates in the form of douche or spray, and,
in very obstinate cases, of sulphurous acid solution, beginning with a weak
solution and gradually increasing its strength. Weber’s douche (not the
syphon form) should be used as a preliminary to other treatment; but when
the crusts are very large and obstruct the nostril, the douche is essential and
must often be repeated. Rumbold’s nasal catheter is also useful. Iodoform
is very useful in the form of pencils made up with cocoa butter. These
pencils can be thrust very high up by the patient himself, and melt at the
temperature of the nostrils, leaving the iodoform to exert its speciﬁc action in
situ, and at the same time lubricating the membrane around. I rarely use
strong caustics in any case of chronic discharge from the nostrils, the difficulty
of ascertaining where they are to be applied being an insuperable objection.
The sulpho—carbolates diluted with sugar and bismuth may be used as snuffs,
and their application is much facilitated by the use of the insuﬁlator (here
shown). Chronic serous and sero-purulent discharges from one nostril have
sometimes been traced to disease in the antrum. A notable instance was recently
brought forward by the President of this Congress, in which after death
mucous cysts were found in the antrum. In these cases, the only indication of
the seat of the disease is that aﬁorded by the circumstance that the ﬂow is
increased in quantity when the head is turned to the side opposite to that of
the nostril affected. The absence of pus from the discharge and the chronic
nature are conﬁrmatory of the diagnosis of antral disease. These are very rare
cases, but others occur in which the sero-purulent discharge is so copious and
lasts so long that there seems to be a general catarrh of the whole lining
membrane of the nasal passage, including that of the antrum. I once succeeded
in checking such a catarrh from one nostril which had been going on for
several years by the use of copaiba and the mineral acids given internally and
applying solution of nitrate of silver to the nostril. These cases are so rare that-
a success of the kind is perhaps worth recording, the use of copaiba for catarrb
of the air passages being, I believe, not very often resorted to.
DISCUSSION.
Dr. KRAUSE, Berlin: I desire to communicate the results of two post—mortem
examinations of pure ozaena, or, as Zuckerkandl has called it, “ genuine atrophy
of the turbinated bones,” which Prosector Dr. Chiari, of Vienna, has placed at
my disposal, and which I examined. They will, I trust, contribute towards
clearing up the question of the origin of the factor in this disease; for it is
undeniable that the whole ozaena question turns, in the ﬁrst instance, upon
this hitherto undecided, and yet so important, point, about which we see such a
divergence of opinion. Ziem states that ozaena can be produced by carious
teeth, and is transferable by pocket-handkerchiefs; according to Michel, the
factor originates in the cavities adjacent to the nose; Fournié seeks the cause
in a speciﬁc quality of the glands of the nasal mucous membrane; and
3 I2 -DISEASES OF THE THROAT.
B. Frankel, to whose observations and conclusions I come nearest, believes that
the cause must be sought in a chemical process of disintegration (ferment),
which I, however, in opposition to him, cannot look upon as being transferable
and coming from without. My two cases were observed during life by Professor
von .Schrotter and Primararzt Dr. M ader, in the Rudolf Hospital at Vienna.
Neither during life nor at the post-mortem were ulcers of the mucous mem—
brane or carious or necrotic processes on the bone found. The histological
examination in both cases was made in such a manner that the mucous mem-
brane of one half of each nose was examined throughout, the sections being
made close to another; from the other halves some specimens were removed
for the purpose of checking the results thus obtained. The results, which the
members present are requested to check by reference to the microscopical speci-
mens in the next room, were brieﬂy and generally as follows: the epithelium
frequently defective, sometimes entirely absent in several places, had under-
gone a horny change. The mucous membrane itself shows marked atrophy.
Everywhere are seen large tracts of a dense connective tissue, which only
become thinner and more delicate superﬁcially, but which even there are
present almost everywhere. As to the blood-vessels, there is a marked loss of
them generally, and those remaining have undergone considerable changes;
the adventitia is thickened, the intima tortuous, the lumen conspicuously
narrowed. The glands are comparatively well preserved in a few places only;
most of them show a much-developed inﬁltration, others a granular or fatty
degeneration; again, large tracts of the mucosa are traversed without detecting
a trace of them. The most remarkable thing, however, in our specimens, is
the presence of an enormous inﬁltration of round and spindle cells, the cells
of which do not _show anywhere a distinct contour, but have disintegrated into
a fatty detritus, which is often still arranged in the former cell form, and besides
this inﬁltration the presence in the mucous membrane of numerous large and small
fat globules, afact which is very suggestive of an explanation of the origin of the
foetor. To this I shall return presently. NowIwish to say that analogous processes
in the mucous membrane are found in xerosis of the conjunctiva, and in the
callous stricture of the urethra.* If we now pass to the question whether
and how the described changes can explain the characteristic symptom of
ozaena—viz., the foetor, I am well aware that I cannot draw positive conclusions
from the results of two post-mortem examinations. On the other hand, however,
the absolute identity of both cases, and the facility with which the mode of
origin of the foetor can be explained by the changes described, admits of a great
amount of probability for my conclusion—viz., that we have to seek in this
enormous fatty detritus, and in the numerous fat globules, the factor which
produces the foetor. We ﬁnd horny epithelium, which appears to be a very
suitable soil for the formation of crusts and scabs; we ﬁnd a considerable loss
of blood-vessels in general, and changes in the individual ones; we ﬁnd further
destruction of the glandular elements which has nearly led to their total
abolition; ﬁnally, we see the fatty detritus and the fat globules. Mucous mem-
branes of this atrophic character can only produce a very tenacious, quickly-
drying secretion, which will form scabs and crusts with the horny epithelium.
The enormous quantity of fat secreted into and beneath the epithelium will
quickly undergo disintegration and change into fatty acids in the crusts, and
will thus produce the sickening and rancid smell, the occurrence of which
cannot under these circumstances be strange. The corroboration that this effect
15 due to the fat we ﬁnd further in the result of the microscopic examination

* See Graefe and Saemisch, Handbuch der Gesammten Augenheilkunde, 187 4; and
Dittel, in Billroth-Pitha’s Handbuch, Stmlcturen der Harm'okre, 1860.
DISEASES OF THE THROAT. 313
'of the crusts in our two cases, which showed fatty degeneration of epithelium,
accumulations of fat granules, fat globules, and numerous‘ crystals of margaric
acid; and in the opinion of Arnold Hiller, on the fatty acids proper, in his
‘“ Lehre von der Faulniss,” p. 75.
Dr. E. FRANKEL, Hamburg: I do not think that Dr. Krause has established
his point—via, that the origin of the foetor is due to the fat, for in my own
case of true ozaena (described in vol. IV. of Vz'rc/zow’s Archiv), which is the
ﬁrst ever giving the results of a post—mortem in this disease, as well as in two
other unpublished cases of mine of true ozaena, this condition was absent, and
yet the factor was present. Also the similarity of the microscopic phenomena
of true ozeena to the changes in xerosis conjunctiva: does not prove anything,
because the crusts of xerosis do not stink. I urgently desire to plead for the
abolition of the expression, “ ozaena,” which indicates only a symptom, and
says absolutely nothing as to the diagnosis.
Dr. KENDAL FRANKS, Dublin: The different views which are held as to
the cause of true ozaena make it important to detail individual experiences. I
have met with several cases of true ozwna where there was no previous history
of catarrh, no disease of the deeper structures in the nose, no ulceration of the
mucous membrane, and where there was no dyscrasia whatsoever, neither in
the patients themselves nor in the members of their families. These cases are
explicable only on the theory which Zaufal has propounded. They all showed
a remarkable absence of the turbinated bones. On examination, the interior
of the nose showed large caverns, through which the posterior wall of the
naso-pharynx, the openings of the Eustachian tubes, and the action of the palati
muscles could easily be seen by anterior rhinoscopy. The mucous membrane
was atrophied and dry, and covered with dry crusts of inspissated mucus.
Amongst the cases illustrative of this condition which I have seen, one especially
was remarkable, in which one side of the nose was thus formed, but the other
normal. In this case there was no factor, which is to be explained by the
expiratory force being sufficient to clear the nostril, as one side was normally
formed. The patient used constant eﬁorts to keep it clear.
Dr. HOPMANN, Cologne: I wish urgently to recommend the use of
Gottstein’s tampon, especially in those forms in which no severe dyscrasia is or
has been present. In these cases tamponade does everything one can wish of
a palliative remedy in a disease which, strictly speaking, is still incurable. Of
100 cases of ozaena which I have seen during the past ﬁve years, and which
have given me the material for the above statement, 54 were cases of average
or greater severity, 16 of these occurring in men, 38 in women. These cases
which remain after the deduction of the cases of recent and past syphilis, of
undoubted scrofulosis, of phthisis, of foreign bodies, of caries, of hyper-
trophies, of formation of crusts, with simultaneous existence of marked atrophy
‘of the turbinated bones without or with very little factor, are distinguished by
atrophy of the middle or lower turbinated bone, or of both; by the formation
of very foetid crusts; by anosmia or diminution of smelling power. These cases
are possibly produced by arrested development of the bony framework of the
nose, especially of the conchae, during the second period of dentition, and some
of them perhaps also during the period of puberty, although the general expla—
nation at the present time is that the atrophy, even of the bones, is the ﬁnal
result of a primary hypertrophic, later on atrophic, morbid process of the
mucous membrane. If the development of the bony framework is arrested, it
is evident that the development of the mucous membrane covering it will also
3 I4. DISEASES OF THE THROAT.
suffer in the end. Although’ Gottstein’s tamponade is useful in almost all forms
of ozaena, it is, according to my own experience, especially so in the last-named
class of cases, in which it does most excellent service in successfully counteracting
the formation of crusts and the foetor. At the same time, it is perfectly harmless
and convenient, provided that no fault is made in its employment.
Dr. BAYER, Brussels: According to my experience the atrophic state of the
mucous membrane is but the ultimate result, whilst the ﬁrst period is charac-
terized by hypertrophy of the mucosa. I have observed in one and the same
family several members suffering from ozaena. The youngest of them showed
a hypertrophic state, whilst in the older ones atrophy was present; in some
both conditions existed simultaneously. As regards the narrowness being the
alleged cause of ozmna, I, in common with other observers, have noted that
often in persons who have one large and one small nostril, ozaena is present in
the large one, whilst it is absent or but little developed in the small one. It
is very difficult to say at what point ozaena proper commences, on account of the
varying smelling power of observers. An acute inﬂammation or catarrh can
become the direct cause in a predisposed person. Very frequently ozaena is
allied to a general dyscrasia, such as eczema or the herpetic diathesis of the
French. In these cases general treatment is absolutely necessary to obtain
radical cure. Garbolic acid is not to be recommended locally, because it often
completely destroys the power of smelling in those cases in which it had been
preserved. The galvano-cautery and the local application of iodine might
destroy glands which have still remained intact.
Dr. MICHEL, Cologne: I think that the nature of ozaena can only be ascer-
tained by numerous post-mortem examinations. The autopsies made by
Zuckerkandl and by E. Frankel speak in many respects for my own views.
Krause’s results are not quite convincing, as they concern older individuals in
whom the malady was already of a retrogressive character. I myself look upon
ozaena as a constitutional disease. No one who is quite healthy gets ozaena. As
regards treatment I am as satisﬁed with my method as others are with the tam—
ponade. My method consists in instructing the patient to syringe, during the
ﬁrst two months, the nose, three times daily each time with two to three pints of
cool water. I use either plain water or a weak solution of soap and water, or of
chlorate of potash, and neither make cauterization nor pulverization. After this
period it is sufficient to syringe twice a day ; later on even only once a day. The
patients are quite free of all complaint under this treatment. I have examined
patients who have treated themselves in this manner for periods of ﬁve to eight
years. As soon as they omit to syringe for eight to fourteen days the
yellowish foetid secretion returns. I would fain request the gentlemen
present to syringe themselves once the nose of a patient suffering from ozaena,
whose nostrils are ﬁlled with stinking crusts, to convince themselves that the
cleansing is complete, and to examine the patient again on the next or on the
second day. They will then convince themselves that the greater part \of the
secretion is to be found in the posterior part of the nose—21¢, where the evacu-
ation of the sphenoidal and ethmoidal cavities takes place. It will be seen
that crusts, bridge-like, join the middle and lower turbinated bone, or, in a
transverse direction, the middle turbinated bone and the septum; or that a thick
yellow mucous tract hangs down from the middle turbinated on to the lower
or into the floor of the nose. The mucous membrane itself will be found fresh,
red, smooth, and shining.
Dr. GoTTsTEIN, Breslau: Dr. Krause’s observations as to the origin of the
DISEASES OF THE THROAT. 3 I 5
factor do not agree with the microscopic investigations of Dr. E. Frankel and
my own. Nor can I agree with the explanation given by Dr. B. Frankel,
inasmuch as there is very frequently in nasal disease stagnation of the pus
without foetor, whilst in the atrophic form the foster appears very early, often
after a few hours. To Dr. Krause’s explanation. the success of the tamponade
is, moreover, opposed; which therapeutical method I urgently wish to recom—
mend, it having the great advantage that the very formation of the crusts is
thereby prevented, whilst irrigation only removes the stinking crusts. I can
conscientiously recommend it not only for the atrophic, but for all forms in
which formation of crusts occurs. The observation of Michel—viz., that the
secretions collect mainly in the posterior part of the nasal cavity—is not borne
out by my own observations. It is quite correct that shortly after the removal
of the secretion the mucous membrane appears red; in the course of one hour
later, however, it appears markedly pale and dotted over with whitish puncti-
form drops of secretion, so that it appears as if it were covered with ﬂour dust.
Professor J URASZ, Heidelberg: I desire to make some remarks on the
atrophic form of ozaena. It is generally taken as granted that this is the ﬁnal
stage of the hypertrophic form; that it consists in a degeneration of the
mucous membrane into connective tissue, and in atrophy of the epithelium, and
that it is, consequently, very difﬁcult to cure, or rather incurable. I cannot
agree to this view for the following reasons : In the ﬁrst place, it seems to me
somewhat hold to draw from the few microscopic examinations the conclusion
that in all cases of atrophy of the mucous membrane there must also be a
degeneration of the same. Further, the so-called “rhinitis atrophica foetida”
sometimes develops without a previous hypertrophy. Finally, the treatment
does not present so little chance of success that this form is to be looked upon
as incurable. Already Weber-Liel has stated that he has observed cures, and I
have seen within the last few years two cases in which ten months and
four months respectively after dismissal from treatment no relapse had occurred.
I use, besides nasal douches, cotton—wool tampons, impregnated with a one to
two per cent. carbolic acid solution. If it is necessary to irritate the atrophic
mucous membrane more powerfully than can be done by means of the
cotton tampon, I make local applications of irritant ﬂuids (tinctura aromatica,
salicylic acid, and veratria). From the fact that in this manner success is
sometimes obtained, I consider myself justiﬁed in concluding that in these
successful cases no degeneration of the mucous membrane, but other processes——
6.9., simple atrophy, or (as already suggested by YVeber-Liel) secretory and
trophic neuroses may exist. In conclusion, I especially wish to state that
in this form I have never observed a good eﬁect from caustics or astringents.
Dr. LowENBERG, Paris: It seems to me that Dr. Krause’s granulations are
not fat, but micrococci, the distinction between which is often impossible.
Besides, his results would not be characteristic of ozaena, for the pus in common
otorrhoea without smell contains fat and crystals of margaric acid. Further-
more, fat becomes decomposed, and fatty acids are formed without the
characteristic smell of ozwna. Again, Dr. E. Frankel’s results speak against
Dr. Krause’s conclusions. The eﬁicacy of Dr. Gottstein’s tampon is a further
proof that this acts as an antiseptic, as formerly shown by Dusoh and Pasteur.
Dr. PROSSER JAMES, London: I do not consider the results of this discussion,
either from an etiological or from a therapeutical point of view, very satis—
factory. For my own part I still adhere to the views which I laid down
in a paper read before the Medical Society of London in 1871. The only
3 16 DISEASES or THE THROAT.
modiﬁcation which has taken place in them is in the direction of extension,
but not in that of change. I wish to urge the necessity of very frequently
repeated examinations, as it is surprising how often with patient examination
local lesions will be discovered which at ﬁrst have been overlooked. The effects
of iodoform, which I long ago recommended, of salicylic and boracic acid, and
of their derivatives, are often remarkable in the treatment of this affection, but
my reliance is chieﬂy on instrumental medication and exploration.
Dr. B. F RliNKEL, Berlin : The diagnosis in well-marked cases is easy. The
great width of the nostril is the consequence, not the cause, of ozaena. The
retention of the secretion alone is not sufficient to produce ozaena; whether a
ferment is necessary for this purpose or not I will leave undecided. The
objections raised by Professor Jurasz against the connection of ozwna and
rhinitis atrophica which I have ﬁrst established are not conclusive. The
speciﬁc smell cannot be explained by a speciﬁcity of the nasal cavity, for all
crusts in the nose are not foetid; and again the same foetor is found in certain
cases in the trachea in which there is no complication with nasal disease. Fat
is a constant product of the disintegration of albumen. A cured ozaena is
unknown to me.
A Case of Wed in Me Lam/12x, pr/oéaély Congem'z‘al.
Dr. ‘G. VIVIAN POORE, London.
I have ventured to bring a case before the Laryngological Subsection,
because I believe it to be of sufficient rarity to interest the members.
The following is a short description of the case :—
Girl, aged 13, healthy-looking, well—grown. Voice, falsetto of peculiar
tone, but not hoarse. Has been liable to attacks of difficulty of breathing when
she caught cold; was in the Children’s Hospital in 1874 for croup. Thorax
well formed, nothing abnormal anywhere.
Laryngoscopz'cally—Web uniting anterior thirds of vocal cords perfectly
symmetrical, smooth, apparently covered by healthy mucous membrane and
with the posterior border concave; consistence of the web everywhere uniform ;
its appearance did not suggest an inﬂammatory origin. During phonation the
web became wrinkled, the glottic chink was of very much smaller size than
usual, circular in form, and when dilated to its utmost about big enough to
admit the tip of the little ﬁnger.*
I formed the opinion that the web was congenital—(1) because the patient’s
voice had always been peculiar since her ﬁrst cry; (2) because from her earliest
infancy she has been liable to attacks of dyspnoea ; (3) from the appearance of
the web, which had nothing about it to suggest inﬂammatory, or other patho-
logic origin. Two questions occurred to me. How were such Webs caused?
Certainly either by the occurrence of disease or inﬂammation in utero; by the
arrest of development; or the survival of some fmtal condition. Normally, I’
believe, there never is a web in the larynx at any period of the development
of the foetus, so that the last theory is untenable.
How common are such Webs? Are they even the unsuspected cause of
“still-birth,” of faulty expansion of the lungs, or of the patency of foetal
vessels giving rise to cyanosis ?
My patient is in perfect health; her lungs are well developed; she is

* The patient was shown at the ﬁrst clinical demonstration.
DISEASES OF THE THROAT. 3 I 7
not cyanotic, and the only inconvenience she suffers is the peculiarity of
her voice.
Under these circumstances I do not think it advisable to attempt any
operative interference. I would at least delay such interference until the
child had completed her development into womanhood.
DISCUSSION.
Dr. SOLIS COHEN, Philadelphia : I have to relate a case of web of the
larynx, the evident result of the agglutination of eroded papillary excrescences,
for the dyspnoea from which tracheotomy had had to be performed a few years
previously. I doubt whether there is sufficient evidence that these cases are
congenital malformations; and I believe that the web may be the result of
irritative agglutination in infantile or even foetal life, in the same manner as in
the case I have narrated.
Dr. BtioKER, Berlin: A woman, aged 30, whose case I have described in
the Deutsclze Med. IVochenschrz'ft (No. 32, 1875), suffered from a membranous
web just beneath the vocal cords, which had originated without any previous
inﬂammatory symptoms or any laryngeal disease. After repeated incisions, the
loosened membrane was removed by means of the forceps, and a complete and
permanent cure was effected.
Prof. SCHNITZLER, Vienna : I think that membranous adhesions of the vocal
cords are not so very rare. I have observed several such cases, some con-
genital, some produced by inflammatory processes. The best method of treat-
ment is the galvano-caustic, though the membrane may also be cut by a simple
knife. Catheterism of the larynx is the best means of preventing re-adhesion.
The Spray Producer; Z/ze des! Means of Making App/[rations
Z0 Z/ze Superior Pom‘z'oee of Me Respz'mz‘oe/y Tracts.
Dr. M. F. RUMBOLD, St. Louis, USA.
The author insisted upon the importance of removing morbid secretions
from, and applying remedies to, every portion of the irregular surface, without
causing the least irritation. He gave arguments to show that the probang,
brush, &c., now in use do not fulﬁl these indications, whereas the spray was at
the same time very mild and thorough in its action and penetrated to the most
concealed part of the diseased surface. He described the different forms of the
spray-producer he employed.
Ueeer dz'e p/zysz'oleg'z'seﬁe umipaf/wlogz'se/ze Se/zlez'maéseezdee/mg'
z'm [Ce/zléojf and 62,67’ Lujtre'ﬁre, sowz'e Bez'z‘m'ige 22W W {1/—
kwzg expeez‘oe'z'render mm’ adsz‘rz'ngirender éez' Se/zlez'm/zaut-
Karate/Men angewena’ez‘er A rznez'mz'tz‘el.
Professor ROSSBACH, 'Wurzburg.
1) Die Secretion des Schleimes ist eine continuirliche. Wenn man den
Kehlkopf und die Trachea stundenlang, sei es laryngoscopisch, sei es direct
bei blosgelegter Kehlkopf- und Trachealschleimhaut beobachtet, so ﬁndet man
3 1 8 DISEASES OF THE THROAT.
l
letztere immer bedeckt mit einer dünnen, wasserklaren, aber ziemlich zähen
Schleimschicht. So oft man auch durch festes Aufdrücken von gutem Fliess—
papier die Schleimhaut trocken zu legen versucht, immerund immer wieder
sieht man unmittelbar nach dieser Procedur den Schleim in kleinen Tröpfchen
aus allen Schleimdrüsen hcrvorquellen, nach einer bis zwei Minuten durch fort—
währende Vermehrung zusammenﬂiessen, und die ganze Schleimhaut von Neuem
mit einer zusammenhängenden Schleimschicht überziehen. Auch wenn man
unmittelbar nach dem Abtrocknen die Schleimhaut mit einer feinen, reinen
Oelschicht überzieht, tritt in ganz gleicher Weise, wie bei der trocken frei-
liegenden Schleimhaut, die Schleimsecretion sogleich wieder ein.
2) Die secretorischen Nerven der Kehlkopf- und Luftröhrenschleimdrüsen
sind bis jetzt noch nicht bekannt; aber jedenfalls können sie nur auf drei Wegen
zu den Drüsen gelangen, entweder mit dem Nervus laryngeus superior, oder
mit dem Nervus laryngeus inferior, oder mit den feinen Aestchen, die von den
Bronchealästen des Nervus vagus aus der Trachea herauﬁaufen. Ferner können
die in diesen drei Nerven in die oberen Luftwege eindringenden Nerven nur
herstammen entweder aus dem Hals-Sympathicus, oder aus dem Hals— und
Brusttheile des Vague. Um darüber Aufschluss zu erlangen, wurden alle diese
Nerven, zunächst der Hals-Sympathicus, dann der Vagus an verschiedenen
Stellen, ferner die einzelnen Nervi laryngei sup. und infer. durchschnitten und
ihre peripheren Enden Zuerst schwach und allmählig immer stärker faradisch
gereizt. Die eintretende stärkere Schleimsecretion auf der gereizten Seite
sollte die Wege der secretorischen Fasern kennen lehren, und die Fingerzeige
für weitere Untersuchungen abgeben. Allein alle mit grösster Sorgfalt ange-
stellten Reizversuche hatten das übereinstimmende und gleiche Ergebniss, dass
durch Reizung weder des Sympathicus und Vagus, noch des Nervus laryngeus
superior und inferior irgend eine dem beobachtenden Auge deutlich sichtbare
Vermehrung der Schleimsecretion auftrat.
3) Durchschneidung dieser Nerven einzeln oder auf einer oder beiden
Seiten zusammen zeigte in den nächsten Stunden und nach mehreren Tagen,
wenn die Thiere die Operation überlebt hatten, a) dass die Schleimsecretion
nach wie vor ihren ungehinderten Fortgang nahm, und nach jedesmaliger Ab-
trocknung der Schleimhaut sich mit nicht geringerer Schnelligkeit wieder
einstellte, wie bei unverletzten Nerven; b) dass bei einseitiger Nervendurch—
schneidung die rl‘rachealschleimhaut auf der operirten Seite stärker injicirt ist
und grössere Schleimmengen secernirt, als die Schleimhaut auf der intacten Seite;
c) auch wenn alle obengenannten Nerven durchschnitten, und ein zwei bis drei
Centimeter langes Stück der Luftröhre durch festes Umschnüren aus allen
Verbindungen mit Oben und Unten losgelö’st war, und dieses Stück sein Blut
nur mehr noch von hinten vom Oesophagus her erlangen konnte, dauerte auch’
in dem abgeschnürten Trachealstucke die Schleimsecretion nach wie vor ohne
alle Verminderung und in alter Intensität fort.
Aus diesen Versuchen glauben wir vorläuﬁg schliessen zu dürfen :
Dass von den N ervencentren entweder gar keine oder nur höchst minimale
secretorische Reize zu den Schleimdrüsen des Kehlkopfes und der Luftröhre
‚gelangen;
Dass dagegen der Blutreichthum der Schleimhaut in innigem Connex mit
«der Stärke der Schleimsecretion steht; endlich :
Dass die Schleimsecretion in den genannten Theilen jedenfalls auch nach
vollständiger Ausschliessung aller etwaigen von aussen kommenden nervösen
Einﬂüsse ungestört weiter fortgehen kann, dass also entweder periphere, in der
Schleimhaut selbst gelegene, die Secretion anregende Nervencentralstellen
angenommen werden müssen, und der Schleimhaut der Luftwege in gewisser
Beziehung eine ähnliche selbständige Stellung zuerkannt werden muss, wie dem
DISEASES OF THE THROAT. 3 19
Herzen, Darm, Uterus u. s. w., oder aber, dass die acinösen Schleimdrüsen der
ersten Luftwege überhaupt ohne nervöse Beeinﬂussung secretorisch thatig sein
können.
Wenn man auf den Bauch einer aufgebundenen Katze zuerst funf bis zehn
Minuten lang feuchtheisse, sodann Eisumschlage macht, so tritt eine halbe
Minute nach dem Auﬂegen des Eises ein ausserordentlich starker Gefasskrampf
in'der Schleimhaut der Trachea und des Kehlkopfes ein ; dieselbe wird todten-
blass und völlig weiss. Dieser Gefässkrampf dauert eine bis zwei Minuten
und fangt dann an einer allm'ahligen Gefasserschlaffung Platz zu machen. Die
Schleimhaut beginnt zuerst ihre normale Färbung anzunehmen. sodann wird
sie rosenroth, und zeigt namentlich über den Trachealknorpeln eine bereits
abnorm starke Injection. Bald darauf wird die gesammte Schleimhaut blut—,
und in fünf bis zehn Minuten schliesslich blauroth. Jetzt sind alle Gcfalsse auf
das Aeusserste erweitert; dabei deutet die blaurothe Färbung darauf hin, dass
die Circulationsschnelligkeit in den erweiterten Gcfassen nicht zu-, sondern
abgenommen haben muss.
Während des offenbar reﬂectorischen Gefasskrampfes bemerkt man eine
Abnahme, im Stadium der Gefasserschlaffung dagegen eine starke Zunahme der
Schleimsecretion, so dass im eigentlichen Sinne des Wortes der massenhaft
secernirte, aber immer noch wasserklare Schleim förmlich herabﬂiesst, also eine
wirkliche Catarrhoe eintritt.
Macht man nun wieder einen recht warmen Umschlag über den Bauch,
dann nimmt die blaurothe Farbe der Luftröhren— und Kehlkopfschleimhaut
sogleich, fast momentan wieder ab und weicht einer rothen Farbe; jedoch
bleibt die Injection immerhin viel starker, als im ursprünglich normalen
Zustande.
Eine nochmalige Eisapplication bringt sodann ebenfalls wieder ein Erblassen
der Schleimh‘alute zu Stande, aber nur in bei Weitem geringeren Grade und viel
später, als das erste Mal.
Es folgt aus diesen Versuchen, dass Verminderung und Vermehrung des
Blutzuﬂusses zur Schleimhaut eine gleichsinnige Beeinﬂussung der Schleim—
secretion zu Stande bringt, dass also zwischen Blutdurchströmung und Schleim—
secretion ein inniger Zusammenhang existirt; ferner, dass der Einﬂuss der
Erkältung, bezw. der Application der K'a'lte auf die vorher stark erwärmten
Bauchdecken auf die Schleimhaut der Luftwege doch nicht so insensibel ist,
und nicht erst nach Tagen auftritt, sondern dass die Erkiiltungsver'a'nderungen
sogar sehr grober Natur und auf dem Wege des Gefa'ssreﬂexes unmittelbar
eintretende sind.
Betrachtlioh und in scharf nachweisbarem Grade gesteigert wird die Schleim-
absonderung durch die innerliche Verabreichung von Apomorphin, Emetin und
Pilocarpin; am stärksten durch Pilocarpin, auf welches nicht bloss in der
Trachea, sondern auch in den Bronchialverzweigungen eine so massenhafte
Production höchst dünnﬂüssigen, wasserklaren Speichels auftritt, dass die Thiere
auf dem ganzen Thorax massenhafte Rasselger'ausche hören lassen, und der
Schleim, wie bei Oedem, selbst die grossen Bronchien füllt, ja während des
Lebens bis in die Trachea massenhaft heraufquillt. Damit nicht der ebenfalls
stark vermehrte Speichel etwa in den Kehlkopf gelangen könne, und dadurch
Anlass zu Täuschungen gebe, war der Kehlkopf vorher durch einen einge-
pressten Schwamm verstopft worden.
Die Gefassfullung der stark secernirenden Schleimhaute zeigte keinen
Unterschied gegen die vorausgegangene normale; dagegen vergrösserten sich
die Schleimdrusen so, dass sie als kleine Knötchen über die glatte Oberﬂäche
der Schleimhaut hervorragten. Dass die Mittel nicht auf indirectem Wege
durch Beeinﬂussung der Drüsen und Drüsennerven ihre Wirkung auf die
320 . DISEASES OF THE THROAT.
Schleimabsonderung entfalten, ergab sich aus dem Verhalten nach Unterbindung‘
aller bedeutenderen, die Trachea versorgenden Gefa'sse, der beiderseitigen
grösseren Carotidenaste und des Truncus thyreo-cervicalis. Die Pilocarpin-
injection bewirkte, trotz der abgesperrten Blutzufuhr, dennoch eine reichlichere
Schleimabsonderung. ‚
Ganzlich aufgehoben wird die Schleimsecretion durch Atropin so, dass die
vorher stark feuchtschleimige Schleimhaut absolut trocken wird ; trotzdem, dass
in Folge dieser Trockenheit, vielleicht auch durch die WVirkung des Atropins,
die Schleimhaut im Laufe der Beobachtung immer hyper'zimischer wurde, blieb
die Schleimabsonderung langer wie eine halbe Stunde aus, ein Beweis, dass
Atropin nicht in Folge von Circulationsstörungen, sondern direot Drüsen und
Drüsennerven beeinﬂusst.
In zweifacher Weise, je nach der Anwendungsart, wirken Alcalien, we-
nigstens das von Rossbach und Aschenbrandt angewandte kohlensaure Natrium
und der Salmiak. Spritzt man von dem ersteren 2'0 Gramm, von dem letzteren
1'0 Gramm direct in das Blut (in eine Beinvene), so nimmt in kürzester Zeit
die Schleimsecretion der Trachea bedeutend ab, hört in einzelnen Fallen ganz
auf; dabei wird die Schleimhaut blutleerer.
Bringt man dagegen die Alcalien in Wasseriger Lösung direct durch Auf-
tr'ziuﬂung auf die Schleimhaut selbst, so wird die Schleimhaut gerötheter, und
die Schleimsecretion nimmt zu. Am intensivsten zeigt sich dies bei Anwendung
selbst sehr starker Verdünnungen von Liquor Ammonii caustici, nach welcher
eine sehr hochgradige Hyperamie und Ausdehnung der kleinsten Gefasse und
massenhafte Schleimsecretion eintritt. Dass durch stärkere Concentrationen
im Verlauf eines Tages schliesslich Croupmembranen auf der Schleimhaut sich
bilden, können auch sie bestätigen.
Oleum Terebinthinae rectif. zeigte, je nachdem es in wasseriger Lösung oder
einfach mit Luft in kleinen Mengen gemischt angewandt wurde, ein verschie— '
denes Verhalten. Wenn man auf eine bestimmte Schleimhautstelle Luft
mittelst einer einfachen Vorrichtung aufblasen liess, die vorher durch ein Glas
mit Terpentinöl geleitet worden War, und demnach sich mit Terpentindampfen
möglich vollgeladen hatte, so nahm die Schleimsecretion immer mehr ab, hörte
schliesslich ganz auf, und die Schleimhaut wurde an der betreffenden Stelle
ganz trocken ; sobald man mit diesen Anblasungen aufhörte, begann die
Schleimsecretion sogleich wieder. Controlversuche mit Anblasung gewöhnlicher
Luft in gleicher Starke ze1gten, dass in Folge des Reizes der starker strömenden
reinen Luft die Schleimsecretlon sogar zunahm, dass also die bei den Terpentin-
versuchen beobachtete Trockenheit nur Folge der Terpentinbeimengung war.
Wurde dagegen eine 1 DlS 2 procentige wasserige Terpentinlösung auf die
Schleimhaut gebracht, dann begann dieselbe sogleich starker zu secerniren,
zeigte aber gleichzeitig eine Abnahme der Blutfülle. Die Schleimhaut blieb,
nach Anwendung von unverdünntem O]. terebinth., trocken; sie wurde run-
zelig, röthlich glanzend; das Epithel hob sich von seiner Basalmembran ab; es
traten Veränderungen desselben ein, die man am ehesten mit croupösen Plaques
vergleichen könnte; es entstanden die deutlichsten Ecchymosen.
Sauren (Essigs‘a'ure) bedingte bei örtlicher Anwendung eine stärkere Schleim-
bildung; nach innerlicher Verabreichung bemerkte man zwar keine Aenderung
in der secernirten Schleimmenge, aber ein rascheres Zusammenballen des aus
den Drüs’chen dünnﬂüssig und klarquellenden Schleimes.
Für die bisher so vernachlässigten Behandlungsmethoden der verschiedenen
Sohleimhautcatarrhe der Luftwege ergeben sich aus den obigen Versuchen
ganz bestlmmte Flngerzelge.
DISEASES OF THE THROAT. 321
DISCUSSION.
Dr. B. FRANKEL, Berlin: I should like to add some remarks on the
conditions of secretion in the nose and in the pharynx, though I have not had
the opportunity of conducting experiments concerning secretion from mucous
membranes. In the nose the presence of seriparous glands and their dependence
on nervous inﬂuences has been proven by Heidenhain. There is also a
pathological hyper-secretion of these glands, which I consider to be very
essential for the coryza of asthma, and which is essentially different from the
inﬂammation of the mucous membrane, generally called catarrh. There exist -
also in the pharynx seriparous glands and hyper-secretion. The latter disease
is. however, to be diagnosticated only if direct observation of velurn and of
pharynx justifies the diagnosis—ale, if it shows that the tongue being depressed
after a very short time the pharynx becomes covered with drops close together
of an almost purely watery secretion. The complaints of a patient suffering from
that form are somewhat manifold, a tendency to repeated swallowing being
especially complained of, and there is frequently morning sickness, &c.
Belladonna preparations cure this affection, and it is worthy of mention that
belladonna generally produces not only a sensation of dryness, but actual
dryness of the pharynx. I believe that the physiological moistening of the
mucous membranes is altogether to be distinguished from catarrh, and I hope
that the continuation of the highly important experiments of Professor Rossbach
will perhaps clear up this question as well.
Professor RossBAcH, \Vi'irzburg: I would urge that no analogies should be
made regarding the conditions of secretion between nose, pharynx, larynx, and
trachea. I agree with Dr. Frankel that in the nose, and probably also in the
pharynx, central inﬂuences act upon the mucous secretion, in the latter, e.g., in
a reﬂex manner for coating the bolus, &c. In the trachea, on the other hand,
in spite of the most careful investigations made on human and animal tracheae
by my pupil Leussler, only acinous mucous glands, never seriparous ones, have
been found, and consequently a serous secretion cannot at the present time be
admitted for the trachea. Some of my experiments, notably the cooling ones,
have I think inﬂuenced the tracheal mucous membrane in a manner very ‘closely
resembling that of catarrh.
Ez'mﬂuss des wez'elz'elzevz Gese/zZee/zz‘sappamz‘s emf Sz‘z'mm-
Organ and Sz‘z'mmez'ldzmg.
Dr. BAYER, Brussels.
Meine Herren! Erlauben Sie mir vor einer so competenten Gesellschaft
'uber ein Thema zu sprechen, woruber viele von Ihnen vermoge grosser
Erfahrung gewiss interessantere Mittheilungen Zu machen im Stande w'a'ren,
als ich es bin. Aber eben desshalb habe ich das Thema gew'ahlt, um die
einzelnen Herren zu veranlassen ihre diesbezuglichen Beobachtungen nicht
der Vergessenheit zu iibergeben, sondern sie bei gebotener Gelegenheit zu
ver'offentlichen.
Ich habe mir niimlich vorgenommen zu sprechen uber den “Einﬁuss des
weiblichen Genitosexualapparates auf das Stimmorgan und die Stimme.”
Das Thema ist nicht neu, und beinahe jeder Tag bringt dem besch'aftigten
Laryngologen dasselbe in Erinnerung. Aber auch die Gyn'acologen und Neuro-
Panr III. Y
322 . DISEASES OF THE THROAT.
logen schenken demselben die verdiente Berücksichtigung und lassen es an
interessanten Mittheilungen und vWürdigungen nicht fehlen.
Zuvörderst will ich kurz einige Autoren erwähnen, welche auf diesem
Felde gearbeitet und den Weg gebahnt haben, und kann natürlich nicht umhin,
vor allen Vater Hippocrates zu nennen, welcher mit seiner Bezeichnung
“Hysterie” und seinem Ausspruch, “Mulier tota in utero” schon an unser
Thema gedacht hat.
Die wahre Würdigung und das eingehende Studium der Frage gehört der
laryngoskopischen Zeit an. Zu nennen sind vor Allen Türck, Gerhardt, von
Bruns, Morell Mackenzie, Fournié, Stork, Krishaber, Mandl, Schnitzler, Lewin,
Nicolas-Dummy, Handfield, J urasz, Thaon und viele andere, welche ich nicht
alle aufzählen will; ausserdem Kussmaul, Landry, Eulenburg,Chairon, Lecorché
und Thalamon, Lasegue und Martineau—Gynäcologen und Neurologen, welche
sich mit der Frage näher beschäftigt und Mittheilungen darüber gemacht
haben.
Complicirt, wie der Kehlkopf ist in seinem anatomischen Bau und seinen
physiologischen Functionen, erleidet er leicht verständlich eine Beeinﬂussung
ersten Ranges durch den weiblichen Genitosexualapparat, welcher eine Haupt-
station bildet in dem weiblichen Nervensystem, und häuﬁg, darüber sind die
Autoren einig, ist es der Kehlkopf zuerst, wo sich eine Affection eben dieses
Apparates manifestirt. Verfolgen Wir das Bild telegraphischer Leitung weiter,
so ﬁnden wir als Innervationscentrum, von welchem die Depeschen aufgenom—
men und ausgesandt werden, die Medulla oblongata, respective den Halstheil des
Rückenmarks; als vermittelnde Bahnen die ganze Cerebrospinalsäule; und als
Leitungsdrähte die Bahnen des Sympathicus einerseits, die des Vagus und Acces—
sorius andererseits. Schon im physiologischen Zustand sehen wir obigen Ein—
ﬂuss sich geltend machen. Zur Zeit der Pubertät z. B.——freilich weniger
ausgesprochen als beim männlichen Geschlecht—veranlasst die Entwicklung
der Geschlechtstheile eine Ernährungszunahme des Kehlkopfes. Seine Di—
mensionen nehmen zu, hauptsächlich im vertikalen Durchmesser, aber auch
die Stimmbänder verlängern sich, und es entsteht damit nothwendig eine
Veränderung in der Stimmlage ; der “ Stimmwechsel” hat Statt.
Ob frühzeitige Entfernung der Ovarien diese Entwicklung verhindert, nach
Analogie des männlichen Geschlechts, darüber sind keine Erfahrungen bekannt
gemacht worden. Menstruation und Schwangerschaft sind von entschiedenem
Einﬂuss auf den Kehlkopf. Nicht selten beobachtet man zur Zeit des
Menstruationseintritts und der Menopause reﬂectorische Reizerscheinungen im
Larynx unter einer der verschiedenen Formen der Larynxneurosen, welche
mit hergestelltem Gleichgewichtszustand des Gesammtorganismus wieder von
selbst verschwinden. Ich habe in der letzten Zeit wieder zwei junge Mädchen
mit bellendem Husten und kaum nennenswerther Röthung der Aryknorpel
behandelt, wo der Husten mit Eintritt der Periode plötzlich ausblieb.
Türck berichtet einen Fall von vorübergehender Aphonie zur Zeit der
Menstruation. ‚
Ich habe eine Opernsängerin behandelt, welche jedesmal zur Zeit ihrer
Periode eine Hyperämie der Larynxschleimhaut mit Auﬂockerung der Stimm—
bänder hatte, so dass ich beim ersten Male an eine schwerere Affection dachte.
In Zeit von 1 bis 2 Tagen war alles wieder in Ordnung und die Stimme vorzüglich.
Was die Schwangerschaft anbelangt, so sah ich bei einer Dame das Gefühl
einer Art Globus im Larynx bei eintretender Schwangerschaft schwinden,
während ich sie noch mehrere Wochen an einem chronischen Kehlkopfcatarrh
weiterbehandeln musste. Eine andere Patientin (Sängerin) War nie so gut bei
Stimme als während der Schwangerschaft. Ich behandelte sie an einem hart-
näckigen Kehlkopfcatarrh.
DISEASES OF THE THROAT. 32 3
Gehen wir nun zum pathologischen Zustand ulcer, so sehen wir vor allen
‘anderen Aﬁ’ectionen des weiblichen Genitosexualapparates am meisten, wenn
auch nicht ausschliesslich, die Erkrankungen der Ovarien und des Uterus einen
reﬂectorischen Einﬁuss auf den Kehlkopf respective die Stimmbildung ausiiben.
Es gehoren hieher von Seiten der Ovarien sowohl Veranderungen des
Dr'usengewebes, wie Hyperplasien, respective N eubildungen, als Veranderungen
des Ovarialstromas, wie Oophoriten, H'almorrhagien, Hyperplasien, etc., ferner
Veranderungen ihrer Lage, respective ihrer Umgebung, wie Dislocationen,
Perioophoriten, Hamatoma retrouterinum, etc.
Von Seiten des Uterus sind zu nennen: Erkrankungen der Uterinalschleim-
haut, Wie Gatarrh, Hyperplasien, Polypen, Epithelialneubildungen, Ulcera-
tionen, etc.
Ich habe zwei Falle ziemlich unbedeutender Papillarwucherungen des
Scheidentheils des Uterus Suffocatio uterina loedingen sehen, welche mit Ent-
fernung der Papillome alsbald verschwand.
Ferner gehoren hieher die Erkrankungen der Muskelschicht, Veranderungen
der Uterushohle, und endlich die verschiedenen Lageveranderungen des
Uterus, sowohl Versionen und Flexionen, als Senkungen und Prolaps.
Gerade hier bietet die Literatur ganz interessante Falle, von Welchen ich
des Interesses halber einige anﬁihren will.
Bekannt ist der Fall von Landry, W0 sicli bei einer aphonischen Patientin
die Stimme sofort Wieder einstellte, als man den anteﬂectirten Uterus in seine
normale Lage zuriickbrachte.
Sehr lehrreicli sind zwei Mittheilungen von Martineau (Traité clinique des
affections de l’uterus, 1878).
Der ' erste Fall betrifft eine Frau, welche wahrend eines ganzen J alzres von
einem sehr hartnackigen, bestandigen, trockenen Husten gequéilt War, der sie
sehr ersch'o'pfte. Alle Mittel waren vergebens gegen den “nerv'o'sen Husten”
angewandt Worden. Nachdem die chronische Metritis der Patientin geheilt
respective die vorhandene Anteversion mit Pessarium und Leibgurtel corrigirt
War, verschwand der Husten plotzlich, um alsbald wiederzukehren, wenn
Patientin Pessarium und Leibgiirtel entfernte, respective der Uterus seine
fehlerhafte Lage wieder einnahm. Reponirte man dann Wieder den Uterus, so
verschwand der Husten von N euem.
Der zweite Fall betriﬁ't eine Dame mit Senkung, und Anteversion des
Uterus. “Aphonie et l\€[utite'.”-—“Si l’on souleve doucement l’uterus avec le
doigt et qu’on remette l’organe en place, imme'diatement 1a voiX revient, 1a
respiration se rétablit. Les accidents reparaissent, quand l’uterus retomloe . . .”
Electricit'at, Morphin, Strychnin, Chloroform haben nur eine palliative \Virkung
und schlagen schliesslich ganz fehl. Aber immer setzt die Reposition des
Uterus die Patientin in den Stand mit lauter Stinnne einige Worte auszu—
sprechen. Sobald der Uterus aber seine felilerhafte Lage wieder einnimmt,
tritt von Neuem vollstiindige Stimmlosigkeit ein.
Weiterhin kommen hier in Betracht die versohiedenen Erkrankungen der
breiten Mutterbander, der Eileiter, und schliesslicli der Vagina und Vulva.
Ich habe eine Dame beliandelt, Welche schon lange Zeit in gyna'cologischer
Behandlung stand, und ausserdem noch Wegen bestandiger Hustenanﬁille und
Hustenreizes an “Bronchite chronique ” behandelt wurde. Die laryngoscopi-
sche Untersuchung und Behandlung ergab ein ungenugendes, nicht ent-
sprechendes Resultat. Ich drang wiederholt auf genaue Untersuchung mit
dem Speculum, da entdeckte endlich ein hiesiger Gyniicologe, Freund von mir,
eine ganz feine Urethrovaginalﬁstel mit deren Verodung sowohl Pruritus
vaginae, und hauﬁger Drang zum Uriniren, als auch die Symptome von Seiten
des Larynx wie mit einem Male beseitigt waren.
Y Q
-l
324 DISEASES OF THE THROAT.
I
Um nun naher einzugehen auf die Besprechung der verschiedenen Formen,
unter welchen sich die Theilerscheinungen der Affectionen des weiblichen
Genitosexualapparates im Larynx manifestiren, können wir drei Rubriken auf—
stellen:
1) Die Aesthesioneurosen oder Störungen der Sensibilität 3
2) Die Kinesionenrosen oder Störungen der Motilit‘at;
Die Trophoneurosen beziehungsweise Angioneurosen.
Beginnen wir sofort mit letzteren und sagen wir kurz, dass sie eigentlich
nur des Systems halber in Betracht kommen. Doch mussten hier etwaig vor-
kommende “ vicariirende ” Blutungen der Kehlkopfschleimhaut eingereiht
werden. Das Gapitel ist dunkel, wie überhaupt das der visceralen Tropho-
neurosen.
Wir haben es daher ausschliesslich mit den zwei ersten Rubriken zu thun.
Die Formen, unter welchen dieselben auftreten, kommen theils als reine
Formen vor, theils, und das ist die Mehrzahl, als unter sich combinirte.
An absoluter Hauﬁgkeit tragen wohl die Aesthesioneurosen den Sieg davon.
Dieselben kommen zu Stande, sobald durch eine der oben angeführten Ur—
sachen die mittlere Erregbarkeit und Widerstandsgrösse innerhalb des Em—
pﬁndungsapparates eine Veränderung erleidet, und dadurch ein Missverhaltniss
entsteht zwischen der Reizstürke und der Reaction im Bewusstsein, das heisst,
der Starke der percipirten Empﬁndung. Handelt es sich dabei um ein Plus
der Reaction gegenüber dem einwirkenden Reize, so haben wir es zu thun mit
der Hyperaesthesie. Dabei erlangt “ die ankommende Erregung erst nach
Ausbreitung über zahlreiche Ganglienzellen den Schwellenwerth, und in Folge
dessen werden excessive, das gesetzliche Maass uberschreitende Reactionen im
Bewusstsein ausgelöst. (Eulenburg)
Die Hyperaesthesie ist die häuﬁgste Larynxneurose. Sie bildet einen
Hauptfactor der meisten andern Larynxneurosen, wie der Paraesthesien, des
Spasmus glottidis, der Suffocatio uterina, des nervösen Krampfhustens, der
Phonophobie und anderer. Als reine Form wird sie weniger h‘a'uﬁg beobachtet,
und es ist eigentlich nur dem Laryngoscopiker vorbehalten eine quantitativ
gesteigerte Reaction im Kehlkopf nach Application eines bekannten Reizes zu
constatiren.
Tritt nun das entgegengesetzte Verhaltniss ein, das heisst, handelt es sich
‘um ein Minus der Reaction gegenüber dem einwirkenden Reize, so haben wir es
zu thun mit der Hypaesthesie und Anaesthesie.
Hier erlangen die Erregungen im Centrum zu früh den Schwellenwerth oder
gelangen gar nicht zum Centrum. Daher bleibt die Reaction unter der gesetz-
lichen Norm zurück, oder wird völlig vermisst.
Die Hypaesthesien und Anaesthesien machen ebenfalls einen Bestandtheil
der unten zu besprechenden Neurosen aus, welche man als Paraesthesien be—
zeichnet. Chairon wollte die Anaesthesie der Epiglottis als pathognomonisches
Zeichen der Hysterie aufstellen. Ziemssen und andere haben jedoch diese
Angabe wiederlegt. Nach Thaon begegnet man nur bei etwa dem sechsten
Theil der Hysterischen mehr oder weniger vollstandiger Anaasthesie der Epi—
glottis. Die Anaesthesie ergreift ‘überhaupt den Kehlkopf in seiner ganzen
Ausdehnung oder seinen einzelnen Theilen, ohne sich an einen Typus zu binden.
Häuﬁg ist sie von partiellen wie diffusen Hautanaesthesien begleitet. Bekannt
ist der anasthetische Fleck an der vorderen Seite des Halses.
Hyperaesthesien und Anaesthesien, bei welchen homologe Reize heterologe
Empﬁndungen auslösen, werden als Paraesthesien bezeichnet. Ihre Eigenthüm—
lichkeit besteht in der Verschiedenheit der Qualitat der durch einen Reiz aus-
gelösten Empﬁndung. Daher kommen die manchmal bizarren Bezeichnungs-
weisen, womit die Patienten ihr Leiden benennen. Die einen klagen über
DISEASES OF THE THROAT. 325
Brennen, Stech-Gefühl der verschiedenartigen fremden Körper, welche in ihrem
Halse stecken, andere über Globus, Titillatio, Kalte, &c., &c., so dass es
gewöhnlich die Paraesthesien sind, welche man unter den Aesthesioneurosen zu
diagnosticiren hat.
Wird schliesslich die Grösse der Gefühlscomponente des physiologischen
Zustandes durch eine der oben angeführten Ursachen in ihrem Verhaltniss zur
Intensität des einwirkenden Reizes gestört, so haben wir es mit einer Dysaesthesie
zu thun, und zwar mit einer Hyperalgesie, wenn jene abnorm gesteigert ist, mit
I-Iypalgesie oder Analgie, wenn sie unter die Norm herabsinkt, oder ganz weg-
fallt. Gesellt sich den heterologen Empﬁndungen noch ein schmerzhaftes
Gefühl im engern Sinne hinzu, so bezeichnet man sie als Paralgien.
Hieher gehörige F alle sind von den Autoren mitgetheilt, gehören aber
immerhin zu den Seltenheiten.
An die Aesthesioneurosen reihen sich die Kinesioneurosen oder Störungen
der Motilitat des Larynx an.
Die Erkrankungen des weiblichen Genitosexualapparates beeinﬂussen die
psychomotorischen Centren auf sympathischem oder reﬂectorischem Wege unter
Vermittlung der Ursprungszellen der excitomotorischen Fasern, welche in dem
verlängerten Mark- resp. dem Halstheil des Rückenmarks, in dem “basalen
Lautcentrum” liegen. Dadurch wird die Erregbarkeit des motorischen Nerven—
apparates des Kehlkopfs gestört. Es entsteht ein Missverständniss zwischen
Reizstarke und der hervorgerufenen Reaction “ der resultirenden Bewegung.”
Es ist entweder ein Plus der Reaction gegenüber dem einwirkenden Reize, oder
ein Minus, im ersten Falle eine Hyperkinese, im letzteren eine Hypokinese oder
Akinese.
Da aber die resultirenden Bewegungsreactionen oft anomaler Natur sind,
so könnte man in der Mehrzahl der Fälle den Ausdruck “ Parakinesen” dem der
“ Hyperkinesen” substituiren. r
Zu den Parakinesen oder Hyperkinesen gehören die Laryngospasmen,
Welche mit solcher Heftigkeit auftreten können, dass schon tödtlicher Ausgang
beobachtet wurde. Im Allgemeinen aber sind sie wenig gefahrdrohend.
Eigenthümlich ist es, dass solche Patienten, selbst nach wenigen intensiven An-
fallen von einer unendlichen Furcht geplagt werden in einem der Anfa'lle zu
bleiben. (Tobold.)
Hieher gehören ferner die hysterischen Hustenkr'ampfe, welche sich durch
paroxysmatisch auftretende, zum Theil sehr heftige, trockene, oft mit pfeifendem
oder bellendem Geräusch oder lautem Schrei verbundene Hustenaniälle characte-
risiren. Zu erwähnen ist hier der “Spasme larynge somnambulique,” welcher
nach Thaon dadurch hervorgebracht wird, dass man den Larynx der hypnoti-
sirten Patienten leicht mit dem Finger berührt. Die Emission der Töne soll
sofort damit cessiren.
Die familiarsten Neurosen des Larynx bedingt durch obige Ursachen sind
die Hypokinesen oder Akinesen, gewöhnlich als “Aphonia hysterica” bezeichnet.
Unter den Lähmungen Hysterischer ist die Stimmbandl‘a'hmung eine der
gewöhnlichsten. (Eulenburg)
Die Mehrzahl dieser Lähmungen characterisiren sich durch ihre Unregel—
m‘assigkeit, das oft plötzliche Kommen und Verschwinden, den Mangel succes-
siver Ernahrungsstörungen der Muskeln, durch völlige Integrität der farado-
muscularen und galvanomuscul'a'ren Sensibilität. (Duchenne, Eulenburg.)
Es kommen Zustände herabgesetzter oder aufgehobener Motilitat vor, welche
wesentlich durch ein krankhaftes Gefühl einer Vorstellung, einen eingebildeten
oder wirklich vorhandenen Defeot an Willensenergie hervorgerufen und unter—
halten werden “ sogenannte ideelle Paralysen” nach Reynolds.
Ich habe neulich ein blühend aussehendes Mädchen von fünfzehn Jahren
326 DISEASES OF THE THROAT.
behandelt. Der Kehlkopf war in absolut normalem Zustande. Die ‘Stimm-
bänder bewegten sich tadellos. Es fehlte nur der Willensimpuls einen Ton
hervorzubringen. Alle ordentlichen Mittel blieben erfolglos. Ein Gelübde an
die “N otre Dame de Lourdes” löste eines schönen Tages die Aphonie! Hinter—
drein trat periphere Hautanaesthesie auf.
Besprechen wir kurz die verschiedenen Formen der Akinesen, so sehen wir
alle Grade vertreten von der leichten Abschwächung der Stimme aus bis zur
completen Aphonie. Häuﬁg beobachtet man Patienten, welche bei der Spiegel-
untersuchung noch Töne hervorbringen, noch einen tönenden, klangvollen
Husten haben, ja gar noch singen können. Man hat sogar Hysterische mit
Aphonie im Traume reden hören. Diese Lähmungen sind es, welchen Tobold
den Namen phonischer Lähmungen gegeben hat. Man unterscheidet drei
Formen, je nachdem bei der Phonation vollständiges Klaifen der ganzen Glottis,
oder nur partielles Klaﬁen derselben, oder endlich nur verminderte Vibration
der Stimmbänder stattfindet. Auf die Details gehe ich nicht ein. Die wich-
tigsten Symptome ergeben sich durch die laryngoscopische Untersuchung. Es
kommen dabei auch Respirationsstörungen vor, und es ist ein Fall bekannt von
hysterischer Paralyse der Crico-arytaenoidei postici, der zwei Mal die Tracheo-
tomie erheischte.
Bemerkenswerth ist, worauf Gerhardt zuerst aufmerksam gemacht hat, das
Fehlen der phonatorischen Vibrationen beim Auﬂegen der Hand aussen auf den
Kehlkopf. Ganz besonders häuﬁg scheint der Muse. arytaenoid. transv. be-
theiligt zu sein, so dass die Aryknorpel nicht schliessen, und die Stimmband—
lähmung so häuﬁg doppelseitig ist.
Als besondere Eigenthumlichkeit ist noch die “Aphonia intermittens” zu
erwähnen, wobei die Remissionen und Exacerbationen öfters ganz typisch sind.
Tobold erwähnt einen Fall, wo sieben Jahre lang eine Patientin vom Erwachen
an bis gegen 10 Uhr kräftig und klar sprach, dann aber ohne jede Veranlassung
die Stimme für den ganzen Rest des Tages einbüsste. Eulenburg hat einen
Fall beobachtet, in welchem die Stimme von 12 bis gegen 4 Uhr verschwand.
Laryngoscopisch war in beiden Fällen während der freien Intervalle vollständig
normale Excursionstähigkeit und Vibration der Stimmbänder nachzuweisen.
Thaon fuhrt als Eigenthumlichkeit der hysterischen Aphonie an, dass sie von
Tag zu Tag einen andern laryngoscopischen Befund geben könne.
Als dritte Form gehören zu den Kinesioneurosen noch die Coordinations—
störungen des Stimmorgans, “ die Laloneurosen.”
Nach Kussmaul verlieren “ Hysterische oft für Minuten, Stunden, Wochen
oder Monate nicht bloss die Stimme, sondern auch die Sprache. Die WVortbilder
sind in solchen Fällen intact, und die Bahn zwischen Gedanken und Worten
ist es gleichfalls. Aber es handelt sich hier um eine Unterbrechung irgendwo
zwischen Bild und Musculatur, oder ist die gesammte corticale oder infracorticale
Erregung, durch die der Begriff in das äussere Wort umgesetzt wird, zu
schwach, und wirkt das Traiteinent moral durch die Kräftigung dieser Erregungs—
Vorgänge mittelst des psychischen Reizes?” Kussmaul theilt dies bezüglich
zweier Fälle mit.
Um endlich zum Abschluss zu kommen, so liegt es auf der Hand, dass der
durch Erkrankungen in der weiblichen Genitosexualsphäre beeinträchtigte
Ernährungszustand des Gesammtorganismus sich sehr bald auch im Kehlkopf
mit seinem complicirten Muskelapparate geltend machen, und Eunctionsstörun gen
dieses Organs hervorrufen muss. Und in der That oft schon unbedeutende
Schwächezustände geben sich als stimmbeeinträchtigend kund, und verschwinden
mit der Besserung des allgemeinen Ernährungszustandes.
Therapie, Diätetik und Hygieine stehen consequenterweise im innigsten
Zusammenhang mit der Diagnose, welche unser besprochenes Thema im ‘gehö-
DISEASES OF THE THROAT. 327
rigen Maasse ber'ucksichtigt. Die Localbehandlung wird unendlich erleichtert
und unterstiitzt, ja oft : “ Sublata causa tollitur eftectus.”
DISCUSSION.
Dr. E. FRKNKEL, Hamburg: I would by no means deny the intimate rela—
tions between diseases of the genital organs and neuroses of sensation, but I
would warn against exaggeration in this respect. As a proof, I will quote a
casein point concerning a young lady suffering from stenosis of the cervix,
and, at the same time, from severe paraesthesia in the pharynx and larynx.
The throat affections have been cured by appropriate local treatment with the
constant current, whilst the trouble in connection with the dysmenorrhoea, and
caused by the stenosis are still in existence. I will here mention the occurrence
of points doztloureux on the neck corresponding to the points of egress of
the superior laryngeal nerve when tested with the constant current. With
the disappearance of the pain the nervous symptoms also disappear. These
neuroses are to be treated by means of the ether spray directed against the
points of egress of the superior laryngeal nerve (Rossbach’s method).
Dr. FELIX SEMoN : From my own experiences, I would deduce the general
practical rule that in all doubtful cases attention is to be paid to the state of the
genital organs, and that they are to be properly attended to, but that the dis—
covery of a uterine disorder does not at once justify a very sanguine prognosis
as to the curability of the laryngeal complaint.

A Contrz'éuz‘z'm Z0 t/ze PaZ/zology 0f Z726 [Vasal Mucous
Meméraize.
Dr. F. H. BOSWORTH, New York.
In years past it has been the usual practice to accomplish the removal of
the thickened tissues which are met within the nose in connection with nasal
catarrh by means of destructive agents, such as the galvano-cautery, chromic
acid, and other caustics. This will account for the fact that our literature
furnishes but scant information concerning the true nature of inﬂammatory
diseases involving this region. For some time I have almost entirely abandoned
these destructive agents for the ingenious little wire snare éoraseur devised by
Dr. W. O. Jarvis of New York.
This instrument has enabled me to remove the oﬁending tissue with less
pain and less reaction, and with much more satisfactory results than the more
severe caustic agents. Above all, however, it has enabled me to remove the
morbid tissue in small masses, and in such a manner that I have in every
instance been afforded an opportunity of investigating, by means of the micro-
scope, the true nature of the morbid process.
Following up these investigations, I have extended my research into both
the hypertrophic form and the atrophic form of the disease, though it need not
be mentioned that in the latter the operation was of course not indicated. I
may state, however, that, as a matter of clinical observation, and to my great
surprise, in every case in which I removed pieces of membrane in the atrophio
form of the disease there resulted a decided improvement in the disease.
The examinations have been made of membrane removed from the middle
and lower turbinated bones, both anteriorly and posteriorly. The membrane of
the superior turbinated bone I have very rarely found diseased. ‘Without
occupying your time now, I will describe the conditions found in the two forms
of disease—via, rhinitis hypertrophica chronica and rhinitis atrophica chronica.
328 DISEASES or THE THROAT.
I. RHINITIS HYPERTROPHICA GnnomcA.
The epithelial layen—This layer is very markedly increased in width, and
its surface deeply corrugated. There are deep valleys running downward into the
adenoid layer, which are ﬁlled with stratified epithelial cells. These latter con-
sist of elongated epithelia displayed in from ten to twelve layers. The outer—
most layer, from specimens taken from the middle turbinated bone, exhibits ﬁne
ciliae, while in the specimen taken from the lower turbinated bones, the ciliae of
this surface layer are found only on patches as it were. The layer nearest to
the adenoid tissue, or the mucous membrane proper, is occupied by distinctly
developed large columnar epithelial cells, which, especially where they go to ﬁll
the valleys mentioned before, are very large and composed of several strata.
The boundary line between the epithelial layer and the adenoid tissue is
distinct everywhere; in some places there is even present a layer without
distinct structure, the so-called structureless membrane.
The adenoid layen—This layer is also markedly increased in width above
the normal. It is composed of a myxomatous reticulum ﬁlled with very
numerous and even densely crowded lymph corpuscles, in the more recent
cases, whilst in cases of long standing the lymph corpuscles seem to be rather
scantily displayed, and the whole mucosa is composed of very dense decussating
bundles of ﬁbrous connective tissue- The mucosa in all instances is richly
supplied with capillary blood—vessels, mostly ﬁlled with blood. In this layer
also we ﬁnd the acinous glands very numerous, evidently increased in size and
number also. They are lined with cuboidal epithelial cells, which in many
instances exhibit the features of inﬂammatory corpuscles. The ducts of these
glands are traceable to the surface, where they open as a rule into the valleys
noticed in the surface layer of the membrane, when \their epithelia blend with
that of the outer epithelial coat.
The submucous [cyan—Beneath the adenoid layer there is found a broad layer
of myxomatous or ﬁbrous reticulated structure in which enormously enlarged
blood-vessels are present, of a venous character. This is the layer alluded to
by K'olliker and Kohlrausch, and subsequently described more accurately by
Bigelow as composing a true erectile tissue in the normal mucous membrane.
The connective tissue between these larger veins, however, is broader than in
the normal cavernous tissue, and is supplied with bundles of smooth muscular
ﬁbres. The muscular coat of the veins is also increased in breadth.
The arteries of this layer, although scantily displayed, are all of a wavy
course, constituting the so-called helicine arteries. This submucous layer also
contains a large number of racemose mucous glands increased in size and
number. The presence of these glands in this submucous layer, as far as I
know, is anomalous. Surrounding these glands there are noticed heaps or
masses of lymph corpuscles.
We ﬁnd, therefore, that the changes which take place in the hypertrophic
form of the disease may be brieﬂy summed up as follows :—
1.—-Hypertrophy of the surface layer, resulting in augmentation of the
covering epithelium, without desquamation.
2.—-Hypertrophy of the adenoid layer, resulting in an increase or thick-
ening of the layer; an increase of its capillaries with stagnation of blood, and
a new formation of ﬁbrous connective tissue, replacing the adenoid layer.
3.—Increase in the size and number of the racemose glands both in the
adenoid and submucous layer.
4.—Hypertrophy of the connective tissue between the enlarged veins in the
submucous layer.
DISEASES OF THE THROAT. 329
II. RHINITIS ATROPHICA CHRONICA.
In this form of inﬂammation the membrane is thin, shrunken, and
bloodless.
The epithelial Zayen—ThiS layer is markedly decreased in width. The
outer nearly smooth surface is occupied by a relatively broad layer of ﬂat
epithelia partially in a state of desquamation. Below this we ﬁnd stratiﬁed
cuboidal epithelia displayed in ﬁve or six layers, while the portion nearest to
the adenoid layer is occupied, in some regions at least, by columnar epithelium;
where the latter is plainly visible, the boundary line between the epithelial and
the adenoid layer is plainly marked. In many places, however, such a boundary
is not traceable, and the adenoid layer blends with the epithelial coat, while the
latter at the same time exhibits many features which are similar to those of the
adenoid layer of the membrane.
The adenoid lag/en—This layer is thinner than normal, and is occupied by
lymph corpuscles, crowded together in quite a marked manner, and supported
by a delicate ﬁbrous reticulum. The blood supply of this layer is very
scanty; the number of the capillaries being notably small, while their calibre
is, as a rule, narrow. Moreover, in nearly every instance they are quite empty
—containing no blood.
The adenoid layer merges into the submucous layer, a layer of a more
ﬁbrous construction, with relatively less numerous lymph corpuscles; this
layer also exhibits very scanty acinous glands; these glands and their
ducts being notably diminished in calibre, but also in number. Their acini
are lined by short columnar and cuboidal epithelium, while the ducts exhibit,
around a large calibre, well-deﬁned columnar epithelium. Around the scanty
acinous glands there are seen heaps of lymph corpuscles. This submucous layer
shows a somewhat larger number of blood-vessels than the adenoid layer, which
also on an average exhibits a wider calibre. The characteristic feature, there—
fore, of the atrophic form of the disease may be summed up as follows :—
1.—Diminution or atrophy of the epithelial layer of the membrane with
loss of the ciliae, together with evidences of profuse desquamation.
2.-—Diminution or atrophy of the adenoid layer, attended with lack of
blood-vessels and destruction of the acinous glands.
3.--Destruction of the submucous erectile tissue, the tissue being converted
into a more or less dense ﬁbrous structure containing no blood spaces whatever.
There are certain general deductions which may be drawn from these in-
vestigations, in the statement of which I shall endeavour to be very brief.
The nature of hypertrophy of the nasal mucous membrane has long been
recognized by all of us, and I do not know that I have been able to do more in
my investigation than to conﬁrm opinions for a long time entertained.
I will only say then, in regard to this form of the disease, that the logical
deduction from the true nature of this form of disease is'that its'proper
treatment demands its ablation, and that in the use of douches, sprays, and
mere cleansing and astringent washes we can afford but a doubtful temporary
relief. I will only say further, as intimated at the opening of my paper, that
with the use of the little wire snare of Dr. Jarvis, I have been able to accomplish
the removal of morbid tissue, not only with success, but also with comparatively
little hmmorrhage or pain, and with no secondary inﬂammation.
In the atrophic form of the disease, I think the investigation throws much
light on many unsettled questions. It is a very prevalent opinion that an
atrophic catarrh may result as a later stage of the hypertrophic disease. This
opinion I for a long time held and taught. This view cannot be entertained.
In rhinitis atrophica we have a form of inﬂammation which, from its outset,
330 DISEASES OF THE THROAT.
is diﬁerent from the hypertrophic form. It consists in a degenerative change
which, apparently, has its origin in the epithelial lining of the acini, leadiicig
soon to a more or less profuse desquamation, which in time results in a loss or
impairment of function of the glandular structure of the membranes, and sub—
sequently to their atrophy. This I believe to be the starting-point of the
disease, and the condition from which all the subsequent phenomena arise.
The subsequent progress of the morbid changes may be brieﬂy stated as
follows :—-The loss of glands robs the mucous membrane of that proper supply
of mucus by which it is kept in a moist and pliable condition. As the result
of this, there is poured out upon its surface a thick and scanty mucus, deﬁcient
in its watery constituents. The result is, that it dries upon the surface of the
membrane, forming a dry, parchment-like pellicle, coating and adhering to its
surface. In drying, this pellicle necessarily contracts, exerting a slight pressure
on the tissues beneath 3 a pressure which is very slight, but continuous. This
process, being continued through months and years, results, not only in promoting
the original atrophic change in the membrane, but also results in inducing that
shrinking of the turbinated bones which is so common a feature of the later
stage of the disease.‘ It is also by this pressure that we ﬁnd the erectile tissue
of the middle and lower turbinated bones disappearing and giving place to the
ﬁbrous structure which is found beneath the adenoid layer in the atrophic
disease.
A still further result is, that as these dry pellicles are formed, mucus is
secreted beneath them. This mucus is imprisoned ; it does not lose its
moisture, but, being retained, it undergoes degeneration and stinks, giving rise
to the odour which is so common in this disorder. The crusts are lifted from
below, and piled up, as it were, by the secretion of the membrane, and then
result large and olfensive masses, which are discharged at intervals of from
three to ﬁve days. This, in brief, I believe to be the manner in which, from
simple degenerative changes commencing in glands of ‘the mucous membrane,
there result the so-called dry catarrh and its sequence, ozaena.
As to the causes of the disease, with our present knowledge, little can be
said. I do not believe that syphilis has any connection whatever with ozaena.
Syphilis in the nose gives rise to ulceration and necrosis; ozaena never gives
rise to either ulceration or necrosis.
I have sought for evidence, clinical and otherwise, of the syphilitic taint in
patients suffering from ozaena, but have never found it. The same may be said
of struma, and all other depressing diatheses. Ihave never been able to connect‘
ozaena with any general constitutional condition, although we are generally
taught in literature the contrary.
It is, then, a purely local disease in its outset, and any impairment of health
which attends it—and I will say that I believe this to be rare—is due to the
disease, and that the bad air that the sufferer from the disease breathes, is the
cause of the impaired health.
DISCUSSION.
Dr. KRAUSE, Berlin: I desire to draw attention to the quantity of fatty
detritus, and to the numerous fat globules in the atrophic nasal mucous mem-
brane, clearly visible in Dr. Bosworth’s microscopical specimens. This Seems
to me a constant occurrence, besides the other changes, such as shrinking, and
even total disappearance of the glands, &c. I shall have to refer to this fatty
metamorphosis in the discussion on ozcena.
DISEASES OF THE THROAT. p 331
Du 707€ de la poﬂz'on Zz'ére de Z’e’ÿzggloﬁe et des fossez‘z‘es glossa-
épzz'gloz‘z‘z'gues.
Dr. GUINIER, Oauterets.
Au cours d’un repas, l’observation constate les faits suivants:
La pulpe ou le bol qui résulte de la trituration et de l’insalivation de la
bouchée disparaît de la cavité buccale et s’accumule dans les fossettes glossa-
épiglottiques, comme sur un palier d’attente, avant toute déglutition.
La contraction progressive du constricteur supérieur du pharynx et des
piliers postérieurs renforce la résistance de la portion libre de l’épiglotte contre
la pression du bol s’accumulant dans le sillon glosso—épiglottique.
La présence du bol dans le sillon provoque le besoin de déglutir, d’autant
plus impérieux que la masse à. déglutir est plus volumineuse et que la mastication
est plus avancée.
Le besoin de déglutir est une sensation musculaire spéciale, comme le besoin
de défécation.
Comme toute sensation du même genre le besoin de déglutir est soumis à. la
volonté ; la déglutition peut être retardée ou même refusée. Une excréation
rejette alors le bol déjà. parvenu contre l’épiglotte.
Mais, si l’on cède au besoin de déglutir,il se produit aussitôt dans l’appareil
de déglutition, proprement dit, une série de contractions réﬂexes, et le bol
franchit brusquement le pharynx œsophagien pour se précipiter dans l’œsophage.
Donc, au moment où le besoin de déglutir apparaît, le bol a déjà dépassé
l’isthme du gosier; il est parvenu contre le bordv libre de l’épiglotte; il a déjà
subi l’action du dos de la langue, de la voûte palatine, du voile et des piliers;
et il est certain que l’acte de déglutition n’est pas encore commencé.
Tous les phénomènes observés jusque la n’ont eu pour but que la formation
du bol, la disposition de la masse pour une facile déglutition; ils n’ont agi que
comme phénomènes préparatoires de l’obligation de déglutir. Ces phénomènes
appartiennent donc exclusivement à la mastication.
Pour la facilité des études physiologiques, pathologiques et thérapeutiques,
le pharynx anatomique doit être divisé en trois portions distinctes :—1. Un
pharynx nasal; 2. Un pharynx buccal; 3. Un pharynx œsophagien.
C’est a l’entrée épiglottique du pharynx œsophagien que le bol s’établit
pendant la mastication, et c’est au niveau de l’étranglement pharynge—
épiglottique que se produit surtout la sensation du besoin de déglutir.
L’arrêt du bol contre l’épiglotte et la coexistence d’un besoin avec cet arrêt
se retrouve au pylore et au rectum. Au pharynx, au pylore, au rectum, il y a
analogie de mécanisme. ‘
Arrêt de la masse alimentaire pour la transformation de la bouchée origin-
elle, en bol dans le sillon glosso-épiglottique, en chyme au pylore, en excrément
au rectum. ~
Obstacle à franchir sous forme de sphincter.
Accumulation progressive contre l’obstacle à, mesure que la fonction s’ac-
complit.
Sensation organique de besoin pour la progression de la masse, perceptible
au pharynx et au rectum, non perçu au pylore.
Ainsi obstacle à franchir, arrêt de la masse à. déglutir, accumulation de
cette masse dans un réservoir d’attente jusqu’à concurrence d’un volume déter-
miné par la capacité du réservoir d’attente, sensation organique d’un besoin, tels
sont les phénomènes caractéristiques qui précèdent toute déglutition.
Conclusiona—L—La portion libre de l’épiglotte joue le rôle de margelle de
larynx pendant la mastication de la bouchée.
3 32 DISEASES 0F THE THROAT.
2.-—Les fossettes glosso-épiglottiques sont le réservoir d’attente du bol
alimentaire pre'paré pour une déglutition.
3.—-La déglutition de l’aliment commence seulement au niveau du trou
pharyngo~épiglottique, apres qu’il a subi déja l’action de la langue, de la voute,
du voile et des piliers, et qu’il a dépassé l’isthme du gosier par une marche
réguliere sans aucun mouvement convulsif.
4.——Le mécanisme de la mastication comprend :
(a)—-La trituration de l’aliment.
(b)-—La transformation on bol par l’association de la trituration et de l’insa—
livation.
(c)—Son transport successif a l’état de bol naissant, dans les fossettes glosso-
e'piglottiques par l’action combinée de la langue, de la voute et des piliers.
(d)—-Son accumulation, dans le réservoir d’attente glosso-épiglottique jusqu’a
ce qu’une déglutition vienne l’y prendre pour le précipiter en un seul temps au
pharynx oesophagien, dilaté et agissant comme ventouse, dans la profondeur de
l’oesophage.
CLINICAL DEM ON STRA TI ON S .
Dr. MoRELL MACKENZIE sent a patient for exhibition on whom he had per-
formed internal oesophagotomy. The instrument was shown at the same time.
He also sent a patient suffering from spasm of the tensors of the vocal cords
(stammering of the vocal cords).
Dr. G. VIVIAN POORE showed the patient with web in the larynx, whose case
he had communicated.
Dr. FELIX SEMON showed ﬁve cases of bilateral paralysis of the abductors of
the vocal cords (posterior crico-arytenoid muscles), and gave a short report of
the individual cases, dwelling upon the fact that the origin of the disease in
some of them was of a central, in other ones of a peripheral, character. In
one of the cases anchylosis of the right crico—arytenoid articulation had super—
vened later on.—He further showed a case of anchylosis of the left crico—arytenoid
articulation, with atrophy of the corresponding vocal cord, which was ﬁxed in the
median line in a woman aged thirty, the subject of late hereditary syphilis—He
also showed the larynx, pharynx, and thyroid gland of a goitrous patient suffering
from carcinoma of the oesophagus, who had died from retro-tracheal haemorrhage
during the performance of tracheotomy. The post-mortem examination showed
that an abscess cavity had formed between oesophagus, trachea, and right lobe of
the thyroid body, which communicated posteriorly through a small opening
with the oesophagus, anteriorly through a large one with the trachea. The
latter being situated just opposite the place of the artiﬁcial incision, the pilot
of the canula had penetrated straight through the trachea into the abscess cavity,
and, injuring there some superﬁcially situated thin-walled veins, had caused the
fatal haemorrhage.
Dr. W. McNEILL WHISTLER, London, Sl’lOVt ed a case of speciﬁc pharyngeal
stenosis, in which he had established a connection between the oral and nasal
parts of the pharyngeal cavity, which previously had been separated from one
another by newly-formed cicatricial tissue. He also showed a patient in whom
a similar condition still existed.
Dr. FOULIS, Glasgow, showed two larynges he had removed during life;
the one the seat of sarcomatous, the other of carcinomatous, disease.
DISEASES on THE THROAT. 333
l)
Dr. MICHEL, Cologne, demonstrated his method of removing adenoid
vegetations from the vault of the pharynx by means of the galvanocaustic
loop.
Dr. URESSWELL BABER, Brighton, exhibited a self-retaining nasal speculum,
and a snare which could be ﬁxed at any angle.
Dr. BosWOR'1‘H, New York, showed the nasal snare which he uses, insisting
on the advantage of using No. 5 piano steel wire. ‘
Dr. FOULIS, Glasgow, showed his apparatus for heating the actual cautery.
He also exhibited instruments for removing the larynx and plugging the trachea,
as well as models of several of the artiﬁcial larynges now in use, including his
own modiﬁcation of Gussenbauer’s contrivance.
Dr. B. FRKNKEL, Berlin, exhibited his modiﬁcation of Whitehead’s mouth-
dilator, consisting in the addition of a tongue-depressor, which forms part of
the instrument itself, and of a self-retaining Voltolini’s palate hook, which is
ﬁxed to the instrument after introduction by means of a simple screw. He also
showed prisms for the better illumination and inspection of the nasal, aural,
and other cavities of the body.
Dr. PROSSER JAMES, London, demonstrated a series of pharyngeal and
laryngeal instruments, the distinguishing feature of which consists in the fact
that each is forged of one piece of steel, and in the sickle-shape of the cutting
blade of many of them, which, varying as it does in size, according to the
nature and size of the parts to be removed (tonsils, uvula, laryngeal growths),
possesses the common advantage that it cannot injure the healthy parts.
Prof. KRISHABER, Paris, showed a series of tracheotomy tubes, which,
besides offering advantages for easy introduction, represented certain distinct
calibres with corresponding numbers, based upon a distinct relationship
which he had found existing between the patient’s body and the diameter of the
trachea. He had given his tubes numbers corresponding to different heights
of the human body, which would be found to ﬁt perfectly the size of the
patient’s trachea. Consequently, if a surgeon living in the country desired to
have at once a tube answering the requirements of his case, after the adoption
of his principle, it would only be necessary to forward an exact statement of
the patient’s height in order to be sure of receiving a suitable tube.
Dr. MORELL MACKENZIE‘S new oesophagoscope was exhibited.
Dr. RUMBOLD, St. Louis, showed his spray-producers.
Prof. STonK, Vienna, sent his oesophagoscope»
Dr. TORNWALDT, Danzig, showed an india-rnbber tampon, to be inﬂated
with water, for the gradual dilatation of laryngeal stenosis from the wound
after tracheotomy had been performed.
Mr. SPENCER WATSON, London, showed a self-retaining nasal speculum and
other nasal instruments.
Prof. CADIER, Paris, showed his tube laryngoscope, which could be ﬁxed to
334 DISEASES OF THE THROAT.
any ordinary lamp and permitted of some inclination, so that the patient could
under all circumstances retain his position.
Dr. GooDwILLIE, New York, demonstrated the use of a surgical engine,
similar to that used by dentists, for drilling exostoses in the nasal cavity.
Prof. VOLTOLINI, Breslau, showed his new and exceedingly simple battery,
which can be used not only for the galvanic and faradic currents, but also for
galvanocaustic currents of any strength. He further demonstrated an ingenious
mode of removing needles and other articles of iron from the larynx by ﬁxing
them from without by means of a powerful magnet and then introducing a
knitting-needle, to which they attach themselves.
Prof. OAsELLI, Reggio Emilia, showed a new galvanocaustic tracheotome
of which he gave the following description :-—-It is made after the model
of Laborde’s dilator, mounted on a long handle curved like the letter S.
One of the lateral branches carries at its extremity a lancet point of
platinum, while the other parallel is isolated by a little plate of ivory.
The central branch is in the form of a platinum knife, and, moving along
the middle simultaneously with the opening of the instrument and the sepa-
ration of the two lateral branches, this central branch retreats in a series of
movements and ﬁxes itself in a special socket: thus the instrument remains
open of itself, leaving the hand of the operator free. On the back of the
instrument are three ivory buttons, marked with appropriate letters. Under
these letters are a series of connections by which the electrical contact is made
and broken. At the free end of the handle are two metal branches, to which
the wires from the battery are attached. Holding the instrument in the right
hand and touching the ﬁrst button, marked P, with the foreﬁnger the platinum
point, so that without any assistant the operator can ﬁx the larynx with the
thumb and foreﬁnger of the left hand, the point of the instrument enters the
trachea at the place selected, passing easily through the tissues. The cessation
of resistance and the sound leaving the tracheotome notify the entrance of the
instrument into the tracheal cavity. Releasing now the ﬁrst button, press the
second one, supporting the thumb and middle ﬁnger on the two small lateral
wings of the instrument. The point then suddenly cools down and ceases to
burn the parts : on pressing the second button and closing the lateral Wings the
galvanocaustic knife retires, cutting the tissues in their entire thickness in front
of the trachea and the tracheal wall also, while the two other branches open
the out parts. When the opening is large enough to allow the canula to be put
in, release the buttons, whereupon the instrument cools down at once. You
have now a cold and blunt dilator of Laborde’s pattern in. situ, and you may
proceed at your ease to insert the canula, and touching then the button
marked S, the blades close, and may be withdrawn from the wound. If, owing
to want of thorough knowledge of the details, any haemorrhage should be set
up, it is easy to touch the button P, which heats up the platinum points, with
which the bleeding—point may then be securely cauterized.—-Prof. Caselli also
showed a new artiﬁcial larynx in ebonite, which he described as follows :——-I
show you to-day a new larynx made of ebonite, which has the advantage over
the other in use of being very durable, very light (only weighing 25 grammes),
and of very moderate cost, the price being about 75 livres of Italian money (£3).
I submit it for your examination, and hope to have your approval. It is com-
posed of a tracheal canula, with an aperture in the convex part. Through this
aperture is introduced the ascending tube, which is articulated at its middle, so
as to adapt itself to the parts and to the movements of the tongue. At the
DISEASES or THE THROAT. 335
upper end there is a vibrating reed. The outer oriﬁce of the tracheal canula
is provided with a valve, opening from without inwards. When the patient
inspires, the valve opens, and air enters the lungs, and when he expires, the
valve closes, so that the air travels along the ascending tube, and causes
the reed to vibrate, and causes the sound of the voice. When the patient eats,
he takes out the ascending branch and inserts an inner tube in the tracheal
canula. This occludes the upper aperture. The anterior oriﬁce may also be
protected by a perforated button to prevent the introduction of foreign par-
ticles into the trachea.
Dr. MEYER, Copenhagen, exhibited the instruments which he employs for
the removal of adenoid vegetations.
DR. BéioKER, Berlin, showed an improved gas lamp, having the advantage of
extraordinary illuminating power, and a tonsillotome of a new description.
In the course of the proceedings the following resolution, moved by Prof.
Schnitzler, Vienna, was carried unanimously: “ That, opportunity having now
been afforded for the ﬁrst time to laryngology to show its capabilities at an
International Medical Congress, and its place amongst the recognized specialities
being now fully secured, a repetition of isolated Laryngological Congresses is
the less required; and that it is therefore desirable to abandon the plan adopted
at the ﬁrst Laryngological Congress, held at Milan last year, of holding a second
meeting next year at Paris.”
At the conclusion of the proceedings votes of thanks to the Chairman and
Secretaries were proposed and carried unanimously ; that to the Chairman being
proposed by Dr. Meyer, Copenhagen, and seconded by Dr. Solis Cohen, Phila-
delphia; and that to the Secretaries being proposed by Dr. B. Frankel, Berlin,
and seconded by Dr. Fournié, Paris. ‘
Altogether 342 gentlemen inscribed their names as members of the Sub-
section ; of these, as far as could be ascertained, 116 were Englishmen and 116
foreigners—via, 35 Germans, 30 Americans, 15 Frenchmen, 13 Spaniards and
South Americans, 7 Belgians, 6 Russians and Poles, 6 Italians, and 4 Austrians.
Of the remaining 110, whose nationality, in most instances, could not be ascer-
tained, some belonged to other nations, the greater part, however, no doubt, to
England and America. The number of those simultaneously present averaged
from 60 to 100. Of the papers sent in 38 were accepted, 20 of which were
introductory papers, the gentlemen who read them having been invited by the
Committee; 10 were contributions dealing with subjects suggested for discussion
by the officers of the Subsection; 8 were papers on independent subjects. Of
these 38 papers, 31 were actually read and 7 taken as read in the absence of the
authors. The number of speeches made amounted to 126, which would allow
an average of 83} minutes to each speech, taking the whole speaking time at
18 hours. Of these speeches (which include the introductory and independent
papers) 60 were made in the German, 53 in the English, and 13 in the French
language. The total number of speakers who took part in the discussion
was 50.
DISEASES OF THE BAR.
—-+_
President‘.
WILLIAM BARTLETT DALBY, Esq.
Vice-Presidents.
Dr. JAMES PATTERSON CASSELLS, Glasgow. 1 Dr. CHARLES Enwmn FITZGERALD, Dublin,
Council.
A. G. Bnown, Esq., London. Dr. Kmrr, New York.
E. CUMBERBATCH, Esq., London. JAMES KEEN, Esq., London.
Dr. DUNCANSON, Edinburgh. Dr. LOEWENBEBG, Paris.
G. P. FIELD, Esq, London. Prof. Lucas, Berlin.
Dr. GELLE, Paris. Dr. Muslims, Paris.
Dr. GUYE, Amsterdam. Prof. Suromur, Milan.
Prof. MACNAUGHTON J oxns, M.D., Cork. Dr. H. R. Swxuzr, Dublin.
Prof. VOLTOLINI, Breslau.
Secretaries.
Dr. URBAN Parrcnann. | W. LAIDLAW Pumas, Esq.
__._§__.
IN AUGURAL ADDRESS,
BY THE PRESIDENT,
WILLIAM B. DALBY, ESQ.
THE gratiﬁcation which is felt by all branches of our profession in this country, in
having the pleasure of meeting our foreign confreres has been expressed so completely
in the eloquent address delivered by the President of this Congress, that I should be
going beyond my duties if I did more than offer the very sincere thanks of the aural
surgeons in London to those who have done us the honour of attending this Section.
Perhaps in no department of medicine or surgery is it more desirable that those who
are practising it should have the opportunity of meeting and comparing their views, than
in that of otology, and this for the reason that from two very distant parts of the globe—
viz., Germany and America, most of the recent researches in the scientiﬁc part, and many
of the advances in the practical portion of this speciality, may be said to have arisen.
It is most ﬁtting, therefore, that London, being in a measure mid-way between these
two countries, should be the privileged ground of a debate, which, I trust will be an
advantage, and cannot fail to be a pleasure, to the representatives of aural surgery in
Europe and America who are here to-day.
In comparison with some other Sections, the subjects selected for discussion at ﬁrst
sight, perhaps, appear to be very few, but this arrangement has not been decided upon
without due consideration, and with a very distinct purpose.
The pathology of certain diseases of the ear may be said to be established, and their
successful treatment is without doubt conducted by all of us upon very much the same
routine.
There are others upon the pathology of which very different views are held, and in
PART III. z
3 38 DISEASES or THE EAR.
regard to whose treatment the most various methods are now advocated and practised.
When I say that, amongst the latter class, especial prominence should be given to the so-
termed proliferous catarrh of the tympanum, its treatment generally, and the several ‘
operations which have been devised and practised for its relief, I feel sure that this state-
ment will receive general assent.
I regard, therefore, the present occasion as aifording a most unusually favourable
opportunity for a thorough discussion upon all points connected with this matter, and
the ﬁrst subject upon the programme—via, “The value of operations in which the
tympanic membrane is incised,” includes all the debateable ground in connection with it.
Patients with this affection (certainly one of the most common diseases of the car) are
every day coming under the observation of aural surgeons, and it must be acknowledged
that from the capitals of Europe and from the United States, the views and practice of
most eminent authorities, whether as regards general treatment or operative proceedings,
are of the most different character, and often opposed to one another even in principle.
This extreme divergence of opinion is of itself enough to indicate the difficulties which
surround the subject.
I may perhaps be allowed to say that the position which operations upon the
tympanic membrane occupies in surgery at the present time is of a somewhat uncertain
and indeﬁnite nature.
It is well known that many surgeons never make an incision into the membrane:
that others in their practice strictly limit this procedure to those cases of acute inﬂam-
mation of the tympanum, in which there is tolerably conclusive evidence of the existence
of pus. A third division, and this includes a very large proportion of those who attend
to ear aﬁ’ections, make use of an incision, not only for the evacuation of pus, but also of
mucus in a more or less ﬂuid state from the tympanic cavity. In the fourth division
must be placed those who, to the indications already named, add, as requiring one of the
several forms of operation on the membrane, cases in which the tympanum has been the
seat either of proliferous catarrh, or of inﬂammation which has left the membrane con-
nected to the ossicles, or the wall of the tympanum by adhesions. Lastly, we come to
the division of the tensor tympani muscle—without expressing any opinion on this
subject, it may be said that, for whatever class of cases it may be practised, it can hardly
be declared to take rank amongst those operations in surgery as one which, in conse-
quence of its results, has received the recognition that is (and must be) accorded to every
surgical proceeding worthy of universal adoption. It cannot, for example, in the present
state of its history, bear comparison with a somewhat analogous operation in the depart-
ment of ophthalmology—via, iridectomy; and whatever position it may eventually occupy,
it would be hardly too venturesome to predict for it a similarly brilliant future, if the
anticipations which were formed by those who introduced and practised it had been even
in a measure realized. What is the precise place which it holds at present, in the
opinion of those well qualified to judge of its merits, we shall hope to hear before this
Section has concluded its discussions. We may, I think, fairly presume that the object
which is sought to be attained, from all operations which include incision of the
membrane, is of a two-fold character—via, the evacuation of the products of inﬂammation,
or the relief of tension, and there are probably no surgeons of experience amongst us who
have not, at some time during their career, performed various operations with these prin-
ciples in view. If a general expression of opinion on the respective merits and demerits
of each and every operation on the membrane is extracted at this meeting, such as may
serve as a guide to those members of our profession who are devoting their energies to
the study of diseases of the ear; the interests of surgery will have been well served, and
I sincerely trust that this may be the result of our deliberations.
DISEASES or THE EAR. 339
The next subject for discussion “Morbid growths within the Ear,” not only includes
the origin, nature and treatment of bony enlargements and exostoses in the external
meatus, of polypus from whatever part arising, of myxoma, sarcoma and cancer; but also
the treatment of perforations of the membrane, inasmuch as this is a very constant
accompaniment and exciting cause of these growths.
Probably no portion of the body so well as the car could be selected to illustrate the
doctrine in pathology which teaches us that a local irritation must precede a homolo-
gous or heterologous formation. To take the last-named examples of myxomatous, sarco-
matous, and cancerous growths. Certainly in none of the cases which I have myself
seen, altogether three in number, or which within my knowledge have been recorded by
other observers, has malignant growth affected the ear, unless it has been preceded for a
considerable period by a purulent discharge secreted from the lining membrane of the
tympanic cavity. The same rule held good in the only case in which I met with a round-
celled sarcoma in the ear. A similar law will, I think, he always found to obtain when
myxomatous tumours are found in this position—we all know how very generally every
form of polypus is but the sequence of a perforation, and even when a polypus takes its
origin from the external canal, a local irritation, represented by a circumscribed inﬂamma-
tion, which involves the periosteum of the canal, has existed previously. In the case,
too, of multiple bony enlargements of the canal, although very often it is' not easy to
point to a local irritation, the history of a perforation of many years’ standing may not
unfrequently be extracted from the patient, so that it is fair to infer that the passage of
a purulent discharge over the surface of the canal has been the direct cause of the so-
called exostosis. In order to show the extreme probability of the truth of this explana-
tioh, we must fall back upon our personal experiences of cases—on ﬁve occasions I have
attended patients with perforation of the membrane, who have been dismissed, and have
presented themselves between two and three years later with multiple enlargements of
bone almost completely blocking up the canal—another point, which also bears out the
theory of a local cause to these growths, is one which I have constantly observed (and it
has been recorded by others). It is that, when the enlargements are found in both canals,
the patients have been much addicted to sea-bathing.
The third subject on the list, “ the loss of hearing where the external and middle ears
are healthy,” embraces a very large proportion of the conditions under which the hearing
s defective, whilst it is at the same time associated with subjective nervous symptoms.
In this category will come syphilitic disease (inherited and constitutional) of the nervous
structures, that very large class of cases to which for want of a better name, and appa-
rently for no other reason, the term Méniére’s disease has been applied; a subdivision of
this class, in the contemplation of which no one, who has had a large experience of ear
diseases, can fail to be struck with the intimate relation which exists between the audi-
tory and pneumogastric nerves; cases of extreme deafness and perfect hearing alterna-
ting, without any explainable reason so far as an examination can detect. Those instances
in which a permanent or temporary loss of hearing is without doubt primarily due to
emotional inﬂuences, form a most interesting and distinct group in themselves. This is
not an occasion 011 which I would venture to occupy your time by the relation of cases,
but I may be allowed to mention by way of illustration that I have known the hearing
in apparently healthy subjects to be almost completely lost on the witnessing a sudden
death of a near relative, on several occasions immediately upon the receipt of news of a
painful nature: in the case of women upon the fright produced by a cry of ﬁre, or an
alarm of burglars in the house; at the witnessing of the terrible sight of a man cutting
his throat : once on the receipt of great good fortune which had not been anticipated.
On each of these occasions the hearing power of the patient was always perfectly good
2 2
34o DISEASES or THE EAR.
up to the time of the catastrophe, and immediately afterwards the deafness was intense,
so that the change in all probability was almost instantaneous. In passing, I suggest as
a possible, though imperfect and incomplete explanation, that in the cases referred to, a
sudden hyperaemia in some portion of the brain, or perhaps in the medulla at the origin of
the auditory nerve, may account for a phenomenon which we are not at present in a position
to explain. In truth, because we cannot actually deﬁne the lesion or even its position, it
is none the less certain that a local origin must exist. We have also to consider the
unmanageable subject, and too often unmanageable symptom of tinnitus: the sudden
and total loss of hearing consequent upon mumps, diphtheria, and some other acute
diseases : the loss of certain ranges of notes whilst other sounds are normally heard.
The list might be readily extended, but it is only necessary to mention what I have
done to show that there is no dearth of material for our deliberations.
In many nervous diseases which come under the observation of physicians, a certain
train of symptoms are met with, at the same time the actual lesion, or sometimes even
the position of the lesion, is uncertain. The diseases are, however, quite familiar to us
all, and we apply the same name to them. Amongst aural surgeons I am sure that
mental notes are often taken, by the help of which, if they received expression, the
nervous diseases of the auditory apparatus would be sorted into groups, nameless perhaps,
but none the less suggestive of the probable termination of the cases, and rich in facts
that might serve as a guide to future observers. That such notes, derived from the
experiences of years, may be laid before us when the third selected subject is under dis-
cussion, I have great hopes. I purposely forbear to refer to any of the eminent men
whose names are connected with the various diseases I have mentioned by suggested
treatment; by the operations which they have introduced; by their valuable investigations
and observations. They are perfectly familiar to all the members of this Section, and it
would be diﬂicult as well as invidious to allude to any without mentioning the names of
many of the distinguished visitors whom we have the good fortune to meet to-day.
N oz‘e sm/ zme modzﬁeaz‘z'oee rapper/fee at [a myrz'agodeez‘omz'e
dams Z’oz‘z'z‘e sele’e/euse.
Dr. A. PAQUET, Lille.
Parmi les maladies de l’oreille, l’une des plus variables dans la forme, 1e mode
de développement, la marche et la curabilite', est la sclérose de la caisse du tympan.
Gette affection revét une allure insidieuse ; depuis longtemps déja elle a commence’ a
se développer, lorsque 1e malade s’apercoit qu’il n’entend plus distinctement d’une
oreille; oertains mots lui échappent, et dans la crainte d’une surprise toujours
désagréable, on le voit préter une attention foroe'e, qui contraste avec ses habi-
tudes antérieures. On constate alors presque toujours des lésions étendues et
anciennes, contre lesquelles la thérapeutique qrdinaire possede peu de ressources.
Toutefois, ces lésions different suivant les sujets, et présentent un certain
nombre de variétés que l’on peut rapporter a deux formes principales; la forme
exsudative ou plotstt'qae, et la forrne scléreuse proprement dite, appelée aussi par
quelques auteurs, ottte seohe.
Dans la forrne plastique ou exsudative, on reconnait l’existence de pseudo-
membranes plus ou moins épaisses, s’étendant comme des travées de la membrane
tympanique aux diverses parties de la face interne de la caisse, englobant parfois
les osselets dans une masse de tissu conjonctif de nouvelle formation, immobilisant
DISEASES OF THE EAR. 34!
ainsi des parties séparées ou mobiles les unes sur les autres à l’état normal.
Plus tard, en vertu de la puissance rétractile de ce tissu conjonctif nouveau, la
membrane du tympan, paroi mobile de la caisse, se trouve attirée en dedans vers
la paroi interne, et ﬁxée dans cette nouvelle position par des adhérences plus ou
moins étendues, plus ou moins denses, qui s’établissent déﬁnitivement; le muscle
tenseur du marteau, dans un état continuel de relâchement, se raccourcit; son in-
action entraîne l’atrophie de ses éléments constitutifs, et après un certain temps ce
muscle et son tendon se trouvent atteints de raccourcissement permanent, ou
rétraction.
D’autre part, l’exsudat plastique envahit les fenêtres, et en particulier la fenêtre
ovale, et l’accumulation a ce niveau de couches ﬁbro‘ides nouvelles enclave l’étrier
et l’immobilise. Les articulations des osselets ne sont pas épargnées, les dépôts
plastiques s’accumulent autour d’elles ; a la longue, ces dépôts se densiﬁent, et les
osselets se trouvent immobilisés par une sorte d’ankylose ﬁbreuse.
Dans la seconde forme, dite scléreuse proprement dite ou otite sèche, l’exsudat
plastique est très limité, parfois même il semble faire défaut, et toute la lésion
paraît constituée par des productions osseuses ou des dépôts crétacés ; il se fait de
véritables hyperostoses des osselets, et des incrustations calcaires dans les mem-
branes ; il semblerait, dans ces cas, que l’hyperplasie conjonctive est moins active, et
qu’au lieu d’ aboutir à des pseudo-membranes plus ou moins épaisses qui établiraient
des adhérences, elle se laisse pénétrer par des sels calcaires; tout en exagérant les
dimensions des osselets qu’elle soude entre eux, elle devient le point de départ de
calciﬁcation des membranes, notamment de celle de la fenêtre ovale, englobant
ainsi l’étrier, et le soudant déﬁnitivement à la fenêtre par la production d’une
ankylose vraie.
Il est assez fréquent de voir ces deux formes se combiner; dans ces cas les
lésions sont disséminées, et revêtent un caractère mixte. Plus rarement la lésion
n’existe que sur quelques points isolés de la caisse, et nous avons plusieurs fois
constaté l’ankylose de l’étrier, alors que la membrane tympanique présentait des
caractères à peu près normaux.
La surdité produite par l’otite scléreuse présente quelques traits particuliers;
elle est constante, progressive, peu modiﬁable par les agents thérapeutiques et par
l’insufﬂation de l’air dans la caisse ; elle paraît être inﬂuencée d’une manière
heureuse par l’ébranlement imprimé aux osselets, car les malades entendent mieux
au milieu du bruit, et pendant qu’ils voyagent en voiture ou en chemin de fer.
Les bourdonnements et les sifflements sont tellement fréquents, qu’ils font en quel-
que sorte partie constitutive du cortège des symptômes de la maladie.
On comprend aisément la gravité d’une pareille affection, dont la marche pro-
gressive est fatale, et le peu de succès des méthodes thérapeutiques dirigées contre
elle. Les moyens ordinaires demeurant inefficaces, on a proposé, pour remédier en
partie à la surdité et aux bourdonnements, la section de la membrane tympanique;
cette opération ayant été pratiquée un grand nombre de fois avec des résultats
variables, mérite de ﬁxer toute l’attention des otologistes; c’est à ce titre que je
crois utile de communiquer quelques-unes de mes observations, et de donner mon
opinion sur une méthode thérapeutique que j'ai eu plusieurs fois l’occasion de mettre
en usage.
J’ai décrit dans mon livre “Sur le Traitement Chirurgical desMaladies desOreilles”
(Paris, Octave Doin, 1879) les indications de l’opération, et j’ai parlé des procédés
employés par Toynbee, Weber, Bonnafont, Voltolini, Simroch, Roosa, Pommeroy,
Spencer, Gruber, Wreden, Miot, &c.; depuis lors, j’ai eu l’idée d’adopter un procédé
342 DISEASES OF THE EAR.
mixte, participant tout a la fois de la myringodectomie antérieure dans laquelle, a
l’instar de Weber, on sectionne le tendon réﬂéchi du muscle tenseur du tympan, et
de la myringodectomie postérieure pratiquée avec ou sans excision d’une portion
de la membrane tympanique. Les succès que j’ai obtenus par l’emploi de ce pro-
cédé m’engagent a le faire connaître, et a le soumettre à l’appréciation des
otologistes.
Je me sers d’un petit bistouri à. manche coudé, dont la lame, large de 2 milli-
mètres, et présentant une longueur de tranchant de 4 millimètres environ, est
recourbée légèrement en forme de faucille; cet instrument se trouve dans toutes
les trousses des médecins auristes. La première incision se fait de la manière
suivante: je ponctionne la membrane tympanique a 1% millimètre en avant de
l’apophyse externe du marteau, puis je sectionne la membrane obliquement en bas
et en arrière, de façon que l’extrémité inférieure de l’incision se trouve placée sur
la demi-circonférence inférieure de la membrane, au point où aboutirait une ligne
verticale menée de l’ombilic à, la circonférence; cette première incision, faite par de
légers mouvements de scie, sectionne non seulement la membrane, mais encore le
tendon réﬂéchi du muscle tenseur du tympan, ou tout au moins la gaine ﬁbreuse
du muscle, décrite par Toynbee sous le nom de ligament tenseur de la membrane
du tympan. Je reporte ensuite le bistouri dans le segment postérieur de la mem-
brane, au niveau de la poche postérieure de Troeltsch, a 2 millimètres en arrière du
manche du marteau, et je pratique la seconde incision, laquelle, se dirigeant d’abord
obliquement en bas et en arrière, parallèlement au manche du marteau, puis en bas
et en avant, à partir de l’ombilic, vient aboutir sur la demi-circonférence inférieure
de la membrane au point terminal de la première incision; de la sorte, je 'fais en
résumé une incision composée en V, à base supérieure correspondant a une ligne
horizontale passant par l’apophyse externe du marteau, et a sommet inférieur placé
au niveau du pôle inférieur de la membrane tympanique; cette incision en V pro-
duit un lambeau de même forme, adhérant par la base, et dont la moitié supérieure
renferme le manche du marteau.
Il est facile, ainsi que je l’ai fait deux fois, d’exciser la portion inférieure du»
lambeau, aﬁn d’obtenir une perte de substance de la membrane qui rende la per-
foration durable.
Les opérations de l/Vreden et de Miot conduisent au même but, par des moyens
différents; reste ‘a savoir s’il faut leur donner la préférence ou si le procédé que
je préconise ne présente pas certains avantages qui doivent en assurer l’emploi
dans la pratique. générale.
L’opération de VVreden se compose de deux temps, dont le premier consiste à
former dans la membrane du tympan un lambeau quadrilatère, dont le bord in-
férieur libre, large de 3 à 4 millimètres, se trouve placée à 2 millimètres au dessous
de l’extrémité libre du marteau. Je trouve a ce mode de confection du lambeau.
deux inconvénients: il est très diiﬁcile à exécuter parcequ’il demande une très
grande habilité opératoire, et il nécessite la chloroformisation complète du malade ;
de plus, il laisse nécessairement un cul-de-sac à. la partie inférieure de la caisse, ce
qui peut entraîner des inconvénients dans les cas où l’on doit assurer l’écoule-
ment d’un liquide, ou gêner laîmanœuvre des instruments destinés à détruire les
adhérences.
Au contraire, le lambeau triangulaire a sommet inférieur situé sur la circon-
férence d’insertion de la membrane tympanique permet l’écoulement naturel des
liquides contenus dans la caisse, et dans le cas d’otite sèche, laisse l’instrument
destiné à détruire les synéchies libre d’agir dans tous les sens; enﬁn, ce procédé
DISEASES OF THE EAR. 343
constitue un mode opératoire qui est à la disposition de tous les praticiens, même
de ceux qui ne possèdent pas une très grande habileté opératoire, ce qui n’est pas
à. dédaigner, dans l’intérêt général.
L’opération de Miot se pratique de la manière suivantè : “ Je coupe le tympan
en rasant le bord postérieur du marteau dans ses deux tiers inférieurs et en pro-
longeant l’incision jusqu’à la partie correspondante inférieure du cadre osseux. A
partir de l’angle supérieur de la plaie je coupe le tympan jusqu’à la partie postérieure
correspondante du cadre osseux. J’ai ainsi un lambeau triangulaire adhérent seule-
ment au cadre osseux; il ne me reste plus qu’a le disséquer dans ces "points et à.
l’enlever. Une fois la première incision faite, on peut faciliter la seconde incision
en maintenant le lambeau avec la pince à. griﬁes que j’ai fait fabriquer.”*
Cette opération est assez facile à exécuter, mais elle me paraît passible de
quelques-unes des objections que j’adresse a celle de Wreden; ainsi, elle laisse un
cul-de-sac a la partie inférieure de la caisse du tympan, et gêne la manœuvre du
synéchotome. Elle ne permet pas non plus de sectionner le tendon réﬂéchi du.
muscle tenseur du tympan.
On peut d’ailleurs, sur mon lambeau, faire agir les sphyrotomes de Wreden,
de Duplay ou de Miot, et réséquer le manche du marteau, ou se contenter de
sectionner avec le bistouri coudé la partie inférieure du lambeau, aﬁn d’obtenir
une perforation durable, ainsi que le prouvent les observations qui‘ font suite.
'Bien que dans le procédé à lambeau triangulaire à. base supérieure adhérente et
à sommet inférieur libre, une grande partie de la longueur du segment antérieur
de la membrane tympanique soit comprise dans la première incision, l’écoulement
sanguin m’a semblé très restreint; aussitôt l’opération pratiquée, ce qui se fait en
quelques secondes, je fais pencher la tête du côté opéré, aﬁn de faciliter le pas-
sage du sang dans le conduit auditif externe, et je l’entraîne au dehors, à l’aide
d’injections légères d’eau savonneuse tiède, ou d’un pinceau à poils trempé dans
le même liquide; puis, je termine par l’instillation de quelques gouttes du mélange
suivant: glycérine 30 parties, borax et hydrate de chloral ana 1 partie, laudanum
de Sydenham 2 parties. Cette instillation est répétée toutes les trois heures, et le
méat fermé par un petit tampon d’ouate de coton.
Pendant les premiers jours qui suivent l’opération, je pratique l’insufﬁation
d’air par la trompe en me servant de la poire de Politzer avec très faible pression;
ces insufﬂations sont peu douloureuses, et ne semblent produire qu’un léger sen-
timent de brûlure dans le fond de l’oreille.
Mes opérés n’ont pas été endormis, mais la tête était solidement ﬁxée par un
aide, aﬁn d’éviter tout mouvement. La douleur produite par les incisions paraît,
être très vive dans le cas où la membrane du tympan n’est pas profondément
altérée dans sa structure, mais elle cède assez rapidement après l’opération.
OBSERVATIONS.
OBSERVATION I.—Otite plastique double avec tension anormale des deux tympans-
Adhérences entre le tympan droit et la paroi interne de la caisse. Surdité presque
complète. Myringotomie par le procédé à lambeau triangulaire a sommet infé--
rieur, et résection de la partie inférieure du lambeau. Section des adhérences.
Amélioration notable et persistante.
Madame A , âgée de 38 ans, bien réglée et ayant en cinq enfants, devient
sourde de l’oreille droite depuis quatre ans, et de l’oreille gauche depuis deux ans.


* Miot, “ Traité des Maladies des Oreilles,” p. 271.
344 DISEASES OF THE EAR.
La surdité s’est montrée progressive depuis la troisième grossesse. Antécédents
rhumatismaux dans la famille; la malade a eu à. l’âge de 26 ans un rhumatisme
articulaire généralisé ; elle est atteinte de pharyngite granuleuse. Elle est de plus
sujette à des vertiges qui redoublent dans l’intervalle des règles, pour cesser com-
plètement pendant la période menstruelle, et 6 à. 8 jours après, ainsi que pendant
toute la durée des grossesses.
Examen des oreillea—l". Oreilles externes: rien de particulier à. noter. Pas de
cerumen.
2°. Oreilles internes: A. Montre: crâne. O. D. passable; O. G. assez bien.
B. Diapason sur le vertex: mieux perçu quand les oreilles sont fermées, et mieux
à droite qu’à. gauche. L’otoscope à. trois branches donne les mêmes résultats.
0. Acuité auditive: O. D. rien au contact de la montre; O. G. très faiblement
au contact. La voix moyenne n’est perçue qu’ä. gauche, et a une distance de 10
centimètres ; a droite, il faut crier très fort, et contre l’oreille; la malade entend un
peu mieux quand elle voyage en chemin de fer. Bourdonnements intermittents,
à. forme de roulements et de sifflements, ou de battements isochrones à ceux du pouls,
se reproduisant la nuit dès que la malade se réveille, et diminuant pendant les
règles; ont considérablement diminué pendant les dernières grossesses; augmen-
tant par les temps humides, et quand la malade passe de l’air extérieur dans un
milieu chaud. Tout travail intellectuel est rendu impossible par l’apparition
immédiate et la persistance des bourdonnements.
3°. Oreilles moyennes z Tympans très concaves, opaques, peu sensibles à. la
pression du stylet; le manche du marteau est comme voilé, et vu en raccourci;
l’apophyse externe est saillante. Le tympan droit paraît plus épais, et présente a
la partie postérieure plusieurs points lumineux trés petits; le reﬂet lumineux
normal fait défaut.
L’insufllation d’air dans les caisses produit un souﬁie rude; l’audition n’est
guère améliorée, mais les bourdonnements disparaissent momentanément, surtout
à gauche.
Traitement—10 Novembre, 1879.-Pulvérisations pharyngiennes avec l’eau
d’Enghien, et injections nasales avec le siphon de Weber. Insuﬁlation de vapeurs
iodées dans les caisses, chaque deux jours. 20 Décembre. Même'état; je pratique
sur le tympan droit l’incision en V de manière à. tailler le lambeau triangulaire,
ainsi que je l’ai décrit plus haut. Après avoir laissé reposer la malade pendant
une demi-heure et bien nettoyé le conduit auditif, j’insuﬁ‘le de Pair par la trompe
droite: le lambeau triangulaire demeure à. peu près immobile; je glisse alors par
la branche antérieure de l’incision un petit bistouri courbé sur le plat, pour sec-
tionner les adhérences; à. un nouvel examen, je constate que l’air insuﬁlé par la
trompe fait ﬂotter le lambeau; j’excise la partie inférieure du lambeau, immé-
diatement au dessous de la spatule du marteau; la malade entend la montre à. 10
centimètres, et la voix moyenne à. 1 mètre 50. J ’instille quelques gouttes de la
solution de borax et chloral dans la glycérine (voir plus haut).
21 Décembra—Réaction assez intense; ﬁèvre, température 39° Centigrade.
Sensation de brûlure dans le fond de l’oreille. Purgatif salin; continuation des
insuﬁîations d’air à faible pression, et des instillations dans le conduit auditif.
Vésicatoire volant à. la région mastoïdienne.
23 Décembre.—-—Amélioration des symptômes locaux, cessation de la ﬁèvre; per-
sistance du bon résultat au point de vue de l’audition.
24 Décembre.——-Suppuration assez abondante; même traitement, plus des bains
locaux avec décoction de pavot tiède, chaque trois heures.
DISEASES OF THE EAR. 345
Les jours suivants, la suppuration va en diminuant; elle a cessé le 14: Janvier,
1880: la perforation se maintient béante, et l’audition demeure aussi bonne qu’après
l’opération.
Les bourdonnements persistant à gauche, la malade réclame la perforation du
tympan gauche, espérant obtenir de ce côté la même amélioration qu’à droite. Je
l’opère par le même procédé, mais sans réséquer la partie inférieure du lambeau;
immédiatement, cessation des bourdonnements, audition de la montre a 15 cen-
timètres, et de la voix moyenne a plus de deux mètres. Phénomènes consécutifs
très simples, réaction inﬂammatoire des plus modérées, les lèvres des incisions sont
un peu rouges et tuméﬁées le lendemain et le surlendemain ; le 26 Janvier la
perforation est cicatrisée.
Trois mois après—le 29 Avril, 1880—je constate l’état suivant: la perforation
droite reste béante, et l’amélioration survenue de ce côté persiste en totalité. Le
tympan gauche est à peu près normal; on remarque seulement de chaque côté du
manche du marteau deux petites traînées obliques, légèrement blanchâtres, indices
des incisions. Les bourdonnements ne se montraient plus qu’à. gauche, eta de rares
intervalles, et principalement lorsque la malade quitte les petits tampons d’ouate
qu’elle porte habituellement dans chaque oreille.
OBSERVATION IL—Otite scléreuse double, plus prononcée à. droite—ä. gauche,
combinée avec un catarrhe de la trompe et de la caisse. Myringodectomie a droite,
par l’incision en V a sommet inférieur. Grande amélioration persistant un an
après.
M. L———, percepteur des ﬁnances, 42 ans, goutteux, atteint de granulations
pharyngiennes, et de catarrhe naso-pharyngien léger, a vu sa surdité commencer il
y a deux ans par l’oreille droite; des bourdonnements alternant avec des bruisse-
ments ont apparu en même temps que la dysécie. Depuis huit mois, l’oreille gauche
se prend a son tour.
Examen otoscopigua—lo. Oreilles externes : quelques lamelles épidermiques ;
diminution de la sécrétion du cérumen.
2°. Oreilles internes: A. montre: crâne; O.D. passable; O. G. assez bien. B.
Diapason sur le vertex: mieux perçu à droite. Résultats peu marqués avec
l’otoscope a trois branches. O. Acuité auditive : O. D. presque rien au contact de la
montre ; O. G. bruit perçu a 5 centimètres. La voix moyenne n’est pas entendue au
contact de l’oreille droite; elle est perçue a gauche a 50 centimètres. Les bour-
donnements sont beaucoup plus marqués a droite, où ils sont continus, qu’à gauche,
où on les trouve intermittents, et plus prononcés lors des rhumes, qui sont assez
fréquents. L’insuﬁ‘iation d’air les modiﬁe a gauche, et ne produit aucun résultat
à droite.
3°. Oreilles moyennes : O. DJ tympan très concave, terne, d’un gris sale, avec
points d’un jaune osseux, notamment dans le segment postérieur. Apophyse
externe très saillante, manche du marteau vu en raccourci, incliné en dedans et un
peu en haut. L’insufﬂation d’air produit un souﬁie rude dans la caisse, et ne fait
pas bomber le tympan en dehors. O. G. : Mêmes phénomènes, sauf un peu de
vascularité le long du manche du marteau; l’insuﬂation produit quelques gar-
gouillements dus à un léger catarrhe lié a un rhume qui existe depuis huit jours.
Traitement—12 Février, 1880.-—Régime anti-goutteux—insuﬁlations par les
trompes ; grande amélioration à. gauche : rien a droite.
28 Février.——J’incise le tympan droit en avant et en arrière du marteau, de
manière a former un lambeau triangulaire a base adhérente et à. sommet inférieur
libre, situé sur la circonférence d’insertion de la. membrane du tympan, au point
346 DISEASES or THE EAR.
d’intersection de la normale abaissée de la spatule du marteau. Douleur très vive,
surtout à la première incision; écoulement de sang, se prolongeant pendant.
quelques minutes. Le malade est mis au repos pendant trois-quarts d’heure, puis
le conduit auditif est nettoyé avec un pinceau et de l’eau alcaline tiède : l’insuﬁia-
tion par la trompe fait ﬂotter le lambeau; pendant cette insuﬂËiation, le malade
accuse une sensation de brûlure vive dans le fond de l’oreille. Disparition complète
des bourdonnements; voix moyenne entendue a plus d’un mètre: montre a 5 centi-
mètres. Pansement a la glycérine additionnée de borax, chloral, et laudanum
(voir plus haut). Pendant six jours, insufﬂation quotidienne d’air par les trompes;
la sensation de brûlure disparaît.
7 Mars—Les incisions sont cicatrisées; la membrane est injéctée, surtout de
chaque côté du manche du marteau. Pendant l’insuﬂiation, on voit la membrane
bomber un peu en dehors; le manche du marteau a repris la direction normale.
7 Avril—Les résultats obtenus se maintiennent; l’oreille non-opérée s’amé-
liore, ainsi que le catarrhe naso-pharyngien.
2 Février, 1881.—-M. L , opéré depuis un an, a conservé la plus grande
partie de l’amélioration due à l’opération; sur ma recommandation, il emploie
chaque jour le procédé de Politzer ; il se considère très heureux de pouvoir continuer
à remplir ses fonctions, alors qu’il ya un an il était sur le point de donner sa
démission ‘a cause de la marche rapide de la surdité.
OBSERVATION IIL—Otite plastique double. Epaississement des membranes.
Adhérences de la caisse. Myringodectomie par le procédé à lambeau triangulaire à.
base supérieure adhérente. Amélioration durable.
Léon M-——, 18 ans, lymphatique; a eu dans l’enfance, des engorgements
ganglionnaires multiples et une otorrhée double à l’âge de 4ans; Depuis deux
ans, il devient sourd au point d’avoir dû interrompre ses classes il y a huit mois.
Rhinites fréquentes : angines catarrhales à. répétition, bien qu’il ait eu les
amygdales enlevées par mon père en 1868. I
Eæamen otoscopiqua—lo. Oreilles externes: conduits libres, peu de cérumen;
léger rétrécissement des conduits (disposition héréditaire).
2°. Oreilles internes; A. montre: crâne, O. D. rien; 0. G. presque rien. B.
Diapason sur le vertex: mieux perçu à droite. C. Acuité auditive. O. D. rien à. la
montre; O. G. un peu, au contact. La voix moyenne est perçue à gauche à.
15 centimètres, à. droite au contact. Bourdonnements continuels en sifflements,
avec bruissements par les temps humides.
3°. Oreilles moyennes: tympans gris-bleuâtres, ternes, très convexes; apophyses
externes en saillie, mais comme voilées; manche du marteau peu apparent, vu en
raccourci; aucune mobilité des tympans pendant l’insufﬂation.
Traitement—9 Juin, 1880. Traitement général anti-scrofuleux. Insuﬁiation
d’air et injections dans les caisses avec de l’eau de goudron; insufﬁations de vapeurs
iodées: résultats presque nuls.
24 Juin.—Myringodectomie à lambeau triangulaire a sommet inférieur libre; le
malade, bien décidé, veut être opéré le même jour des deux côtés. Douleur modérée,
écoulement sanguin très restreint. Après une demi-heure de repos, insufﬂation
d’air; peu de mobilité des lambeaux; résection de la portion des lambeaux située
sous l’extrémité du manche du marteau. Pansement a la glycérine boratée, avec
chloral et laudanum.
25 Juin—Peu de réaction à. gauche; réaction intense à droite; sensation de
brûlure et de tension au fond du conduit; ﬁèvre, température 39°. Deux sangsues
de chaque côté, 1’une au'tragus, l’autre a l’apophyse mastoïde; bains d'oreilles
avec décoction de guimauve et de pavot; aconitine.

DISEASES or THE EAR. 347,
27 Juin.—-Cessation de l’état febrile ; écoulement séro-purulent, plus prononcé
a droite.
30 Jilin—Cessation de l’écoulement; les membranes tympaniques sont forte-
ment congestionnées; les perforations sont béantes, a levres tuméﬁées.
5 Juillet.-—-Oessation des phénomenes inﬂammatoires; la montre est entendue
a 7 centimetres a gauche, a 4 centimetres a droite; la voix moyenne est percue a
2 metres 50, plus de bourdonnements.
2 Février 188l.—Depuis huit mois, les perforations se sont rétrécies, la droite a.
la dimension d’une téte d’épingle, la gauche est presqu’ oblitérée; l'amélioration est
a peu dc chose pres ce qu’elle était quinze jours apres l’opération.
DISCUSSION.
Dr. GUYE, Amsterdam: I consider that the cases in which the operation has
been performed by me could be divided into four classes—viz.: 1. Cases of acute
inﬂammation of the cavity, with redness of the membrane, serous, or sanguinolent
exudation, and generally intense pain. 2. The sub-acute or chronic catarrh of the
tympanum with mucous exudation, which may be very consistent. 3. The cases of
old catarrh of the tympanum, with grave lesions in the internal ear, deafness,
tinnitus, vertigo. 4.‘. Paradoxical cases of inﬂammation of the tvmpanum, of which
the characteristic symptoms were, a very acute inﬂammation of the cavity, with
great pain and fever, and without any swelling of the Eustachian tube. This
swelling of the Eustachian tube, which acts an important part in the etiology of
inﬂammation of the middle ear, plays another critical part in so far as it produces
an accumulation of the secreted ﬂuid in the cavity, and in that way a perforation
of the membrane. In the ﬁrst class are those cases where we meet with a chronic
catarrh of the nose or pharynx, and in which, by the inﬂuence of some external or
internal cause, an acute inﬂammation is produced. Amongst the external causes
that which occupies the ﬁrst place is cold, whether produced by the introduction
of cold Water into the auditory canal, or by a current of cold air. Amongst the
internal causes are ranged the constitutional ones, such as paludal, febrile, syphi-
litic, &c. What is the value of the incision of the membrane in these cases P By
incision in cases of simple acute inﬂammation we follow the natural march, that is
to say, the normal one. In the most simple cases, as in children, we see the pain
is endured for a few hours, and then a spontaneous perforation takes place, from
which a serous, or sanguinolent, discharge escapes, the pain ceases, and, in the
majority of cases, if there be no inveterate catarrh of the nares and pharynx, nature
effects in a few days a spontaneous healing. At a more advanced age the mem-
brane is more resistant, and is able to bear the strain for -a few days, or even till
the acute attack has passed, without perforation or discharge. When, in such
cases, we perform myringodectomy, we obey a natural indication by doing what
nature would do in a short time for herself. 'When, from some unknown reason,
the membrane resists rupture for a considerable time, a spontaneous perforation is
followed by a great loss of tissue, and therefore a corresponding difficulty in cica-
trization. By surgical interference we cut short the process, and save much time
and agony. In such simple inﬂammations, I have obtained a more rapid and more
complete recovery than in those allowed to form a natural opening. In cases due
to scarlet fever or syphilis, although I think local treatment important, I am of
opinion that in a great number of cases it is not required. In regard to typhoid
fever, I cannot place it in the same category. In cases of typhus, complicated
348 DISEASES or THE EAR.
with disorders of the ear, there are some in which no perforation is to be found,
and others in which, after typhus is over, perforation and purulent discharges are
found, the diagnosis of the ear affection having been obscured by the grave typhoid
symptoms. In the second class of cases I place the sub~acute, or chronic catarrhal,
with consistent mucous—cases well known to all aurists. When we see the masses
of viscid mucus which are sometimes removed by incision and injection, followed
by rapid cicatrization of the membrane and splendid results to the hearing, we can
have no doubt of the beneﬁt of the operation. The diagnosis in these cases is not
always simple, and incisions are frequently made without ﬁnding the mucus
expected. Fortunately, there is no great damage done. Such a case brings us to
the next class, in which the results, although of no great beneﬁt, are not to be
despised. Third class : This embraces those numerous chronic cases, in which the
affections of the internal ear predominate, and the local treatment consists chieﬂy
of the injection of vapours or liquids through the Eustachian tube with the view
of accelerating the circulation, nutrition, and reabsorption, so as to act in this way
indirectly on the internal ear. In this class of cases the incision of the membrane is
very useful. The perforation allows of the passage through the cavity of liquids
and vapours with a more complete and satisfactory result. By this means we may
maintain a discharge from the cavity for a considerable time—a discharge acting
beneﬁcially in the internal ear. I have repeatedly performed the operation in this
class of cases several times—once ten times—in the same membrane. Some of the
best results in this class have been obtained in cases of chronic catarrh consecutive
to typhus fever, where the tinnitus is so distressing. The fourth class is formed
by two paradoxical cases. The ﬁrst was that of a workman suffering from great
pain in the ear, with muco-purulent naso-pharyngeal catarrh, but without discharge
from, or perforation of, the membrane. The Eustachianjtube was very patent, and this
was, I thought, the reason for the non-perforation of the membrane. The swelling
of the Eustachian tube, usually seen with inﬂammation of the cavity, and which
often plays an etiological role in the development of the inﬂammation of the cavity
may also play a salutary one, in that it allows of the accumulation in the cavity,
which exerts a pressure, and perhaps a solvent action, on the membrane, and so
accelerates the perforation of it. The easy discharge of the accumulation through
the tube is generally a favourable circumstance in mild cases; but in more acute
inﬂammations, where perforation of the membrane is the natural result, it becomes
a dangerous circumstance, as it prevents the perforation taking place. In this case,
paracentesis was performed, and the treatment of the whole mucous membrane
carried out for some time with the most satisfactory result. The second paradox-
ical case was somewhat analogous to that just given. I was asked to see a lady
suffering from acute earache. I found the membrane slightly red, the Eustachian
tube well opened by Valsalva’s method. Politzer’s method and the use of the
catheter were of no beneﬁt. There were no carious teeth to which I could ascribe
the affection. A V-shaped incision was made, and carbolized solutions injected,
with results which, in a few hours, were most gratifying. In this, as in the pre-
ceding case, the patient could blow through the perforation immediately after the
incision was made. There was little redness of the membrane, no discharge, no
inﬂammatory swelling of the Eustachian tube. The indications for the operation
were by no means precise, and yet the results were beneﬁcial. The after-treatment,
of course, varies with the nature of the case. One point on which I lay much
stress is, that we must guard the operated car from cold, as I have repeatedly seen
serious consequences therefrom.
DISEASES or THE EAR. 349
Professsor VoLToLINI, Breslau: The maintenance of a permanent opening
in the m'embrana tympani is to me as yet an unsolved problem. When a foreign
body is present behind the membrane it is necessary to perform the operation to
remove it, The most frequent cause requiring the operation is when exudation
is present in the cavity, either as mucus, serum, ‘ or pus. To determine the
diagnosis of such exudations in the cavity, I ﬁnd sunlight the most convenient
light, which I convey into the ear by means of a modiﬁed Brunton’s speculum.
By this modiﬁcation I also introduce the knife by which the paracentesis is made.
In certain cases in which a polypus has foreed its way through the membrane, I
have found it necessary to incise the membrane in order to arrive at the root, and
act upon it by the galvano-caustic.
Dr. LOEWENBERG, Paris: May I ask Professor Paquet for precise indications
for this operation? I am at a loss to understand how this operation can produce
a permanent opening when all other operations have failed in doing so. Does
suppuration follow the operation? I am somewhat astonished at not having heard
mentioned one of the most important classes of cases in which paracentesis is
useful, in the enlarging of an opening in adenoid disease to free the mastoid
cavity.
Dr. GELLE, Paris : Will Professor Paquet explain the permanence of the open-
ing? I have performed the multiple section with a triangular incision of the mem-
brane for many years, without having been able to maintain a permanent opening.
I should think there would be difﬁculty in forming the ﬂap proposed
Professor PAQUET, Lille : In answer to MM. Lo'wenberg et Gellé, I may state that
there are two principal indications for using myringodectomy—viz., the removal of
exudations, and the formation of a permanent opening. The latter is not to be
obtained by incisions, but by excisions of as large portions as the operator can obtain.
The cavity of the tympanum in its normal state is highly vascular; but in the cases
of sclerosis of the cavity, the vascularity of the membrane is much diminished, and,
therefore, the probability of inﬂammation following the operation is less likely,
and the chance of the ﬁlling up of the perforation decreased.
Dr. THOMAS BARR, Glasgow: I have practised incision of the tympanic mem-
brane in two classes of cases: 1st, when there was purulent, mucous, or serous
exudation in the cavity of the tympanum, or in the interstices of the tympanic
membrane; and, 2nd, in cases of chronic simple catarrh, with no ﬂuid exudation,
and in which tinnitus was a prominent symptom. The propriety of the operation
in the former class of cases cannot be gainsaid, as it is based on ordinary sur-
gical principles. In acute purulent collection in the middle ear where the tympanic
membrane has become thickened and more unyielding, in consequence of previous
disease, the operation is eminently called for. In such a case timely incision of
the membrane may prevent the extension of the disease to the labyrinth, or to the
meninges. In mucous or serous exudations in the middle ear the operation is in-
dicated, ﬁrst, where the quantityr is so great as to cause a distinct saccular bulging
of the membrane, especially at its posterior part, a condition not unfrequently
met with in children ; second, when the mucus is thick and viscid, although not in
such quantity as to produce distinct bulging. Here the operation, timely per-
formed, may avert important and permanent structural changes in the tympanum.
DISEASES OF THE EAR.
My experience of cutting operations in the tympanic membrane, when no ﬂuid
exudation exists, has not convinced me of their value. I have at times observed
more or less transient improvement in the hearing or in the tinnitus, but my good
results have not been at all notable. In these cases of dry catarrhs I usually
injected, after performing the incision, a weak alkaline or other stimulating ﬂuid
through the Eustachian tube into the cavity of the tympanum, and that the ﬂuid
did reach the tympanum, I had ocular proof on examining the seat of the incision
immediately after the injection. On the whole, experience seems to show that the
operation of incising the membrane is of value, mainly in cases of ﬂuid exudations
in the middle ear.
Dr. PIERCE, Manchester: With regard to Dr. Paquet’s V-shaped incision of the
membrana tympani, including that of the tensor tympani, it may be very advan-
tageous so far as the durability of the perforation is concerned. As to its value in
sclerosis, it does not affect the disease which constitutes sclerosis—via, permanent
thickening of the entire mucous membrane of the tympanum. As to the value of
Dr. Paquet’s operation for the evacuation of ﬂuids in the tympanic cavity, it does
not offer any advantage over the ordinary incision in front of or behind the manu-
brium. I hope my experience of Dr. Paquet’s operation may prove its advantage
as a means of obtaining a durable perforation.
Dr. URBAN PRITCHARD, London: There can be no difference of opinion as to
the value of this operation,'when there is ﬂuid behind the membrana tympani. But
in cases of sclerosis is it worth while running the risk of further injury to the‘
middle ear, for the chance of improving the hearing power in those few cases where
a permanent opening‘ is beneﬁcial, even supposing this permanence be obtainable?
Dr. GASSELLS, Glasgow: I have never performed the operation of tenotomy of
the tensordtympani, because in all my experience I have not seen a case of ear
disease in which this operation could have been employed. From our distinguished
confrere, Dr. Weber-Liel, I had this operation brought under my notice many years
ago, and also, according to his opinion, the cases in which it could be used with
success were sclerosis of the tissues of the tympanic cavity, with contraction of the
tendon of the tensor tympani, accompanied with distressingly loud tinnitus. As to
the incision of the membrana tympani itself, I have to say that I belong to the
fourth class of aural surgeons mentioned in our President’s opening address, 11.0., I
use multiple incision of this structure when it is relaxed with the best effect:
simple incision of it to sever mucous bands in the tympanic cavity, and other
adhesions ; also for enlarging a small perforation in the membrane, so as to bring
about cicatrization, or to terminate a persistent ear-discharge. Also in serous
catarrh of the tympanum, in acute muco-tympanitis, in cases of; chronic and solid
mucous accumulation in this cavity. I also perform it in exanthemal catarrh, acute
or chronic, scarlatinial or rubeolar, and in malarial catarrh, and also in cases in which
there is pent-up pus in the mastoid cells ; also any other casein which this operation
is indicated. I have rarely had to re-incise the membrane, more especially in
children, for I perform this operation on very young infants, as also on children of
a greater age, in whom the ears become affected during the progress of an attack
of scarlatina, as soon as ever a slight injection of the tissues of the organs appears;
in this way cutting short what might prove to be a serious ear disease. Therefore,
were I asked my opinion of this operation, I would reply that it is the most
DISEASES OF THE EAR. 3 5 I
valuable one in the domain of aural surgery; and if I were asked further, by what
means I had done the most good as an aural surgeon, I would reply, without hesi-
tation, by incising the membrana tympani.
Dr. LoEWENBnnc, Paris: I think that all aurists agree upon the necessity of
opening the membrana tympani in order to let out pus, thus applying general
surgical rules, which teach us that opening a collection of pus is preferable to
allowing the natural breaking to take place. This operation, too, enables us im-
mediately to prevent septic poisoning, which, in my opinion, is the important point,
and not that of combating already existing germ infection.
Professor S. J. .I ONES, Chicago: In considering the question of the propriety
of puncturing the membrana tympani, the object in making such punctures should
be kept distinctly in view. First, if that object be to give exit to ﬂuids conﬁned
within the middle car, which endanger the integrity of the ear, and sometimes
jeopardize life, the operation is not only justifiable but is demanded, as is now
generallyconceded. Theincision substitutesa straight cut, forthe more or less circular
opening from spontaneous perforation, which usually results if the case be left alone,
being accompanied by loss of tissueIwhich makes recovery slower than in cases where the
membrane has been incised. Second. if the object be to remove an accumulation of
inspissated mucus from the tympanum, as was practised nearly a century ago and
abandoned, and recently revived, such puncture is of, at least, questionable pro-
priety, for removal of it can be effected without incision. Third, if the object
be to secure a permanent opening in the membrana tympani, in the hope of im-
proving hearing, or of relieving tinnitus, the results so far obtained do not seem
to warrant frequent repetition of the operation, for it is diﬂicult to make a per-
manent opening in the membrana tympani, artiﬁcially, the opening generally
inﬂuences but slightly, if at all, the hearing power, and many of the causes of
tinnitus still remain, even after opening both the membrana tympani and the
Eustachian tube, and relieving rarefaction of air in the middle ear. Fourth, if the
object in opening the membrana tympani be to get access to the middle ear for still
further operative procedure within the tympanic cavity, such as division of the
tensor tympani, there are doubts whether any operation for that purpose has yet
divided the tensor tympani, or, if it have, whether permanent beneﬁts has resulted.
Even if the results of such operations were negative, objections to the operations
exist, but when the anatomy of the parts is considered, how small the space is, and
how deeply situated, in which the operations have to be performed, the probabilities
of serious injury to the delicate structures of the middle ear, and possibly of
the internal ear, raise a grave doubt as to whether incision of the
membrana tympani, and subsequent operations within ‘the tympanum are
even justifiable. It is not a sufficient answer, that the cases seemed hopeless
before, and that they could not be made worse by operation, for it is
difficult to estimate the extent to which even such serious cases may be'
aggravated; and, besides that, it is not for such seemingly hopeless cases that these
operations are proposed. From this, the natural conclusion is that the cases in
which the best results may be expected from artiﬁcially opening the membrana
tympani are those in which it is desirable to remove hypersecretion, as a result of
acute inﬂammation, from the middle ear, especially if the membrana tympani has
been thickened by prior disease; that opening that membrane for other reasons
is usually of, at least, doubtful propriety; and that opening it, as a means of
352 DISEASES or THE EAR.
gaining access to the cavity of the middle ear for further operative procedure
therein, seems unjustiﬁable, in nearly all, if not in all, cases.
022 Z/ze A‘Zz‘iology 0f Aural Exosz‘oses, and on their Removal
6y 0 New Opemz‘z'mz.
Dr. JAMES PATTERSON CAssELLs, Glasgow.
Historical.
In order that a clear idea of the whole subject of osseous tumours of the ex-
ternal auditory meatus may be formed, I will ﬁrst of all quote the opinions of
other aurists.
Dr. Erhard, of Berlin, says that it has not been satisfactorily proved that after
the period of ossiﬁcation of the membranous meatus exostoses and hyperostoses
can develop in the bone in consequence of certain primary pathological irritations.
The two external auditory meatuses varying more or less in structure in all in-
dividuals, it follows that a one-sided narrowing may easily mislead in this direc-
tion. It has also not yet been proved that syphilis exercises a speciﬁc inﬂuence
in this respect. It is true that hyperostoses are met with in cases of obstinate
otorrhoea, dating from early childhood, but I have never seen them develop at a
more advanced age.
Prof. Seligmann, of Vienna, says that Europeans are less subject to these
exostoses of the auditory canal than certain races of American Indians, because it
is still the custom of the latter to elongate the cranium artiﬁcally. In six cases
of Titicacas deformed in this way, he found ﬁve times the anomaly in question,
but he did not ﬁnd it in other American races, the Avares, for instance, whose
craniums were deformed in exactly the same way.
Welcker says that he found these osseous excrescen ces also in N orth—American
Indians, whose craniums were not deformed. That transatlantic races are more
predisposed to this defect than Europeans he proves by the fact, that among all
the skulls he examined, those of Europeans showed not a trace of it, although
their number was by far the largest.
Triquet says that they are only observed in syphilitic persons, and that they
are a tertiary manifestation of the disease.
Nélaton says that the only tumours, which can be called exostoses, are those
which have originated through a partial abnormal expansion of the osseous tissue,
or through osseous deposits in circumscribed places. He also remarks that the
slow growth of these tumours seems to be in accordance with their density.
Schwartze believes that the term “ spongy” or “ compact” exostoses only ex-
presses different phases in the development of the new formation; that, for instance,
the spongy exostoses may become solid, and vice versct. This opinion is shared by
Virchow and Nélaton. Schwartze further says that this is the only case in ear
disease where hereditary disposition may be accepted without reserve.
Von Troltsch says that he has observed them almost always simultaneously
in both meatuses. He also refers to the extreme sensibility of these tumours when
touched with an instrument, while most of the other investigators go so far as to
say that it is one of their peculiarities that they are insensible to touch, and can
even be cut away without pain. He recommends Wild’s écraseur for their removal.
DISEASES or THE EAR. 353
Wilde has rarely seen them at the same time in both ears. He says that these
exostoses originate from ostitis or periostitis, which opinion is shared by Rau.
Wilde recommends local bleeding and the inward application of mercury.
Toynbee always found exostoses of the auditory meatus to be composed of a
compact osseous tissue. He says that the abuse of alcoholic drinks is of inﬂuence
upon the production of these tumours. This opinion is shared by Von Troltsch.
Toynbee considers them an outcome of a gouty or rheumatic diathesis. He recom-
mends painting them with iodine, and has always painted them with a solution of
nitrate of silver.
Bonnafont at ﬁrst practised gradual lancing and gentle cauterization with
nitrate of silver; later on, trepanning.
Heinicke, of Erlangen, removed the tumours by means of the gouge and mallet.
Clark, of Bristol, has obtained good results from electricity.
Delstanche ﬁls, of Brussels, in his pamphlet on “ Osseous Tumours” in the
external meatus, comes to the conclusion that they may arise either before or after
the period of ossiﬁcation of the canal ; that the causes are hereditary disposition,
inﬂammation, or spontaneous or traumatic irritation of the bone or periosteum,
either primary or secondary; that they may appear in any part of the osseous
meatus, but they most frequently occur in the posterior portion; that medical
treatment has seldom good results, but that surgical treatment may, in certain cases,
bring about a complete cure.
Clarence J. Blake, Boston, measured 199 crania of the mound-builders of the
Cumberland Valley, in Tennessee; the average diameters of the meatuses were :—
vertical, 101 mm.; antero-posterior, 6'3 mm. In thirty-six of these, exostoses
were found in one or both canals. In thirty the average diameters, without refer-
ence to the narrowing effected by the exostoses, were: vertical 108 mm. ; antero-
posterior, 5'7 mm., showing a more decided narrowing in cases of exostosis, being
accounted for in part by a general thickening of the anterior and posterior walls of
the canal. Measured also ﬁfty-ﬁve Californian crania; average diameter of
meatuses : vertical, 11'1 mm. ; antero posterior 8'61 mm. Of 108 Californian crania
superﬁcially examined, ﬁve had exostosis in one or both canals; in three of the
ﬁve there was a corresponding narrowing of the canal.
.I. Barnard Davis found aural exostosis in a cranium from the Marquesas
Islands, in one from the Loyalty Islands, in three Kanaka crania from the Sand-
wich Islands, in one belonging to the Khas tribe of Nepaul, in four Peruvian crania
belonging to the Ouichua Indians, and in the skull of an ancient Roman.
Professor Turner, Edinburgh, found in an artiﬁcially deformed Peruvian cra-
nium both meatuses almost entirely occluded by hard, ivory-like exostoses. In
the right meatus there were two; the one pedunculated and pea-like in shape,
almost blocking up the oriﬁce; the other more elongated in shape, and attached to
the anterior wall with a broad base. There were also two in the left meatus; one
of the size of a small pea arose with a broadish base from the anterior wall, the
other of the size of a small shot from the lower part of the posterior wall. The
exostoses almost touched in the middle of the meatus, so that in the living person,
when the integument was in place, the passage must have been’ quite blocked up.
In both ears the exostoses grew from the wall formed by the auditory plate of the
expanded tympanic ring. He also found exostoses in both ears of an adult skull
of a ﬂat-head Chenook Indian. These two craniums, as well as those observed by
Professor Seligmann, were altered in shape by artiﬁcial compression, the zygoma
and the parts around the meatus had, however, preserved their normal form,
PART III. A A
354 DISEASES OF THE EAR.
While Professor Seligmann found exostoses in ﬁve out of six crania, Professor
Turner only found them in the above-mentioned two, out of seventeen artiﬁcially
deformed crania of North and South American Indians, examined by him. In at
least three of these crania, where‘there were no exostoses, the shape of the auditory
meatus was modiﬁed, the vertical diameter being markedly greater than the antero-
posterior. He is, however, not prepared to ascribe this to artiﬁcial compression, as
he has observed in several Peruvian skulls, which were not deformed, a similar
anomaly of the meatus, the entrance into the right external meatus of one being
narrowed into a vertical slit. It therefore appears to him that in American
Indians a tendency for modiﬁcation in the conﬁguration of the external auditory
passages exists. '
The Author’s views on this subject.
I regard all the difficulties that have hitherto surrounded the study and treat-
ment of these tumours as arising, for the most part, from regarding all the bony
tumours that are found in the external auditory meatus, as exostoses. The fact
being, that in that canal we have tumours which are exostoses, and others that
are hyperostoses with structures quite distinct from each other, the former being a
new growth of tissue, while the latter is a hyperplasm.
The following conclusions, which appeared in the British Medical J carnal of the
15th of December, 1877, in regard to the origin of aural exostoses, are the results
of several years’ observation.
Premising that aural exostoses and hyperostoses are totally distinct affections
in regard to origin, structure, form, site and treatment, an aural exostosis is
benign in origin, only to be found arising at the outer half of the external auditory
meatus, and has its point of attachment nearly always at the posterior wall; is
pedunculated and has its origin in the periosteum of the mastoid, close to the
meatus.
The origin and development of an aural exostosis are as follows :—At the out-
set, a sub-periosteal abscess forms over the mastoid, and makes its way out and
into the meatus by way of the line of least resistance, ordinarily coming out be-
tween the cartilaginous and osseous portions of the canal, sometimes even through
the cartilage of the canal, discharging itself and continuing to do so for some time.
By-and-by highly vascular, granular-like growths sprout from the opening of the
abscess, and go on increasing in size, while, at the same time, they are being gradually
changed into bony tissue in their interior, by the gradual conversion of their cells
into bone cells.
The ﬁnal size of the osseous tumour or exostosis, as well as its form, is deter-
mined by the original size and form of the granular-like growths. After complete
ossiﬁcation no further increase takes place in the size of the tumour.
Sometimes these granular growths seem to spring from around the lip of the
oriﬁce of the abscess, forming a little hollow cone, through the apex of which pus
continues to escape freely for some time.
As to the treatment of these cases in their early stage, when the growth is still
granular in character, their removal by Wilde’s écraseur and the cauterization of’
the tiny canal of the abscess and its sac, with a probe coated with the nitrate of
silver, generally sufﬁces, if effectually done in the ﬁrst place, to effect a complete
cure without further treatment. When the tumour has become more solid, because
of its gradual conversion into bone tissue, Wilde’s écraseur, armed with a stout steel
wire, may suffice to effect the removal of the tumour, if its pedicle be thin and deli-
DISEASES OF THE EAR. 3 5 5'
cats; if, however, the pedicle be massive, and dense in structure, other measures
are to be had recourse to, to which I shall presently refer.
In 1874, a‘ young lady, ﬁfteen years of'ageﬁ“ came to me, complaining of a hard
body in her left car; on examination I found that the body was whitish in colour,
resistant in structure, globular in form, attached by a very short pedicle to the
outer half of the posterior wall of the meatus. Supposing it to be an ordinary
ﬁbrous polypus, I used Wilde’s écraseur and removed it; I found, however, that
the pedicle was very resistant to the passage of the wire. On examination the
pedicle was found to be composed in great part of bony tissue.
Fig. 9.


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Polyp from External Auditory Meatus.
View of section of the whole polyp under a low power ; the osseous pedicle at A ; the
thickened irregular covering of rete mucosum and epidermis at B and along the edge; at
O the bony deposit can be seen penetrating into the tissue of the tumour and the cellular
groups from the tumour continuous with the cell masses in the cancelli. The mass of the
tumour is a ﬁbrous network, enclosing groups of small cells.
Fio‘. 9 of the illustrations is a magniﬁed section of the tumour.
Fig. 10 is the appearance represented by the pedicle.
Since then I have seen two or three cases in consultation, in which the removal
of full-grown exostoses was objected to, on the ground that the risk of the opera-
tion counterbalanced its probable beneﬁts; all these cases, I may say, could have
been removed as easily as the one I am about to relate brieﬂy.

* Seen in consultation with Dr. Wood Smith, of Glasgow.
A A 2
3 56 DIsEAsEs or THE EAR.
I show you a water-colour drawing, taken by myself, of one of these cases,
which occurred in the person of a celebrated university professor, who declined to
have the tumours removed, although he was rendered almost totally deaf by their
presence.
View of edge of osseous deposit in tumour (Fig. 9) near 0, as seen under a power of
350 diam. : shows the _cells of the tumour gradually becoming enclosed by calcareous deposit
and being converted into bone cells (after decalciﬁcation by dilute nitric acid).


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Section of Surface of a Polyp of the Ear almost entirely Ossiﬁed.
A. The osseous tissue decaleiﬁed with weak nitric acid.
B. The remaining coating of ﬁbre-cellular tissue.
0. The covering of skin over the tumour with irregular papillae.
Hartn. object. 6 : eye-p. 4.
In 1878 I was consulted by a man, aged forty, who, eighteen years previously, had
been discharged from the army for ear disease. When I saw him, a ﬁbro-vascular
tumour projected from the oriﬁce of the meatus to the extent of half-an-inch, the
DISEASES or THE EAR. 357
appearance of which is well represented by ﬁg. 12. The removal of this tumour,
which was followed by very profuse haemorrhage, led to the discovery of an
exostosis, nearly blocking up the lumen of the meatus near its outer oriﬁce; a
water-colour drawing, which I have here, gives a good representation of it before
its removal, while ﬁg. 13 shows its size after removal, and ﬁg. 11 shows its micro-
scopical structure.
The operation for its removal was as follows :—
A loop of wire was passed over the tumour to its base or pedicle, and twisted
upon itself, so as to grasp the pedicle of the tumour ﬁrmly. The patient was now
Fig. 13.


Aural Exostosis.
Nat. size. Nat. size.
chloroformed, and a sharp gouge, with a curve, carefully adjusted to that of the
posterior and outer end of the auditory canal, was carried down to the base of
the tumour, close to its union with the posterior wall of the canal.
While ﬁrmly held there the head of the chisel was struck three smart blows
with a mallet, the separation from its attachment to the wall of the meatus was
easily effected in this way, and its removal from the depths of the meatus, into
which it had sunk, was as easily accomplished by the wire ligature, which had
been attached to the tumour before the operation.
The patient recovered without a bad symptom, and was ﬁt for work in about
a week after the operation. When the case was last seen, there was no return
of the growth.
As I believe that every aural exostosis may be removed as easily as this one
was, I commend this new method of operating to the attention of my confreres.
NOTE. —The above illustrations are from sections made and drawn on wood by Dr. David
Foulis, Pathologist to the Glasgow Royal Inﬁrmary.
Conclusions derived from the foregoing.
The osseous tumours of the external meatus are of two kinds, the one, named
hyperostosis, being a hyperplasm; the other, exostosis, being a new growth.
These differ from each other in origin, size, shape, structure, and number. Hyper-
ostosis is seen only in the inner or osseous end of the external auditory meatus;
exostosis is found arising from a point near the junction of the osseous canal with
its cartilaginous portion; hyperostosis is never seen till the osseous meatus is
completely ossiﬁed; exostosis appears before the complete ossiﬁcation of the
meatus; hyperostosis is always conical in shape, never pedunculated. In exostosis,
on the other hand, there is always a pedicle, and its shape varies; hyperostosis is
of ivory hardness; exostosis, before complete ossiﬁcation has taken place in the
tumour, can be pierced to a varying depth; hyperostosis is not movable on pres-
sure; exostosis is slightly movable, even when complete osssiﬁcation has taken
place; hyperostosis is often seen without any other disease of the ear, and if an
ear-disease exists, there is no causative relation between them; they exist alto-
gether independently, and apart from each other ; exostosis is nearly always com-
358 DISEASES or THE EAR.
plicated with another affection of the ear, past or present; hyperostosis, therefore,
may existin the meatus with normal hearing; exostosis, on the other hand, is
almost always attended by a defect in the hearing. The deafness which accom-
panics hyperostosis, in the absence of any other disease of the ear, is due to the
size of the growth, and is mostly mechanical, or it is due to the presence of debris
between or behind the tumours. In exostosis the defect in hearing may also be
mechanical; this defect, however, is generally due to ear disease, either past or
present.
Operation for the removal of hyperostosis is only justiﬁable when its mechani-
-eal pressure has been ascertained to be the sole cause of the deafness, or when a
coincident ear-discharge exists, the escape of which may be hindered or altogether
arrested by the presence of the tumour. The commonest cause of deafness in
uncomplicated hyperostosis is the presence of debris around the tumours, cerumen,
»epidermic masses or other matters, or to mechanical irritation and inﬂammation of
the tissues that cover them. The hearing is mostly restored on the removal of the
debris or inﬂammation. The operation for the removal of hyperostosis is best
affected by a mechanical drill, such as dentists use; this is the safest method of
removal.
For the operation of the removal of an exostosis, a gouge is the best instru-
ment, because the tumour can be removed at one operation, whereas a hyperostosis
usually demands several operations as well as separate sittings for its complete
removal, when this is possible. There may be several hyperostoses in one ear,
but there never is more than one exostosis. Both classes of tumour may exist
together in the same ear.
B iblicgraphy.
Bonnafont.——Mémoire sur trois cas de guérison de surdités produites par des
tumeurs osseuses développées dans le conduit auditifexterne : Bulletin cle Z’Académie
(le Méclecine, 13 Octobre, 1863, t. xxix. p. 29.
Erhard.——“ Vortrage iiber die Krankheiten des Ohres,” gehalten an der Friedrich
lWilhelms Universitat zu Berlin. Leipzig, 1875, p. 173.
Von T1"c'>ltsch.—~“ Lehrbuch der Ohrenheilkunde.” 5te Auﬂage, 1873, p. 124:.
Welcker.——Ueber knocherne Verengerung und Verschliessung des ausseren
'Gehorganges : Archiv fur Ohrenheilhuncle, i. pp. 163—74.
Ne'laton.——-“ Elements de Pathologie Chirurgicale.” 2me ed. 1869, t. p. 478.
Prof. Turner, M.B., F.R.S.——Exostosis within the External Auditory Canal;
Journal of Anat. and Ph/ya, J an. 1879, p. 200.
Schwartze.—-—“ Pathologische Anatomic des Ohres.” Berlin, 1878, p. 40.
Toynbee.--“ The Diseases of the Ear.” London, 1859, pp. 107—119.
Kramer.——“ Traité des Maladies de l’Oreille.” Traduction Francaise.
Bellefroid. Bruxelles, 1840, p. 112.
Wilde—“Nature and Treatment of Diseases of the Ear.” Traduit en alle-
rnand par Haselberg. 1855, pp. 24.11, 24.2. \
Rau.—“ Lehrbuch der Ohrenheilkunde.” Berlin. 1856, p. 194.‘.
Triquet—“Lecons Gliniques sur les Maladies de l’Oreille.” 1866, pp. 280, 381.
J. Gruber.—“ Lehrbuch der Ohrenheilkunde,” 1870, p. 4413.
A. Politzer.—Oontribution a l’Anatomie Pathologidue des Affections Con?
sécutives des Sinus : Archie fit/r Ohrenheilhuncle, i., neue Folge, p. 288.
E. Politzer.—Seltener Fall eines einfachen chronischen Mittelohrcatarrhs:
Archie fit/r Ohrenheilhuncle, Band i. neue Folge, p. 418.
DISEASES or THE EAR. 359
D. C. Miot.——Du Rétrécissement du Conduit Auditif Externe: Gazette ales
Hé‘pita/ua, 1871, Nos. 95, 96.
George Field—On the Etiology of Aural Exostoses ; Osseous Tumours following
Extraction of Polypus : British Medical Journal, February 2, 1878.
Dr. Aldinger.--Zwei Falle von Exostosen im ausseren Gehorgang, &c.:
Archiv fiir Olzn'cukeilkuucle, Band xi. p. 113.
Dr. Thomas E. Clark—Cure of an Exostosis of the Auditory Canal by Electro-
lysis: British Medical Journal, Dec. 6, 1873.
Delstanche ﬁls.——“ Contribution a l’Etude des Tumeurs Osseuses du Conduit
Auditif Externe.” Bruxelles, 1879.
Clarence J.Blake.—On the Occurrence of Exostoses within the ExternalAuditory
Canal in Pre-Historic Man : American Journal of Otology, April, 1880.
J. Barnard Davis.—“ Thesaurus Cranium.” London. 1867. And Supple-
mentary Volume. London, 1875.
Moréz'a’ Growzfks of the Ear, and z‘kez'r Treaz‘mem‘. will;
fllusz‘raz‘z'ue cases. “
Dr. LAURENCE TURNBULL, Philadelphia.
The tumours, or morbid growths, which are found in the ear, causing deafness
either by direct pressure, or reﬂex action, are sebaceous, encysted, ﬁbrous, ﬁbro-
cartilaginous, othaematomata or angiomatous, epithelioma, sarcoma, chondro-sarcoma,
and alveolar. The ﬁrst variety are usually attached to the meatus by a small pedicle,
consisting of the cerium and epidermis, and are ﬁlled with white, slightly glistening,
contents, consisting of cholesterine, epithelial cells, ﬂat globules, and crystals of
lime. Sebaceous tumours vary in size from a millet seed to a large hazel nut, having
a ﬁrm enveloping membrane of connective tissue. Gruber ﬁgures and describes an
atheroma of large size?‘ The structure of these tumours, or morbid growths,
is of ﬂattened cells, which are arranged in layers, proving to us that they are
only masses of desquamative epithelium. We have seen numerous cases of them
enlarging the meatus, perforating the membrana tympani, and ﬁnally perforating the
bone, by a gradual atrophy from pressure of the mass. Osseous growths in the meatus,
or auditory canal, are sometimes mistaken for tumours, being covered by the dermis.
Pressure with the extremity of a probe is usually suﬁicient to determine the character of
the growth within the ear. These growths of bone cause great narrowing of the
meatus, and are often found with caries of the middle and internal ear ; they are removed
by means of the chisel and mallet, and the dental engine.
Treatment.—Removal_of the encysted and sebaceous tumours by careful dissection of
the epidermic layers by the use of the forceps and scoop, or by repeated syringing with
awarm solution of borate of soda, or caustic potash. The whitened and altered condition
of the tympanic membrane, which is caused by the long pressure, is to be treated by
a solution of sulphate of zinc or nitrate of silver, and its depression by inﬂation, by means
of Politzer’s air douche. If there is perforation of the membrane, the patient’s system is
to be built up by tonics, any excessive discharge removed by means of a solution of boracic

Lehrbuch cler Ohrenheilkuude, Fig. 5, s. 407.
36o DISEASES or THE EAR.
acid and absorbent cotton. Should there be granulations, they are to be touched with a
probe on which a small head of nitrate of silver is fused, and then an. artiﬁcial membrane
worn until the parts heal.
Fibrous and Mymoﬁbromatous Tumours—This form of tumour is chieﬂy to be found
among the females of the coloured races and in the lobule of the ear, from simple piercing
of the lobule in the upper portion. It has been stated, and we at one time considered
it, to be entirely due to the irritation of the mixed metals in the. earrings worm, but we
have found such not to be the case, because so many of the coloured women wear these
earrings without any irritation, but only when the lobule has been pierced at its lower
point, and the cartilage cells escaped. Having seen a large number of cases, we feel con-
vinced that, in the coloured race all forms of irritation of the cellular tissue cause it to
take on a peculiar form or growth of ﬁbrous tissue ; this we have noticed in various portions
of the body, even penetrating to the uterus and ovaries. The form of ﬁbroma is recurrent,
and a simple puncture will sometimes develop them in a system that is predisposed.
. They are rarely found in the light-coloured, but mostly in the darker races. I have
Fig. 14.


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Fibroma of Lobule.
never seen them in the white. In nine cases of which I have notes, ﬁve required a
second operation for removal, two a third, and in two others the entire lobule was
removed for a complete extirpation of the disease. If, however, in the ﬁrst operation,
every portion of the ﬁbrous tissue is removed, there is no return ; but if there be left but
a single ﬁbre of this elastic tissue, a tumour similar in structure will develop from the
cicatrix. In my early operations, I simply removed these tumours as recommended in
works on general surgery, but found they always returned, so that in 1869 I resolved to
make a change in my method of operating—i.e., by carefully dissecting back the skin
nIsEAsEs or THE EAR. , 361
covering them, then cutting out the entire ﬁbrous tissue until nothing was left of it,
and seeing that a sufficient number of stitches either of ﬁne black silk or silver
wire, were employed to close the wound, leaving a small opening at the base for
drainage, which opening subsequently closes by granulation. The lobule of the
ear is supported by isinglass plaster and a bandage, and dressed with lint. In the
microscopic examination of the tumours they are found to contain yellowish white
ﬁbres and some fat cells. The following is an interesting case, showing how large they
will grow after imperfect removal, and also that they are frequently found in both ears.
Mary A., aged twenty-ﬁve, single, dark-coloured skin, was distressed with the deformity
of symmetrical ‘tumours, of unusually large size, on both ears. The tumour seen in
Fig. 14 had been removed‘ by a surgeon six years previously, but had again returned,
very much increased in size, and was trilobed. The tumours involved the whole of the

Myxoﬁbroma of Auricle.
lobe and part of the helix and antitragus. It required a tedious dissection, to save
sufficient skin to cover the exposed surface, and to avoid deformity, which was happily
accomplished. The patient was under the inﬂuence of ether as an anmsthetic for one
hour, and eight ounces were employed. The second car was operated on in a similar
manner; the patient, however, passing more quickly under the inﬂuence of hydrobromic
ether, and the operation was completed in half an hour, with the use of ‘two ounces of
ether.
,3 62 DISEASES or THE EAR.
ZlIymoﬁbro-ma of Auricla—The next variety is termed myxoﬁbroma of auricle. The
‘microscopical characters in a case of this occurring in a white-skinned individual, are of
interest.
The young lad, aged eleven,was a patient of Dr. J. M. Smith, of Gordonsville, Virginia.
At the age of two years he received a scratch from'a toilet-pin upon his left auricle.
The scar soon developed into a distinct tumour, which, at the end of eighteen
months, being of the size of a buckshot, was removed by the knife. Almost imme-
diately it returned in the place of the scar, but was not removed until at the end of
about two years, when it was carefully dissected from the cartilage, and found to be about
three times the size of the original growth. The wound was touched with carbolic acid,
and allowed to heal by granulation. Again the growth returned, and having obtained
‘the size of double that of the second tumour, was, after the lapse of two years, removed ;

Angioma springing from the external auditory meatus, escaping in part by the meatus,
and in part behind the ear making its way between the cartllage and the bone.
but on this occasion, as upon the previous-ones, in such a manner as to include in the
dissection as little as possible of the surrounding tissue.
On December 19, 1877, the‘ case came under the care of Dr. C. R. Agnew, of New
York, who reports?“ It presented the external physical features delineated in ‘the
accompanying illustration (Fig. 15), taken from the tumour immediately after removal.

* Trans. Amer. Otol. Society, vol. ii. Part ii. 1878.
DISEASES OF THE EAR. 363
After consultation with Dr. William H. Van Buren, the tumour was removed, and with
it nearlyl'all the cartilage of the auricle, down to the bony ring of the external auditory
canal, leaving the pendant lobule, and skin enough to make a projection somewhat
resembling a small auricle. The wound healed by primary adhesion throughout. In
June, 1878, the tumour again began to recur, showing itself as a small nodule in the
_lower end of the scar near the lobule, while the other part of the line of healing re-
mained quite healthy. Immediate removal was'again advised—whether the advice had
been carried into effect the doctor had not heard.
Dr. C. Heitzmann made a careful microscopic examination and drawing, and reported
the tumour to be a myxoﬁbroma. _
Cylindroma is a name‘ given to a tumour which, according to the terminology of the
present day, would be called a myxoma cartilaginum.aie
Angiomata are bloody tumours of the car, which grow in the meatus and in the depres-

Angioma of External Auditory Meatus.
sion between the mastoid process and the condyloid process of the lower jaw. Fig. 11 is
an example which came under our care, the pressure causing absolute deafness, facial
paralysis, and injury to the brain. The larger mass was in the meatus, and the smaller
one passed out, making its way behind the cartilage, causing atrophy of the mastoid
process, witha tendency to rupture of the larger tumour, which ultimately took place,
and death followed. N o opportunity for a post-mortem was given.
Another instance (see Fig. 17) came under my care, and this, as will be seen by the
drawing, emerged from, and was attached to, the meatus. This tumour was ligated and
covered with tannic acid, and was entirely cured by this treatment. It is reported that
J iingken ligated the common carotid artery for a rupture of one of these tumours, and
a nearly fatal haemorrhage occurred. Seven years after the operation there occurred a

* Charité Annalen, “Pathological Anatomy of the Ear,” H. Schwartze, p. 38.
364 DIsEAsEs or THE EAR.
fresh haemorrhage from the tumour, and death. Another form of blood-tumour is
termed othaematoma, haematoma auris. This is usually a tumour in the early stage, of
which ﬂuctuation can be felt. The ﬂuid is blood, and it is situated under the skin of
the auricle, and when of a severe or aggravated form, as seen in the insane, the blood,
or serum of the blood, may be found between the perichondrium and cartilage. In
the early stage there may be heat, redness, and pain, especially if it is of a traumatic '
origin, as from a blow, or bruise against a stone wall, &c. In this latter form, sup-
puration and spontaneous rupture may occur.
Pathology.—-It is said to depend upon a pathological condition of the brain, but we
believe that it is produced by violence, &c.
By the application of cooling lotions the haemorrhage is generally reabsorbed; and
if tincture of iodine is employed, with support, the perichondrium may again become
attached to the cartilage, and no permanent deformity be left; but if it is neglected,
thickening and cicatrical shrinking of the auricle takes place, caused by chondromalacia
or softening of the cartilage. A gelatinous material takes the place of the true hard
cartilage.
Malignant tumours are to be found involving the cartilage of the ear, the meatus,
and the temporal bone. One form is termed the chimney-sweepers’ cancer, which has
been described by English surgeons. Epithelial cancer of the auricle is also met
with, and, in the case of an old woman, we found it extend into the middle and
internal ear. A case of primary epithelial cancer of the meatus is described by
Delstanche, which began as a small nodule upon the inner surface of the right
tragus, accompanied by severe pain in the ear and over the side of the head. This soon
ulcerated, destroyed the tragus, and extended into the meatus, leaving a surface destitute
of epithelium, and covered with small growths, resembling granulations, which on
microscopic examination showed the characteristics of epithelial cancer. At the end of
eight months the patient died, having gradually lost the sight of the right eye, and the
senses of taste and smell—the disease having steadily progressed till nearly the whole of
the temporal and sphenoid bones had been destroyed.
Schwartzei‘ states that he has seen three cases of primary epithelial cancer of the
temporal bone, and he gives a list of ﬁve others. There have been twenty cases in
all, in which death generally resulted from marasmus or pressure on the brain, sometimes
from basilar meningitis.
When malignant tumours involve the skin they can. be removed by caustics.
If the cartilage is involved the only effectual treatment is entire removal. If in
the meatus the operation is more difficult, and the only agent which exerts any
control (where the knife, saw, or sharp spoon cannot be used) is the internal adminis-
tration of Fowler’s solution of arsenic, continued in small doses, from one to two drops
three times a day for months.
Osteosarcoma of the tympanum, extending into the meatus, has been observed by
several surgeons, and a number of cases of round-celled sarcoma. Reports exist of three
cases of the above, all occurring on the left side.
A boy, 3% years old,"{' healthy, and of healthy parents, without previous pains or
inﬂammatory symptoms, had a serous discharge from the right meatus, and two“
weeks later the meatus contained a tumour, which was supposed to be an ordinary
polypus. 0n removing this with the snare, four weeks from the beginning of the
discharge, the deeper meatus was found to be ﬁlled with other Similar growths, resembling-

a Op, Cit,’ pp, 25, 27_ + Archives of Otology, March, 1880.
nIsEAsEs or THE EAR. 365
granulation tissue, springing from all parts of its walls and the tympanum. The drum
membrane and ossicles had been discharged. The patient died.
Schwartze* describes a well-marked lymphoma or lympho-sarcoma tumour, the result
of inﬂamed glands lying over the mastoid process. We have seen these glands much
inﬂamed, but never so large as described by Schwartze, who states that he has seen
one as large as the ﬁst, hard and extremely sensitive tothe slightest touch. The same
authority states that epithelial cancer can occur primarily in the mastoid process, be-
ginning with darting pains and a red, extremely hard, swelling of the mastoid. After
incision or spontaneous rupture a foul ulcer is formed, which rapidly becomes deep, and
give rise to frequently recurring haemorrhage. After some months the hard inﬁltration
of the neighbouring lymphatic glands extends to those in the parotid, which lie
in front of the auricle. In the treatment of these lymphatic gland tumours, free-leeching,
and the subsequent use of iodine, both externally and internally, is our usual prescription.
In the second class, we would advise the removal of all diseased bone; While the use of
arsenic, internally, should be employed. Cases of parotidean and intra-tympanic malig-
nant tumours are rare, and of a complex nature, adenomatous, sarcomatous, cartilaginous,
and myxomatous; the literature on this subject is scantyrf' An interesting case is reported
by Dr. H. Knapp, of New Yorkl We have only given the important points in the
case. First, its origin : which was in the parotid region. There was an external tumour
which had existed six years before the internal made itself noticeable; and it then ex-
tended to the middle ear. Its course was inwards, causing deafness in one night, this
deafness was the result no doubt of the pressure of the tumour occluding the whole
cavity, from serous or hmmorrhagic effusion, or of pressure on the nerve. The age of the
gentleman was thirty-seven, his left ear was affected with chronic otorrhoea, his right
ear never discharged. When the left car was closed he could understand ordinary speech
at ﬁve feet, and hear the watch tick when in contact with the right ear, mastoid process,
and forehead. The right membrane tympani was uniformly bluish red, slightly convex,
and greatly dislocated forward. The cone of light was absent, but there was a dull
roundish reﬂex on the posterior lower part. The drumhead yielded to the probe (with
no increased sensibility to the touch) as if a soft substance, harder than liquid, were he-
hind. On the next day,'_ﬁnding the condition of the patient unchanged, Dr. Knapp
made an incision with a paracentesis needle into the drum membrane, in front of and
below the handle of the malleus. The edges of the wound at once retracted, and through
the gaping opening a ﬂeshy growth extruded, ﬁlling the space. The incision gave rise
to considerable haemorrhage. The clinical diagnosis was primary parotidean growth, which
entered the tympanic cavity, through the Glasserian ﬁssure or its vicinity, and that the
tumour was adeno-chondrosarcomatous. Dr. Sands, by the request of Dr. Knapp,
removed the parotid or external tumour on June 26, by a vertical incision, measuring
from three and a half to four inches in length, extending from the level of the meatus
down to the lower end of the growth, but as much of the latter as possible was removed
by means of the ﬁngers and dressing forceps, without chiselling the bone. The patient
remained in the hospital until the wounds had almost healed. July 26.—The wound in
the neck is,almost healed, but the pain in the region of the ear continues. By means of a
curved blunt-pointed knife portions of the growth were cut off, bleeding active. The
reduction of the size of the mass was attempted by Dr. Buck, who had the patient then in
charge, by gnawing away small portions with a miniature “rongeur,” Dr.Knapp then being

* Op. cit.
i‘ Paget, Lectures on Surg. Path, i. p. 201 z—Virchow, large work, chapter Chrondromata,
vol. i. p. 435.
1 Archives of 01501091], vol. viii. No. 4, Dec. 1879.
366 DISEASES or THE EAR.
absent in Europe; but after one or two attempts he was obliged to desist. As the blood
poured from the ear in a continuous stream, the bleeding had to be arrested by stufﬁng
the ear with cotton, and applying pressure by means of a bandage passed over the head
and under the jaw. On the same day another attempt was made, but with no better
success, and it was followed by the formation of a large abscess on the side of the neck
just below the mastoid process, and the patient was again transferred to Dr. Sands. No
other operative interference was made by the surgeon, and the tumour- continued to grow,
and by October its base was six inches in diameter, and there were repeatedly profuse
haemorrhages. In the last stage, according to Dr. Peck, who took charge of the ease, the
tumour measured in circumference at the base twenty-two inches, in antero-posterior
diameter eight inches, in the vertical seven inches. The patient died ﬁfteen months
after the ﬁrst operation. Dr. Knapp in his concluding remarks adheres to the opinion
that there was a connection between the tumours, and holds to the idea that the aural
tumour might have been removed, together with the parotidean, from the posterior part
of the glenoid fossa. We are also of the same opinion ; and if a part was removed, why
not all the tumour by Dr. Sands. This was the only chance for the patient. The micro-
scopic examination of the condition of one of the masses removed, revealed with a low
power that the tumour was composed of round, oblong, and branching alveoli ﬁlled with
medium-sized cells, in other words, cartilage cells, which seemed to enter largely into the
composition of the matrix of the tumour. No post-mortem was permitted.
Finally, the following are offered as conclusions : that all morbid growths of the ear
may be comprised under the following heads :—
1.—Under the head of sebaceous, encysted, osseous, ﬁbrous, ﬁbro-cartilaginous
and teleangiectatic, or bloody tumours, associated with caries of the temporal bone
or mastoid process, and involving the auditory nerve or some of its branches.
2.-—Morbid growths, including angiomatous, epitheliomatous, sarcomatous,
chondromatous, and alveolar. These may ﬁll the external meatus, or the internal
auditory canal, and ﬁnally involve the auditory nerve, causing death from
marasmus, pressure on the brain, or basilar meningitis.
3.-—-Osteo-sarcomata, chondromata,lympho-sarcomata,ﬁbro-sarcomata, involving
the common trunks of the facial and auditory nerves, the tumours being found at
the bottom of the internal ear.
Ali—Tumours may be gliomata, cerebral tumours, or morbid growths, usually
found involving the eye at ﬁrst, but in a case described by Bruckner, which was
the result of a fall on the back of the head, accompanied with complete deafness,
giddiness, and inﬂammation of the middle ear, pulsating tinnitus, and ending
fatally.
Fatty metamorphosis of the organ of Oorti, resembling sarcoma of the audi-
tory nerve, as described by Moos, amyloid degeneration of the auditory nerve as
described by Voltolini, and corpora amylacea, found in the semicircular canals of
man, and described by Lucae.
Treatment of morbicl growths of the ear.—-Where such growths can be
reached, the only successful plan of treatment is the early removal by excision by
the knife, preventing danger of heemorrhage by the use of the ligature, clamp-
forceps, thermo- or galvano-cautery. Removal of diseased bone by forceps, sharp
spoon, revolving knives, or the surgical or dental engine.
The most important plan of treatment is the removal of all vascular or polypoid
growths as soon as they are brought to the notice of the aural surgeon. All punc-
turing or irritating of the above growths by means of needles, small sharp knives,
or caustics, is to be entirely avoided, for, in our experience, all such meddlesome
nIsEAsEs OF THE EAR. 367
surgery tends to increase and inﬂame them, and may change an originally benign
growth into a malignant one.
The only remedy that we have found to prevent the spread of malignant
growths is some one of the preparations of arsenic, and none has been borne so
well as the old preparation of the arsenite of potassium, or Fowler’s solution, given
in small doses, and continued for a long period.
When the system shows the inﬂuence of the arsenic, by oedema of the eyelids, great
whiteness of the skin, with puﬂiness of the same, it should then be withdrawn for a
time, to be again employed in smaller doses, always well diluted with water. Arsenic ﬁrst
locates in the plasma; it then forms a part of the histological elements, and penetrates
every part through the nutrition, even into the hair (Gubler).
Morbid growths are organic substances possessing an inferior degree of organiza-
tion or development; and therefore arsenic is the agent to be employed for their
removal, as we know that it destroys the large as well as the smaller organizations.
We might make an exception in favour of arsenic as an escharotic, as it seems
almost possessed of intelligence; and, if watched, will be found to attack the different
layers in a new formation like cancer, and spare the neighbouring healthy tissues.
DISCUSSION.
Dr. MENIERE, Paris: The extent of the subject is very great, too great to
allow of its being disposed of at one discussion. I shall conﬁne my remarks
accordingly to aural polypi. The classiﬁcation of these I will not discuss, nor the
causes giving rise to them, but say that they may appear with or without otorrhoea.
I go straight to the treatment, which is my important point. The most rational
treatment is excision with cauterization of the pedicle. The instrument generally
used is Wilde’s snare, with various modiﬁcations, one of which, proposed by myself,
enables us to place the tube in different directions, so that the wire can be easily
passed to any position necessary. For the after-treatment of cauterization, I
prefer the saturated chloride of zinc, and the nitrate of mercury. In cases where
the root of the polypus is hidden by the membrane, and the perforation is too
small to allow of the proper application of the caustic, Politzer advises the incision
of the membrane to look for the pedicle. This is not easily effected, and the
operation is objected to by many patients. In such, I have seen good results arise
from the application of rectiﬁed spirits to the parts for the space of ten or ﬁfteen
minutes two or three times daily.
Dr. GUYE, Amsterdam: According to my experience, multiple exostoses gene-
rally come to a standstill as to their growth when they touch each other. I have
seen an Osseous bridge formed between two exostoses, and removed it. The for-
mation of such a bridge probably arose from erosion of the summits of the exostoses
by a purulent discharge existing for a considerable period. As an instance of the
inﬂuence of the meeting of the exostoses on preventing their further growth, I may
instance the case of a young lady, whom I had treated for a chronic deafness. At
that time there was no exostosis present. I saw the patient again two or three
years afterwards, and found three large exostoses, which nearly met in the centre.
I was then alarmed lest a closure of the meatus should ensue: but saw her some
six or seven years afterwards, and found no further development. I cannot agree
with Dr. Cassells as to the distinction he drew between exostoses and hyperostoses.
M. GELLE, Paris: I once came across an aural polypus growing on a psoriatic
368 DISEASES or TIIE EAR.
plaque. It occurred in a man suffering from psoriasis in an aggravated form.
The left ear was covered by a large furfuraceous patch of psoriasis, and the right
ear presented a polypus protruding from the external meatus. There was no
discharge. On removal, it was found to arise from a yellowish red surface external
to the membrane. The polypoid proliferation without discharge is the remarkable
feature of the ease, thus allowing of a proliferation without the attention being
called to it till the hearing became affected by the size of the growth. Will Dr.
Oassells tell us whether he has seen a great number of cases of exostoses, if otherwise,
I cannot understand how he could present us with so complete a description.
For my part, I have seen very few cases—two or three—and these were in gouty
persons. I am struck by the great number of cases to be seen in a short time at
Glasgow, compared with what I have seen in Paris in a great number of years.
I will describe what has been the result of my examination of sixty skulls of ﬂat-
headed Indians belonging to the anthropological museum of Paris. In these, ten
skulls showed simple or multiple exostoses of large size, generally on both sides.
In six others, the external auditory canal is obliterated or narrowed by the general
closure of the walls.
Dr. Gellé showed drawings of these lesions. The exostoses in some were tooth-
shaped or pear-shaped of different sizes, and pediculated. Others had a large
base. They were frequently found on the posterior wall.
Dr. LOEWENBERG, Paris: I have seen a case where in both ears the common
exostoses existed, but were oined by a thin transverse plate of bone, which com-
pleted the closure. The galvano-cautery destroyed them, and improved the hearing.
I have come to a conclusion opposite to that of Dr. Gellé, as I have found exostoses
frequent in Paris. I have never seen polypi arise without suppuration, and as they
often develop after scratching in eczema, so in psoriasis, they are produced by
scratching, and not by the disease itself, which is a dry one. In the same way, after
furuncles polypi increase rapidly. I strongly recommend the galvano-cautery,
not the snare, for their removal. A pointed end should be used for passing
through aperforation into the cavity.
M. GELLE, Paris : In reply to M. Lowenberg, I would remind him that in psoriasis
there is no itching. The proliferation of the skin has been seen and described in
diﬁerent parts of the body besides the ear.
Dr. KNAPP, New York : A year ago, Dr. G1. .I. Blake was kind enough to take
me through the Peabody Museum, in Boston, and show me 200 or 300 skulls of
the Mound Builders of Tennessee, among which he had found, in about 25 °/O,
exostosis in the auditory canal. I saw that these growths were situated on
the tympanic portion of the canal, were oblong and ragged, of different sizes,
but never ﬁlled the calibre of the meatus completely. The skeletons of these
pre-historic people showed many diseases of bone, especially healed fractures, but no
symptoms of syphilis. Two weeks ago I had the privilege of speaking with
Professor Virchow on this subject. He said these formations in the pre-historic
- man were supposed to be the result of continued irritation from foreign bodies,
which these races probably used to stick in their ears. As to the exostoses in the
inner part of the ear canal, I know that in a low state of development they are
quite frequent. We are only too much accustomed to overlook them, as they
cause no trouble. I am not so convinced as Dr. Guye, that the multiple
mammillary exostoses never occlude the canal totally. In one recent case I found
DISEASES or THE EAR. . 369
that the skin bridged over three of them uninterruptedly. On incision I found
that only a thin probe could be passed through the little aperture which their
bony crests left free. I chiselled the canal wider with good result. In another
case I found the bony closure complete, but not having observed the case before,
and the history being unsatisfactory, I did not know positively whether the bony
closure was the result of mamillary exostoses or not. In regard to the hyperostosis
of the ear I would say that syphilis should not be left quite out as a cause. I will
mention one case as representative of many. A young man had parenchymatous
keratitis four years ago, i.e., in his ﬁfteenth year; two years later he acquired a
chancre, as he stated. For a whole year his hearing has diminished, not suddenly.
He came to me six months ago, completely deaf on both sides, the inner parts of
his ear canals pinkish and narrowed (verte) by swelling of the walls, which gave a
bony feel to the probe. The membranes tympanorum were pinkish, thickened,
scarcely movable with Siegle’s otoscope—symmetrical characteristic pharyngeal
ulcers. It ‘seemed that he was doubly tainted—viz., with inherited and acquired
syphilis. His deafness must have been in the inner ears as well as in the outer and
middle, for even a complete bony ankylosis of the footplate of the stirrup would
not account for his absolute deafness. I took him to the New York Ophthalmic
and Aural Institution, gave him the best of care, and Hg, KI, and Zittmann’s
decoction, as much as his system would stand, for ﬁve months. The pharynx get
well, the hyperostosis of the ear canal diminished, so as to make the parts almost
appear normal, the membranes tympanorum became pale and thin, but thedeafness
remained absolute.
Dr. URBAN PRITCHARJ), London: In the course of my experience I have met
with three forms of exostoses. First, the multiple smooth rounded exostoses which
are hyperostoses,due,I believe, in most cases to a gouty or rheumatic diathesis,
these are found very frequently in private patients, very rarely in hospital patients.
Second, the exostoses found as the result of bone irritation in old standing
otorrhoea, these are not so rounded, but have usually broad bases, they are not
so frequently met with (except in hospital patients) as the ﬁrst class. Lastly,
a rare form of exostosis, which is single, usually pedunculated, and with a soft ex-
terior. Dr. Pritchard related a case of this third variety, showed the tumour removed
entire, and a section of it under the microscope. The removal of this tumour
was eventually effected by softening with dilute nitric acid 3%; per cent., and subse-
quent breaking through the pedicle by means of a dentist’s elevator. There
was no other disease of the ear, so that the hearing was completely restored.
Professor J ONES, Chicago, related a case of single exostosis in which the growth
disappeared without treatment.
Dr. BARR, Glasgow : While exostosis belongs more to the nature of tumours, hy-
perostotic contraction of the external auditory canal seems usually to have an inﬂani -
matory origin. It is often associated with, or the result of, chronic otorrhoea, although
it does undoubtedly occur in the non-suppurative catarrhs. I have found generally
that hyperostosis is attended by a swollen inﬂamed state of the cutaneous lining
‘of the external canal of the ear. I look upon hyperostosis more as the result of a
chronic periostitis with increased formation of osseous tissue, and this increased
osseous formation may at the same time exist in the walls of the tympanum and
in the mastoid cells in the neighbourhood of the internal canal of the car. A case
PART III. B n
370 DISEASES OF THE EAR.
was related showing that treatment of the inﬂamed, thickened condition of the
cutaneous lining of the canal of the ear, associated with hyperostosis, was attended
by great improvement in the hearing.
Dr. Rnnvn, Toronto, could not agree with Dr. Cassells as to the causes and
development of the bony growths.
Dr. SAPOLINI, Milan, exhibited anew instrument for at once holding and cutting
the polypoid growths in the external meatus. It is especially useful when the
pedicle is strong, hard, and dense. It can be employed in any position in which
the pedicle may be found.
Dr. ÛASSELLS, Glasgow: The various gentlemen who have spoken in this dis-
cussion have overlooked the most important point of my paper—viz., the difference
between aural-exostosis and hyperostosis—conﬁning their remarks to those bony
growths which have their origin in the osseous portion of the external auditory
meatus. In reply to Dr. Gellé, who has asked if I have made a special study of the
subject, I refer him to the illustrated sheet of exostoscs removed from the ear by
operation (using a mallet and gouge for that purpose) as an evidence that I have
done so. I have never seen bony tumours of the external meatus arising in the
cases of patients who have had syphilis, as Dr. Knapp has described in the course
of discussion.
Les lésions new/eases dans la Surdité.
Dr. GELLÉ, Paris.
Quand on trouve de la surdité par la voie crânienne on ne peut conclure à. une
lésion de l’oreille interne que si l’on a acquis la certitude que la platine de l’étrier
est mobile. La proposition généralement admise que l’auscultation par la voie des
os du crâne peut fournir des notions exactes sur l’état du nerf labyrinthique, est
démontrée fausse par l’observation clinique. On trouve souvent, en effet, sur la
même oreille, l’audition crânienne perdue et celle par l’air conservée.
Le diagnostic diﬁérentiel est toujours délicat et souvent impossible. Cependant,
l’immobilisation de la platine de l’étrier est rarement une lésion isolée, et des
lésions de l’oreille moyenne accessibles a nos moyens d’investigation guident le
diagnostic. Il peut être, cependant, difficile de faire la part de ce qui revient à
chaque lésion dans la production de la surdité. Le clinicien devra, en ce cas, surtout,
se guider sur l’existence des symptômes nerveux, connus pour être surtout d’origine
labyrinthique: telle la trilogie de Ménière, surdité, vertige et siﬂiement, avec ou
sans chûte. Sachons, cependant, que sans lésion du labyrinthe, cette trilogie symp-
tomatique a pu exister. Le nerf auditif peut être actionné par des lésions extra-
labyrinthiques auriculaires ou autres. Quand l’étrier se ruent, l’oreille moyenne
étant saine, l’origine nerveuse des troubles observés est évidente. L’étrier est-i1
mobile, le labyrinthe est-il enmuré P “ That is the question.”
C’est ici que l’expérience de Lucae trouve son application. Lucae comprimer
fortement l’oriﬁce du méat, cette pression, transmise par l’air au tympan, agit de là
sur la platine de l'étrier et sur le labyrinthe, en ﬁn de compte. Si l’étrier est
soudé, rien ne se meut ; et les efforts de la pression sont nuls, si l’étrier est mobile
et que le labyrinthe soit sain, le son de la montre ou du diapason, par voie osseuse
DISEASES OF THE EAR. 3 71
(bosse fI'On‘cale droite, par exemple), est affaibli et quelques bourdonnements prennent
naissance; mais quelque soit l’eifort fait sur le méat, l’audition n’est pas atteinte ;
si, au contraire, le labyrinthe est l’origine des phénomènes dits de Ménière, on
s’aperçoit que le bourdonnement diminue ou cesse au moins, que des vertiges appa-
maissent, et l’audition par la voie osseuse est éteinte, s’il en existait encore trace ;
ce sont bien la des signes labyrinthiques.
Ce procédé est douloureux et peu pratique; je l’ai modiﬁé de la façon suivante :
un tube de caoutchouc, long de 0,15 centimètres, s’adapte d’un bout au bec de la
poire à insuffler ordinaire, et de l’autre est introduit dans le conduit auditif extérieur,
où il est ﬁxé hermétiquement. Dès que le diapason normal en vibration est posé
sur le tube, l’audition a lieu. Si on presse alors la poire à. air, le sujet annonce
que le son devient moins intense, et si le son était déjà faible, il disparaît. Aussitôt
queila pression cesse le son reparaît. Grâce a l’élasticité naturelle des parties, on
peut répéter à volonté l’expérience avec la même succession de piano et de forte;
ceci se passe à l’état sain, sans douleur, sans trouble. On obtient la même oscilla-
tion, si le diapason est posé sur le front (bosse frontale). Si le tympan est raidi,
immobilisé, l’épreuve est sans effet. Si le tympan est ramolli, il cède à la poussée,
et le son s’éteint à la première ou à la deuxième pression centripète.
Si en ce cas le labyrinthe est malade, hyperesthésié, &c., a chaque pression il
reçoit un choc qui cause, soit un vertige, soit du bourdonnement d’oreille.
Avec cette manœuvre on interroge le nerf labyrinthique, on agit sur lui par
l’intermédiaire de l’étrier, de la chaîne et du tympan. Les modiﬁcations de l’audition
qui naissent sous l’inﬁuence des pressions montrent l’état de mobilité et d’élasticité
de l’appareil de transmission du son; les troubles nerveux annoncent une lésion
du nerf lui-même.
Eagpérience du téléphone à ﬁcelle et de la tige conductrica—J’ai trouvé ce pro-
cédé pour sonder plus avant la capacité acoustique et la mobilité de la platine de
l’étrier. Voici quel il est: une tige cylindrique de 3 millimètres d’épaisseur,
longue de 10 a 12 centimètres, bien arrondie a ses deux boutons est introduite
doucement et sans hésiter le long de la paroi supérieure du conduit auditif jusqu'au
contact des osselets (apophyse externe et vestige de la chaîne et du tympan, pôle
supérieur). Au bout extérieur de cette tige d’ivoire est attachée la ﬁcelle courte
d’un petit téléphone. On a alors un chemin direct et court du dehors à l’étrier;
la transmission possède ainsi une grande puissance, et j’ai pu par ce procédé faire
entendre nettement, en parlant dans le téléphone, des gens qui ne percevaient
d’ordinaire que le bruit d’une voyelle criée à l’oreille.
Enﬁn, une deuxième expérience est possible: sur la tige on peut appliquer le
diapason en vibration, et le son acquiert une force de pénétration extrême; on peut
ainsi aller un peu plus loin que par les procédés connus à. la recherche de la sensi-
bilité acoustique et de la mobilité de l’étrier.
La surdité sans lésion de l’oreille moyenne et externe se rencontre dans bien
des cas; pour les étudier méthodiquement j’emploie la division suivante en trois
chapitres: le premier étudie l’anatomie pathologique suivant que la lésion cause
siège au labyrinthe, sur le nerf auditif, dans le nerf facial trijumeau, &c., le centre
nerveux: le deuxième chapitre parle des affections causes, diathèses, hémorrhagies,
diabètes, albuminurie, &c.; le troisième fait la séméiotique des symptômes dits
labyrinthiques. Le quatrième s’occupe du traitement. ‘
Voici quelques cas de ma pratique où la lésion existait ailleurs que dans
l’oreille moyenne et externe, où il y eut surdité avec ou sans bourdonnements ou
vertiges.
B B 2
3 7 2 DISEASES OF THE EAR.
l.-—Surdité et paralysie faciale gauche, hémorrliagies conjonctivales, Voile
paralysé, pas de bourdonnements, ni de vertiges. Mort par hémiplégie et coma.
Diagnostic : tumeur intra-crânienne au niveau du trijumeau, du facial et de
l’acous’cique.
2.——Surdité unilatérale, vertiges avec tournoiement et menaces de chute,
bourdonnement d’oreilles, dyspepsie, gastralgie. Guérison par l’hydrothérapie.
3.—-—Surdite complète, après névralgies faciales de longue durée, cataracte de
l’œil droit, bourdonnements a droite faibles, pas de vertige.
4:.—Hémorrhagie cérébrale, hémiplégie gauche et faciale gauche, hémianesthésie
gauche des organes des sens, retour de l'ouïe le dixième jour, aucune lésion; de
l’oreille.
5.—-—Surdité sans lésions visibles, vertiges, crises gastriques chez un goutteux,
congestion céphalique et du pharynx.
6.——Surdité à la suite d’hémorrhagies internes extrêmement abondantes, bour-
donnements surtout après le repas, estomac excellent, anémie.
7.-Oéphalée nocturne atroce, surdité, éblouissement, vertiges avec tendance à
se renverser en arrière, regard vague, léger Strabisme, difficulté de la marche,
congestions énormes des yeux, à. répétition, pas d’accidents épileptiformes, pas de
douleurs fulgurantes.
8.-Surdité dans la convalescence d’une maladie grave, surdité complète, totale,
en deux jours, après une bronchiopneumonie grave, de trois mois, légère albu-
minurie.
9.-—Surdité, syphilis intra-crânienne, tumeurs gommeuses a la voûte palatine,
paralysie faciale, anesthésie après névralgies faciales, obtusion de la mémoire, œil
engorgé à droite, rien a l’oreille.
10.-Surdité dans le tabes, au début; phénomènes très‘variables d'intensité,
bourdonnements par moments agaçants—le cachet spécial est que l’ouië se perd peu
à peu pendant la conversation, par fatigue nerveuse probable.
11.—Surdité verbale, service de M. Magnan; une thèse du Dr. Skworsoff, parue
1881. J’ai été appelé à examiner les oreilles qui étaient saines.
Z 257/ p/zysi/calzkcken dgfkreizz‘zlellem Dzkzgﬁosz‘z'é z'wz'sc/zm 51/-
Ærmzémzg des scﬁalllez'z‘mderz Appm/m‘es mm’ New/@12-
z‘cmökez'z‘. M22‘ Demmzsz‘raz‘z'omn.
Professor A. LUCAE7 Berlin.
In allen Fällen, namentlich in den chronischen Fallen von Schwerhörigkeit bei
erhaltenem Trommelfell und freiem ausseren und mittleren Ohre bedarf es neben
der objectiven Untersuchung noch anderer diagnostischer Hilfsmittel, um eine
Erkrankung des schallieitenden Apparates von einer Affection des Nervenapparates
zu unterscheiden.
Die bisher zu diesem Zweck übliche Prüfung der Schallleitung durch die
Kopfknochen mit Hülfe ein er, auf den Scheitel gesetzten Stimmgabel, genügt dieser
Aufgabe allein nicht. Auf Grund der Theorie von Professor Mach, nach welcher
die, durch die Schadelknochen im Labyrinthe angelangten Schwingungen durch
den schallleitenden Apparat nach aussen abﬁiessen sollen, hat man bekanntlich
die pathologische in dem allein oder schwerer erkrankten Ohre auftretende Tonver-
DISEASES OF THE EAR. 37 3
Stärkung auf eine Erkrankung des schallleitenden Apparates bezogen, während
man in dem Falle, dass der Ton der Gabel in dem gesunden oder in geringerem
Grade erkrankten Ohre stärker gehört wird, eine Erkrankung des innern Ohres
annahm.
Redner hat bereits früher durch eingehende Untersuchungen jene Theorie von
Professor Mach widerlegt, und ﬁndet seine Ansicht durch neuere Experimente voll-
kommen bestätigt. Er demonstrirt zunächst einen von ihm angegebenen älteren
Versuch, welcher von folgendem Gesichtspunkte ausgeht: Wenn die Schwingungen
der auf den Schädel gesetzten Gabel wirklich aus dem Ohre entweichen, so müsste,
sobald man den Ton derselben Gabel gleichzeitig durch die Luft in den äusseren
Gehörgang leitet, eine Interferenz und Schalldämpfung eintreten. Dies ist edoch
keineswegs der Fall; man hört im Gegentheil den Ton bei dieser doppelten Zulei-
tung zum Ohre sogar merklich verstärkt.
Mit Hülfe des, von Dr. Rinne angegebenen Versuches, lässt sich ebenfalls die
-Unhaltbarkeit der Mach’schen Theorie nachweisen. In diesem Rinne’schen Ver-
suche wird eine Stimmgabel auf den Schädel gesetzt und gewartet, bis der Ton
gänzlich verschwunden ist; nähert man dann die Zinken der nicht wieder ange-
schlagenen Stimmgabel der äusseren Ohröffnung, so hört das normale Ohr den
Ton von neuem, oder—wie es hier der Kürze wegen heissen soll—der Rinne’sche
Versuch fällt positiv aus. Bekanntlich hört man die auf den Schädel gesetzte
Stimmgabel auf dem zugehaltenen Ohre auch dann stärker, wenn das letztere nicht
vollständig luftdicht abgeschlossen ist ; es lässt sich nun nachweisen, dsss auch in
diesem Falle der Rinne’sche Versuch positiv ausfällt, wenn man die Stimmgabel
nach dem subjectiven Abklingen vom Schädel dem so geschlossenen Ohre nähert.
Man beobachtet ferner an Schwerhörigen zuweilen, dass die Stimmgabel vom
Scheitel aus auf dem schlechter hörenden Ohre stärker gehört wird und der Rinne-
sche Versuch trotzdem für dieses Ohr positiv ausfällt. Es kann also in allen
diesen Fällen von einer Behinderung des sogenannten Schallausﬂusses keine Rede
sein.
Weit bessere Anhaltspunkte für die Diagnose giebt,nach langjähriger Erfahrung
des Vortragenden, eben dieser Rinne’sche Versuch in Verbindung mit einer sorg-
fältigen Prüfung der Luftschallleitung auf tiefe und hohe Töne. Man benutzt am
Besten eine kleinere tiefe (c) Gabel und als A'nsatzstelle den Processus mastoides.
In Fällen von bedeutender Schwerhörigkeit, wo die Fliistersprache nur in der Nähe
des Ohres gehört wird, beobachtet man nun gar nicht selten einen positiven Aus-
fall des Rinne’schen Versuches, was mit Sicherheit auf eine vorwiegende Affection
des innern Ohres, respective auf eine jenseits der Trommelhöhle gelegene Erkran-
kung schliessen lässt; je länger hierbei die Stimmgabel vor dem kranken Ohre
vernommen wird, desto sicherer ist eine gleichzeitige Störung im schallleitenden
Apparate auszuschliessen. ‘Vird jedoch die Stimmgabel vom Processus mastoides
aus, längere Zeit gehört, «Je, fällt der Rinne’sche Versuch negativ aus, so handelt
es sich um eine Störung im schallleitenden Apparate; es bleibt hierbei jedoch un-
gewiss, ob nicht gleichzeitig ein Leiden des Nervenapparates vorliegt. Zur Unter-
suchung dieses letzteren Punktes dient schliesslich die Untersuchung der Luft-
schallleitung auf sehr hohe in der viergestrichenen Octave gelegene Töne, welche
erfahrungsgemäss selbst bei bedeutenden Hindernissen im schallleitenden Apparate
noch relativ gut, dagegen bei Störungen im perispirenden Nervenapparat sehr
schwach, respective gar nicht wahrgenommen werden. Redner bedient sich zu
diesem Zwecke namentlich der auf Fis 4 abgestimmten Gabel.
Zu einer genauen Untersuchung auf die genannten tiefen und hohen Töne wird
374 DISEASES OF THE EAR.
die Horzeit des zu untersuchenden, kranken Ohres mit der Ho'rzeit des gesunden
Ohres des Beobachters verglichen. Die Differenz, mit Hiilfe einer gewohnlichen
Taschenuhr oder besser eines Ghrononops in Sekunden gemessen, stellt den Grad
der Horstorung fiir jene Tone dar. (Naheres hieriiber, Archie fill?‘ Oh're'nhe'illa,
Bd. xv.).
Die Beweise ﬁir die Brauchbarkeit dieser Methods ﬁndet Redner einmal in der
Section zweier Gehororgane, welche die bei Lebzeiten gestellte Diagnosen einer
Erkrankung des Nervenapparates (Atrophie des Acusticus) und der Trommelhohle
(Adhesion des Trommelfelles und der Geh orknochelchen) bestatigte. Er hat ferner
in 25 Fallen, wo er lediglich mit Hiilfe dieser Untersuchungsmethode die Diagnose
einer Erkrankung des s'challleitenden Apparates stellte, die totale Excision des
Trommelfells mit dem Hammer vorgenommen; in keinem einzigen dieser Falle
trat eine Verschlechterung der Horfahigkeit, bei einigen sogar eine merkliche Hor-
verbesserung ein.
0% Certain Conditions of z‘ﬁe Eyes as a Cause of Loss
0fHea1/z'1eg 5y Reﬂex [1/1/z'z‘az‘z'01/z.
Dr. GEORGE T. STEVENS, New York.
The relations between aﬁections of the ear and some parts not immediately
connected have long been recognized. Thus worms in the intestines have been,
doubtless with reason, regarded as cause of disease of the ear, and the process of
teething in children, is, according to the experience of many, a somewhat proliﬁc
ource of earache. Several writers have recently pointed out in considerable
detail the sympathy between the ear and the mouth, each demonstrating the
fact that an irritation arising from some portion of the oral cavity has given rise to
some form of nervous or nutritive disturbance in the ear. Efforts to explain these
reﬂex phenomena by demonstrating a direct nervous communication between the
mouth and the various parts of the ear aﬁected would seem to be superﬂuous, for
that it is unnecessary to establish the fact of any direct nervous line, in order to
account for reﬂex irritation, must be evident to those who fully accept the doctrine
of such reﬂex irritations. While it would be possible, perhaps, to point out real or
fancied direct nervous communications between almost any two parts of the body,
the doctrine of reﬂex irritation, as stated by the best authorities on such subjects,
does not demand, as a condition of remote irritation, that there shall be a direct
line of nervous communication.
According to this law, “ the same peripheric cause of irritation, acting on the
same centripital nerve, may produce the greatest variety of effects, including every
functional nervous affection or disorder.” -
According to this law, also, different classes of conducting nerve ﬁbres may be
the subjects of irritation from the same cause ; so that from the same excitation,
modiﬁcation of sensations of nutrition or of power may result; or, in other words,
pain or loss of sensibility, inﬂammation or ulceration, increase or decrease of
muscular power in a part, may each arise from the same cause of irritation, which
may be seated in some distant part.
This being true, it is important that every source of irritation should be known
and recognized. It is a fact in practice that the greatest proportion of diseases
of the car are regarded by writers upon ear affections as of purely local origin, or
DISEASES or THE EAR. 375
of simple extension from contiguous parts; and the cases of reﬂex irritation have
not been made to occupy a very prominent place in the literature of the subject.
It is the object of this brief paper to call attention to a source of sympathetic
irritation to which I have seen no reference.
My own experience and observation lead me to believe that reﬂex irritations
arising from the eyes and affecting the sensations or nutrition of the ear are not of
unfrequent occurrence, and, indeed, that they are much more common than would
be supposed from the fact that so little attention, if any, has been bestowed upon
them.
I have, in a Paper presented to another section of this Congress, endeavoured to
point out certain principles relating to reﬂex phenomena resulting from difficulties
in performing some of the functions of the eyes. My experience, as shown in that
communication, and in various other Papers which I have presented to the pro-
fession within the last few years, appears to demonstrate the fact that many dis"
turbances of nervous function, both of sensation and nutrition, may be induced by
unfavourable conditions of adjustment of the eyes. That irritations may arise
from the eyes, and be manifested in the remote parts, is evident; but areasonable
doubt may arise whether the amount of irritation arising, for instance, from a high
degree of hypermetropia, or a state of insufficiency of ocular muscles, is of a degree
sufficient to propagate itself in other organs. This doubt can only be solved by
experience, and according to my own observation the irritation thus caused would
seem to be a proliﬁc source of nervous disturbances. I have often known a
chronic neuralgia which has continued as a destroyer of the peace of the sufferer
year after year, yield to the inﬂuence of appropriate lenses for the correction of the
hypermetropia, or the astigmatism which existed. I have known chorea of many
years’ standing disappear, as if by magic, after a partial tenotomy of an ocular
muscle.
Every oculist knows that diﬂiculties in the adjustment of the eyes may, and
often do, cause pain in the temples and brow. Then, according to the law
of reﬂex irritations, it may cause pain or other functional disturbance in the
ear.
Admitting that there are theoretical grounds for supposing that such sym-
pathy may exist, we should still be bound to inquire whether there are any clinical
facts to sustain the theory.
When, several years ago my attention was directed to the reﬂex disturbances
from the eyes, I naturally sought to‘ know whether the principle could be of prac—
tical application in diseases of the ear, and I have been accustomed during several
years to examine the eyes of my private patients consulting me for ear troubles.
The result is that in very many instances ocular defects have been found coincident
with the ear disease. This fact alone would prove of little practical value, but an
associated fact is that many cases of otherwise obstinate ear troubles yield quickly
when the source of ocular irritation has been removed.
It is no part of my purpose to introduce statistics of cases to establish the
truth I have advanced, but in illustration of it I will, in the briefest manner, allude
to a single instance which cannot but suggest the value of relief to the eyes in
some cases of ear diseases.
A lady of forty-two was tormented by subjective sounds, and her hearing was
reduced one half. The cars when examined gave no indications of disease. Inﬂa-
tions with Politzer’s bag gave no relief, general tonics, electricity, bromides, a
‘change of air, all failed to modify in any degree the tormenting noises which de-
376 DISEASES or THE EAR.
stroyed sleep, added to the general nervous irritability of the patient, and made her
miserable. There was slight insufficiency of the external recti muscles, and there
were pains in the temples and brows. After three months of fruitless attempts to
relieve the patient by such~measures as have been mentioned, a partial tenotomy of
one of the internal recti muscles was made. In a very few days the roarings and
hissings ceased, the hearing returned to the normal standard, and the lady was
greatly improved in her general nervous condition. In this instance it is as certain
as any thing in medicine that the relief not only followed, but was the legitimate
result of, the greater freedom of the eyes, which up to the time of the slight opera-
tion had been kept constantly on the alert to maintain monocular; vision. '
I will not detain the Section by citing further illustrations, although many
could be adduced, to show that relief to hypermetropia, to myopia, and other un-
favourable conditions of the eyes, has been largely, and in some instances wholly,
instrumental in restoring the hearing.
If I have with sufficient clearness suggested that ocular defects may be classed
among the reﬂex causes of loss of hearing, I shall ﬁnd it easy to impress upon
those who hear me the importance of habitually examining the visual condition of
ear patients, and of affording such relief to defective states of vision as the science
of ophthalmology so richly affords.
DIS GUS SION .
Dr. KNAPP, New York : Not long ago I saw a young lady who during mumps had
become completely deaf in one ear, without showing a trace of abnormity in the
outer and middle ears. The other car was perfect. The good ear being closed, she
heard equally well when the had was left open or also was closed. Tuning-forks by
bone conduction were heard in the good car only; passed up and down, when in
vibration, they were heard in puffs before the good, but evenly and weaker before the
bad ear. She evidently did not hear this with the bad, but with the good car. This
experiment to ascertain complete one-sided deafness, which I communicated four or
ﬁve years ago, has since been of good use to me in a number of other cases. I
know nothing of the anatomical cause of the deafness in cases like the above. They
have been very rare in my practice, whereas I have not infrequently seen middle-
ear disease (suppuration) as a complication in mumps. It may, perhaps, not
be without interest to the Section if I say a few words about quinine blindness
and deafness, of which recently a number of new cases have been reported
in America (Archives of Ophthalmology). After taking doses from four grammes
daily or more, sudden total blindness and deafness, with intense tinnitus aurium,
set in. The deafness disappears in a day, the total blindness may last weeks
and months; then central vision returns and slowly improves, frequently to the
normal standard. The ﬁeld of vision remains contracted. The light and colour-sense
are weakened, but gradually recover their normal strength. The ophthalmoscopic
appearances are most striking,——complete anaemia of the optic discs. This condition,
showing in the developed cases the picture of total atrophy with exceedingly thin and
scarce vessels, is permanent. There are milder cases also which last only one or
several weeks and then get entirely well. The ears, even in the marked cases, show
no abnormity in their outer and middle portions. I have examined the hearing of
such patients by different tests; it was normal in every respect. They heard the
whole range of musical tones, there was no contraction of the ﬁeld of audition,
and also the character of sound—clang tint, sound colour, or timbre—was well
perceived.
DISEASES or THE EAR. ' 37 7
Mr. GnnssWELL BABER, Brighton: I have been always much impressed with the
importance of obtaining a means of diagnosis between middle and internal ear-
deafness. I have employed Rinne’s experiment in a considerable number of cases,
and have found it of value. I would call attention to the effect of excessive
pressure artiﬁcially applied to the ear in diminishing the perception of the tuning-
fork applied to the bones of the head, as previously described by me in the
Lancet (April, 1881), and consider it of importance, as showing the ease with
which alterations in the state of the middle ear can interfere with the bone con-
duction.
Dr. BARR, Glasgow: If a person with perfectly normal hearing becomes sud-
denly affected with marked deafness, severe tinnitus aurium, and perhaps with
giddiness, nausea, and vomiting, also with loss of the perception of the osseous
conduction of sound, and on examining the ear soon after, no evidence of disease
is found in the external and middle ear, the strong presumption is that we have
to do with a sudden pathological change in the interior of the labyrinth-—
probably in the semicircular canals and vestibule. But in a case of pretty long
standing, it would be Wrong to assume that the cause of these symptoms is ex-
clusively conﬁned to the nervous apparatus of hearing, because no change is to be
seen in the tympanic membrane or to be found in the Eustachian tube. Impor-
tant changes may, for example, exist in the fenestral membranes, or in the re-
cesses leading thereto, which cannot be recognized either by ocular inspection or by
any other mode of examination. Indeed, the whole series of symptoms included in
the term Méniere’s disease may, as is well known, be called forth by diseased pro—
cesses in the middle ear, which may produce undue pressure on the labyrinth
ﬂuid, Such as thickened fenestral membranes, or undue pressure inwards of the
ossicular chain. It was pointed out how abnormal states of the circulation of the
brain must inﬂuence the circulation in the contents of the labyrinth, when we
consider that the internal auditory artery is really a brain artery, and that the
veins of the labyrinth open into the venous sinus of the dura mater. With respect
to the treatment of hyperaemic conditions of the labyrinth, local blood-letting over
the mastoid region would be a reasonable procedure. "We know that the stylo-
mastoid artery which supplies the soft parts over the mastoid process, inoscu‘lates
freely with the internal auditory artery in the tympanic cavity, and in this way a
distinct vascular connection is brought about between the labyrinth and the ex-
ternal parts.
Fmzaz‘z'om de [a Trompe d’Eusz‘ac/ze.
Dr. EDOUARD FoURNIE, Paris.
La communication de M. le Dr. Fournié porte sur deux points essentiels =—1. Sur
les usages de la trompe d’Eustache. 2. Sur la question de savoir si le conduit
de la trompe est habituellement ouvert ou fermé.
Sur le premier point, M. Fournié pense, avec la plupart des phy siologistes, que
1e conduit de la trompe sert a mettre l’air de la caisse du tympan en e'quilibre avec
l’air extérieur et a donner issue aux sécrétions de la cavité tympanique. En
outre, il croit pouvoir afﬁrmer qu’un des usages essentiels de la trompe d’Eustache
est d’empéoher, par ses rapports immédiats avec l’air extérieur et avec l’air de la
378 DISEASES OF THE EAR.
caisse du tympan, la résonnance incommode des bruits extérieurs transmis ‘par les
parties solides dans la caisse du tympan.
M. Fournié appuie sa manière de voir sur ce fait que, lorsque nous fermons le
conduit auditif externe, nous entendons les bruits organiques parce que les vibra-
tions transmises par les parois du conduit acquièrent dans la cavité close, ainsi
fermée, une intensité qu’elles n’ont pas lorsque le conduit est ouvert. Il en serait
de même si le conduit de la trompe était fermé, d’ailleurs en pratiquant cette
occlusion par la contraction des péristaphylins, on obtient un bruit analogue à
celui qui se produit quand on bouche le conduit auditif externe.
M. Fournié réalise ces conditions au moyen d’un dispositif expérimental qui
montre, en effet, l’usage isolant de la trompe.
Ce nouvel usage suppose donc la nécessité de la béance permanente de la
trompe, mais comme la plupart des physiologistes et des auristes pensent au
contraire que la trompe est habituellement fermée, et qu’elle ne s’ouvre que d’une
manière intermittente sous l’inﬂuence des péristaphylins qui dès lors seraient des
muscles dilatateurs, M. Fournié a dû démontrer par toutes sortes de preuves : 1°, que
la trompe est habituellement ouverte; 2°, qu’elle se ferme d'une manière intermit-
tente sous l’inﬁuence de la contraction des péristaphylins qui, dès lors, sont des
muscles constricteurs ou obturateurs.
Preuves anatomiquea—Par une coupe verticale pratiquée sur une trompe on peut
s’assurer que le cartilage tubaire circonscrit un espace vide d’un millimètre de
diamètre dans la partie la plus étroite. De plus, si on examine les rapports de la
trompe avec les muscles on ne peut s’empêcher d’admettre que la contraction
musculaire ne peut que comprimer, fermer la trompe.
Preuves physiologiquea—Si on remplit les poches gutturales d’un cheval avec
un liquide coloré, et si on applique les excitateurs d’un appareil d’induction sur les
parois de la poche, le liquide est projeté au dehors, preuve que les muscles qui
agissent sur la trompe ont une action obturatrice.
Preuves physiquea—lo, au moyen de petites sondes ayant un conduit de l à 5
millimètres de diamètre, M. Fournié s’est assuré que les ondes sonores ne sont que
très faiblement transmises quand le conduit n’a qu’un millimètre, par conséquent,
les trompes ne transmettent pas les sons qui se produisent dans leur voisinage;
2°, l’air ne circule pas a travers un tube capillaire fermé à un de ses bouts.
M. Fournié le démontre au moyen d’un appareil dans lequel le gaz d’éclairage ne
traverse le tube capillaire fermé à un bout qu’alors que ce dernier est transformé
en tube ouvert aux deux bouts. Cette expérience prouve qu’il n’y a aucun danger
que la poussée de l’air par la trompe ouverte vienne léser le tympan; elle prouve
aussi que l’air ne peut pénétrer dans la caisse à travers la trompe que s’il est
poussé par une force assez grande. Cette force est représentée, sur le vivant, par
la contraction des muscles péristaphylins qui ne peuvent être que des muscles
- obturateurs.
Preuves pat7wlogiques.——De l’aveu de tous, une des causes les plus fréquentes de
l’altération de l’ou'ie est l’occlusion des trompes par un état inﬂammatoire ou
catarrhal, et la conduite des médecins auristes repose sur ce fait quand il s’appli-
quent a rendre l’ouïe. Or, comment expliquer la genèse de l’altération de l’ouïe
si on admet, avec le plus grand nombre, que les trompes sont habituellement
fermées? Il est vrai qu’on peut dire: dans l’état normal le renouvellement do l’air
se fait par la contraction musculaire, tandis que dans l’état pathologique cette
contraction ne suffit pas, d’où il suit que l’air de la caisse n’étant pas renouvelé, la
raréfaction de l’air entraîne des désordres intra-tympaniques, qui sont la cause de
DISEASES OF THE EAR. 3
l’altération de l’oui'e. Si on admettait cette maniere dc voir on ne comprendrait
pas que l’on puisse faire pénétrer de l’air dans la caisse par le catéthérisme alors
que la contraction musculaire, beaucoup plus puissante que nos pompes ou poires
de caoutchouc, serait incapable de le faire.
Gonclasio'na—l. La trompe est destinée a transformer la cavité close du tympan
en cavité ouverte, dans le but d’empécher les vibrations intérieures et extérieures
d’arriver a trouver les parties solides dans une cavité close, et d’y provoquer une
résonnance incompatible avec la bonté de l’ou'ie.
2.--La trompe d’Eustache est toujours ouverte et la communication de l’air
extérieur avec celui de la cavité du tympan est incessante.
3.——Le faisceau externe du pharyngo-staphylin, les péristaphylins interne et
externe sont des obturateurs de la trompe d’Eustache et non des dilatateurs de ce
conduit comme on-le croit généralement.
4.——L’obturation de la trompe d’Eustache n’est jarnais que momentanée—sauf
dans les cas pathologiques—et elle se produit jour et nuit pendant les mouvements
de déglutition, pendant la prononciation de certaines lettres, pendant le chant.
5.——Le circulus de l’air de la trompe et de la caisse du tympan représente une
sorte de respiration dans laquelle les muscles obturateurs font office de forces expi-
ratrices, tandis que l’élasticité propre du cartilage tubaire représente les forces
inspiratrices. ‘
DISCUSSION.
Dr. THOMAS E. RUMBOLD, St. Louis : I believe that the function of the
Eustachian tube is to allow air to pass continuously into the middle ear to supply the
deﬁciency occasioned by the air being absorbed by the mucous membrane lining it
and the mastoid cells, and that this supply is such as to cause a slight rarefaction of
the air in the middle ear and the mastoid cells, consequently the air in the middle
ear and mastoid cells is never equal in density to the air on the outside of the
membrana tympani. This partially prohibitory action of the Eustachian tube is
necessary to maintain a slight concavity of the external surface of the membrana
tympani; and, as this slight concavity must be uniformly constant, it precludes the
idea that the Eustachian tube is opened into the middle car during the act of
deglutition. There are quite a number of facts that prove that there must be a
slight but uniform pressure on the manubrium; one is that every substance that is
used as an artiﬁcial membrana tympani must be made to slightly press on the
small bone, or on some of the ossicula, if this one is absent. Hearing depends
upon the impingement, reception, and transmission of the sound waves by the
membrana tympani, rid the ossicula auditus and liquid in the internal ear, to the
auditory nerve. To allow a uniform transmission of the nervous undulation to
the auditory nerve, the membrana tympani must be in a uniform degree of tension.
The relation between the tension of this membrane and its vibratory capacity is as
much governed by physical laws as is the tension of a piano-string to give forth
one uniform tone, or the convexity of a lens to converge a focus at a given point;
neither of the three will allow of any deviation, yet we are asked to believe that
this indispensable uniform condition can be maintained by an irregular act. A
continuous air absorption necessitates a continuous renewal; either you must stop
the continuous exhaustion, or you must allow a continuous supply. The alternative
is physically unavoidable.
380 DISEASES or THE EAR.
T he. Coz‘z‘on Pellet as cm Arz‘zﬁcz'al Drumheaa’.
Dr. KNAPP, New York.
The acoustic eﬁicacy of artiﬁcial drumheads, ever since their introduction, has
been a matter of controversy into which I need not enter. Sure it is that some
forms of artiﬁcial drumhead—for instance, Toynbee’s rubber disc—so rarely yield
results in any way commensurate with the amount of labour bestowed on their
application, that the majority of aurists, no doubt, like the present speaker, have
often thrown them away in disgust. On the other hand, however, there are
patients whose hearing is so unexpectedly improved by an artiﬁcial drumhead that
we are irresistibly forced to return to it. If there are cases, for instance, like that
of the lady whose history I published in the Archives of Otology (vol. ix.
p. 60, 800.), who from her sixth year could not hear more than loud words at the
distance of one foot, but by means of moist cotton pellets could understand speech
at the distance of 20 inches, and who has worn these pellets with the same advan-
tage, and free from aural inﬂammation, these nine and twenty years—in fact, who
cannot be without them. If such cases do occur, it is incumbent upon us to give
this subject our careful attention. I have done this, I must shamefully confess, for
the last year only; and yet in that brief space of time the results of my experiments
have been so gratifying that I venture to speak of them even before you. The
cases in which I have used the cotton ‘pellet as an artiﬁcial drumhead with
marked and substantial beneﬁt have not been rare at all—I dare say at least one
- - l--3 15-20 - - -
a week. The hearing was 1mproved from V: 137 to V we. ordinary voice,
which was understood only at the distance of from 1 to 3 inches, was by means of
the pellet understood at 15 to 20 inches.
V=%% was the greatest hearing power to which I have thus far been able
to raise a deaf person’s hearing by means of an artiﬁcial drumhead. I must,
therefore, consider this fraction, one-third of the normal standard, as the limit of the
acoustical efficacy of the artiﬁcial drumhead. I have received equally good results
from Dr. Blake’s disc of sized paper, which was spread over old perforations in the
membrana tympani. In this respect, as also in the use of the cotton pellet, my
experience concurs with that of Dr. Burnett, of Philadelphia. I have not syste-
matically tried the other forms of artiﬁcial drumhead. If V=%% is the limit of
the acoustic eﬁcacy of an artiﬁcial drumhead, it follows that for acoustic purposes
it is indicated only in cases of greater impairment of hearing. If a person hears
conversation still at 10 or 15 inches, he will not derive a great beneﬁt from
the artiﬁcial drumhead. The proper sphere of the little device are patients of
Vzﬁla to 75-55;; these are delighted with the improvement. If only one ear is hard
of hearing, the services of an artiﬁcial drumhead are not conspicuous enough to be
appreciated by the patient.
The protective eﬂ'ect of the cotton pellet is of utmost importance, as is exempliﬁed,
again, by the patient just quoted. Scarlet fever in her sixth year, copious and offen-
sive discharge with repeated exacerbations of the chronic purulent otitis, and the
hearing practically abolished until she was twelve years old; then judicious
treatment for two months, after which the constant wearing of cotton pellets ever
since, i.e., for twenty-nine years, and, during all that time the secretion con—
trolled, the hearing good enough to understand conversation across a room, and no
more attacks of inﬂammation—a child of wealthy parents, who, before she wore the
DISEASES or THE EAR. 381
artiﬁcial drumheads, lived like a deaf mute, and whose life was always threat-
ened, afterward restored to health, usefulness, and all the enjoyments of reﬁned
society, a happy wife and mother; all this by the judicious wearing of little pellets
of cotton, and whenever she leaves them off, she is to-day as deaf as she was in
her childhood. Gentlemen, this shows the protective effect of the pellet to be as
important as its acoustic effect, but it is at the same time so great a therapeutical
result as would justify the envy of any branch of medicine, even of modest otology’s
proud sister, ophthalmology. It would be carrying coals to Newcastle if, at the
present day, I attempted to explain in which manner the cotton pellet protects the
ear; it is, of course, by keeping off the atmosphere with all its horrors.
In this lies also one part of its curative importance, but the other, less appre-
ciated, because of being less efficient, before we had good absorbent cotton at our
disposal, lies in its action as a drain. Drainage, gentlemen, is as essential and
beneﬁcial to an ear affected with chronic otitis purulenta as it is to a swamp. In
both cases the stagnating ﬂuid, decomposing and causing decomposition, infecting
the mother soil, and all that it comes in contact with, must have a ready outlet as
soon as it is secreted. You cannot constantly syringe an ear, and even syringing is
only partially eﬂicient, being unable to dislodge coagulated and inspissated sub-
stances, you cannot thoroughly and constantly wipe the tympanic cavity out, the very
acts of syringing and wiping cause irritation and new secretion, which, mingling with
the old decomposed parts in the recesses of the cavity, will soon become likewise
infected. After cleansing a running ear by syringing and wiping, a wick of
absorbent cotton, one end of which is pushed into the tympanic cavity, is an
excellent drainage-tube. I direct the patient to renew it as often as it becomes
moist, every two hours, or more rarely, three times or twice daily, according to the
circumstances. Eﬁicient, persevering and judicious cleansing will in most cases
suﬁice to cure the otorrhoea; but it can, of course, be materially assisted by the
local remedies, of which I prefer alcoholic solutions of astringents. Recent litera-
ture and several of my friends praise boracic acid powder.
When in this way the discharge is reduced, I give the cotton pellet more and
more the shape of a wafer, impregnate it with a quarter per cent. solution of gly—
cerine, and let it act both as an acoustical appliance and as a drainage-tube, for
even in this form it still absorbes the serum in the cavity.
The mechanism of the artiﬁcial drumhead, you all know, has been abundantly
discussed, and I shall not occupy your time in “rehearsing the different theories.
I think it is safe to say that in some cases it beneﬁts hearing by tightening
the chain of ossicles, in other cases by loosening it; in other words, and including
these cases in which the ossicular chain is defective, by pressing the footplate of
the stirrup inward, or in other cases drawing it outward. Pressure upon the
upper part of the hammer, including the short process which lies ust above the
axis of rotation of the chain of ossicles, will diminish their tension, and act bene-
ﬁcially when the membrana tympani is relaxed or extensively destroyed. The
tensor tympani muscle in such cases draws the tip of the handle powerfully and
permanently toward the promontory, pressing the footplate of the stapes inward
toward the labyrinth. In fact, A. Politzer, has been able to verify this theory by
experiments. Some persons, showing the just-described conditions, heard better
when, with a probe, he pressed upon the short process ; but in other cases he pro-
duced an improvement of hearing by pressing upon the lower part of the manu-
brium.
That both these conditions,incrcase and diminution of tension, act prejudicially
382 DISEASES or THE EAR.
on the function of hearing, is proven also by other facts—viz., in chronic otitis
myringotomy and myringodectomy frequently cause considerable and immediate
improvement of hearing, I think by tightening the chain of ossicles. Before the
division of the drumhead the tough membrane was too powerful for the tensor
tympani muscle, to keep the articular surfaces in proper apposition. In the same
way an artiﬁcial drumhead may act by pressure, as has often been expressed.
The improvement of hearing subsequent upon the division of the tendon of the
tensor tympani muscle, which is reported, but upon which I have no personal
experience, would act in relaxing the ossicular joints, analogous to the experiment
of pressing upon the short process and upper part of the hammer. The conditions
of both abnormally increased and abnormally diminished tension are those which
invite our attention. Their mechanical inﬂuence upon the function of hearing, if
possible to be ascertained in each particular case, may furnish indications for the
application of an artiﬁcial drum-head, and of division of the membrana tympani
and the tensor tympani muscle. A great deal, you know, has been said and done
in this direction, and yet not enough.
Now, how are those cases to be explained, where the partial or entire covering
of an old perforation, without secretion in the tympanum, increases the hearing at
once and very considerably? Allow me an example.
Three months ago a lady came to me with chronic otorrhoea and impairment of
hearing. The right ear showed an almost total destruction of the drum mem-
brane. The ossicles were preserved. A moistened cotton pellet raised her hearing
from V. 3% to %%.
In the left ear a thickened drumhead showed an old perforation of ﬁve or six
mm. in diameter. I cut apiece of ordinary note paper so as to ﬁt exactly upon the
aperture. Hearing improved from V. BEE to {31%. Patient delighted. I left the
piece of paper in position for two weeks, and during all that time she heard well
with that ear, while the pellet in the other had to be changed every day or every
few days.
The explanation I offer in this and similar cases is as follows : The tight
thickened and rigid drumhead loosened the ratchet joint between hammer and
anvil, so that the sound waves, inpinging upon the defective and stiffened mem-
brane, were insufficient to cause vibrations in the anvil and stirrup. But when
the paper disc was spread over the defect, a larger surface, of which the paper
part was in good condition of vibration, received the sound waves and the excur-
sions of the membrane were now extensive enough to be given off from the
hammer to the anvil.
So much upon the mechanical action of the artiﬁcial drumhead. Another,
perhaps more important, effect of the cotton pellet is its inﬂuence upon the
secretion of the tympanic cavity. We frequently ﬁnd its aid to hearing most
marked when the drum cavity is completely dry, in defects of the membrana
tympani with sclerosis of the mucous membrane of the drum. In such cases the
cotton pellet steeped in glycerine keeps the parts moist by stimulating secretion
and preventing exsiccation from evaporation. On the other hand, in cases where
there is too much secretion, a dry or only slightly moistened cotton pellet will act as
an absorbent. In this way, by judicious use of the cotton pellet, we can keep
the tympanum in the safest condition for the health of the patient, and the best
for acoustic purposes. The action of the cotton pellet is therefore two-fold : (1) me-
chanical, (2) physiologico-therapeutical. The cotton pellet is found to be an essential
help in that large group of cases of chronic otorrhoea which are so great an annoy-
DISEASES or THE EAR. 383.
ance to the patient and even a source of danger to his health and life, but which,
when treated with perseverance, give the most satisfactory results. We must,
however, take them in hand ourselves, not merely “ prescribe ” for them. Among
all car diseases they are those which I treat with predilection, because, being diﬂﬁcult
to manage, they stimulate my own energy, and because, being dangerous, they
demonstrate that the physician’s work is of value. If the inﬂammation is cured
and the deafness relieved by an artificial drumhead, these cases are for the aurist
what cataract is for the oculist, whereas the chronic aural catarrh is at a line with
amaurosis. In these, let the patient go home with a candid statement; in the
others, indefatigable labour is a gratifying duty.
DISCUSSION.
Mr. CUMBEEBATCmIondon: The function of the stapes and effect of pressure on
the fenestra ovalis are too imperfectly known for us to say for certain how the cotton
wool pellet acts. I have been told by two patients that in course of years the
artiﬁcial drum acts less and less and requires to be pressed harder in its place.
I believe that the good effect of the artiﬁcial drum is produced by pressure on
the stapes, but I ﬁnd it acts best where the perforation is large.
Dr. GZAEDA, Prague, showed a new artiﬁcial membrane, made of a disc of
Lister’s antiseptic silk. He at the same time exhibited a new pump syringe for
the nose and ear, a new douche for the naso-pharyngeal cavity, a speculum, and a
snare for polypi.
Mr. KEENE, London, showed a punched piece of linen which he used.
Dr. MACMILLAN, Hull: The satisfactory results of the application of pellets of
cotton wool will depend much upon the condition of the lesion of the membrane,
the condition of the ossicular chain and also of the middle ear. I have used them
with success, and as you advance ingestoring hearing, the cotton must be more
condensed. I have used artiﬁcial membranes of diﬁerent kinds of wool, with
diﬁerent results, and a small inﬂated bag has also been followed by improve-
ment.
Dr. CASSELLS, Glasgow: The cotton wool pellet or so-called artiﬁcial drum-
head I have used for many years back with the greatest success, as an aid to
hearing, and as a therapeutic agent of great importance and value in many cases.
As to its mode of action, I am of the same opinion as Dr. Knapp. I have never
found it to lose its eiﬁcacy; on the contrary, in well-selected cases the patients
could in a year or two give up using it, not needing it.

Odjccz‘z've [Vczlves 2'12 Z/ze Ear.
Dr. C. E. FITZGERALD, Dublin.
The subject of objective noises in the cart is one which has not, so far as I am
aware, been treated of in any of the English text-books on otology ; nor can I ﬁnd

* By objective noise in the ear is meant a noise which is heard not only by the
patient but by the surgeon also.
384 DISEASES on THE EAR.
any case illustrative of this affection reported in British medical literature. I
desire, then, to place on record three cases of objective noises in the ear, and I have
endeavoured to collect all the hitherto published cases of this comparatively rare
aﬂ‘ection, so as to render the literature of the subject as complete as possible.
The ﬁrst case is as follows :—
Anne B ——-———, aged 32, a strong, healthy-looking young woman, presented herself
at the Dispensary at the Richmond Hospital, on the 12th of February, 1875. She
stated that when she was an infant she had had a discharge from the right ear, and
that as long as she could recollect she had suffered from an almost constant noise
in it, which was audible to bystanders. Her mother said she had noticed it since 1
she was seven years old. Sometimes the noise ceased, and then she experienced a
feeling “ as if something fell into her throat,” and that she was choking. When
ﬁrst subject to these attacks, she was perfectly cognizant of all that was going on
around her ; but latterly she had lost consciousness completely during them. While
in this state, her hands are tightly clenched, and cannot be opened till the peculiar
feeling leaves her throat; as soon as it does so, the noise again commences in her
ear. Latterly she has had from four to ﬁve of these attacks generally every day.
She had one in the train on her way up to Dublin, but she had not any since her
arrival in the city.
On examination, a clicking sound was audible in the right ear, and could be
distinctly heard at a distance of ﬁfteen feet away from the patient. It was very
regular, but was not synchronous with the heart beat. The hearing was defective
in this ear; but unfortunately the exact amount of defect of acuteness was not
noted. There was a large perforation in the membrana tympani, involving the
lower and anterior segment. No movement could be detected in the handle of the
malleus, or remaining portions of the membrane. On inspecting the oral cavity
and pharynx, a remarkable rhythmical elevation and depression of the velum palati
was observed, and this was found to be perfectly synchronous with the clicking
sound in the ear. Air was now introduced into the tympanum by Politzer’s
method, and immediately both noise and movements ceased. It was afterwards
found that this had always the effect of checking the noise and movements of the
palate for a time. Pressure inwards with the ﬁngers, behind the angle of the
inferior maxilla, was attended with a similar result. The patient was admitted
into the hospital, and ordered a mixture containing bromide of potassium. Un-
fortunately, the same evening, some accident cases were admitted into the ward she
occupied, and she became so alarmed, that nothing would induce her to remain in
the hospital. She continued, however, to attend the Extern Department for some
time. The noise gradually became much less constant, being at times, absent for
several hours. Though Politzer’s method of inﬂating the tympanum Succeeded in
temporarily stopping the noise and palate movements, the patient could very
generally reproduce them by making a forcible movement of deglutition. Some-
time after the patient had ceased to attend regularly, she again visited the hospital,
and described herself as greatly improved. She had then considerable intervals of
freedom from the noise. Since that time I have lost sight of her. By a singular
coincidence, on the very day following that on which this patient presented herself
at the hospital, there appeared in the Philadelphia Medical Times, a paper by Dr.
Charles Burnett, of that city, on a case of objective noises in ears, accompanied by
spasmodic retraction of the membrana tympani and of the velum palati. Fortu-
nately my colleague, Mr. Thomson, saw the journal on its arrival in this country,
and kindly directed my attention to it. From this paper I obtained information
DISEASES or THE EAR. 38 5
relative to the literature of this subject, and I was able to consult the majority of
the references, as they were, with three exceptions, published in the Archicfih‘ Oh'ren-
heillczmde. Dr. Burnett’s case, in the most essential particulars, closely resembled
mine—via, in the loudness of the noise, and the spasmodic movements of the palate.
One very interesting point was ingeniously demonstrated by Dr. Burnett, namely,
the movement of the membrana tympani during the spasms. He says :—
“At the ﬁrst examination, Nov. 25, 1874,, by simple inspection, I could detect
no motion in the membrana tympani at each snapping; but in the course of a
month, the thickening of the drumhead becoming less, I could detect at each
' snapping sound a very slight retraction of the drumhead at its antero-superior
quadrant. Before I could thus see any motion in the drumhead by simple inspec-
tion, I placed a small glass manometer, devised by Politzer, with its capillary
calibre, one millim etre in diameter, ﬁlled with coloured water into the meatus of the
right ear, also ﬁlled with water, the two columns of water being hermetically joined
by an india-rubber stopper on the manometer. The column of water thus brought
into contact with the membrana tympani showed anegative ﬂuctuation of one-half
millimetre at each snapping sound, thus demonstrating a retraction of the membrana
tympani, too small to be seen at that time by inspection, but since apparent upon
close and attentive inspection.”
In this case, the patient stated that “deglutition and rapid respiration increased
the frequency of the snapping noise in the ear ; but that, when he held his breath,
the spasms (in the velum palati) and the snapping noise in the ear ceased entirely,
to begin again with renewed respiratory acts.” Dr. Burnett, by examination, con-
ﬁrmed this, and he also found that the sounds, but not the spasmodic elevations of
the velum, could be arrested in two other ways. He writes :—“By throwing the
patient’s head back as far as he could get it, the spasms in the velum palati went
on with the usual intervals; but neither the patient nor I could hear any
snapping.”
“ I could also arrest the noise by pressing my ﬁnger ﬁrmly against the velum,
and pushing it upward towards the pharyngeal opening of the right Eustachian
tube; while 1 could still feel a‘powerful twitching with the usual intervals of
repose of the muscular structures thus pressed, all snapping noise ceased. ”
“ Pressure upon the left half of the velum palati, and mediately upon the pharyn-
geal opening of the left Eustachian tube, revealed no twitching in that region, nor
did it inﬂuence in any way the spasms and noises on the opposite side of the
pharynx and in the right car.”
As to the cause of this peculiar sound, the majority of the authorities appear to
be now agreed that it is “ due to a spasmodic contraction of the muscles of the
velum palati, producing a sudden separation of the anterior from the posterior wall
of the pharyngeal portion of the Eustachian tube.”
Johannes Miiller, who, I believe, could voluntarily produce a clicking sound in
his cars, which was audible to others, taught that it was due to the contraction of
the tensor tympani, and in the report of a case quite recently, by Bremerﬁ“ I
see the latter adopts the same view. Dr. Holmes, of Chicago, who has also lately
reported a cased” while admitting the separation of the walls of the Eustachian
tubes as in some measure contributing to the production of the sound, says that a

Monatschrzlft fitr Ohrenheillcundc, Oct. 1879. (The London Medical Record, Feb. 15,
1880.)
'1‘ Archives of Otology, vol. viii. No. 2, p. 144. New York,’ July, 1879.
PART m. c c
386 DISEASES or THE EAR.
spasmodic contraction of the tensor tympani is possibly the “most important” factor.
With reference to this point, it may be noted that Professor Moos, in the second
volume of the Archives of Ophthalmology and Otology, 1871, has recorded a case
of contraction of the left tensor tympani, synchronous with the act of mastication
and accompanied by a loud grating noise. “ This was heard very plainly without
any instrument, near the patient, on movements of the lower jaw. The examina-
tion of membranae tympanorum showed no material anomaly; on examination,
while the patient was chewing, the left membrana tympani showed a to-and-fro
movement.” Nothing similar could be observed on the right side. The author
makes the following remarks on this case :—
“ The phenomenon is especially remarkable, because the result was conﬁned to
one side. If it had been observed on both sides it would have been less remarkable,
‘as the muscles used in chewing and the tensor tympani receive their nerves from
the same source. (On voluntary contraction of both tensores tympani, compare
A Schapringer, “ Transactions Austrian Acad. of Sciences,” vol. lxii. sect. 2 ;
‘October, 1870. Presented October 18th, 1870.) As is well known, Helmholtz
first drew attention to the grating noise caused by violent concussions of the car.
He explains it by the striking together of the ratchet-teeth of the malleo-incudal
"joint. Politzer contests the correctness of this explanation from experiments of his
own. According to him, the sound is derived from the whizzing noise of the mem-
brana and the ligaments of the ossicula. Politzer could produce this whizzing in
the ear of a corpse, even when the malleo-incudal joint was artiﬁcially anchylosed.
Wochenblatt cler h. h. Gcsellschaft eler Aerzte, N o. 15, Vienna, 1870.)
On the other hand, in a report on the progress of otology, in the ﬁrst half of
“the year 1878 (Archives of Otology, vol. viii. N o. 2, July, 1879, New York),
1by Hartmann, there is a notice of a case of chronic spasms of tensor tympani
muscle, without subjective sensations, recorded by Blau in the Archie far
ﬂlwenheilhancle, Bd. xiii. p. 261. The following appearances were observed :—
“ In variable succession, sometimes frequently or again more rarely, spasmodic
motions of the membrana occurred; changes of the cone of light, or total retrac-
tion of the membrana, occurring ‘ with lightning rapidity,’ were observed. There
was no connection with respiration. The boy had no subjective sensations of the
motions of his membrana tympani. The author considers the motions of the
.zmembrana tympani attributable to contractions of the tensor tympani muscle.”
There is no mention of any objective noise, yet surely, if contraction of the
“tensor is capable of producing a noise, it ought to have been heard in this case.
The earliest recorded case of this peculiar affection which I can ﬁnd is one
referred to by Dr. Holmes in his remarks on the case already quoted ix‘ “ In 1854
I had an opportunity of examining a most interesting case under the care of Pro-
fessor H. J. Bigelow, who had reported its history in the Boston Medical and
Surgical Journal, November 8, 184.7. In this patient, a young lady about sixteen
years of age, the sound, a sharp “click” audible across the room, appeared to’
come from the throat. I have been informed by Professor Bigelow that this
patient, and another similarly affected, who subsequently came under his observa-
tion, ﬁnally recovered. Unfortunately, when these patients were under observa-
tion, the rhinoscope was practically unknown.”
This case appears to have been overlooked by the German authorities. Pro-
Afessor Schwartze of Halle, in the Arch/iv far Olm‘enhe'ilhancle, Bd. i. 1864, in a

* L00. cit.
DISEASES OF THE EAR.’ 38 7
paper on “ the Scientiﬁc Advancement in Aural Surgery during the last ten
years ” alludes to some experiments of Politzer’s, which proved that the objective
noise sometimes heard in the car was due to the separation of the walls of the
Eustachian tube. Politzer’s view was simultaneously and independently enun-
ciated by Luschka.
In same Archives (Bd. ii.) Schwartze subsequently published a case, in which
the noise was synchronous with the movements of the palate. At the same time
there was a sensible retraction of the membrana tympani which was most apparent
at the extremity of the handle of the malleus. Von Triiltsch and Politzer appear
to have established the fact that in persons who can voluntarily produce a noise
in the car, by elevating and depressing the palate, this movement of the manu-
brium also takes place. It is not diﬁicult to understand this when we call to
mind the tubal origin of the tensor tympani.
In the same volume of the Archives, Dr. Boeck, of Magdeburg, records a case
which is also corroborative of the views of Politzer and Luschka. In this case
there was a movement of the thyroid cartilage with each repetition of the sound.
A rhinoscopic examination showed a separation of the anterior and posterior lips
of the Eustachian tube with each elevation of the palate and thyroid cartilage.
Curiously enough the noise in this case was synchronous with the pulse, but I am
inclined to think this was merely a coincidence. If at any time the noise ceased,
it could be at once reproduced by the act of swallowing. Dr. Boeck alludes to
Funke’sit‘ explanation, namely, that it is due to the sudden stretching between
the malleo-incudal joints, in fact analogous to what takes place when the ﬁngers
are suddenly and forcibly stretched. Dr. Boeck, however, who is an upholder of the
views of Politzer and Luschka, argues that if this explanation be correct, the noise
should also occur when air is injected into the tympanum. In this case the
induced current proved of some beneﬁt.
The next case is recorded by Politzer in the same Archives (Bd. iv. 26). It is
that of a young person who in consequence of an acute tympanic catarrh, occur-
ring during scarlatina, had a perforation of the membrana tympani. In this
occasionally some secretion lodged, and during the act of yawning this was driven
out through the perforation, thus proving the associated movement of the tensor
tympani. _
Politzer also gives some interesting notes of a case of voluntary contraction of
the tensor tympani.
In the same volume of the Archives (Bd. iv. p. 229), Professor Schwartze
reports two cases, and alludes to a case published by Leudet in the Gazette
llfe'dicale de Paris, 1869, No. 32, 35. He also speaks of an observation of Wreden’s,
who supposed that there might be in those cases a chronic spasm of the stapedius.
The ﬁrst of Schwartze’s cases presented the following features:
“A man aged between forty and ﬁfty suffered from a loud cracking noise in
both cars, which could be heard all round the room and was involiuitary. At one
time the snapping sounds followed each other rapidly but rhythmically, and then
for a short time ceased. He had had the noise since he was twelve or sixteen
years of age. He cannot reproduce it during apause. It is much louder than the
normal noise, which so many persons can produce. There is no movement of the
membrana tympani. The noise is not synchronous with the pulse. There is a

* Funke, “Lehrbuch der Physiologic,” Bd. 113, 2te Auf.
c e 2
388 DISEASES on THE EAR.
movement of the palate, but none of the thyroid. The rhinoscope showed anarrow-
ing of the pharyngeal openings of the tubes.”
Schwartze alludes to the frequency in these cases of the power of reproducing
these noises, during a pause, by swallowing. He expresses some doubt as to
whether the noise in these cases has its origin in the Eustachian tube.
Case 2.——“ A girl, aged ﬁve, for six months had complained of a snapping noise
in both cars, which could be heard by a bystander at the distance of some inches.
Before this noise began, a diﬂiculty of hearing had existed for some time, but this
had disappeared spontaneously. Latterly the child had frequently cried out on
account of a violent pain in the ear. So far as the parents could determine there
were no remains of the former deafness, nor could any pathological changes be
detected in the membrana tympani. The snapping noise had a great resem-
blance to the cracking of the ﬁnger-nails. At times it ceased, and then again
continued as regularly as the‘, ticking of a watch. There was no movement in-
wards of the membrane visible, nor any sign of movement of the palate. The
noise was not synchronous with the pulse, and could not during a pause be
reproduced voluntarily by swallowing.”
A rhinoscopic examination could not be made, on account of the narrowness of
the naso-pharyngeal space. Relying upon the favourable accounts of Boeck and
Politzer regarding the induced current, the author says it would seem applicable
to such cases, but he states that as regards his own experience he had met with
no permanent results from its use.
I believe Schapringer has recorded a case in the Reports of the Austrian
Scientiﬁc Academy ; but I have not been able to consult the reports, and so can
give no account of it.
Dr. Kiipper, in the Arch/iv fil'r Ohrenheilhancle (N .F. Bd. i.), reports a case of
chronic spasm of the muscles of deglutition. The patient, a man aged twenty, during
an attack of measles suffered from a slight catarrh of the tubes and tympani from
which he soon recovered. Immediately afterwards he had a constant naso-pharyn-
geal catarrh, and he complained of a peculiar noise in the ears, which was audible to
any one standing close to the patient, and resembled the cracking of the ﬁnger-nails.
Synchronously with the noise there was an upward movement of the thyroid, the ﬂoor
of the cavity of the mouth, the root of the tongue, and the soft palate; the sides of the
palate arched and approached ; at times there occurred quick transitory spasms of the
muscles of the eyes, nose, and mouth. The intensity of the sound varied ; frequently
it was scarcely audible when the ear was placed close to the patient, and frequently
it was heard at a greater distance. The frequency varied likewise, 140 was reckoned
in the minute, the rhythm was the same in both ears, and the intensity mostly the
same also. Sometimes the noise ceased on one or both sides for a long time; the
movements of the thyroid, 81.0., were always present. During sleep the noise was
also audible, respiration and the frequency of the pulse had no connection with
these phenomena. The hearing power for tones and noises was quite normal in
both ears, no abnormality in the bone construction was present. The inspection of
the membrana tympani revealed no change in its concavity. With the otoscope,
when air was passed into the tube, a distant rustling noise was audible. The
mucous membrane of the nose and pharynx was very red and swollen.
Dr. Kiipper looks upon this form of spasm as due to a reﬂex spasm transferred
from the sensitive nerves of the affected mucous membrane to the motor nerves.
He compares it to the spasm of the orbicularis palpebrarum from a conjunctival
affection.
DISEASES or THE EAR. 389
As such spasm is frequently momentarily removed by pressure on a certain
spot, so in this case by pressure on the root of the tongue the spasm was arrested,
and lessened by pressure on the small occipital nerve, close to the insertion of the
sterno-cleido-mastoid. The treatment consisted of local applications, astringents,
gargles, catheterisation, baths, blisters, together with bromide of potassium,
valerian, &c., and frequent use of the constant current; all with no good results.
Dr. E. L. Holmes reports a case in Knapp’s Archives (vol. viii. part 2), of
a seamstress, seventeen years of age, in whom there were involuntary spasmodic
elevations of the larynx, as in Swallowing, accompanied by a peculiar sound in
each ear, distinctly audible at the distance of 18 inches from the patient on the
left side, and 5 or 6 inches on the right side.
A similar sound could be produced by rubbing the edges of the thumb and
ﬁnger-nails obliquely over each other. The sounds and the pharyngeal spasms
occurred forty times in the minute, but remitted as regards intensity and intervals.
Swallowing or holding the breath increased the distinctness of the sounds, which
were lessened by colds in the head, without any increase of the slight deafness
from which she suffered. The membranes moved slightly with each pharyngeal
spasm, and were white and thickened in the centre and upper parts. Synchronous
with spasm and sound, the velum rose, and the labii of the Eustachian oriﬁces
which were bathed in a thin muco-purulent ﬂuid separated. Treatment with Fowler’s
solution, cod-liver oil, quinine and iron, for a twelvemonth, caused no beneﬁcial
effect.
In the same volume of the Archives is a notice of a case by Poorten, of a
woman, aged forty-ﬁve, who suﬁered from beating in the left orbit, and a loud
blowing noise in the left ear, audible at a distance of eight inches, and due to an
aneurism in the left orbit following an injury.
In the Archives (vol. viii. part 4:), there is a case recorded by Dr. Burnett,
of Washington, of a gentleman, aged forty-four, who from childhood had been
able to voluntarily produce a sound, referable to the ears, by a contraction of the
muscles of the threat. The sound is a ﬁne mucous rale, like the sound in the case
reported by Dr. Holmes just noticed, and can be heard at 50 inches from the right
ear, and at a somewhat less distance from the left. The production of the sound,
while he is performing Valsalva’s experiment, causes the air to pass with much
greater freedom into the ears. He has not the power to produce it separately
at each side. Dr. Burnett failed to detect any movement of the malleus, from
which he inferred that the tensor tympani did not participate in the contraction.
During the contraction the anterior wall of the pharyngeal oriﬁce of the tube
remained perfectly stationary, while the posterior lip moved forward and upward
across the mouth of the tube, the edge sometimes reaching to the anterior border,
completely closing it, but usually going only about two-thirds of the distance
across. The uvula was at the same time drawn upward. The mouth of the tube
was in a perfectly normal condition.
In the “ Abstract of American Otological Literature” for the third quarter of
1879, published in Knapp’s Archives, (vol. viii. part 4!), a case is quoted
which was reported by Mr. W. R. Amick. The patient, a woman of thirty, had
ﬁrst noticed snapping sounds after some fainting-ﬁts when she was eighteen.
They were loudest when she was excited, and could then be heard at a distance of
It feet. A very slight movement of the membrana tympani is perceptible when the
noise is loudest. There are about ﬁfty-four sounds per minute, the pulse being 80,
but there is no regularity about their occurrence. The cavity of the drum is
390 DISEASES OF THE EAR.
healthy, and the hearing normal. Mr. Amick considered the sounds to be tubal,
but no mention is made of an examination of the mouth of the tube during the
production of the noise.
In the London Medical Record of Feb. 15,I see the notice of a case reported
by Dr. Bremer, in the Archie; fc'iq' Ohrenheilkancle, Oct. 1879. The patient, a boy,
had suffered from tinnitus for six months in the right ear The right membrana
tympani was irregular and indrawn; the cone of light was absent, but in its place
were several Streaky or dotted reﬂexes. The membrane was transparent, and
movable with the pneumatic speculum; there was slight pharyngeal catarrh.
Hearing for Politzer’s acoumeter was normal, general loud speaking was under-
stood at from 15 to 20 feet. No noise was present at the time, but at a subsequent
visit, a short, snapping, irregular noise was audible at a distance of 10 feet. It
was repeated about 100 to 150 times per minute, and resembled the/ noise of a
telegraph apparatus heard at a distance, or a noise produced by tapping the nails
on oilcloth stretched over a table. It lasted about ten minutes, ceasing gradually,
and was heard loudest in and under the right ear. The boy could produce and Stop
it at will. During its recurrence no movement in the muscles of the face, or in the
drumhead could be seen, neither could any movement in the jaw or pharynx be
detected, and it continued uninterrupted whilst a bougie was passed up the
Eustachian tube. The author considers that it was probably due to contraction of
the intrinsic muscles of the ear, especially the tensor tympani.
These are all the published cases I have been able to collect, and along with my
own, the number is only seventeen. I can ﬁnd no reference to the subject in any
English work on otology, so that I presume it is fair to conclude that the aﬁection
is a rare one. I confess I ﬁnd it hard to believe that the noise can be produced, as
Muller and Bremer believe, by the contraction of the tensor tympani. It seems
incredible that the contraction of such aminute muscle could be heard at a distance
of ten, or as in my case of ﬁfteen feet, whereas the absence of the palate move-
ments occurring in only two of the cases is strongly in favour of the view that
the sound is caused by the separation of the walls of the tube.
I now come to another form of objective noise in the ear, of which I have met
with two well-marked examples.
The ﬁrst case was brieﬂy as follows :—
Mr. B. consulted me in November, 1878. He stated that about ten days pre-
viously he had noticed a pulsating noise in A. S. He did not observe it during the
day-time, but as soon as he lay down in bed it became apparent. His wife could
also hear it distinctly when she placed her ear near his. He enjoys good health
as a rule, except that he is subject to indigestion. He has had a good deal of
mental anxiety from hard work, being engaged in extensive business as a solicitor
He had a brother who had died from the bursting of an aneurism, and consequently
he felt some anxiety about this noise, thinking it might proceed from an aneurism.
His hearing was perfectly normal on both Sides, and the appearance of both ears and.
membranes quite healthy. On placing a stethoscope over the left meatus, a dis-
tinct pulsating, blowing sound could be heard. It was also audible on placing the
stethoscope on the mastoid, immediately above the auricle. Pressure on the carotid
stopped it, and it could not be heard tillthe patient assumed the recumbent posture.
I prescribed ﬁfteen m. of hydrobromic acid to be taken three times a day. Four
days afterwards I again saw the patient, who stated that he was much better,
and that the noise had decreased. Some days later I could not detect the noise,
and I desired him to take the acid four times daily. In another week he was
DISEASES OF THE EAR. 3915.
very much better ; the noise did not now, as before, prevent him sleeping.
After this he again visited me, and described himself as suffering very much from
dyspepsia, and stated that the noise had again returned with considerable’
intensity. He then consulted Dr. James Little for the constant dyspepsia from
which he suffered ; and meeting him some time afterwards, he informed me
that the noise had almost, if not completely, disappeared.
The other case was that of a young lady who consulted me last October on
account of a beating noise in the right car. This had ﬁrst commenced the previous
Christmas, and had lasted for three months, after which it quite ceased. Six
months before her visit to me it began again. By turning her head to the right
side she could stop it. With the otoscope I could hear a distinct bruit of a blowing
character in A. D., which was stopped by pressure on the carotid. The patient was
distinctly ehlorotic. Hearing and appearance of ear normal. Ordered hydroe
bromic acid. I then prescribed Bland’s well-known sulphate of iron pills with the
most marked beneﬁcial results, for in time the noise completely disappeared.
In the Transactions of the American Otological Society for 1878 (vol. ii..
part 2), Dr. J. Orne Green describes two cases of systolic murmurs in the ears
controlled by pressure on the carotids. Both patients were of the male sex, and.
in both the membranes, Eustachian tubes, and throat were healthy. “In both
there were certain abnormal conditions which were noticed when the sounds were
present; in the boy the sounds were always complained of during and after general
headaches, which could only be classed as nervous, as they came on after violent
or exciting play, and were apparently independent of any digestive trouble. In
the man, the sounds appeared just about the time he had begun to notice a loss of
strength and appetite, when, in fact, there was some debility. One peculiarity in
both cases is worthy of special mention; that is the extreme sensitiveness of the
vase-motor nervous system, as shown by the intense and rapid suffusion of the
face on the slightest excitement or surprise—a condition to which both were sub-
ject, and which had been often noticed by their friends.”
The boy recovered, but in the man’s case the noise continued up to the date of
publication. '
In explanation of the occurrence of the phenomenon, Dr. Green seems inclined
to accept that which Dr. Richardson gives as explanation of the subjective noises in
the ear accompanying alcoholic dyspepsia.
“ These are produced,” he says, “ by a reduced vascular tension, especially of the
internal carotid artery, which allows the walls of the artery to lie in direct contact
with the osseous walls of the canal in the petrous bone, and thus permits the
transmission of the vibrations of the blood directly to the osseous structures in
close connection with the car. He does not speak of these vibrations as ever being
heard objectively ; but if his explanation is the true one, the noises are positive in
contradistinction to the subjective irritations of the auditory nerve, which are purely
sensational; and this being the case, the perception of the sounds objectively, vie,
by another person, must merely depend upon'their intensity. This explanation
of Richardson’s, it seems to me, is very possibly applicable to these two cases, for
in both there were pathological states which could have induced a reduced vascular
tension.”
DISCUSSION.
Dr. LOEWENBERG, Paris: I agree with Dr. Fitzgerald in ascribing the noise to a.
palatal movement opening the Eustachian tube. I may remind my confreres the
~4-
392 DISEASES OF THE EAR.
proof of this fact is in the Oentralblatt of 1863, where it is called a spastic noise,
because it is provoked by a contract-ion of muscle. '
T/ze Sense of Touch as a Siana’ami 0f Comparison for
Hearing P0 wen
Mr. A. GARDINER BROWN, London.
For examining auditory perceptivity the tuning-fork is to be preferred to the
watch; among other reasons, because its pitch, being determinable, enables diﬁerent
observers to compare their results.
The Middle-C fork (= 256 vs.) is, for this purpose, an excellent standard of
pitch, corresponding as it does with about the middle of the compass of the human
voice as used in conversation. I'Vhen the “ﬁeld of audition ” (Knapp) is being
determined, higher and lower pitches are made use of.
Hitherto the best way of employing a tuning-fork has been to strike it with a
measured blow to ensure uniform amplitude of its vibrations, instantly applying it
to the patient’s head and noting the duration of his hearing-power (Magnus).
The author has now conceived the idea that the point in the lessening amplitude
of the vibrations, corresponding with the moment of their loss to the sense of touch
in the thumb and ﬁnger of the examiner, forms an excellent and convenient Standard
of Reference for the auditory perceptivity of the patient.
Hearing-power, falling short of this Point, the author has designated as minus,
that exceeding it as plus, time being reckoned in half seconds (to save fractions),
this may be done by means of a stop-watch, but the author prefers simple counting
in half-seconds, easily and accurately done after a little practice; or the time may
be estimated by a tubular sandglass, which he has had constructed for the purpose.
The most suitable points for ordinary examination are over the mastoid for bone
conductivity, and at the focus of the concha for aerial sound-waves.
Example 'of use of Middle-C tuning-fork :,
Case of P. S., aged 46, simple middle-ear catarrh (left side).
Right ear. Left ear. Left car (after Politzer’s inﬂation),
Over mastoid. . . + 9 .... .. + 13 ............. .. + 13
Focus of concha . . + 17 .... .. —— 13 ............. .. —— 5
The dimensions of the “ Standard” tuning-fork are :
Length of prong. . . . . . . . . . = 98'() mm.
Width . . . . . . . . . . . . . = 7'0 ,,
Thickness . . . . . . . . . . . . : 3'5 ,,
DISCUSSION.
Mr. LAIDLAW PURvEs, London: How do you propose to estimate the pressure
employed and the sensibility of the ﬁngers of different observers?
Dr. KNArr, New York: I think that, as a personal test, the method may be quite
‘reliable; but, as a general method, it is subject to the objection that different
observers have different acuteness of feeling in their ﬁngers. In testing the instru-
ment with my neighbour in this room, I found an essential difference between his
observations and mine. As a general acoumeter, I can fully recommend Politzer’s
DISEASES OF THE EAR. 393
little hammer instrument. Four years ago I brought one of these instruments to
New York. The diﬁerent instrument makers made others so accurately resembling
them that, even now, after very many artists of New York have used them for
years, they still are, and act So much alike, that we are not able to distinguish the
imitations from the original.
Mr. LAIDLAW PURVES, London: showed a method which he had employed for
some time, by using an ordinary table as a sounding-board, or by applying two bodies
to the mastoids of the patient, which were again connected with the mastoids, or
the meatus, of the observer.
De Z’Accommodaz‘z'mz a'e Z’Orez'Z/e : Ream/a’ de [a Smsaz‘z'mz—
Ez‘ua'e P/cysz'o-paZ/zologz'gue.
M. GELLÉ, Paris.
Je laisse de côté les diverses phases de l’accommodation générale, telles que
l’orientation, la recherche de la direction du son; j’ai montré dans des études
précédentes comment se divise le champ de l’audition, l’isolement des sensations
auditives latérales, et le rôle du pavillon dans cette fonction.
L’accommodation au ton ou au timbre existe-t-elle autrement que par les dispo-
sitions anatomiques du limaçon pour celui-ci, de la membrane du tympan pour
l’autre? ce n’est pas ma thèse. Je veux traiter de l’accommodation au point de
vue unique de l’intensité du son, par conséquent de la portée de l’onïe.
On sait combien les variations de tension de la membrane ont d’action sur la.
portée de l’ouîe; que le son soit apporté par l’air, ou par les os du crâne, il est
atténué quand on tend artiﬁciellement la cloison (pression ou insuﬁiation d’air).
L’appareil d’accommodation constitué par la chaîne des osselets et ses muscles
moteurs n’a pas d’autre fonction que de modiﬁer l’état de conductibilité du tympan
et de l’appareil de transmission. Rappelons aussi combien sont limités en dedans
les mouvements de déplacement du tympan et de combien peu sa tension doit varier
pour s’accommoder du grave a l’aigu.
La maladie agit d’une façon bien plus brutale sur la tension du tympan; tantôt
elle le rend\plus mou, le détend, l’allonge, tantôt elle le sèche, le durcit, l’épaissit,
l’immobilise. Ces modiﬁcations tiennent à des lésions soit de la chaîne, soit de ses
muscles, soit de la cloison elle-même.
Je laisse de côté ici les lésions labyrinthiques capables de modiﬁer l’audition de
certains sons isolément, ce qui les indique assez nettement du reste.
J ’ai cherché à étudier les modiﬁcations de la conductibilité de l’organe de l’ouÏe
sous l’inﬁuence des lésions précédentes.
Je me sers pour produire les tons graves ou aigus de diapasons actionnés par un
courant de pile; et le son est transmis à l’oreille par un téléphone, et gradué dans
son intensité au moyen de la bobine a chariot.
Dans une première série d’observations, la lésion cause était bien nette, c’était
un ramollissement avec détente du tympan. L’audition reparaissait très bien à. la
première insufﬂation d’air, qui tendait passivement la membrane, pour les sons
aigus surtout. Dans les cas où le tympan est très enfoncé, tendu par la rétraction
de la chaîne et des ligaments par des brides interposées, et peu mobile même a la
304 J
DISEASES OF THE EAR.
douche d’air, c’est l’audition de sons graves qui laisse à. désirer, on assiste aux
efforts d’attention des patients. Toutes ces lésions modiﬁent la portée de l’ou'ie et
altèrent la perception des sons d’intensités diverses.
L’organe ne peut plus s’accommoder. Au moyen du dispositif précédemment
indiqué, j ’ai pu étudier ce défaut d’accornmodation dans des cas où l’ouïe n’était
pas complètement éteinte.
Dans un premier examen, on note la limite extrême de l’audition pour un son
donné; puis on replace le chariot; on fait entendre un premier son fort; et,
éloignant brusquement la bobine, de façon à. fournir le même son, mais très affaibli,
on constate si la sensation a été continue, ou s’il y a eu interruption dans le courant
sonore après cette modiﬁcation d’intensité du son. A l’état normal, il n’y a pas
d’interruption du son, il faiblit, mais on n’a pas cessé un seul moment de l’en-
tendre.
Dans les cas pathologiques de l’ordre que j’indique un phénomène curieux se
passe: il y a un temps de silence ; le sujet n’entend plus rien, et s’en étonne 5 c'est
lui le plus souvent qui l’annonce, puis, qui reconnaît ensuite tardivement le son
très affaibli. On compte avec intérêt le temps très sensible qui s’écoule entre le
déplacement de la bobine et le moment où le sujet déclare entendre de nouveau.
J ’ai compté 10, 25, 30 secondes de retard dans la transmission du son.
Le phénomène ne peut s’expliquer que par un retard de l’accommodation. Il
ne s’agit pas là. d’une absorption du son par une impression trop vive, étourdis-
sante; il y a silence. Que se passe-t-il pendant cette phase silencieuse P
C’est sans doute un travail, ou un essai de travail d’adoptation de l’organe a la
sensation nouvelle.
Pourquoi donc est-il aussi lent, et aussi difficile?
Il sufﬁt d’avoir vu une pièce pathologique d’ancienne otite indurée pour com-
prendre cela. Grâce a l’enfonçure du tympan et de tout l’appareil, grâce à. la
raideur générale, à la propulsion en dedans du manche et de l’étrier, la course
qu’il peut fournir en dedans se trouve accomplie; il ne peut obéir davantage à
l’action du tenseur, de plus celle-ci est amoindrie par l’atrophie quelquefois. Si le
tympan est seulement ramolli et enfoncé sans rien aux osselets que le susdit dépla-
cement en dedans l’action est analogue ; le tendon du tenseur se trouve détendu,
il est trop long pour agir normalement, enﬁn la moindre contraction achève
d’enfoncer l’étrier dans le labyrinthe. Dans ce cas, si l’on donne un peu de champ
aux parties par une insufﬂation d’air, par exemple (ceci vu sur les pièces fraîches),
on s’aperçoît que le labyrinthe recommence à. subir les oscillations de la platine,
à. peine visibles auparavant.
C’est cette incapacité fonctionnelle qui cause le retard de la sensation et
explique la lenteur, l’insufﬁsance et souvent la nullité de l’accommodation.
Mais, il n’est pas besoin de graves lésions de l’organe pour constater le phéno-
mène du retard de l’accommodation; un de mes malades très intelligententendait la
montre a 50 centimètres et mal la voix parlée. Il avait un retard manifeste et
très sensible pour lui-même. C’était donc bien les variations brusques de l’inten-
sité qui mettaient son organe en défaut.
En allant doucement dans la diminution de la force du son il n’y a pas d’arrêt
dans l’audition. ,
Cela semble rendre compte de ces faits curieux, notés par tous les observateurs,
où l’audition de la parole est mauvaise, où le sujet fait répéter tandis qu’il entend
le son du diapason et de la montre et la musique a une distance remarquable. La
parole est en eﬁet composée de sons rapides et d’intensités diverses. J ’ai été con-
DISEASES OF THE EAR. 395
ﬁrmé dans ces idées et dans cette interpretation des faits, par l’examen d’oreilles dc
sujets atteints de paralysis faciale sans lésion tangible sérieuse de l’oreille
moyenne, ou apres la disparition du processus initial; alors c’est le moteur de la
chaine, le tenseur tympanique, qui n’ayant plus d’antagoniste ne peut graduer son
action et dépasse le but.
Cela nuit a l’accommodation de l’organe auditif et pour la parole surtout.
Il est possible de juger du retard apporté a l’accommodation avec mon appareil
a courant; or, ce phénom‘ene apparait ici avec une grande intensite' ; sur un de mes
malades, il fallut pres d’une minute pour qu’il put s’aecommoder; et qne le son
faible fut percu. J’ai calculé un intervalle de plus d’une minute entre le moment
on je bouge la bobine de place et celui ou le sujet annonee entendre.
Au reste le malade se rend parfaitement compte de ce temps perdu, de l’inter-
ruption de la sensation et de sa reprise tardive.
On comprend bien ainsi que la parole soit mal entendue alors que la musique
et le diapason et la montre n’ont pas cessé d’etre percus a une portée excellente.
Parez‘z'c Deaﬁzess.
Dr. EDWARD WOAKES, London.
Amongst the forms of deafness which are unattended with any marked objective
conditions when the ear is externally inspected, that which I have called “ Paretic”
deafness constitutes an important group. Having already discussed the subject
elsewhere at considerable length, I propose new simply to summarize the salient
features of the disease.
Symptoms—These usually commence without any cause which the patient can
associate with his ears : very frequently the symptom which ﬁrst attracts attention
is some degree of tinnitus in one or both ears. He then ﬁnds he is deaf, but
vertigo is nearly always absent. As regards the degree of deafness, this is liable
to frequent variations in the direction of improvement, followed by relapses; it is
worse at night, and after fatigue, whether mental or physical. There is but slight
tendency to pass beyond the point at which it ﬁrst attracted notice, subject, how-
ever, to the variations mentioned above. Occasionally there is no deafness, but
tinnitus only.
The objective symptoms are contributed by the palate, which presents varying
degrees of loss of muscle power. This is shown by the obliteration of the anterior
arch of the palate, on one or both sides, so that the soft palate droops and hangs
at a lower level than in the normal state. In bilateral paresis, owing to this cir-
cumstance, the uvula is lost sight of until the tongue is strongly depressed. In
unilateral paresis, which is most common on the left side, and corresponds to the
affected ear, the uvula is occasionally drawn to the sound side. The irritability of
the muscular contingent of the velum—ie, its capacity to respond to stimuli, does
not always correspond with the indications of paresis above described; while at
times it is quite insensitive, remaining passive when touched, and even roughly
handled; in other cases it moves freely under these circumstances. The signiﬁ-
cance to the deafness of this wiping out of the superior and anterior arch of the palate
resides in the relationships of the tensor palati muscle to the organ of hearing.
The complicated character of these relationships was ﬁrst pointed out by Weber-
Liel, whose work in this department is simply unique. In the necessarily brief
396 DISEASES or THE EAR.
allusion which I can now make to this subject, it must suffice to point out that a
portion of the tensor palati is attached to the fascia of the Eustachian tube, which
fascia has intimate connections with the tensor tympani muscle throughout its
entire length. This fact seems to me to necessitate the conclusion that any loss of
power in the palate muscle will disturb the point cl’appui from which the tympanic
muscle acts. The physiological function of the latter is to regulate the conducting
power of the ossicle for sound waves, so that the impression conveyed to the per-
ceptive apparatus may correspond to that of the original impression received by
the drumhead. The sensitiveness of’the tympanic muscle which is mainly con-
cerned in this process may be readily conceived, and its liability to derangement
must be proportionately great. It is obvious, therefore, that any loss of power in
the palate muscle, such as is indicated by its inability to support the superior arch
of the velum, will materially interfere with the stability of the fulcrum from which
the tympanic muscle acts.
But, further, the tensor palati, being a dilator of the tube, though not the only
muscle subserving this end, its paresis will modify the admission of air into the
middle ear.
Another consideration arises out of the identity of nerve supply of the two
muscles in question—via, from the otic ganglion. As will be shortly pointed out,
there is good reason to believe that the ganglionic centres are themselves the fre-
quent seats of defective nerve inﬂuence, and supposing such a paresis of the otic
ganglion to obtain in the cases under review—to be, in fact, the starting point of
the lesion—it is fair to infer from the palate paresis which we can see, a similar
loss of power in the tympanic muscle, receiving its nerve supply from the same
source. That is to say, we infer the existence of paresis of the tensor tympani
when we see its congener of the palate to be in that state. This assumption is
fortiﬁed by the ﬂat and relaxed appearance of the drumhead when viewed from
the meatus.
Thus otic ganglionic paresis is seen to necessitate deﬁcient ventilation of the
middle ear—though not complete suspension of this function, because the remain-
ing tubal muscles which supplement it are not implicated, having a distinct inner-
vation on the one hand; and on the other, defective accommodation power of the
drumhead. These two conditions explain the deafness, and also account for the
slight objective indications which the subjects of paretic deafness afford upon
inspection of their ears.
Etiology of Pa'retic Deafness.——Passing to the causes which give rise to this
form of deafness, these will be seen to be exactly those which impair the vitality
of the subject. In one of its aspects it may be regarded as the tribute
of our over-wrought civilization to the domain of otology. Thus the effects
of mental wear and tear’, especially the nervous tension and worry consequent
upon competition in the modern race for wealth, tell largely upon the energy
capable of being exerted by the nutritional nerve centres. Certain habits, however
pleasant in themselves, tend undoubtedly to localize the nervous exhaustion in the
centres of the head and neck, such, e.g. as tobacco-smoking, must be included in
this category. Sudden shocks to the system generally belong to it, and amongst
my patients, affording examples of this cause, has been one who lost much blood
from the accidental division of an artery in the wrist, and another who was
suddenly immersed in the water while skating.
It is especially the phase of deafness initiated in women during the period of
activity of the reproductive function, the over exercise of which activity, to the
DISEASES or THE EAR. 397
great detriment of the wife’s constitution, is a glaring defect in our pretentious
system of modern domestic life. Indeed, that woman may be considered happy,
who, in the exercise of her marital relationship, escapes with the annoyance of deaf-
ness only, consequent upon the exhaustion of her ganglionic nerve force in the
rapid reproduction of her species. That I am not alone in the opinion just ex-
pressed, is proved by the evidence of Weber-Liel, who recognises the causes I am
referring to as constantly operative in inducing the allied phase of ear disease,
described by him as “progressive” deafness.
Though usually affecting the well-to-do classes, such a combination of circum-
stances may happen, as cause the appearance of Paretic deafness in the lower ranks
of life—when, for example, as in the winter of 1877-78, there occurred a prolonged
period of severe and exhausting cold weather, coupled with wide-spread poverty,
due to commercial depression, and aﬂiecting large masses of the community. It was
after this winter that there occurred among my out patients at the throat hospital,
a considerable number who presented paresis of the palate, and who concurrently
complained of deafness, that my attention was called to this aspect of ear disease.
Diﬁe're'ntz'al Diagnosis—The chief characteristics which differentiate paretic
deafness from progressive deafness, to which it has some afﬁnities, have been
already hinted at. They are, ﬁrst, the almost negative condition of the membrana
tympani. What slight departure from the normal state can be detected is seen
chieﬂy in the modiﬁcation of the cone of light, which may be truncated towards
its apex at the umbo, causing it to appear smaller than it usually does in the
healthy drumhead. This may be accepted as indicating a slight degree of change
in the natural curvature of the part—it is ﬂatter than in health. Whereas, in pro-
gressive deafness, one sees a marked indrawing of the membrane, especially in its
anterior segment, with abnormal prominence of the manub. mallei, and of the proc.
brevis. Other diﬁerences are the non-progressive character of the deafness, and
the absence of giddiness, as well as the greater curability of the disease in the
paretic form.
Referring to the identical point of departure in these two phases of ear disease
-—paresis of the tensor muscle of the palate—the question naturally arises whether
any grounds exist by which to account for the distinctive action of the tensor
tympani muscle exhibited in them. It does not appear that lVeber-Liel in his
aﬁfection considers the latter muscle as primarily aﬁected, but, regarding it as
antagonistic in its action to the tensor veli, its behaviour is dictated by removal of
this counterpoise. It may thus be said to have the ﬁeld to itself, and to become
spasmodically contracted in consequence. Perhaps, however, this divarication of
the state of the muscles is better explained by the causes which primarily induce
the lesion. In paretic deafness these are rather of the nature of a sudden shock,
or its equivalent, taking effect upon a part of least resistance, and resulting in an
equal loss of power in both muscles—while l/Veber-Liel’s disease appears to arise
from a more chronic impairment of nerve supply consequent upon the gradual in-
roads of disease, usually catarrhal in its origin.
Most of the foregoing features will recur in the details of the following cases :—
Gase 1.—Mrs. , a widow lady, aged 38, seen in April, 1881. She states that
eighteenmonths ago shereceived anincised wound of the wrist which severed an artery,
and that she lost a great deal of blood. Since then has had ringing noises in right
ear, extending over the side of the head. She is not deaf, nor is she subject to
giddiness. On testing the hearing power with the voice and watch, this was shown
to be normal. M.t.t. normal, except that on the right side the bright spot was

398 DISEASES or THE EAR.
smaller than on the left. There were constant tidal noises in the right ear, and the
Eustachian tube on that side did not admit air. There was marked bilateral
paresis of the palate, but no catarrh of the pharynx or post~nasal region.
She was given a pill containing iron, quinine, and Strychnine, and the catheter
was introduced every week. She improved rapidly in health, the palate resumed
its normal condition, she shortly became able to perform Valsalva’s process: the
noises also gradually abated. In ﬁve weeks she was quite well. Ihave seen this
lady recently, and she remains free from tinnitus.
This patient was fortunate in getting treatment before the impairment of the
tubal function had produced deafness, for though catheterization was not at ﬁrst
successful, it is certain that air must have entered the middle ear to some extent,
or more objective conditions would have been apparent in the drumhead. Perhaps
the circumstance that this lady had only one child favoured the rapid recuperation
of her constitutional debility, consequent upon the accident, when placed under
treatment calculated to reinstate it.
Case 2.——Mrs. ———, aged 24;, a delicate-looking lady, seen in the spring of this
year. She states that after her Second conﬁnement, ﬁfteen months previously, she
experienced noises in her right ear, with some diminution in hearing power, though,
as she said, this had not been noticed by her friends. The deafness was worse at
night.
On examination, the hearing power, which was very good, for the voice gave with
the watch .1; in 40 for the right, and 7 40 for left ear. There was no vertigo but constant
tidal sound in the right ear. Mt t. ﬂat with very diminished bright spot, but no
prominence of manub. or of processus brevis. Right Eust. tube obstructed, left
patent. The soft palate was anaemic and thin, it exhibited double paresis in a
marked degree. There were no other abnormal conditions present.
The treatment was similar to the preceding case, and was attended with a like
improvement as regards tinnitus. The faradic current was applied three or four
times to the palate. She left to visit the Continent at the end of six weeks, at
which time the hearing power for the watch had improved to the extent of two
inches only. The noises were imperceptible except occasionally after exertion.
The cases just quoted are sufficiently typical to illustrate the character of the
disease under review. Having already published several others, it is needless to
occupy your time by multiplying them on this occasion. It is necessary, however,
to remark, that the paretic symptoms are occasionally overlapped by others due to
catarrh, and unless the observer be prepared to recognize the palate signs which
bear evidence of the existence of paresis, the catarrhal state of the naso-pharyngeal
space may monopolize his attention. The result will then be a partial improve-
ment only; one, that is, which is not equivalent to what the case is capable of
attaining to under other circumstances.
In conclusion, I beg to submit that the phase of “ paretic deafness” described
above, in which objective signs in the outer ear are almost nil—is of sufficiently
frequent occurrence to justify the distinctive term I have applied to it. And I
would fain hope that its recognition will prove a distinct aid to the diﬁerential
diagnosis of the causes of ear disease.
DISEASES or THE EAR. 399
The Acz‘z'ovz of Syp/zz'lz's 0% Me Em’.
Dr. F. M. PIERCE, Manchester.
The effects of congenital and acquired syphilis on the ear less observed than
its effects on the eye, teeth, skin, &c.
Syphilitic ear affections analogous to corneo-iritis and amaurosis.
The signs and symptoms of syphilitic aural affections must be considered
together with the history and collateral signs of syphilis and the failure of
anti-catarrhal treatment to relieve apparent catarrhal symptoms.
Are the obstinately relieved symptoms of aural syphilis due to a periostitis of
the parts, or to a proliferous form of inﬂammation of the mucous membranes con-
cerned? If the former, aﬁections of the bones (mastoid, petrous, and temporal)
with inner ear implication, should preponderate over middle ear catarrhs.
Primary sores of the ear are very rare; secondary squamous, pustular, and
papular eruptions are common. (Cases quoted.)
The evidence of syphilis attacking the middle ear is mainly of a catarrhal
character, with a marked prevalence of anomalous auditory nerve symptoms, and,
in adults, these symptoms are suggestive of acquired or congenital syphilis as a
predisposing cause.
(Forty cases of acquired syphilis affecting the ear referred to.)
Congenital syphilis manifested from 11 to 18 years as average.
Most frequent in females, as 4 to 1.
Access of deafness, gradual but rapid : in from three weeks to one year. About
period of puberty in females, rather later in males.
The membrana tympani dull, pearly opacity, collapsed, the light spot large
and dull and the manubrium of malleus red, ﬂat, and retracted. The meatus dry
and polished. The nasal passage swollen, and seat of chronic thickening and
discharge.
The deafness generally preceded by speciﬁc chronic interstitial keratitis, re-
covery from which is signal for accession of extreme deafness of a very intractable
character. The early decay of the characteristic teeth of congenital syphilis pro-
duces frequent earache.
(The effects of congenital syphilis of the car have been noticed in thirty-ﬁve cases.)
As a summary of the characteristics of acquired and congenital syphilis affect-
ing the car, we see—
1.-—Extreme degree of deafness manifested early in the progress of the disease.
2.——Rapidity of progress and absence of pain.
3.—Early and extreme loss of hearing for the tuning-fork over the vertex.
4lib—Frequent imperviousness of both Eustachian tubes.
5.—Constancy of the tinnitus, of a hissing kind.
6.-—Frequency of simultaneous inner ear symptoms.
IT.—-Improvement of pre- or co-existing eye affection.
8.-—More decided affection of the naso-pharnyx than in catarrhal ear disease.
9.—Less complete recovery than in simple catarrh.
Intolerance of sound, like that of light in syphilitic eye affections, is not a
noticeable feature in syphilitic ear affections.
If most syphilitic ear aﬁections are due to inﬂammation of the periosteum of
the petrous and temporal bones, how can we explain the rapid loss of auditory
nerve power, which is usually of slow occurrence in such cases?
400 DISEASES OF THE EAR.
Caseeus Aeeumalaz‘z'ons in the Middle Ear, regarded as
a Proéahle Cause of Mz'lz'ary Tether/ale.
Dr. THOMAS BARR, Glasgow.
At the recent discussion on the Pathology of Phthisis and Tuberculosis held
by the Glasgow Pathological Society, I ventured to make a suggestion as to a
possible source of tubercular infection to which hitherto but little attention had
been directed. At that discussion, the question of the tubercular infection of the
system by a virus arising from the softening of caseous deposits, the results of an
antecedent inﬂammatory process, was one of the points most keenly discussed.
The frequent coincidence of caseous deposits with miliary tubercles is admitted by
all; but our enthusiastic advocates of the doctrine of self-infection have to admit
that careful examination of the body after death sometimes fails to discover any
such caseous source of infection, and the failure to discover such a focus, even in
a few cases, strikes a serious blow at the doctrine of self-infection, as taught in
the absolute manner of Buhl, Virchow, Niemeyer and others in Germany, and by
Dr. Hamilton in this country.
The object of this paper is ﬁrst, to draw special attention to a part of the body
almost invariably neglected by the pathological anatomist, where the conditions
for the production of caseated products exist, probably more frequently than in
any other part of the body; and, secondly, to inquire whether the local form of
tuberculous meningitis may not frequently be the result of the absorption by the
lymphatic vessels of softened caseous matter formed in the ear.
I shall ﬁrst show that, in the osseous cavities of the middle ear, catarrhal pro—
ducts are very frequently formed under conditions which favour, in a remarkable
manner, their prolonged retention, stagnation, drying, and caseation.
The middle ear is more spacious than is generally supposed. It includes the
Eustachian tube, tympanum, antrum mastoideum, and mastoid cells. The antrum
mastoideum is generally looked upon as one of the mastoid cells, but it is so con-
siderable in size, and so important in its pathological relations, that it has received
a distinctive name. It is always well developed, and even in the young child, when
the other mastoid cells are represented only by porous bone, this cavity is con-
stantly found, and is often as large as a cherry-stone. While under the inﬂuence
of purulent collections, it often enlarges very considerably. The mastoid cells
proper form an exetnsive series of larger and smaller air-ﬁlled cavities. They are
not limited, as is often assumed, to the mastoid part of the temporal bone, but are
found scattered through the greater part of the temporal bone, extending inwards
as far as the apex of the petrous part of the bone, and outwards as far as to the
root of the zygoma.
The inner surfaces of these hollow spaces are lined by mucous membrane,
which is probably more liable to catarrhal and inﬂammatory processes than any
other mucous membrane in the body. The most frequent kind of catarrhal pro-
cess to which this mucous membrane is subject is, undoubtedly, that attended by
ﬂuid exudation. Out of 1,000 consecutive cases of ear disease, the records of which
I have preserved, 4100 consisted of chronic purulent inﬂammation of the middle
ear and its consequences, while a considerable number consisted of acute purulent
and mucous collections in the middle ear. Then of these 400 cases, in 140 the
disease existed on both sides.
DISEASES OF THE EAR. 401
The exudation in the middle ear in these exudative diseases varies in composition
and consistence according to the degree and character of the inﬂammatory process.
In the severe and acute forms of inﬂammation, it is purulent, and contains chieﬂy
pus corpuscles, or the pus may be mingled with a considerable quantity of mucus.
Or the exudation may consist of a thin serous ﬂuid containing few pus corpuscles
or epithelial cells. Or, again, it may consist of thick, viscid mucus, containing a
large quantity of mucous corpuscles, some pus corpuscles and exfoliated epithelial
cells. Mixed with all of these there may be blood corpuscles in greater or smaller
number.
We have now seen, 1st, that we have, in the middle car, an extensive series of
enclosed spaces capable of containing a considerable quantity of material; and,
2nd, that these spaces are very frequently the seat of catarrhal affections with
copious mucous, serous, and purulent formation, as well as of epithelial prolifera-
tion. '
I must now point out that there are circumstances'or conditions which favour,
in a remarkable manner, the retention, drying, and ultimate caseation of these
inﬂammatory products in the middle ear.
1st.——The structural peculiarities of the middle car are such that there is a great
tendency to the retention of secretions in the middle ear, especially in the antrum
mastoideum and mastoid cells. The position of the outlet to these parts is very
unfavourable to the spontaneous escape of their contents. We all know how im-
portant it is that the opening in an abscess should be in a dependent situation, in
order to ensure the thorough evacuation of the contents of the abscess. The open-
ing provided by nature for the escape of secretions in the mastoid cells and antrum
mastoideum is situated above the level of these spaces. More than that, the situa-
tion of this oriﬁce is such, that secretions formed and contained in the tympanum
are very apt to ﬂow from the tympanic cavity into the antrum mastoideum, and
thence into the mastoid cells, when the patient is lying on his back in bed. The
outlet by which secretion in the tympanum may escape outwards is situated near
to the roof of that cavity. Generally, however, a perforation in the tympanic
membrane is the means by which secretion escapes from the tympanum, and this
perforation is always above the ﬂoor of the tympanum. The outlets, therefore,
provided by nature for the removal of exudations in the middle ear must, by the
ordinary laws of gravity, be ineffective. Again, pathological changes in the middle
ear, consequent upon catarrhal aﬂections, often prove serious hindrances to the
passage outwards of secretions formed in the deep parts of the middle ear. Such
obstructions are often formed, for example, by adhesions of the tympanic mem-
brane to various parts of the walls and contents of the tympanum, by the plugging
of the outlets by polypi, or by inspissated pus or mucus. '
Unfortunately, also, in very many cases, no efforts are made to wash out the
muco—purulent or purulent masses, so that these very frequently lie in the interior
of the ear, undisturbed by treatment, for months or years, and only the overﬂow
as we might say, escapes by a hole in the tympanic membrane, or by a ﬁstulous
opening in the cortical part of the mastoid cells.
It is therefore clear, I think, that inﬂammatory products formed in the cavities
of the middle ear are very likely to accumulate, and to be retained for an indeﬁnite
time. These cavities of the middle ear may thus be looked upon as frequent store-
houses for inﬂammatory products.
The question now presents itself, “ What becomes of these inﬂammatory pro-
ducts thus conﬁned in the ear P” In a considerable number of cases, especially in
PART III. 1) n
402 DISEASES OF THE EAR.
the mucous and serous varieties, the process of absorption, either spontaneously or
by the aid of treatment, removes them before they become inspissated.
But the collections of muco-purulent or purulent products have usually a longer
history, as the large proportion of chronic purulent cases in my 1,000 cases of ear
disease shows. We must, of course, exclude those cases in which the morbid pro-
cess has been limited to the readily accessible part of the tympanum, and where
the opening in the membrane has been suﬁcient to give free exit to the secretion.
In such cases, which are usually readily cured, nothing more than local injury to
the organ is likely to ensue. We must also exclude those cases where, by the aid
of appropriate treatment, the inflammatory products have been effectively cleared
out of the upper part of the tympanum and the antrum mastoideum, and the
secreting process stopped. This is a desirable result which might be gained in a
large number of cases, if Such cases were brought under treatment. Excluding all
those in which such favourable terminations are happily attained, there is a large
number left, in which, if no other fatal complication, such as pyaemia, supervene,
the accumulated inflammatory products in course of time inspissate, and become
converted into cheesy masses. This change is most likely to take place after the
active secreting process has ceased in the seat of the collection. These cheesy
masses may remain, and probably often do remain, in the inaccessible parts of the
ear for a life-time without provoking any disturbance of the organism. But is it
not possible that they may at any time soften, and then,'becoming absorbed by the
blood-vessels or lymphatics, they may constitute the virus which reveals itself in a
general tuberculosis or in a local tubercular meningitis P
Just as the presence of decomposing purulent matter does not always produce
pyaemia or septicaemia, so the presence of caseous collections in the cavities of the
ear excites tubercular disease only in certain persons or under certain conditions.
Dr. Hamilton says the caseous matter must soften before the virus is elaborated.
According to Cohnheim’s view, the caseous matter is converted into tubercular
matter by the action of certain particles from the air, and then absorbed, just as
bacteria from the air acting upon pus convert it into a virus which when absorbed
produces Septicaemia. In any case, when caseation takes place the absorption
of the caseous matter is more likely to take place in scrofulous individuals. It.
has been said that tuberculosis is built up almost without exception upon scro-
fula as a basis, and that scrofula is one of the chief etiological factors in tuber~
culosis of the pia mater. Probably the absorption of the caseous matter converts
scrofula into tuberculosis.
Apart from this, we may reasonably conjecture that all conditions or circum-
stances which tend to depress the vitality will add to the danger of these collec-
tions, Such as bad hygienic conditions, the irritation of dentition, diarrhoeas,
colds, badly ventilated apartments, improper food, especially infants fed through
the bottle. In these circumstances we may suppose that, with cheesy collections
in the ear, a child is more exposed to tuberculosis of the pia mater than a child
brought up under more propitious circumstances.
Having seen how the peculiar structure and conditions of the middle ear make
it a probable source of tuberculosis, through the absorption of caseous matter col-
lected there, I have now to inquire whether tubercular meningitis, of the child
especially, may not frequently have its source in caseous collections in the middle
ear. Exudative catarrhs of the middle ear are extremely frequent in children.
Associated in their origin, as these conditions of the ear frequently are, with ex-
anthematous diseases, their frequency in childhood might be expected. Of the-
DISEASES or THE EAR. 403.
400 cases of chronic purulent disease of the middle car which I have already
referred to, in no less than 320 the diseased process had begun at an age under ﬁfteen
years. But the frequency with which such cases come under the notice of the‘
family medical attendant, or of the aural specialist, does not fully or correctly
represent their actual frequency. Thus, of 24 unselected children, under 3% years,
whose temporal bones were examined after death by Von Trtiltsch, the middle car
was found normal in only 9, or in 38 0/O. In ﬁfteen of these there was a collection of
pus and mucus in thetympanum and antrum mastoideum, without any perforation
of the membrane. Of eighty children examined by Wreden, of St. Petersburg, the
middle ear was found normal in only 17% 0/o; and again, of 300 children examined
by Kutzchariany, of Moscow, the middle car was found normal in only 25 C’/o.
Now we all know that tubercular meningitis is pre-eminently a disease of early
life. Is there any causal connection between the frequency of tubercular menin- '
gitis in early life and the frequency of exudative catarrhs of the middle ear at the
same period of life? If the caseous hypothesis of tubercular infection be true, there
can be little doubt that there is such a connection. On this subject, Dr. Coats says,
“ We meet with a local tuberculosis of the brain, but where the virus comes from
I do not know. It certainly does not come from a caseating centre, so far as I
can discover.” On the other hand, Dr. Hamilton says, “ There is, I say it unre-
servedly, in those cases of so-called isolated tubercular meningitis, invariably,
either in the brain substance, the bone, or the encephalic membranes, a cheesy
deposit, which usually has an ordinary inﬂammatory origin.”
In the pathological work by Jones and Sieveking, we ﬁnd that meningeal
tubercle is fouiid, only in the rarest cases, to be the original morbid process. The
antecedent disease is not always, however, tubercle of other organs, but it may be
any form of degeneration or scrofulous inﬂammation, or anything which results in
the formation of caseous masses.” Again, in Ziemssen’s “ Cyclopaedia,” we ﬁnd that
“in the immense majority of cases of tubercle of the pia mater, a cheesy focus
exists in the body ;” also, in the same work, we ﬁnd that “ miliary tuberculosis of
the pia mater is part of a general speciﬁc disease or absorption or infection, which-
has the same relation to the cheesy focus as pyaemia has to a centre of decom-
position.
Supposing we have such a cheesy focus in the tympanum and antrum
mastoideum of the child, on one or both sides—and they are generally on both.
sides—how may the virus be transmitted to the pia mater?
In infancy and childhood the mucous lining of the middle ear is very intimately
connected with the interior of the cranium. There is at that time a considerable
ﬁssure in the roof of the middle car, through which a large prolongation of dura
mater, with vessels and nerves, passes from the interior of the cranium to the
interior of the middle car. In this way the middle ear, in childhood, may be
looked upon as in direct communication with the meninges of the brain. Other
gaps often exist in the roof of the tympanum and antrum mastoideum, and at such
gaps the mucous membrane and the dura mater are in direct contact.
Thus the seat of the deposition of tubercle in tubercular meningitis is very near
to the seat of the caseous centre in the car.
When the infective matter is in the neighbourhood of the tubercular for--
mation, it is usually believed that the medium of absorption and transmission
is by the lymphatic vessels. The pia mater is extraordinarily rich in lym-
phatic vessels, and the tubercular growths are found on the inner surface or
endothelium of these vessels. These lymphatic channels surround and enclose the
n D 2
404 DISEASES OF THE EAR.
very numerous small arteries which ramify in the pia mater before they enter the
substance of the brain. All the blood vessels of the brain are accompanied by
these lymphatic vessels, or, as they are called, perivascular sheaths. Now, the
internal auditory artery, the terminal branch of the basilar, which ramiﬁes in the
pia mater, close to the favourite seat of the tubercular deposits, inosculates freely
with the stylo-mastoid artery, which furnishes the main arterial supply to the
mucous membrane of the middle car. In this way there is a ready lymphatic con-
nection between the middle ear and the pia mater. Again, my friend, Dr. Adams,
Demonstrator of Anatomy to the Glasgow University, shows, in a recent able and
suggestive article in the Glasgow Medical Journal, how communication by the
veins may take place between the middle ear, the brain, and its immediate
covering, the pia mater.
Undoubtedly the great richness of the pia mater in lymphatic vessels must
render it a likely place for the tubercular deposition. The infective agent, carried
by the lymphatics, say from the ear, acts as a speciﬁc irritant upon the endothe-
lium of the lymphatic vessels, and we have as a result the formation of miliary
tubercles.
Why does the tubercular formation show a preference for the base of the brain P
In the frequency of caseous formations in the middle ears of children, intimately
connected with and close to the base of the brain, may we not have an explanation
of the otherwise mysterious preference of tubercle, at that period of life, for the
base of the brain.
We know that there is a channel, be it by lymph vessels or by blood-vessels, by
which matter absorbed in the car may reach the brain even when healthy tissue
intervenes. Practical experience and observation in the cases of cerebral abscess,
consequent upon disease of the ear, give too many examples of the possibility of
such a means of communication.
We have now advanced reasons for believing that in caseous collections in
the middle ear we have a likely source of tubercular disease, and especially of
tubercular meningitis. The question which now awaits an answer is, Do prac-
tical experience and observation conﬁrm our d priori reasoning?
Undoubtedly in the examination of the middle ear after death in persons who
have suffered from chronic purulent disease of that part, caseous debris is fre~
quently found to occupy the cavities of the middle car.
So, far, however, as my reading has extended, I do not ﬁnd any pathologist
referring to this region as a source of the caseous ‘virus. I have little doubt that
the cause of this strange omission is to be found in the unfortunate indifference
still shown in the profession towards the subject of disease of the organ of hearing ;
Professor Von Troltsch, however, the accomplished aural surgeon, of Wiirtzburg
related in Virchow’s Archiv, so far back as 1859,* three cases of acute miliary
tuberculosis occurring in persons who had suffered from chronic purulent disease of
the middle car. At that time he suggested, before he was aware of Buhl’s writings
on the auto-infection of tubercle, that some cases of tubercular disease might be due
to the absorption of inﬂammatory products collected in the car. He asks the
question, “ Whether many cases of suddenly beginning and rapidly coursing tuber-
culosis might not generally be due to an infection of the blood from a purulent
collection at some part of the body?” It is also remarked by him, that in tracing
the history of patients who have had otorrhoea, he has observed that many of them

* Virchow’s Archiv, Bd. xvii. Section xiv. xv. and xvi.
DISEASES OF THE EAR. 4.05
die young. In such he found that tubercular meningitis, or tuberculosis of the lungs,
or of the bowels, was generally the causes of death. Again, my friend Dr.
Finlayson, Physician to the Glasgow Western Inﬁrmary has shown me his papers
hitherto only published in the form of an abstract,* containing notes of two cases
in which death from miliary tubercle took place in children suffering from chronic
purulent disease of the car. In one of these there was a chronic local tuberculosis
giving rise to hemiplegia as well as the more acute affection which terminated life.
A case is also reported in the Archives of Otology for March of that year by H.
Steinbriige, of Heidelberg. It was that of a boy, ﬁve years of age, who in course of
treatment directed to the evacuation of purulent collections in the mastoid cells
was seized with symptoms of intracranial mischief terminating in death. The
autopsy revealed tubercular basilar meningitis. No direct transmission of the
morbid process to the brain could be discovered.
The following case has recently come under my own observation. A. B., a boyr
seven years of age, was brought to me suffering with a purulent discharge from
the right ear of four years’ duration. There had also been a discharge from the
left ear, but this had ceased. The discharge dated from an attack of scarlet fever,
when three years of age. The deafness had been so considerable as to interfere
very much with the articulation and intonation of the boy. He was, nevertheless,
remarkably smart and intelligent. He had not been, however, very robust, and
had suffered seriously from the scarlet fever.
On examination I found a polypus protruding from the right internal auditory
meatus. In the left the membrane was perforated but there was no secretion.
In the course of treatment it was found that there were three polypi, which
had grown from the upper and back part of the tympanic cavity, and the posterior
half of the membrane was destroyed. The discharge was evidently coming in
great part from the antrum mastoideum and from the upper part of the tympanum.
After three months of treatment the polypi were eradicated and the purulent
secreting process put an end to. The hearing was markedly improved, and as a
consequence the articulation and intonation became also markedly improved. He
had gone to school and was progressing satisfactorily. To the inexpressible grief
of the parents, and to my own painful disappointment, these gratifying results
were only for a short time enjoyed, for a deadly disease quickly brought the boy’s
life to a close. Three months after the treatment for the purulent disease of the
ear had ceased, the boy began to complain of pain in the head, followed in a day
or two by vomiting and pyrexia. Without recounting all the symptoms and course
of the illness, suffice it to say that the boy died in three weeks from the onset of
the disease of what was regarded by the consulting physician who watched the
case as tubercular meningitis. I saw the boy the day previous to his death. He
was then comatose with abdomen collapsed and to all appearance in the last stage
of tubercular meningitis.
When we consider such features in the history of this case as the duration and
source of the discharge, it is almost certain that the antrum mastoideum and the
other mastoid cells were occupied with purulent mucous and epithelial débris
This débris would be retained, for the reasons already described, and in course
of time would probably caseate, then soften, constitute the virus, which, carried
by the lymphatics to the pia mater, produced an eruption of tubercles.
No doubt there have been many other cases observed in which tubercular

* Cases of Hemiplegia in Children : British Medical Journal, April 30, 1870.
.406 DISEASES oE THE EAR.
meningitis or acute miliary tubercle occurred in persons who were suffering from,
-or had been suffering from, exudative disease of the middle ear.
In all such cases, however, it may be fairly urged that the existence of the
disease in the ear is a mere coincidence, having no etiological relation to the tuber-
cular disease. Or it may be reasonably maintained that the disease in the ear
is a manifestation of the same constitutional tendency which produced the tuber-
cular disease, that, in fact, instead of being the cause of the tubercular disease,
the ear disease is the result of the tubercular tendency in the system.
I can only say, in answer to these objections, that in the light of the views of
the etiology of tubercular disease which are held by some of the most eminent
pathologists of our time, it seems probable to me at least, that the tubercular
disease may, in many of such cases, have a sequential relation to the disease in
the ear. ‘
Unfortunately, in consequence of this part of this body being usually ignored
‘by the pathologists in post-mortem examinations, the condition of the middle ear
is rarely ascertained after death from acute miliary tubercle or tubercular menin-
gitis. Unfortunately, also, the examination of the state of the ear is generally
omitted during life by the physician.
I think, gentlemen, I have at least made out a case for the necessity of further
investigation. In order to remove this matter from the region of reasonable con-
jecture to that of certainty, we require the aid of the pathological anatomist and
the practical physician. The presence or absence of caseous collections in the
middle ear should be made an important point for investigation in the case of per-
sons who have died from tuberculosis, and especially from tubercular meningitis.
Perhaps the missing link in the chain of evidence for the caseous theory of tuber-
culosis may be found here. -
By the method suggested by Dr. Foulis, in the British Medical Journal for
‘Oct. 16, 1880, the middle ear may be examined with sufficient minuteness to Show
the presence or absence of caseated inﬂammatory products, in the space of two
minutes. The routine examination of the ear in the post-mortem room is, by this
method, rendered simple and expeditious.
I have prepared these imperfect observations, partly with the hope of stimu-
lating discussion here, and of thus hearing the views of my professional brethren
on this most important subject. But in preparing this paper, I have also enter—
tained the hope that the ventilation of this subject might contribute, in some de-
gree, to increased attention to the organ of hearing, whenever acute miliary tuber-
culosis, and, especially, whenever tubercular meningitis comes before the physician
*or the pathological anatomist.
Knm/amgeschz'c/zz‘e zma’ Secz'z'oméefuna’ ez'nes cm Carcinoma mm
mm’. ea‘ Laéym'm‘k dem‘. versz‘oréenm 47-jzzﬁ1/zgm Ma'm/zes.
Prof. ADAM POLITZER, Vienna.
I. KEANxENeEscHIcHTE.
H. S. wurde nach langerer ambulatorischer Behandlung am 30. December 1879
mit Otit. med. supp. chron. c. perf. m. t. et polyp. dxtr., sowie einer haselnuss-
grossen Geschwulst hinter dem Ohre aufgenommen. Nach Entfernung des Po.
lypen besserte sich der Zustand des Patienten derart, dass er am 4*. Februar 1880
nIsEAsEs OF THE EAR. 4o 7
gebessert entlassen wurde und wieder in ambulatorische Behandlung trat. Rasche
Vergriisserung der Geschwulst hinter dem Ohre, Zunnahme der Otorrhoe, begin-
nende Driiseninﬂltration machten die Wiederaufnahme des Patienten nothwendig,
besonders da Patient eine Operation wiinschte.
Stat. praes. am, 15. April 1880 : Hiihnereigrosse, gelappte, unebenhiigelige,
ﬂeischrothgefarbte Geschwulst, mit stinkendem Eiter bedeckt. Hervorwuchernde
Parthien des Neoplasmas im Gehiirgange, starke Otorrhce, Eiterretention, leichte
Facialparese, die Ohrmuschel weit vom Kopfe abstehend.
Incision hinter und ober der Ohrmuschel; Entleerung eines bedeutenden Quan-
tums stinkenden, dicken, blutigen Eiters. Erleichterung des Zustandes. Deutliche
Facialparese.
Die microscopische Untersuchung der Geschwulst ergibt die Diagnose: Car-
cinom. -
In den folgenden Tagen tritt collaterales Oedem der Augenlider auf. Con-
stantes Wachsthum des Neugebildes hinter dem Ohre. Heftige Schmerzen. Mor-
phininjectionen.
Am 13. Marz erscheint Patient hinfallig, somnolent. Uebergang der Facial-
parese in Paralyse. Entfernung neuer Wucherungen aus dem Gehdrgange.
Am 19. Marz tritt Erysipelas fac. der rechten Gesichtshalfte auf, welches sich
bald iiber die behaarte Kopfhaut ausbreitet mit Oedem der betreffenden Haut-
parthien. Temperatursteigerungen bis iiber 39°. Erst am 22. Marz beginnen
Erysipel und Oedem abzunehmen und sind am 31. dieses Monats vollkommen ge-
schwunden.
Am '7. J uni wird Patient auf Verlangen ungeheilt entlassen und in’s Rudolfs-
spital transferirt, von wo er Anfangs Juli 1880 in das allgemeine Versorgungs-
haus transferirt wurde.
Als ich den Kranken daselbst zum ersten Male untersuchte, fand ich denselben
vollkommen soporcs, weshalb eine Priifung der Htirfunction unmtiglich war. Die
Neubildung hinter dem Ohre war in grosser Ausdehnung exulcerirt, an der ausseren
Ohrotfnung wucherte die carcinomattise Masse stark hervor.
Am 6. Juli 1880 trat der Tod unter Erscheinungen von Hirndruck ein.
‘II. SECTIONSBEFUND DES H. S.
Nach Entfernung der Ohrmuschel zeigt sich cine vom vorderen Itande des proc.
mast. bis zum hinteren Rande des Jochfortsatzes reichender etwa 6 Cm. grosser
Knochendefect, welcher von einer hirnmarkahnlichen Masse ausgefiillt ist. Nach
oben ist der Knochendefect durch einen fast horizontal laufenden, dem oberen
Rande des kniichernen Gehtirganges entsprechenden, ausgezackten Knochenrand
begrenzt. Die ausseren Parthien der unteren und vorderen Wand des kntichernen
Gehiirganges zerstort. Der Warzenfortsatz selbst ausserlich unverletzt.
Die Dura mater iiber dem Tegmen tymp. von der Neubildung in der Ausdehnung
von circa 5 Om. durchbrochen, von wo aus die, den ganzen Trommelhohlenraum
ausfiillende N eubildung gegen die Schadelhﬁhle wuchert und an der unteren
Elache des rechten Schlafelappens eine tiefe Depression bewirkt. In der Um-
gebung der Durchbruchstelle am tegmen tymp. ist die Dura in grosserer Aus-
dehnung durch die Krebsmasse vorgewiilbt.
Die pars pyramidal. des Schlafebeines ist vollkommen beweglich durch Substi-
tuirung des, mit dem Schlafetheile sic verbindenden Knochens durch Krebsmasse.
Die unteren Parthien des sin. sigm. sind von Krebsmasse inﬁltrirt, die intima selbst
vorgebaucht, ohne Erscheinungen von Phlebitis.
408 - DISEASES or THE EAE.
Trommelfell gestört, desgleichen ein Theil des Trommelfellpelzes ; der l/Varzen-
fortsatz ist nach innen cariös, misfärbig. Die Pyramide nach hinten ebenfalls
cariös und misfärbig, die Trommelhöhlenwand derselben von Krebsmasse ver-
drängt, nur die hintere Wand derselben ist erhalten, das Ganze gegen die übrigen
Theile leicht beweglich.
lII. DIE MICROSCOPISCIIE UNTERSUCHUNG DES LABYRINTHS.
Nachdem die zum Theile carcinomatös degenerirte Pyramide durch mehrere
"Wochen in Ohromsaure unter Zusatz von Salpetersaure decalcinirt und später in
Alcohol gehärtet worden war, wurden senkrecht auf die Längsaxe der Pyramide
von vorne nach rückwärts microscopische Schnitte durch die Schnecke, den Vorhof
und die Bogengänge geführt.
Die der Trommelhöhle zugewendete Spitze der Schnecke war durch krebsige
Destruction der inneren Trommelhöhlenwand eröﬂnet, wodurch die Krebswuche-
rung in das Innere der Schnecke eindrang.
Die Lamina spir. in der zweiten und letzten W'indung ist stellenweise durch—
brochen und sowohl die Scala tymp. wie die Scala vestib. durch gruppenweise
angehaufte Krebszellen zum Theile ausgefüllt, welche theils an der äusseren
Schneckenwand, theils an der Lam. spir. und dem Modiolus aufsitzen.
Von besonderem Interesse ist der Befund in der ersten Schneckenwindun g, hier
sind die Lam. spir. ass. e. membr. intact. An der Scala vest. sieht man an beiden
Durchschnitten an der ausseren Schneckenwand eine Gruppe ‘von Krebszellen,
welche sich bis in das Corti’sche Organ erstrecken. Die Scala vest. von der einen
Seite ist ganz frei, an der anderen Seite hingegen sieht man den Durchschnitt
eines von der ausseren und unteren Schneckenwand ausgehenden, gelappten
Krebsknotens, welcher fast zwei Drittheile der Scal. vest. ausfüllt. Quer durch
denselben zieht ein Bindegewebsstrang, welcher mit der von der inneren Schnecken-
wand losgelösten Bindegewebsauskleidung zusammenhängt.
An einzelnen Schnitten lasst sich ein Durchbruch der Krebsmasse in den inne-
ren Gehörgang constatiren. Der Vorhof war ebenfalls von der Trommelhöhlen-
seite arrodirt, die hautigen Gebilde desselben jedoch meist intact. Desgleichen die
Bogengänge, welche stellenweise von einer homogenen, lichten Masse ausgefüllt
und umschlossen waren.
Same Diﬁienlz‘ies in Me Diagnosis, Prognosis, and
Ti/eaz‘neenz‘ of Middle Ear Deafness.
Dr. P. MCBRIDE, Edinburgh.
My present purpose is to lay before you, in as few words as possible, some of the
diﬂiculties which beset us in the diagnosis, prognosis and treatment of some cases
of that middle ear affection which is by Roosa most aptly and appropriately
designated proliferous inﬂammation of the tympanum.
Although I cannot perhaps throw much light upon the question, yet I trust
that by carefully stating what seems to be the present extent of our acquaintance
with this subject, and by calling attention to apparent gaps in it, this paper may
lead others, who are possessed of riper experience and greater knowledge, to a state.
ment of their views concerning a form of ear disease which cannot be said to be
fully discussed in any of our standard works.
DISEASES OF THE EAR. 409
The term “ proliferous inﬂammation ” is necessarily a wide one, and is meant to
contain a large number of cases with which we are not concerned here, and where
the diagnosis can be made with tolerable accuracy, as in adhesion of the tympanic
membrane and malleus to the labyrinthine wall of the drum, or between the mem-
brane and long process of the incus. It may, therefore, be well, before going further,
to deﬁne the form of middle ear disease which it is more especially intended to
discuss in this paper.
It is to those forms of deafness in which all the facts we can obtain from an
examination of the organ of hearing are of a purely negative character, and in which
we are called upon to form a diagnosis without any positive data, that I would
invite your attention.
In these cases, the patients when they present themselves for examination are
usually decidedly deaf, but occasionally the symptom most complained of is tinnitus ,
and the impairment of hearing has not yet become so great as to interfere with
ordinary every-day pursuits. However, it is not so much of history and symptoms,
as of the results of physical examination, that it is proposed to speak.
On ascertaining the amount of deafness in any case, the ﬁrst object of the sur-
geon is generally to ascertain whether the hardness of hearing be due to changes
in the sound-conducting, or sound-perceiving portion of the ear. Let us suppose
that the practitioner has convinced himself of the fact that deafness is due to a
lesion in the external, or middle ear, by the results obtained from applications of the
vibrating tuning-fork to the cranial bones or teeth, his next object is to ascertain
its nature. With this end in view he proceeds to inspect the meatus and tympanic
membrane.
In a few cases of chronic non-suppurative middle ear disease, the condition of
the former may afford a slight clue to the discovery of the exact nature of the
lesion. Thus if we ﬁnd the walls of the bony canal in a state of hyperostosis, the
possibility, at any rate, occurs to one’s mind of a similar state of matters in the
tympanum; but the cases of middle ear catarrh which produce changes in the
external auditory passage are the exception rather than the rule.
Turning now to the inspection of the tympanic membrane, we may also here ﬁnd
no changes to account for the presence of deafness. I cannot help thinking that
from any large aural clinic a number of cases could be collected of middle ear
deafness, where the appearances of the membrana tympani are, to put it moderately,
not inconsistent with the presence of perfect hearing power. In a large number of
cases of proliferous inﬂammation, changes are met with in the drumhead. It is
frequently more or less indrawn from obstruction of the Eustachian tube, or it may
be evidently thickened, and its mobility shown to be impaired, by using Siegle’s
pneumatic speculum; but there are also cases in which the membrane is, to all
intents and purposes, normal, and in which we can draw no conclusions whatever
from its appearance. There is no doubt that in many cases we ﬁnd what may be
considered a perfect membrane with the exception of an irregularity in the outline
of the malleus which Von Troltsch thinks may be due to ossiﬁcation of its cartil-
aginous capsule; but although this appearance is frequently met with in cases of
proliferous or dry catarrh, its meaning must be demonstrated, post-mortem, before
we can attach to it characteristic signiﬁcance, and besides, even this slight change
is by no means always present.
In those cases where the tympanic membrane is normal in colour, mobility, and
position, we not unfrequently ﬁnd the patient able to perform Valsalva’s experiment,
and auscultation, while air is blown through the Eustachian catheter, shows the
410 DISEASES OF THE EAR.
tubes to be open and free from mucus. Injection of air into the middle ear,
however, in cases of proliferous inﬂammation such as we are considering, generally
fails to produce the slightest improvement in hearing. Some authors are inclined
to attach considerable importance to the presence of inspissated mucus in the
tympanum as a factor in the production of symptoms and signs resembling those
of proliferous inﬂammation; but, in cases where the deafness was distinctly due
to this cause, Mr. Hinton seems to have been able to produce distinct, though
transient improvement, by means of the air douche, and in patients whose histories
he records the presence of the hardened mucus was generally due to a number of
attacks of subacute catarrh. Besides, in many cases inspection rendered the
existence of a foreign body in the tympanum probable, if not certain. Dr. Woakes
has recently described a group of cases in which deafness occurs without any
changes in the tympanic membrane, and is due to paresis of the tensor tympani.
Paretic deafness is characterized, according to this author, by a pendulous state of
the soft palate, ill deﬁned faucial pillars with local anaesthesia and often inability
to perform Valsalva’s experiment. From these conditions he diagnoses paresis of
the palate muscles, and assumes a similar condition of the tensor tympani.
Granting, however, that Dr. Woakes’ explanation of middle-ear deafness, without
characteristic changes in the membrane, may account for a certain proportion of
cases, there yet remain others in which we have no signs of palate paresis. To
Dr. I/Veber-Liel’s “Progressive Schwerhorigkeit” I need not refer, for, as I under-
stand it, in this form of disease marked deafness only results from secondary well
marked changes, of which some are due to retraction of the tensor tympani, while
others are of an inﬂammatory nature.
It would be most desirable for aural surgeons to come to a deﬁnite and
unanimous understanding of their position with regard to cases of middle ear
deafness where there are no physical signs and, of course, no characteristic changes
in the tympanic membrane. Among the latter we can hardly include localized
patches of opacity. In chronic non-suppurative middle ear diseases there may be
indrawings of varying degree, changes from the presence of ﬂuid exudation in
tympanum, atrophic patches, cicatrices, ormarked thickening and immobility of the
drumhead. Of course, in the presence of any one of these conditions, more or less
positive conclusions may be drawn ; but I venture to think that there are many
cases in which, even if the membrane be not quite normal in colour or lustre, its
condition affords us not the slightest assistance of a positive kind.
There are cases, and those not very few, in which the results of objective
examination are purely negative, and diagnosis must be based solely on the
subjective sensations of the patient—via, deafness for sounds conducted by aerial
vibrations, uninﬂuenced by the air douche, and increased perception of sounds
which are conducted directly to the labyrinth through the cranial bones, as shown
by the tuning-fork test. In such cases we are justified in assuming that the
deafness is due to intra-tympanic changes, and from what pathology has revealed,
we must probably assume the presence of one or both of the following conditions :-
1.—Thickening or proliferation of the mucous membrane—most likely an
increase of its ﬁbrous or connective tissue elements.
2.——-Thickening or new deposit of bone, or ossiﬁcation of cartilage.
It is evident that, as a result, there may follow anchylosis of the ossicles, or
impaired mobility in their joints and the membrane of )the fenestra rotunda; but
whether the lesion be at the malleo-incudal joint, or at the attachment of the
stapes to the fenestra ovalis, whether the incus be anchylosed at its attachment
DISEASES OF THE EAR. 41 I
to the tympanic wall, or a ﬁbrous plug ﬁlls the round window, we cannot tell.
All we are justiﬁed in assuming, in many cases, is that one or other of these
conditions is present. The late M12. Allen, I know, made an attempt to localize
tympanic lesions from symptoms, but some of his assumptions in physiology
require further proof. It is possible that very strong evidence in favour of
anchylosis‘ of the stapes may be furnished by Bing’s method, which consist, in
comparing the hearing power for sounds conducted through the Eustachian catheter
with that for sounds, conducted into the meatus by means of an ordinary speaking
tube ; but the practical application of this method—although its theory is good—
must yet be considered as on its trial. Hearing better in a noise Politzer is inclined
to associate with a ﬁxed stapes, but opinion is still divided as to the meaning of
this symptom. As far as I can judge, from a limited experience, proliferous inﬂam-
mation may owe its origin to various causes. '
1.—-In the ﬁrst place it may exist as the remains of a catarrhal process, which
has originally extended from the throat along the Eustachian tube to the middle
ear. The former may have recovered its lumen, and the tympanic membrane its
position, but deafness persists. In such cases the drumhead is generally more or
less opaque, and the bright spot changed in shape, but still there may be no
appearances present which are inconsistent with good hearing power.
2.—-Then again, a process, ending in very considerable or even total deafness, may
have its beginning and end in parts which are inaccesible to examination by either
inspection or auscultation, as for instance the labyrinthine wall of the tympanum.
3.-—In syphilitic patients we occasionally have evidence of the rapid formation
of intra-tympanic adhesions, or proliferation of tissue. This fact has also been
observed by others. To quote from Roosa: “There are no peculiar aural symp-
toms by which we may positively distinguish a case of chronic disease of the
middle ear that was caused by syphilis from one occurring in a non-syphilitic patient,
yet we may say in general that a syphilitic diathesis seems to cause proliferation
of tissue to be more rapid and less amenable to treatment. “ Schwartze,” he goes
on to say, “ believes that the pathological change in these cases is a periostitis, and
this view seems to be correct.” From the observation of several cases of middle
ear deafness, occurring in the course of syphilis, I am strongly inclined to endorse
this view. I cannot help thinking that, where marked middle ear deafness, without
any acute symptoms, has come on with great rapidity and where inﬂation of the
middle ear fails to improve the hearing, we ought carefully to examine for evidence
of a speciﬁc taint, and that in many such cases we shall ﬁnd it. It would be
interesting to know whether the experience of others points to any such connection
of symptoms, as affording presumptive evidence of a speciﬁc process.
Now if syphilis has a speciﬁc effect upon the middle ear, the question may fairly
be asked whether other diatheses may not also produce tympanic changes. In the
tympanum we have a large variety of tissues and the parts are so situated that a
very little lesion may produce the most disastrous results. The mucous membrane
of the tympanum is a double structure. Its outer layer is mucous membrane, but
its deeper parts are periosteum. It is then liable to be attacked, not only by catarrh,
but also by periostitis. The joints of the ossiclcs are tolerably complete in their
structure, having the same constituents as oints situated elsewhere, and there seems
no good reason why they should not be involved in arthritic diseases. Indeed, Dr.
Buckler, in 1853, called attention to the fact that chronic rheumatism may involve
. the ossicular joints. Of the value of his observations I have no means of judging,
as I have been unable to obtain the original work; but as gout, rheumatism, and
412 DISEASES or THE EAR.
rheumatoid arthritis attack other joints throughout the body, there seems no reason
why those of the auditory ossicles should enjoy any special immunity. I am not
aware that any recent observations on this point have been made, although
Toynbee attached importance to the arthritic diathesis as a cause of anchylosis of
the stapes.
The diagnosis of middle-ear deafness, with negative appearances on the tympanic
membrane, is not always either easy or satisfactory. In cases where there are no
objective signs to guide us, the ﬁrst diﬂiculty is to make out whether the deafness
be due to middle ear disease or to changes in the sound-perceiving apparatus. For
this purpose we are entirely dependent upon the tuning fork test. Where the latter,
applied to the middle line of the head, is heard best in the deafer ear, and where
its vibrations are perceived for a normal length of time we may fairly assume that
the sound-conducting apparatus is at fault; but where perosseal audition is
defective, we meet with considerable difliculty.
It is admitted on all hands that, after the age of ﬁfty, inability to hear the
vibrating tuning-fork placed on the cranial bones is so common that the symptom
loses its value. Now it seems to me extremely doubtful whether we have any
reliable means of distinguishing proliferous middle-ear disease with open Eustachian
tubes, and normal membranes, from chronic changes in the internal ear, or auditory
nerve, occurring in persons of advanced years. The question may, I believe, be
considered an open one whether pathological conditions, which produce an unyield-
ing condition of the stapes and membrane of the fenestra rotunda, may not in them-
selves cause impaired hearing of sounds conducted through the cranial bones; and
this does not at all simplify our diagnostic problem.
However, in cases where, by means of the tuning-fork test, we are enabled to
localize the cause of the deafness in the middle ear, and where there are no changes
to guide us in the drumhead, we usually conclude that the lesion belongs to the
class of proliferous inﬂammation when we are unable, by several successful inﬁa-
tions of the tympanum, to produce any improvement in the hearing power. This
shows that the pathological condition is of such a kind that it is not inﬂuenced by
the mechanical action of the air douche- In some cases the probability is that
there is ﬁxation of the stapes, but this can at best be only a conjecture. The unfor-
tunate fact remains that there are many cases in which we cannot know anything
more exact, concerning the morbid condition we are called upon to treat, than that
there is, in all probability, a thickening or new formation of bone or ﬁbrous tissue
which interferes with the sound-conducting mechanism.
In the face of these ditﬁculties, what is to be said of prognosis and treatment?
It is far from my purpose to enter into all the various methods of treatment that
have been tried in proliferous catarrh. I shall content myself with alluding to
some of them in a general way. We have in these cases, as I have attempted to
show, to deal with new formation of bone or ﬁbrous tissue, obstructing the move-
ments of parts concerned in the act of hearing. We require to get rid of these
adventitious tissues to effect a cure. By applying our reason to this problem,
we ﬁnd that the means at our 'disposal resolve themselves into (1‘) operative ;
(2) therapeutic.
I do not think that the former is ever likely to recommend itself to the majority
of the profession in cases of the kind we are discussing. In the present state of
our knowledge, the serious and not always harmless operation of myringotomy,
would have to precede any other step—in other words, an operation for the purpose
of diagnosis must be undertaken before attempts at severing adhesions are made.
DISEASES or THE EAR. 413
Therapeutic treatment must have for its object the absorption of the impeding
bone or ﬁbrous tissue; in some cases, more especially where there is a syphilitic taint,
constitutional remedies are used to produce this result; but by most surgeons
most reliance is placed upon various local applications to the tympanum (besides,
of course, treatment to the naso-pharynx where this is indicated).
Some authors seem to think that drugs, such as very weak solutions of iodide
of potassium, corrosive sublimate, &c., injected into the tympanum produce each
a speciﬁc effect. Others, as, for instance, Griiber, adopt the more probable view
that where these substances produce an effect, it is by exciting a slight inﬂam-
mation, and in this way producing absorption.
For my own part, I cannot help thinking that, even adopting this latter
theory, it is very diﬂicult to understand how fully organized ﬁbrous tissue comes to
be absorbed in this way. In the early stages of its development, however, before
the round cells have assumed a spindle form, it is comprehensible that absorption
should take place. Whether fully developed cicatricial tissue or bone is capable of
being made to disappear in the same way, I cannot but doubt. It seems almost
easier to believe that in those cases of old standing proliferous catarrh, when good
results follow the injection of ﬂuids or vapours into the tympanum, the beneﬁt is
due to the long continued mechanical inﬂuence of the air douche which is a
necessary accompaniment of injections through the Eustachian catheter or of the
ﬂuid itself when it is used in large quantity, as in Griiber’s method of forcing
ﬂuids into the middle car, without resorting to the latter (catheter).
0% 1/16 Prevem‘z'mz of Dzmzéness in 5/1056 cases w/zere 2'!
follows Loss of Hearing.
Mr. ARTHUR KINsEY, London.
Mr. PREsLnnNr AND GENrLEMnN,—I feel it a very high privilege indeed to be per-
mitted to submit aPaper to a Section of this most important Congress—a meeting
at which so many illustrious members of the medical profession are gathered
together from all parts of the world, to interchange ideas, principles, and forms of
practice, for the alleviation of human suffering and affliction in all their many and
varied phases.
As a layman, I should not have ventured to trespass upon the special province
of this Section—viz., “ Diseases of the Ear”—were it not in order to obtain an oppor-
tunity of inviting your careful and earnest consideration to the after-condition of
those of your patients whom you have had the sad duty to declare incurably deaf
from their earliest childhood.
To the little child this verdict appears nothing—is not heard, and is not under-
stood—but on the parents, however, is reﬂected the full force and extent of the
calamity ; and when they appealingly ask of the physician or surgeon, “ “That is
to be done with our little one now P ” it were sad indeed to think they should receive
mere words of kindly pity and commiseration, instead of cheering counsel and
practical suggestion.
To show that I am not overstating the case, I submit the following quotation
from a pamphlet published in 1877, entitled, “ Vocal Speech for the Dumb.”
“As soon as our child’s loss of hearing was beyond question, we brought her
here to London for the best medical, surgical, and educational advice. We
414 DISEASES or THE EAR.
hoped, indeed we never doubted, that we should have received the best advice about
the education of our child from those of the medical profession whom we consulted.
But such was not the case. Sad and disappointed, we turned to those who had
devoted their lives to the education of the deaf.”
Now, it is true the incident here recorded took place eleven years ago, and no
doubt a certain advance has been made since then by the medical faculty and the
general public in a knowledge of the true condition and requirements of that unfor-
tunate class of the community, so long known as the deaf and dumb—but it is
strongly to be desired that this knowledge should become universal. I turn with
pleasure to two pamphlets written by the distinguished President of this Section; one
published in 1872, wherein he expresses a hope that a fair trial might be given to
a system of education for the deaf and dumb, whereby dumbness would be averted ;
and to the second published last year, again dealing with the question of educating
deaf mutes, in which the writer says :—“ In view of their advice being asked by the
parents of deaf mutes on the question of education for such children, it has be-
come a necessity for medical men throughout the country to acquaint themselves
with the respective merits of both the old and the new systems.” I will not detain
you with a description of the two systems here mentioned beyond premising that
by the “ old ” is meant the “ French,” or sign system, and by the “ new ” the
“ German,” or speaking method. But this deﬁnition as to age is not exact—for
history tells us that the speaking system was in vogue long before any method of
Signs was introduced. However, this is a small matter, the important point
of the question being “Dumbness 1). Speech. Hitherto, in this country, up to a
very recent date, the unfortunate little one afﬂicted with deafness has grown up,
lived, and passed away in utter and lonely silence—dependent upon motions of the
hands and ﬁngers for communication with his fellow sufferers, and, to a lesser
extent, with the hearing world. Now, not to dwell upon all that is lost by
reason of deafness—Which doubtless was unavoidable—I must ask you to reﬂect
that the secondary evil of dumbness has been, and is yet, entailed through
improper treatment by those entrusted with the child’s educational welfare. Such
a melancholy state of affairs, it is fervently hoped, will cease when the medical pro-
fession protest with no uncertain voice against the continuance of deaf-dumbness,
and awake the general public to an indignant knowledge of a gross scandal existing
throughout the land. The average number of deaf mutes to the hearing population
is estimated at about 1 in 1,600; 20,000 persons being returned in the census of
1871 as deaf and dumb. It is not impossible that the returns for this year will
show an increase, from one cause or another, of over 10,000; and, taking the usual
calculation of 16 per cent. being of school age, we shall ﬁnd about 6,000 children
growing up for the most part as speechless as the animal world.
This applies to our own country. Now let us direct our attention abroad. In
most countries on the Continent—via, Germany, Bavaria, Austria, Holland,
Switzerland, Italy, and in some cases Russia, Sweden, Norway, Belgium, Spain,
and even now in France itself—the very birthplace of the sign system—we ﬁnd
dumbness practically abolished; but ‘in Great Britain, and all her vast colonies, in
the United States of America, and, in fact, in all countries where the English
tongue—or what does duty for it—is spoken, we ﬁnd the deaf child, with some
exceptions, debarred its use. Why this should be, it is difficult to understand, as
it is an evil fully to be remedied, and,’_so long as it remains, a grave reproach to
us all.
Upon this point of allowing our deaf to become dumb, Dr. Oassells, of Glasgow,
DISEASES or THE EAR. 415
one of your excellent Vice-Presidents, very pertinently asked in the Edinburgh
Medical Journal for February, 1878, “ Why, for instance, are such children in this
country permitted to grow up, not only ‘ in'loneliness of soul,’ but in absolute
silence; while, on the {Continent of Europe, they enjoy the blessings of social
intercourse, and the freedom of speech? Why are hearing children alone destined
to share the beneﬁts that ﬂow from improved educational methods, and the deaf
ones condemned to be ‘ fossilized’ by a method that seems incapable of appreciating
their destinies P”
Why, indeed? But yet, for the major part, it is so, despite the laudable efforts
of certain philanthropic persons, alas! too few. From our treatment of the mass
of the deaf, we make them dumb—and this making them dumb is productive of
further mischief.
We are well aware how the physical and mental constitution of man is affected
by modes and habits of life; how certain occupations and trades entail well-deﬁned
beneﬁts or evils, and we may in general trace these to a speciﬁc cause—via, a pure
or impure state of the blood. We may also freely admit that a perfect action of
the respiratory apparatus and the circulation is essential to that absorption of
oxygen and elimination of carbonic acid, which is a vital necessity. Fortunately
for us, Nature has wisely provided that ordinary respiration, like many other func-
tions of the human organism, is an involuntary action, but there can be little
doubt of the beneﬁcial effects of increasing respiration up to a certain point by
voluntary eﬁort, as by active exercise, speaking, singing, shouting, and laughing—-
in ordinary parlance, giving the lungs full play, and so maintaining a healthy
condition of the blood. ,
Now, this is just what does not happen in the case of the dumb. They do not
use their lungs freely in any way. Not in laughing or shouting, nor do they employ
their vocalising organs, except in moments of great excitement, to give vent to a
few most unpleasant and discordant sounds. They have little inclination, when
young, to indulge in those games so favoured by school children, and which
certainly seem (at, least in this country) specially adapted to promote healthful
respiration and circulation. So far as the deaf mutes are concerned, it would
almost appear that but for the liberal use they make of their arms and bodies in
sighing, they would have little exercise calculated to develop the chest in the
slightest degree.
We ﬁnd, further, in their case, that defective respiration occurs at the very
outset—in the inspiratory act, which is usually performed through the mouth,
instead of the nose, the latter organ being, as a rule, blocked up with mucous and
other matter.
It is unnecessary before a learned body, specially conversant with hygienic prin-
ciples, for me to dilate upon the natural results of what has just been described ;
but I should desire to adduce one or two authorities upon this point.
Dr. Harvey Prindle Peet, of New York, a man of large experience of the deaf
and dumb, in his “ Researches and Opinions,” remarked that “in the deaf there
was a liability in particular to pulmonary diseases,” and in dealing with the sta-
tistics of the New York Institution for deaf mutes (1854) stated, “ Among the deaf
and dumb, between the ages of ten and thirty, the mortality of males is about 25
per cent. greater than among an ordinary healthy population of the same sex and
ages, and that of the females full twice as great. The difference against the health
of deaf and dumb children and youth, as compared with the general popula-
tion of the same age, is but too distinctly accounted for by the prevalence of
416 DISEASES or THE EAR.
pulmonary disease among the former. The period of greatest danger being once
passed, they often attain a good old age.”
James Hawkins in his work “ On the Constitution of the Deaf and Dam ” says,
“Their average duration of life is considerably less than that of the hearing. They
are as children particularly disposed to tubercular phthisis, cerebral disease, and
scrofulous tumefactions.” Of ﬁfty-nine deaths within nine years among 850
children under seventeen years of age, forty-one were from consumption.” I
cannot afford in the brief limits of this paper, to cite further cases, but must
content myself with referring any one who may wish to inquire more closely
into the matter, to a Paper “ On the Health of Deaf Mutes,” written for the
recent International Congress at Milan, by Dr. Symes Thompson, of London, a
gentleman taking a most active part in securing for them the joint beneﬁts of
health, speech, and mental attainments. “ Mens sana in corpore sano.” scrofula
would appear frequently to be the cause of deafness, and consumption the result of
the ensuing dumbness. James Hawkins bearing upon this question says, “ The mys-
terious taint of scrofula is detected in those born deaf, and in those who lose their
hearing after birth. The majority of these who are deaf from malignant forms of fever
or cerebral diseasesbelong to families in which scrofula is idiopathic, and scrofulous
families intermarrying with other scrofulous families often ﬁnd congenital deafness
one of the many culminating effects of their imprudence.” And this scrofulous dia-
thesis, if not checked by proper diet, muscular exercise, pure air and active respira-
tion, will probably develop into one of many diseases, not the least likely of which
being consumption. So that dumbness may indirectly arise from a disease—viz.,
scrofula, through entailed deafness, and consumption being the ultimate result; if we
remove the secondary consequence of the disease, we may render the causation of
the ﬁnal and more fatal mischief in operative.
Reliable statistics concerning the deaf are difﬁcult to obtain, and I am not at
present in a position to produce ﬁgures for comparison with those already given;
but the opinion expressed by foreign teachers to me has been, that the deaf, taught
to speak, are healthier and happier than those who are kept dumb.
I will not detain you with the causes of acquired deafness, merely reminding
you how frequently deafness results from a shock, such as a fall or a blow on the
head—this should be widely known, especially among those to whom are entrusted
the education of children, for, in the present day, as the old fashioned method of
corporeal punishment is so generally discouraged, impatient, sorely-tried instructors
are apt to resort to the box-on-the-ear punishment—one to be condemned as dan-
gerous in the extreme, as rupture of the tympanic membrane or displacement of the
ossicula, and even further mischief may ensue, from what is usually considered a_
harmless form of correction. Now to the very important point—the causes of
congenital deafness. I shall limit myself to the two principal causes—via, the
intermarriage of blood relations; and, secondly, intermarriage of congenital deaf
mutes. I may mention, in respect of the ﬁrst, what is well known to you, doubtless,
that deafness is only one of the many terrible afﬁictions which may result from such
intercourse. I am quite aware that this is a moot point, and in 1875, Mr. George
Darwin read a paper before the Statistical Society on “Marriages between First
Cousins in England, and their Effects ;” from that I take the following passage :
“There is no evidence whatever of any ill result accruing to the offspring in conse-
quence of the cousinship of their parents.” Now myself having had access to many
of the sources from whence he obtained particulars, I cannot agree with the con-
clusion arrived at. A supporter of his views, in an article contained in the
DISEASES OF THE EAR. 4.17
Westminster Review, October, 1877, wishing to prove that consanguineous
marriages were harmless to the offspring, quoted from M r. Darwin’s paper,
showing how that gentleman considered such marriages productive of evil to the
amount of 4s per cent. only. The writer in the Westminster Review, however,
went further, and endeavoured to prove that not only were they non-injurious, but
‘rather the reverse, and were in particular conducive to proliﬁcness. To support
this view he quoted from a report to the American Medical Association made by
Dr. Bemiss, United States America, showing tha “ 883 marriages of consan-
guinity produced 3,942 children.” Here he stops short, leading the reader to infer
that these children were all sound and healthy. Let me ﬁnish the passage “of
whom there were defective, in one way or another, 1,034; deaf and dumb 145; blind
85; idiotic 308; insane 38; epileptic 60; scrofulous 300; deformed 98.”
In addition to which there died young, 883. ' From these ﬁgures we see that of
the surviving children, we have upwards of 50 per cent. defective in some terrible
way. Dr. Bemiss adds that after very careful examination of various asylums, he
was satisﬁed that his researches gave him authority to assume that over 10 per cent.
of the deaf and dumb, 5 per cent. of the blind, and nearly 15 per cent. of the
idiotic in the State Institutions of America were the offspring of kindred parents, or
of parents themselves the descendants of blood intermarriages.
Dr. Caspar Singer, of Vienna, estimated from statistics in 1876, that 25 per
cent. of all deaf mutes are the result of consanguineous marriages.
Dr. Dudley Peat, of New York, writing on the subject, 1856, said “Of all
known causes intermarriage is the most proliﬁc causes of predisposition to deafness.
It has been settled, beyond a doubt, that intermarriages of ﬁrst cousins, and
even some of second cousins, give rise to offspring which are generally of imperfect
development, either idiotic, blind, or deaf and dumb.”
M. Boudin, of Paris, in a Report in 1876, stated that consanguineous mar-
riages represent (in France) about 2 per cent. of all marriages, while the proportion
of congenital deaf mutes born from consanguineous marriages is to the whole
amount of deaf mutes: in Lyons 25 per cent., in Paris 28 per cent., in Bordeaux
30 per cent.
It will be noticed that these ﬁgures agree with the American and Austrian
statistics. Now to turn to the intermarriage of congenital deaf mutes. Here
again we ﬁnd opinions differing in regard to the consequences of such unions.
Heads of institutions for the deaf and dumb, and medical men connected with
them, are generally unanimous in considering these marriages productive of evil,
not perhaps so often in the ﬁrst succeeding generation, but very frequently indeed
in the second—transmitted deafness thus showing a resemblance to other forms of
hereditary defect by passing over a generation. Mr. Buxton, the late head of the
Liverpool Institution, and present Secretary to the Ealing Society for Training
Teachers of the Deaf, &c., instances the following remarkable cases. 1st. A mother
of three mute children, who was the daughter of a deaf mute; the grandfather,
though his own children heard perfectly, was one of eight deaf mutes, in a family
of sixteen; of these sixteen, half were males, and half females; four of each sex
could hear, while the other eight (four males and four females) were born deaf and
dumb. Secondly, in a family of eight, three males and one female were deaf and
dumb—— one of these deaf women afterwards being married to a hearing husband,
had two hearing daughters, each of whom, by hearing husbands, became the parent
of a deaf son.
The Rev. W. W. Turner, of _the US. America, stated at a Conference of Prin.
PART III. ' n R
418 DISEASES or THE EAR.
cipals in 1868 (after 20 years experience amongst deaf mutes), “ That every con-
sideration of philanthropy, as well as the interests of congenitally deaf mutes-
themselves, should induce their teachers and friends to urge upon them the impro~
priety of intermarriage.” Dr. Harvey Peet, already referred to, calculating the
chances of hereditary transmission of deafness, determines, in the case of both
parents being congenitally deaf, the proportion to be one in ten : one parent being‘
born deaf, the proportion falls to one in 130. The average number of cases of con‘
genital deafness amongst the children of hearing parents being as already stated}
about one in 1,600. I fear I must not dwell any longer upon this important ques-
tion, doubly important too, for the reason that the resulting mischief of the class of
marriages just alluded to has been disputed—the denial being based on the fact.
that, taking a number of marriages, the offspring are found to be in perfect posses-
sion of all the senses, from which it is argued these unions are not productive of
ill-effects; but if the examination be extended in both directions—to the more
remote ancestry and descendants, we shall most surely ﬁnd congenital deafness
apparent. Time will not allow me to deal with several points which are mentioned.
in the abstract of this paper, therefore I must crave your indulgence for passing
them over in silence. In conclusion, I should wish strongly to impress upon the
public mind, through the medical profession, that deaf-dumbness is not a defect, as
are blindness or deafness—vie, arising from imperfect organic structure, or nerve
lesion—but is simply the outcome of neglect and mismanagement. Next, that
dumbness has a marked tendency to produce or promote pulmonary disease.
Then, in regard to congenital deafness, that it is only too frequently engendered
by ill-advised marriages.
It has been well said of acquired deafness, that one of the chief causes of the
affection is owing to the increased skill of the physician—that there are fewer dead,
but more deaf, victims of malignant fever and inﬂammatory disease. Let us hope,
most fervently, that, through the eﬁects of Congresses, such as the one we are
assisting at on the present occasion, the skill of the physician may be yet further
extended, and that not only rescued lives will be the reward of devotion and science,
but lives physically perfect in all that was designed and intended by Nature.
Comment Z’Omie Scum/e m/m'oe am Cem‘re Acousz‘z'gue.
Dr. SAroLINI, Milan.
Quoique n’ayant que des idées a l’état de doute sur le sujet, je les soumets,
aﬁn que par les réﬂexions et les études des membres, elles puissent arriver a une-
théorie.
1.—-La membrane du tympan est-elle toujours passive, ou s’y trouve-t-il des
éléments actifs pour ses mouvements?
2.—-Les sons pour arriver au centre auditif nerveux doivent-ils passer a travers,
la chaine des osselets P
3.—Les sons passent-ils par la fenétre ovale ou par la fenetre ronde?
4.-—Est-ce par la rampe spirals moyenne que les sons sont appréciés P
5.—-—L’endolymphe du canal spiral est-elle isolée ou communique-t-elle avec
l’endolymphe vestibulaire?
COMMENT L’oNDE SONORE EST roR'rEE AU CENTRE.
Le son et son intensité dependent de l’intensité de l’air, au sein duquel il prend
paissance et non de l’air an sein duquel il est entendu. Par les poumons l’air est
DISEASES OF THE EAR. 4.19
expulsé, et par les grosses bronches et la trachée vient,poussé comme dansun porte-
voix dans la cavité inférieure du larynx. Dans cette cavité un premier cri ou voix
peut être produit. En traversant suivantment les cordes vocales, le son vient
informe, et c’est la que le timbre du son est constitué, voilà. le porte-voix. Par
les muscles de l’arrière bouche, qui modèlent l’onde sonore, et plus tard les muscles
linguaux innervés, surtout par le nerf dit corde du tympan, Wrisberg dit que la
parole peut être articulée et que l’éloquium se produit. L’onde sonore ainsi constituée,
et expulsée par les lèvres, co—opératrices de la parole, se trouvera encore au milieu
de l’air. Elle se trouvera donc dans le même véhicule où elle est née, et si l’intensité
de l’air et de son élasticité ne sont pas changées, l’onde sonore ne changera pas non
plus de timbre, sauf quelque dispersion latérale. L’onde sonore, semblable aux billes
d’ivoire, par un mouvement de va-et-vient, c’est-à-dire par ses condensations et ses
raréfactions, continuera bien sa course, et arrivera au pavillon et au conduit
externe. Le pavillon, avec ses multiples angles de réﬂexion et d’inﬂexion, favorise,
selon la perfection de sa facture, l’introduction de l’onde sonore dans le méatus.
La disposition et la silhouette du pavillon sont admirablement douées à. cet eiïet
et maintes considérations physiognomoniques peuvent être déduites à. propos des
penchants de l’individu—lesquels trompent rarement un observateur.
Un petit bourgeon, vous le savez, paraît au premier abord de la vie embryonnaire,
couvert par la peau—peu a peu se développe en même temps d’ailleurs que l’embryon,
par des ligaments ; le dit bourgeon cartilagineux est ﬁxé à sa place dévolue.
La lame dermoïde, douée d’éléments musculaires, couvre de près le dit cartilage,
et c’est par les attaches et les tiraillements de ces muscles que le cartilage se
modèlera en pavillon. Si nous admirons si souvent la beauté du pavillon, il faut
l’attribuer aux efforts contractifs de ces muscles. Sans les muscles héliciens
l’élégante forme estétique de son bord ne serait pas produite, et si l’anthélix est
bombé, il le doit aux muscles postérieurs et au grand et petit transverse; et si
le muscle postérieur et les supérieur et antérieur auriculaires n’existaient pas, la
conque ne présenterait plus sa belle concavité. La forme du pavillon est dictée forcé-
ment par ces attaches et par l’action de ces muscles. Si l’on prend une toile en
caoutchouc ﬂexible, coupée à peu près en ovale, et si aux lieux voulus on ﬁxe des
ligaments, on peut, par des tractions, former un pavillon qui ressemblera beaucoup
au nôtre. Rien du hasard ne se trouve dans la facture de notre corps; tout est
l’eiÎet d’une cause raisonnée.
Les ondes sonores arrivent au pavillon qui les accueille toutes et les amène a
la conque, au conduit acoustique externe, qui, impregné du même air, favorisera la
continuation de la vibration sonore; et, par les angles multiples d’inﬁexion, la conc
densation des ondes sonores s’accomplira. Le son dans ce conduit est encore
favorisé, soit par la chaleur qui se trouve au fond du méatus qui rendra l’air plus
élastique, soit, parce que le dit conduit étant ouvert à une seule extrémité, il devient
plus résonant.
L’onde sonore présente au devant d’elle une forme convexe due à. sa condensas
tion, et cette convexité touchera et poussera la membrane du tympan; et puisque
cette membrane a une concavité normale de la périphérie au centre, ainsi toute onde
se portera a son centre (qui, notons bien, n’est pas le vrai point central de la dite
membrane), et la principalement la pulsation sonore sera projetée.
L’onde sonore doit, après, transpercer la membrane du tympan, mais alors elle
perdra de son intensité qui s’aﬁ'aiblit, devant passer d’un corps léger à un solide.
La membrane du tympan.—-—En peu des mots, permettez que je détermine son
analyse anatomique. Cette membrane ovulaire est composée extérieurement par la
E E 2
420 DISEASES OF THE EAR.
couche dermoïdale, négligeons l’épiderme. Toute lame dermoïdale étant un tractus
cellulaire doit, ou peut, ‘contenir des ﬁbres musculaires ou simplement des ﬁbres
élastiques rétractiles. Cette lame dermoïdale, en s’enfonçant dans le conduit
cartilagineuxüet plus tard osseux, s’appliquera au cercle tympanique, un des os
operculaires, où elle s’enfonce et se ﬁxe dans sa rainure. Cette lame présente un cul-
de-sac, mais puisque de son bord périphérique elle se porte au centre, elle devra
exhiber des stries radiaires, qui si elles ne sont pas musculaires, sont au moins des
ﬁbres élastiques qui vont s’imbriquer soit à la pointe soit au manche entier du
marteau. La membrane du tympan est revêtue en dedans par un autre tractus
qui provient, comme Blainville nous Pa, dit, de la lame muqueuse qui, passant de
la bouche le long du tube d’Eustache, vient tapisser la cavité tympanique. Toute
muqueuse est, on peut être, composée de ﬁbres musculaires, comme l’intestinale
et la bronchiale, ainsi la page de cette muqueuse qui s’applique à la membrane
du tympan, apportera ses contingents anatomiques; ainsi la partie externe de
la muqueuse viendra en contact direct avec le côté interne de la lame dermo‘idale
externe. Mais la lame externe de la muqueuse ne pourra pas présenter
comme l’autre des rayons radiés, car elle a formé son cul-de-sac à la partie posté-
rieure interne de la cavité tympanique et par la raison que cette lame y a subi
un fort élargissement en tapissant la dite cavité, elle présentera une forme utriculaire.
Imaginons une ampoule avec un col long, étroit, qui représente le tube d’Eustache,
et que le ventre de l’ampoule naine soit comprimé sur les deux côtés opposés,
et nous aurons la forme de la cavité tympanique. Si une masse de verre en fusion
était striée par des couleurs, l’ouvrier en soufflant formerait la bouteille, sur le
ventre de laquelle nous trouverions dessinées des stries presque circulaires.
Ainsi la page interne de la membrane du tympan se présentera dessinée avec des
stries circulaires, et les deux membranes, Tune a l’autre appliquées, desquelles
se compose la membrane du tympan, ressemblera à. l’iris.
Le manche du marteau se trouve serré au milieu des mailles des deux dites
lames desquelles la membrane du tympan est composée. Revenons à. la vibration
de l’onde sonore sur la membrane du tympan: une vibration est composée de deux
moments, le premier de condensation qui convexe, frappe, ou je dirai mieux, presse
sur la membrane du tympan, et l’eﬁet immédiat sera sans doute de la pousser de
dehors _ en dedans—le second temps c’est la raréfaction, c’est-à-dire, que, à. la
convexité énoncée, succédera la concavité, et ainsi de suite, par les ondes qui se
suivent, il s’établira un va-et-vient propre à toute onde sonore lumineuse ou liquide.
J e pense que la concavité créée par la pulsation doit naturellement exciter la
réaction des ﬁbres propres de la membrane du tympan, et cela autant de fois que
l’onde sonore ou sa vibration a été vive, tandis que dans le cas de calme, la simple
raréfaction de l’onde suŒra à rétablir l’équilibre de la membrane du tympan.
CAVITÉ DU TYMPAN.
Ce n’est aucunement mon but de vous détailler la silhouette de ce boudoir,
chaque meuble qui le décore est bien connu par vous, et mon dire serait une
goutte portée à l’océan de vos connaissances, mais pour mieux en arriver a ma raison
ﬁnale et pour mieux pouvoir m’expliquer, permettez que j’en parle, fût-ce même au
risque de votre ennui.
Depuis la ligne d’attache supérieure de la membrane du tympan, au-dessus de
’apophyse grêle, et même au-dessus du muscle grand extenseur de la membrane,
on peut séparer mentalement une cavité osseuse, dont le plafond nous oﬁre
DISEASES OF THE EAR. 421
un véritable arc. Cet espace rond contient latête du marteau et la moitié supérieure
de l’enclume; un ligament descend du dit plafond etil peut tout seul, isolé, tenir en
suspens le marteau. Le dit espace arcué est bien plus large que le contenu, ainsi
la tête du marteau qui est externe et le corps de l’enclume qui lui est postérieur et
interne, peuvent bouger en tous sens.
La tête du marteau est rondenet bombée du côté de l’enclume, limitée en bas
par un collet fortement prononcé, qui à son tour est limité par la dite apophyse
grêle. L’enclume qui pris dans son ensemble se dessine en triangle, offre au
centre, qui en est le corps, une facette fort concavisée, sémilunaire, ayant donc
une corne supérieure et une corne intérieure. C’est dans cette concavité que la
tête postérieure bombée du marteau se pose, et par la, la corne supérieure de
l’enclume montera un peu au-dessus de la tête du marteau, tandis que la corne
inférieure se nichera dans le coin anguleux du dit collet du marteau. Par une
- capsule résistante les parties décrites des deux ce sont couvertes et serrées, tandis
qu’entre elles il existe une articulation complète qui leur permet des mouvements.
L’enclume, autant que le marteau, et un levier qui a son hypomochlion dans la
grosse apophyse, est ﬁxée à la paroi postérieure de la cavité tympanique, au moyen
d’une petite surface arti laire, ce qui lui permet un mouvement de rotation
sur son apophyse.
Nos deux osselets, mai beau et enclume, sont unis entre eux et forment une tête
complexe de laquelle se détachent le manche du marteau et la jambe de l’enclume
qui descendent en bas, sciant la cavité du tympan perpendiculairement ; de
sorte que la coupure tombe au devant du manche et épargne ainsi la fenêtre
ovale, &c., que l’étrier reste en place. On croit avoir en perspective un
polype, ou un monstre dymésitrique avec deux jambes tordues et valgues. L’une
qui provient du marteau, s’unira a la membrane du tympan, se tournant en
dehors, et l’autre jambe plus courte se tordra en dedans visant à. la paroi
Dymére interne de la cavité tympanique. (Suivons la chaîne pour ne plus y revenir.)
L’extrémité de la jambe de l’enclume dessine un angle presque droit, sa pointe
est ronde et convexe et c’est la que la concavité de l’os lenticulaire s’adapte:
le petit os à son tour montre une petite convexité qui devra s’adapter aussi a la
tête concave de l'étrier; le dernier osselet oiÏre, on le sait, deux branches qui ont
une position horizontale. 11 faut remarquer surtout que l’étrier depuis sa con-
nexion avec le lenticulaire monte, offrant ainsi un plan incliné de bas en haut
depuis la pointe terminale de l’enclume a la fenêtre ovale; il en résulte que la
platine de l’étrier tout en fermant la dite fenêtre laisse une rigole ouverte au bord
supérieur postérieur de la dite fenêtre ovale. L’angle droit donc que nous avons re-
marqué le long de la courbure de la dernière portion de l’enclume, deviendra par l’os
lenticulaire et plus tard par la tête de l’étrier un angle aigu. Tel est la position des
trois osselets a l’état normal c’est-à-dire de repos, position, qui devra naturelle-
ment être changée lorsque la dite chaîne sera mise en mouvement.
J e ne veux pas laisser ce point sans évaluer et apprécier grandement la facture
et la position toute spéciale du petit os lenticulaire. Souvent on l’a considéré comme
inutile, tantôt il fut négligé et parfois même nié—pour moi il a une grande impor-
tance. Il me fait l’eﬁ'et avant tout de ces boules qui dans les étaux facilitent tout
mouvement; il est le vrai centre de tout mouvement entre l’extrémité de l’enclume
et la tête de l’étrier, ôtez-le et les dits mouvements seront difriciles, et si par une
raison donnée, il arrive un mouvement brusque,il arrivera une désarticulation entre
eux; ôtez-le et un mouvement rapide de l’enclume sera communiqué brusquement
a la fenêtre ovale.
422 'f
DISEASES OF THE EAR.
Le lentieulaire est un osselet très providentiellement confectionné qui montre
encore une fois comme la nature avec peu sait suppléer et apporter de grands effets,
et devant ce grand facteur artiste qui nous donne a chaque instant le code des lois
et des forces physiques je m’incline plein d’admiration. L’os lenticulaire est un vrai
bijou, indispensable au milieu de la chaîne des osselets.
Après cet aperçu de la position d’ensemble de la chaîne des osselets et de leurs
mouvements réciproques possibles, résultant de leurs attaches et articulations,
tâchons de suivre quelques-uns de leurs mouvements principaux.
L’onde sonore, en vibrant, apporte sa pulsation convexe sur la membrane du
tympan qui devra s’y accommoder, donc se courber mécaniquement du dehors en
dedans—1a pointe et le manche du marteau devront plier dans le même sens, mais
étant ﬁxé au bord supérieur de la membrane du tympan, et par des attaches
ligamenteuses, et par le muscle externe postérieur, et par l’apophyse grêle sur
le devant de laquelle s’imbrique le muscle antérieur interne, la tête du marteau
sera portée en dehors autant que le ligament suspeusoir le permettra—la con-
cavité semilunaire du corps de l’enclume sera a son tour obligée de suivre la
tête du marteau et de se porter conséquemment a l’extérieur, tandis que sa
jambe s’élèvera. De la l’angle aigu, dessiné a l’état de repos, entre la dite
crus, et l’os lenticulaire et le plan de l’étrier, cet angle aigu deviendra angle
droit. Par un tel mouvement la platine de l’étrier qui par son bord supérieur,
nous disions tant soit peu éloignée du contour supérieur de la fenêtre ovale, en bas-
culant de bas en haut, devra la fermer complétement. L’onde sonore en pous-
sant en dedans la membrane du tympan, poussera aussi en dedans la platine de
l’étrier. Si le premier temps d’une vibration est la condensation, suivi du
second, la raréfaction, tout le mouvement décrit devra rétrograder et reconduire la
chaîne à, l’état primitif du repos; mais les ondes se suivent et continuent, et le
mouvement de va-et-vient se continuera aussi.
L’on comprend qu’une série de différents mouvements peut s’eﬁ'ectuer le long de
la chaîne des osselets, et nous pouvons les comprendre et les apprécier toutes les fois
que l’un des muscles s’attache par exemple au-dessous du collet du marteau et qu’il
est mis en contraction ou en relâche. Mettons en action par exemple le grand muscle
extenseur en tirant sur le marteau, il porte son manche avec la membrane du tympan
en dedans, sa tête en haut et à, l’extérieur, le corps de l’enclume doit suivre, sa jambe
sera portée en hautet en dedans; ainsi modiﬁé l’angle aigu ou angle du repos, qui est,
facilité par le petit nœud lenticulaire, se relèvera de bas en haut les branches de
l’étrler—l’angle aigu sera positivement devenu angle droit, et la platine de l’étrier
fermera complètement la fenêtre ovale, aidée par son muscle homonimc.
Les détails de ces mouvements multiples commandés par ces muscles nous
entraîneraient trop loin, il y aurait confusion et ennui tandis que chacun de nous, soit
mentalement, ce qui est un peu diﬁicile, soit tenant en mains les grandes
photographies du Dr. Politzer, pourra parfaitement saisir les différents mouvements
possibles de la chaîne selon l’action de l’un ou de l’autre muscle, ou de la simple
pulsation de l’onde.
Il est dit par nos maîtres en physiologie que le son passe atravers la membrane
du tympan et par la chaîne des osselets et ainsi traduit au centre son effet spécial.
J’en doute. Le son perd avant tout, disons-nous, de son intensité en traversant la
membrane du tympan, après, en passant à travers le long de la chaîne, il perdra
encore davantage de son intensité.
Est-ce que la nature peut avoir construit un tel échafaudage tordu pour mieux
traduire le son au centre: c’est-à-dire un manche de marteau tordu et imbriqué au
DISEASES OF THE EAR. 423
milieu des deux pages de la membrane du tympan, et a travers les quatre articu-
lations qui lient entre elles les osselets.
L’enclume doit faire une dispersion du son par sa grosse apophyse qui se
‘pose a la paroi postérieure de la cavité tympanique; de l’enclume, le son continuera
rson chemin le long de sa jambe rachitique et puis a travers son angle aigu et parle
lenticulaire sera transmis à la tête de l’étrier où le son devra être divisé sur ses deux
branches et de là enﬁn poussera la platine pressée contre la périlymphe du vestibule.
valait-il bien la peine de placer aussi près de la membrane du tympan un centre sen-
ssible pour que l’onde sonore eûtà faire un si long chemin? Notons que les osselets
ne sont pas composés d’une texture uniforme: spongieux dans leur milieu et seule-
ment revêtus d’une couche dure. La membrane muqueuse a plis serrés ou lâchés
revêt les osselets et leurs jointures. Tous ces éléments physiques ne sont-ils pas
fort contraires à la transmission des sons?
Quel peut être le service que la chaîne nous rend?
Voila une proposition que j ’avance et que je soumets à vos études. Vos réﬂezn'ons
:sur un tel point, faites avec la sagesse sérieuse que vous apportez en toute chose,
ﬁnira par une solution physiologique, et j’espère que bientôt cela s’accomplira par
vos efforts, car je n’ai pas longtemps a attendre.
Et c’est pour gagner du temps que je vais, avec une juste reluctance,
soumettre mes idées ou mes doutes a votre jugement.
Pour moi la chaîne des osselets ne doit pas être le milieu créé pour la transmis-
:sion du son. Ils seront peut-être enveloppés par l’atmosphère résonnante de
la cavité tympanique, mais pas le rail sur lequel l’onde s’achemine et glisse. La
«chaîne n’est pour moi 1° qu’un moyen d’alarme donné parle petit choc de la platine
de l’étrier a la périlymphe du vestibule et par la au centre essentiel de l’audition ;
2° la chaîne doit par son dernier osselet agir en étouffant le son qui, en vibrant trop
‘vivement, pourrait ébranler le centre nerveux.
Chacun de nous a dû se plaindre et être désagréablement frappé par un son
inopinément arrivé a notre oreille. Un coup de canon imprévu nous a désagréa-
blement secoués, mais le même coup de canon ou de tonnerre ne fera pas le même effet
«et nous pouvons assez bien le braver sachant qu’il doit vibrer et éclater. Et quel
'est le moyen utile pour obtenir cela? C’est, je pense, par le muscle dit extenseur
de la membrane du tympan. Connaissant le jeu des mouvements qui peuvent se
prononcer dans les osselets, il nous sera assez facile de comprendre que le dit
muscle volontaire, l’extenseur, qui a son point d’insertion au-dessous du collet du
marteau, en se contractant, tirera en dedans et en haut le manche du marteau et
.avec lui la membrane du tympan, conséquemment l’enclume sera poussée aussi en
haut et en dedans. Par la Tangle aigu normal dessiné entre l'enclume et le lenti-
culaire et l’étrier deviendra angle droit et la platine du dernier sera serrée contre la
fenêtre ovale et la fermera totalement.
Plus haut en parlant du petit os lenticulaire ’ai taché de lui donner toute son
importance, et c’est ici, dans ces mouvements, que nous devons grandement l’évaluer;
car, par le choc vif que la rapide contraction du muscle extenseur peut donner à.
toute la chaîne des osselets, la petite et ﬁne membrane circulaire qui réunit la platine
au bord ovulaire de la fenêtre ovale, si le lenticulaire n’excitait pas, le mouvement
n’aurait pas, avant tout, sa rapidité; et, trop souvent, la chaîne serait interrompue et
cassée. Le muscle extenseur par sa contraction doit, je le répète, empêcher que le
.son abrupte et violent puisse affecter le centre ; et la platine de l’étrier agira, a mon
point de vue, comme un étouﬁ‘oir.
Il en résulterait, si j’ai pu bien m’ezrpliouer que ce n’est’pas a travers la longue
424 DISEASES OF THE EAI’.
chaîne des osselets que l’onde sonore passera, mais qu’elle doit servir seulement.
d’obstacle, prévoyant le choc violent au vestibule.
Et pourtant je ne nierai pas qu’un son puisse ﬁltrer à travers la fenêtre
ovale. Je crois al’envers de ce que le célèbre Scarpa a écrit, e crois que l’audition.
automatique ne se fait pas par la fenêtre ronde, mais par l’ovale qui à. l’état de-
repos présente une ﬁne rigole due à l’inclinaison normale de la platine de l’étrier,
mais cette audition automatique ne s’accomplit aucunement par le médium des‘.
osselets.
Par où donc l’onde sonore passera-t-elle et sera-t-elle traduite au nerf spéciﬁque F
Très modestement et avec peu de ressources probatives je vais vous présenter
mes idées et mes pensées craintives. J ugez-les !
Une onde, dix, mille, tout un orchestre arrive sur la surface de la membrane
du tympan. La dite membrane, sensible, mobile, est libre surtout au segment
inférieur, c’est-à-dire au-dessous de l'insertion terminale du marteau; la elle est
transparente, homogène et plus apte à laisser passer les sons. Arrivée au-dela le
ﬂot des ondes, se trouvera presque en face de la fenêtre ronde qui est encadrée par
une espèce d’entonnoir collecteur des ondes. Mais quelles preuves de cela? Je
dirai avant tout que l’on peut perdre une partie ou presque toute la chaîne des ossee
lets, que la chaîne peut être interrompue, qu’il peut ne rester que la platine de l’étrier
contrainte dans sa niche ov alaire et que néanmoins, l’ouïe restera suﬁisante; que si,
par une cause mécanique, la périlymphe cochléaire s’écoule en dehors par une ﬁssure
de la fenêtre ronde, toute audition cessera; que, si après quelque temps la dite ﬁssure
heureusement se cicatrise de nouveau, le périlymphe, abreuvant les rampes coch-
léaires, l’ouïe se rétablira. Une preuve peut-être concluante, nous la trouvons dans
le fait que si le manque d’air ou de vide a lieu dans la cavité du tympan, l’audition
s’inﬁrme et diminue tellement que l’on n’entend rien du tout. Eh bien! si l’onde
sonore, depuis la membrane du tympan, avait pour son médium de translation au
centre la chaîne des osselets, l’audition devrait s’accomplir quand même.
Du reste, rien de plus juste et de plus naturel que le son, né dans l'air, arrive à la
membrane du tympan, et, de nouveau dans l’air, dela cavité homonime ait àcontinuer
sa course dans le même milieu aëré. L’onde sonore serait alors recueillie dans le
petit bassin ou entonnoir de la fenêtreronde, et de 12;, pénétrerait dansle lim açon.
La cochlée, ou limaçon, est tellement construite, il y a la tant d’éléments
anatomiques qu’un nouvel horizon se révèle, qu’un monde nouveau, plein de
beautés et de doutes difficiles, se présente a nos considérations. Je crois que
voulant construire un simulacre grossier de cet organe pour mieux comprendre sa
facture interne, étant donnée la tige osseuse, il n’y aurait rien de mieux a faire que
de prendre deux tubes coniques ﬂexibles, en caoutchouc. Coupez leurs deux pointes
coniques et sondez-les ensemble, il en résultera alors un seul tube qui sera plus:
étroit à. son milieu et les deux ouvertures élargies se trouveront a leurs extrémités.
Fixez leur centre sur l’extrémité ﬁne de la tige, et les deux tubes descendant en
dorloir et posés l’un sur l’autre vous les enroulez sur la dite tige et de telle manière
vous aurez construit le limaçon. Les parois des dits tubes qui se touchent
formeront la lame spirale membraneuse qui est divisionnelle des deux rampes-
Si vous façonnez la tige centrale a l’instar du modiole, qui n’est que la
charpente et le soutien au contour duquel se prononce une épine osseuse, cette
crête circulaire large au commencement et de plus en plus étroite vers sa sommitéa
représentera la rampe osseuse qui se nichera entre les deux parois superposées;
des dits tubes élastiques, lesquels forment la lame spirale membraneuse. Les.
deux tubes superposés et pressés l’un contre l’autre prendront dans leur inté‘
DISEASES OF THE EAR. 425
rieur la forme, chacun, d’un demi-canal ovulaire ayant une paroi ronde et une
plate. Dans le canal tympanique, la paroi ronde se dessinera en bas et la paroi plate
en haut, tandis que pour le canal vestibulaire le rond plafond sera en haut et le
plat paraît en bas.
Les deux parois plates réunies et collées donnent l’image grossière de la lame
spirale.
Au milieu des dites parois, il y a donc la crête osseuse qui fait partie intégrante
du modiole qui contient dans son milieu les irradiations du nerf cochléaire qui
devront s’étaler sur la lame spirale membraneuse, la dentelée et la pectinée. Cette
lame membraneuse, toujours représentée par nos tubes élastiques, va se terminer en
un ligament, ou muscle de Todd et Bowman, et se ﬁxer à une petite crête qui se trouve
à la périphérie du tube complexe osseux. Et dans ce point encore les deux parois
plates de nos tubes élastiques s’écartent pour faire place au vaisseau veineux,
l’hélicoïde.
En résumé, le canal osseux du limaçon n’est qu’un cône large en bas et très-
étroit en haut, qui doit contenir les deux tubes ﬂexibles représentés plus haut,
et le périoste du cône osseux, et qui formeront à. son milieu une membrane
divisionnelle. Et c’est par cette division que nous avons la rampe tympanique et
la vestibulaire.
La première, tympanique avec sa portion inférieure et large, commence au petit
évasement de la fenêtre ronde, qui est fermée en dedans par une membrane propre
ou périostienne, qui est doublée en dehors par la membrane muqueuse de
la cavité tympanique.
Rien ne se pose sur cette membrane—elle est libre ; les ondes sonores dans l’am—
biant de la cavité tympanique sont arrivées et libres dans leur direction et dans leur
véhicule aérien naturel, et ayant regagné le peu d’intcnsité qu’elles avaient
perdues en traversant un corps solide, la membrane du'tympan. Par la chaleur de
la dite cavité, le ﬂot des ondes sonores accumulées a la fenêtre ronde passera
dans la rampe inférieure tympanique, et après avoir monté le long de deux tours
et trois quarts, arriveront à. la sommité, au schiphus, et, par l’ouverture laissée
entre les deux tubes cono‘ides réunis par leurs côtés externes, les ondes, suivant leur
course et poussées par de nouvelles, descendront par la rampe supérieure ou
vestibulaire.
Tous nous connaissons cette rampe par les grands travaux anatomo-microsco-
piques du Marquis Corti, et par Reissner, Table, Doprat, Huchske, Schultz,
Todd et Bowman, Kôlliker, et par bien d’autres, qui avec leur talent et leurs
investigations l’ont si patiemment illustrée; et sur elle, permettez-moi que j’ajoute
quelques réﬂexions.
Remarquons de nouveau que la rampe vestibulaire étant constituée par la moitié
supérieure du cône cochléen, elle présente une forme a l’envers de la rampe tympae
nique. La rampe vestibulaire, si le tympan a donc un plafond arqué, est en voûte et
ses parois déscendantes s’implantent sur la lame spirale; par cette facture les
sons doivent être mieux disposés à être absorbés par le grand étalage nerveux propre
de la dite lame, car une voûte est physiquement mieux résonnante, car de ses angles
la réﬂexion des ondes sera accomplie et projetée sur la lame plate.
La lame spirale membraneuse, qui est toute simple et lisse du côté tympanique,
est au contraire très-composée du côté vestibulaire, où des éléments multiples et
diversement disposés y sont étalés. C’est sur ce point bien difiicile et important,
que des savants anatomistes ont exercé leur patience, si bien que cette lame à été
divisée en portion sillonnée, dentelée, et en portion pectinée.
426 ' DISEASES OF THE EAR.
Les nerfs cochléaires extrêmement subdivisés, lorsqu’ils transpercent la paroi
fomminulenta du fond du méatus acoustique interne, entrent dans la tige ou
modiolus, et, se subdivisant de nouveau en un réseau admirable, ils se plient en
dehors; enfermés dans la crête osseuse canalisée, qui se façonne, a sa dernière
limite, en deux tablettes, les dits nerfs se rendentàla rampe supérieure, de la sur la
face vestibulaire. Ce qui arrive après, la disposition toute spéciale qui s’y modèle
vous est bien connue, seulement je vais user de vos études et de vos préparations
microscopiques pour arriver a des idées physiologiques touchant directement l’ouïe.
Le ﬁot des ondes sonores monte par le canal demi-conique tympanique, si
un obstacle se rencontre ou dans la rampe ou au sommet congénital, ou occasionné
par maladie, soit dans les parois osseuses ou périostiennes, soit par du sang épanché.
Si non, toute onde sonore serait en partie ou en totalité empêchée dans sa course et
refoulée en bas tumultueusement et la il résulterait une fausse audition ou un
manque d’ouïe, et une myriade de bruits diversiformes musicaux qui tourmeuteraient
nos malades et les médecins.
Et la surdité peut avoir son point de départ bien souvent dans le sommet i1
peut s’y constituer une digue qui, partiellement ou totalement, empêche le passage
des sons à travers la lagena pour descendre dans la rampe vestibulaire, la où les
nerfs sont évidemment disposés pour être enveloppés par les ondes sonores, qui, à.
l’instar d'une rivière pulvérisée, seront absorbées.‘
Plus de quarante gerbes ou faisceaux nerveux peuvent être énumérés, et tous ces
faisceaux sont a leur tour composés d’une série divisionnelle de ﬁlaments, et tous
viennent du milieu de la lame osseuse et de bas en haut, comme à travers d’un ﬁn
tamis pénètrent dans la rampe moyenne, c’est-à- dire qu’ils s’étalent sur le pavé du
canal spiral médian pour constituer tout ce monde sublime et nouveau d’éléments
nerveux qui furent si bien étudiés et décrits par Corti le premier. J e crois que toutes
ces dents des deux rangées, que la ﬁne disposition des ﬁbres innombrables et des
articles placés sur la rampe moyenne doit être le point essentiel créé pour l’appré-
ciation des sens. Il y a sur cette planche merveilleuse, qui est le pavé du canal
spiral interne ou rampe médiane, une longue série d’octaves constitués par des
touches sans ﬁn qui doivent être abreuvées par les ondes sonores. J e pense que ces
nerfs diversement façonnés doivent former une toile ﬁne et suivie, de sorte que les
sons qui nous arrivent par notes détachées sur cette toile doivent se réunir et se
suivre. ’
Parmi les instruments inventés, ceux a anche sont ceux qui répondent le mieux
pour faire disparaître les traits d’union, les battements entre note et note, et notre
larynx répond par excellence a ce but; mais, néanmoins c’est une facture si admirable,
que les notes émises montrent et marquent a une ﬁne oreille musicale les dits traits
d’union entre elles. La note chantée, même ﬁlante, est l’eﬁet complexe de
plusieurs agents matériels mises en action, mais juste a cause de ce grand effort, le
chant reste toujours un canevas 5. mailles plus ou moins serrées, mais bien loin
’être une ﬁne batiste.
Il y a donc une distance entre note et note, qu’ une voix ﬁnement construite et
soigneusement éduquée peut diminuer, mais que des oreilles très ﬁnes attrapent
encore.
La rampe médiane est couverte par la périlymphe a travers laquelle les sons
doivent ﬁltrer, ce qui doit donner aux sous une enveloppe moelleuse, veloutée. Mais
il y a plus; il y a une autre enveloppe encore plus homogène qui protège ces nerfs.
Les nerfs cochléens spéciﬁques ne sont pas directement en contact avec la tenue
périlymphe, car de l’angle supérieur du demi-canal spiral, une membrane dite
DISEASES OF THE EAR. 42 7
homogène par Corti le premier, s'étend, qui se porte jusqu’a la terminaison de la
membrane spirale et qui ﬁnit à la crête externe osseuse de sorte qu’un canal
médian se constitue sur le pavé duquel les dents, les ﬁbres, avec ses articles,
multiples sont disposés. Dans ce canal,'ou sinus médian, une humeur extrêmement
tenue et transparente, les abreuve, c’est l’endolymphe cochléene. Peut-on imaginer
quelque chose de plus ﬁnement merveilleux? Nul organe ne montre une si sublime
facture. Tous ces petits organes, ces dents, ces ﬁbres, ces articles, passez-moi la
comparaison grossière, sont autant de touches à différentes séries disposées, et
sont l’un et l’autre entrelacés.
L’onde sonore déjà moëlleuse, veloutée, est encore obligée de se tamiser a travers
la membrane homogène et endolymphe avant de trouver sa touche ou mieux son
article à l’unisson, et toute cette longue myriade de ﬁbres nerveuses et d’articles au
lieu de résonner sont caresses, embaumés par cette douce atmosphère musicale.
J’ai parlé des touches comme d’un grand clavier, mais dans celui-ci les touches
frappant sur la corde au point déterminé produisent le son, tandis que les touches
de la lame spirale attrapent, absorbent le son qui lui est apporté déjà tout fait.
Il me paraît qu’ét‘ant porté en leur contact cette pulvérisation sonore, ces
petits organes en sont inhalés. Il y a la comme un mirage ﬁn, vibrant, qui
danse sur les dits organes. Déjà les dessins de Breschet nous montraient que
chaque gerbe nerveuse est anastomosée par des anses nerveuses à la prochaine
gerbe, et que toutes les ﬁbrilles nerveuses desquelles chaque gerbe est composée
sont a leur tour réunies par d’autres anses multipliées et sans nombre.
Ainsi disposées, ainsi entrelacées, anastomosées a l’inﬁni, toutes ces ﬁbrilles ner-
veuses constituent un tout uni : le moindre mouvement de l’une doit forcément être
aperçu par toute autre ﬁbrille. C’est un prodige ! Un son avant d'arriver au point
sensible est distillé a travers la périlymphe tympanique, c'est un premier ﬁltre
chimico-physique, et c’est au milieu de ce médium uniforme, que le son montant par
la rampe inférieure perdra sa raideur; et ses angles vifs trop résonnants ou disson-
nants seront émoussés.
Le son passé outre la Zagena, descendant par la rampe vestibulaire continuera
dans le même ambiant, la périlymphe, et sera de mieux en mieux monté et épuré.
Par la membrane homogène le son transperce l’endolymphe cochléene ou l’abreuve,
et un cqgtact mystique sur les dites touches s‘opère et par la la vraie planche, ou
rampe sentiente, la rampe diatonique, appréhende, attrape, absorbe le son pour le
transmettre tout élaboré au vestibule membraneux où les papilles nerveuses
du nerf acoustique central en sont instruites pour les emmagasiner, pour les
apprendre, et s’en souvenir. Tout cela s’accomplit dans le bulbe acoustique cérébral.
Par plusieurs anatomo-microscopistes, la rampe médiane et sa membrane
homogène ont été réconnues, et aussi l’endolymphe de ce canal spiral, mais où cette
endolymphe médiane se déverse-t-elle? Reissner, Huschke, Kôlliker et d’autres
indiquent que ce canal et son contenu ﬁnissent dans le sac membraneux du vestibule,
mais ces auteurs si diligents glissent même trop vite sur ce point, et ils ne nous
ont pas indiqué ni dessiné aucunement à. quel point le tube spiral cochléen avec
son endolymphe s’abouche au vestibule.
Il y a. là un doute qui devra, par des travaux opiniâtres microscopiques, être
éclairé. Par la congélation et avec la loupe, je n’ai rien vu ni constaté, et pourtant
.ce canal spiral avec son endolymphe ne peut pas rester isolé et ﬂottant tout seul,
il doit faire partie intégrante d’un tout. Pouvait-on faire mieux que cela? et
notre cerveau qui contient en lui tant de prodiges, serait-il capable de construire
:un tel appareil et de tels organes? La nature est une chose créée, Dieu en est le
428 DISEASES OF THE EAR.
créateur, et pour nous simples créatures elle restera toujours diﬁicile si pas impos-
sible à. comprendre.
On vise, l’on ébauche une analyse, mais pour bien des choses, la synthèse nous
fait défaut et même trop souvent.
Le son d’un orchestre est apprécié par une espèce d’impression, par une telle
disposition des organes laquelle toute faite seraltransférée au dit centre par la même
endolymphe où nagent les voies harmoniques, où la ﬁne otoconie s’encroûte sur le
nerf acoustique, le vrai bulbe sensible. L’otoconie, par sa nature spéciale et sa.
disposition, empêchera la dispersion du son dans le sac pour qu’il soit mieux et en
totalité compris. Arrêtons-nous ici pour ne pas divaguer davantage et que les
égarements poétiques ne prennent pas la place du raisonnement. L'on croit avoir
du talent, on pense au génie, avouons-nous tout court d’etre bien petits, ce qui fait.
que pour nous sauver de notre ignorance, l’on crie souvent au miracle. Cela
accuse tout simplement notre insuffisance intellectuelle.

Nouveau Cas de Guérison de [a Snrdi-Mnz‘ﬁe' Infantile par
Oz‘opz'e‘sz's (de oâç, (grog, 01/ez'lle ; m'eacç, compression).
Dr. BOUCHERON, Paris.
Certains cas de surdité infantile conduisant à la mutité ont pour origine une
aﬁection auriculaire qui est curable au début de son évolution et qui devient incu-
rable à un moment donné.
Le processus de cette surdité est un processus de compression du nerf acoustique.
Tant que la compression n’a déterminé qu’uneîanesthésie auriculaire sans lésion
grave, la surdité peut cesser. Quand la compression a, au contraire, été assez pro-
longée ou assez intense pour déterminer une dégénérescence du nerf acoustique, la
surdité et la surdi-mutité sont irrémédiables. C’est ce qui explique comment les
sourds-muets âgés sont incurables.
Le processus de compression du nerf acoustique dont nous parlons est analogue
comme eﬁet au processus de compression du nerf optique dans le glaucome. Et
l’on sait que le glaucome donne lieu également à une cécité que l’on peut faire
cesser au début, en relâchant la compression nerveuse. Mais cette cécité glauco-
mateuse devient bientôt déﬁnitive, si l’on a laissé se prolonger trop longtemps la
compression du nerf optique qui en est la cause. a
Le mécanisme de la compression de l’oreille et du nerf acoustique en particulier
(otopiésis ou neuropiésis) est le suivant :—
Quand la trompe d’Eustache est oblitérée par le gonﬂement inﬂammatoire de
sa muqueuse, l’air contenu dans la caisse (l'oxygène tout au moins) est absorbé,
comme on le constate si facilement dans l’emphysème sous-cutané. Alors un vide
plus ou moins complet se fait dans la caisse, vide qui tend à se combler par la
dépression de la membrane tympanique sous le poids de la pression atmosphérique.
Le déplacement en dedans de la membrane tympanique entraîne le déplacement
en dedans des osselets y attachés— et plus spécialement l’enfoncement de l’étrier
dans le labyrinthe.
La pression atmosphérique sans contrepoids dans la caisse pèse donc sur le
labyrinthe par l’intermédiaire de l’étrier qui s’y enfonce.
Dans le labyrinthe, la pression ne peut s'exercer ni sur le liquide incompressible
par nature, ni sur les parties osseuses et inextensibles de la paroi; cette pression
DISEASES OF THE EAR. 429
s’cxerce en ﬁn de compte sur les parties molles de cette cavité, c’est-ä-dire sur le
nerf acoustique à son entrée dans le labyrinthe, et sur les vaisseaux labyrin-
thiques.
La valeur de cette pression peut être calculée dans une certaine mesure. Si
l’on admet que l’oxygène soit absorbé par les vaisseaux de la caisse, comme l’air
renferme 21 parties d’oxygène pour 79 d’azote, il se produira dans la caisse un
vide d’un quart d’atmosphère. La pression atmosphérique s’exerçant sur la mem-
brane tympanique, qui chez l’adulte est d’environ 1 centimètre carré, la pression sup-
portée par cette membrane sera égale au poids d’une colonne de mercure d’un
centimètre carré de base et de 19 centimètres de hauteur soit 19 centimètres carrés
de mercure dont le poids est de 19 x 13 D = 247 grammes, soit approximativement
en chiﬁres ronds 250 grammes. Si une partie de l’azote est absorbée, le vide sera
plus important, la pression sur le labyrinthe plus considérable, elle dépassera 250
grammes et s’élèvera proportionnellement au vide de la caisse. L’absorption totale
en quelques jours de l’air dans l’emphysème sous-cutané indique la rapidité possible
de ces phénomènes d’absorption du gaz aérien.
Le poids brut doit être diminué de la résistance qu’opposent les membranes
déprimées. Toute diminuée qu’elle soit, cette pression n'en est pas moins consi—
dérable.
Si nous comparons maintenant cette pression auriculaire ou otopiésique à, la
compression oculaire ou glaucomateuse, on reconnaîtra facilement que la compres-
sion otopiésique est plus considérable que la compression glaucomateuse.
En eiÎet, on voit par l’ophtalmoscope, que la compression glaucomateuse est
incapable de déprimer complètement les petites artères de la rétine, et cependant
cette pression glaucomateuse est suffisante pour déterminer à la longue la dégéné-
rescence du nerf. La pression glaucomateuse est donc moindre que la pression
sanguine dans les petites artères rétiniennes. Nous pourrons connaître la tension
glaucomateuse quand nous connaîtrons la tension des artères rétiniennes. Voici
comment la pression des petites artères peut être approximativement évaluée:
Dans l’aorte, la pression sanguine est d’environ :3; d’atmosphère, soit {33%. Dans
la veine cave, a son entrée dans l’oreillette elle est tout près de zéro, elle est estimée
à. î—à-o- d’atmosphère. Les capillaires généraux, placés à mi-chemin supportent une
pression intermédiaire, soi 95% ou % d’atmosphère, ou 9 à 10 centimètres de mercure.
Dans les petites artères, la pression est un chiffre intermédiaire entre T1525 tension
capillaire et {139-0- tension de l’aorte. La tension des artères rétiniennes ne peut être
supérieure à {1,90- ou îloî‘o- d’atmosphère, ce dernier chiffre représente 14 centimètres de
mercure environ. i
La pression de ces petites artères étant inférieure à T1335, la pression du glaucome,
qui est capable de déterminer l‘atrophie du nerf optique et qui cependant n’eﬁ‘ace
pas le calibre des artères rétiniennes, est inférieure à 14 centimètres de mercure.
On voit donc que) la pression otopiésique, qui est au moins égale à à; d’atmo-
sphère et peut s’élever plus haut encore, est également capable de produire sur le
nerf acoustique des lésions comparables au glaucome.
La compression otopiésique, avons-nous dit, dépend du vide relatif de la caisse,
et le vide est la conséquence de l’obstruction des trompes.
Quant àla cause de l’obstruction des trompes, la plus commune c’est le catarrhe
naso-pharyngien a répétition, catarrhe soit accidentel, soit constitutionnel, soit
héréditaire. Dans ce dernier cas on en retrouve l’analogue chez l’un des parents
et même chez les grands-parents où il y a. souvent produit un certain degré de dys-
aoousie, grâce a des attaques multipliées, plus ou moins légères, mais répétées.
430 DISEASES OF THE EAR.
L’hére'dité du catarrhe naso—pharyngien se transmettant aplusieurs générations
successives, permet d’ lucider, d’une part, l’origine de la surdi-mutité dans les-
unions consanguines entre parents affectés l’un et l’autre de catarrhe naso-pharym
gien hére'ditaire.
Un certain nombre de lésions de l’oreille moyenne peuvent surajouter leur action
nocive a l’effet physique de la compression du nerf. On les a constatées depuis
longtemps. Loin de diminuer la puissance de la cause primordiale, capitale et
sufﬁsante de la surdité infantile qui est la pression otopiésique, ces lésions ne sont
que des causes aggravantes de la premiere.
Le traitement a pour but de faire cesser la compression du nerf acoustique en
faisant cesser le vide de la caisse. On y arrive par les insuﬁiations d’air dans la
caisse et par la perforation de la membrane tympanique.
T/ze Acoustic Poz‘em‘z'als of Me Human Aunt/e.
Mr. A. GARDINER BROWN, London.
There is much difference of opinion as to the real acoustic value of the auricle,
“ many authors denying that it has any marked inﬂuence on the function of hear-
ing, whilst others consider it as a sound-conductor, sound-condenser, or as a
resonator for higher tones” (Urbantschitsch). It is to this latter function that
I wish to call further attention.
Janfal pointed out that friction on the tragus would produce in some cases the
middle O, by reason of the vibrations excited in its cartilage.
In some experiments on the auricle which I have lately tried in musical people,
I have ascertained not only that the pitch of the friction-sound on the tragus is
as above stated, but that in a well-formed auricle the whole free margin of the
cartilage gives a beautifully graduated ascending scale of notes, forming a complete
octave from the tragus in front to the posterior ,border of the helix behind.
The antitragus forms a distinct and isolated note, the E.
The notes, or friction sounds, are produced by passing the ﬁnger over the
different parts indicated in the diagram, ﬁg 18.
It is very remarkable that the notes forming, as it were, the basis of all music—-
viz., the ﬁrst major triad, or tonic, are very distinctly produced by friction on the
tragus, antitragus, and middle and upper border of the helix successively.
The cartilage of the rim of the helix in a well-formed ear diminishes gradually
both in width and thickness from before backwards, and the amount of hollow
space formed by the various fossae allotted to each section of the rim, as marked
off in the diagram, diminishes in the same way; these two facts are quite in keep-
ing with acoustic principles. Upon a careful examination ofithe intrinsic muscles
of the pinna, we must be forced to the conclusion that they are serviceable only
in increasing the tension, and thus heightening the resonant pitch of the different
parts of the cartilage.
The following simple experiment will illustrate this :—
Take an ordinary visiting card, and bend up and over one of its long edges, a.
quarter of an inch in width, without cracking the card; this edge, upon being
rubbed, will give a note; now bend it slightly and at right angles in the opposite
direction, that is, across its shorter diameter; as you bend it'more and more the
DISEASES OF THE EAR.
431
note keeps rising, until it has passed through a complete octave. This is due to
increased tension of its edge and tendency to form’a nodal point at the intersection
of the two bendings.

,_ External surface of the auricle, in-
dicating the positions of the friction-
sounds referred to in the text.
(Henle).
In a similar manner the intrinsic muscles of the pinna
increase the tension of the cartilage and nodal points,
and so raise the resonance pitch of its various parts.
This will now be shown in detail.
Intrinsic muscles of outer s'mjfctca—M. tragicus raises
the pitch of the C, and when its ﬁbres reach as far as
the spine of the helix it probably also heightens the D
above. ' I
M. antitragicus probably sharpens the antitragic E.
M. helicis minor and major sharpen the D, E, 1*‘,
and G.
Intrinsic muscles‘ of posterior smfaca—Transversus
auriculaa probably sharpens the G, but especially the A,
B, C. Obliquus aurioulae sharpens D and E.
The extrinsic muscles of the ear no doubt much assist
in the transmission of the vibrations received by the
auricle to the inner car, by rendering more tense its
attachment to the head during the act of listening.
\.
Partial dissection of the anterior
surface of the auricle, showing—
A, m. tragicus, with E, its occasional
elongation to spine of helix.
helicis major. D,
C, m.
m. helicis 13111101‘

Posterior surface of the
cartilage of the auricle,
showing A. m. obliquus
auriculae. B, m. trans—
versus aurioulze (Henle).
432 DISEASES OF THE EAR.
0/2 Dz'jﬁeulz‘ Cases 0fz'1ez‘roduez'ng Me Eusz‘ae/zz'em Caz‘lzez‘er, and
a M eZ/zoa’ facilitating Me Operation in Z/zese Cases.
Dr. LOEWEN BERG, Paris.
Gatheterism of the Eustachian tube, when practised by a surgeon familiar with
the operation, mostly offers no difficulty, nor causes any pain to the patient.
We nevertheless meet sometimes with cases in which the contrary takes place,
and even an experienced aurist ﬁnds serious obstacles. I do not allude here to
the difficulties of inﬂating the middle ear, when the beak of the catheter has already
arrived in the pharynx; but I shall only treat here the obstacles the instrument
encounters rather frequently, whilst penetrating through the nasal cavities.
Various methods have been proposed to facilitate catheterism in ordinary cases,
but very few rules are given as to the aforesaid very embarrassing circumstances.
I therefore think it may not be useless to point out an easier method, which helps
us to foresee and to overcome the difficulties in these cases.
It surely would seem incredible, if a surgeon practised an operation on a visible
part of the human body without guiding himself by his eyes : well, this is gene-
rally done in catheterism of the Eustachian tube, which nobody thinks of executing
under inspection of the nasal cavity he is operating on. The idea of surveying
this cavity, not only previously to, but together with, introduction of the catheter,
though seemingly extremely obvious, does not appear to have been conceived. As
far as I know, at least, this precious auxiliary, simultaneous exploration, is not
recommended in thesmost recent text-books of aural surgery; and even so eminent
an aurist as Professor Lucae, of Berlin, does not mention it, in an exhaustive
paper on Aural Gatheterism, at least as far as I have been able to learn by the ab-
stracts three special journals have given of his memoirs. Nay, not even previous
specular exploration is recommended in most treatises.
In discussing this question, I shall omit examination of the anterior nasal cavity
with the naked eye, a method which every aurist should practise before catheter-
izing a patient for the ﬁrst time ; this examination shows at least if there are any
gross malformations of the cartilaginous parts which would obstruct the very
entrance of the nose. The object of this communication is to dwell upon inspec-
tion of the nasal fossae with speculum and reﬂector—
1. previous to catheterism.
2. combined with catheterism.
(l) A long time ago eminent aurists, and especially Professor von Troltsch—
to whom, after the great English aurists, our science is indebted for its ﬁrst de-
cisive progress—strongly recommended the examination of the fauces of each aural
patient, and this practice has become universal. It should be the same, in my
opinion, with the equally important cavities of the nose. Besides the capital part
they play in the passage of air, and thereby in the health of the pharynx, the
aspect of their lining membrane enables us to judge of the state of the immediately
adjacent mucous membrane of the pharyngeal opening of the Eustachian canal.
Furthermore, the conformation of the nasal passage is of the highest importance for
catheterism. Inspection teaches us, whether or not there are obstacles, and of what
size, shape and nature they are. We therefore conclude which kind of catheter,
and which way of introducing it, may be the best to overcome existing difficulties.
‘We thus are enabled to spare useless pain to the patient, and to avoid inspiring-
him with an invincible aversion for this operation.
DISEASES on THE EAR. 4 3 3
(2) But there is a still more useful application of anterior rhinoscopy, simulta-
neous inspection and catheterism, and I wish to call your attention specially to
this combined method. Its execution is very simple. The bivalve dilating specu-
lum is applied to the patient’s nostril, and maintained with one hand leaning
against his nose. Daylight, or better, the strong light of a gas-burner, is thrown
deeply into the nasal fossa by means of the forehead reﬂector, a method familiar
to every aurist. Operating thus in a brilliantly illuminated space, the catheter
avoids easily the prominent obstacles which encumber its way.
I have now used this system for several years, and owe to it so much facility in
catheterizing difficult cases, that I cannot but strongly recommend it to the pro-
fession. With this combined method, I have been able to catheterize successfully
in cases where experienced hands had failed, and where I hasten to say I should
have probably failed too, but for this effective method.
As to the amount of pain, the difference between the ordinary way and the one
I propose is such, in these diﬁicult cases, that the patient imperiously claims the
employment of the combined application in subsequent operations.
Amongst the obstacles in the nasal passage which this method makes us avoid,
there is a special one which, in my opinion, is most frequently the cause of diffi-
culty: this is deformity of the septum narium, not so much the large deviations
of this partition, but a peculiar anomaly, very frequent, which I have recently
described in a paper on the treatment of simple chronic coryzaﬁ'F This anomaly
consists in the existence of horizontal protuberances of the septum, implanted
where vomer and cartilage join. These prominent growths direct themselves out-
wards, often so far as to reach the lower turbinated bone. Sometimes, they are
isolated and pointed; often, on the contrary, they extend as a kind of crest hori-
zontally along the septum.
In my opinion this anomaly forms the most frequent obstacle to catheterism,
as far as introducing the instrument through the nose is concerned. According to
my experience, hypertrophied turbinated bones, or even mucous polypi, seldom form
a serious hindrance, as their surfaces generally yield under a gentle pressure,
suﬁiciently to let the catheter pass.
When the instrument, on the contrary, is introduced in cases of septum
protuberance, its point being turned downwards, as usually, its curved part im-
mediately strikes against these growths. Then not only the operation cannot be
continued, but extreme pain is caused by the pressure, the lining of these protu-
berances being compressed between their hard substratum and the catheter.
When combined with catheterism inspection not only shows us the obstacle, but
teaches us at once how to avoid it. The obstruction exists here especially in the
vertical direction, the important one in catheterism. “Tell, guided by the eye we
turn the point of the instrument sidewards and outwards at an angle of about 90°
and not of 180°, as often recommended as “tour de maitre.” 90° are sufficient to
place the principal dimensions of the instrument in the horizontal direction, where,
under these pathological circumstances, it ﬁnds more room than in the perpen--
dicular one.
In cases of very greatly hypertrophied and exceptionally resistent lining of the
lower turbinated bone, even this method meets with difﬁculties when we use the
common forms and sizes of catheters. But these difliculties disappear by choosing

* B. Loewenberg, Contribution au Traitement du Coryza Chronique Simple: Inst.
Union Médicale, 28 J uillet, 1881.
PART III. E r
434 DISEASES OF THE EAR.
a very short-pointed form, which I have used many years in narrow nasal passages
or pharynx. Sometimes I was even obliged to employ a special form I had made
long ago in a very diﬁicult case, a form in which the point starts from the instru-
ment at a right angle.
I conclude these remarks by recommending in all cases of ear disease the
practice of ocular exploration of the nasal fossae previously to catheterism; and
in cases where the afore-named or other malformations are met with, to use the
very easy method of combining inspection with catheterism. This method hitherto
has enabled me to catheterize, in each case, the ear by the corresponding side,——a
thing, I believe, preferable to passing through the opposite one, on account of the
difﬁculty of inserting the catheter in the opening of the Eustachian tube lightly
enough to practise effective inflations.
I would venture to say this method will be successful in every case; but I
prefer leaving the decision to the distinguished confreres here present.
Ueéei/ ez'nﬂz'isszlges, lcz'imz‘lz'cﬁes Trommelfell.
Dr. T. MICHAEL, Hamburg.
Zu künstlichen Trommelfellen vermittelst welcher man bekanntlich bei manchen
chronischen Perforationen ausserordentliche Gehörverbesserungen erzielen kann,
sind bisher stets feste Körper, Gold schlagerhautchen, Gummiplattchen, Papier,
Wattekügelchen verwendet worden. So vortreﬁlich zuweilen deren Wirkung ist, so
verbietet sich sehr häuﬁg ihre Anwendung durch den Umstand, dass sie von den
Patienten gar nicht oder nur kurze Zeit ertragen werden, und subjective Geräusche,’
Schmerzen oder Schwindel erzeugen. Um auch solche Patienten, und zwar ist
dies die bei weitem grössere Zahl nach meinen Erfahrungen, welche diese Apparate
nicht ertragen, die Wohlthaten des künstlichen Trommelfells geniessen zu lassen,
ersetzte ich die festen Substanzen durch eine Flüssigkeit, nachdem ich die auch
bereits von Toynbee und Tröltsch beobachtete Thatsache verwerthete, dass der-
artige Patienten oft wesentlich besser hören, wenn ihnen nach dem Baden oder dem
Ausspritzen des Ohrs etwas Wasser im Gehörgang zurückgeblieben war. Die
Beschreibung meines Vorgehens knüpfe ich an die Erzählung des nachfolgenden
Falles :
E. J ., 20 Jahre alt, leidet in Folge von Scharlach seit 10 Jahren an doppel-
seitiger Perforation mit geringem Secret und hochgradiger Schwerhörigkeit. Er
war von verschiedenen Aerzten mit Adstringentien und Lufteinblasung ohne jeden
Erfolg behandelt worden. Ich versuchte das Wattekügelchen. Rechts blieb das-
selbe erfolglos, links hatte es eine vorzügliche Wirkung. Es wurde indessen kaum
eine Minute ertragen, erregte Schmerzen und Schwindel und musste daher entfernt
werden. Da der Patient angab nach dem Baden oder Ausspritzen wesentlich besser
zu hören und ich darauf die Hoffnung begründete ihm zu helfen—so machte ich
folgenden Versuch: In ein bleistiftdickes—unten zugeschmolzenes Glasröhrchen
goss ich einige Tropfen Oollodium elasticum. Nach einer Viertelstunde überzeugte
ich mich, dass sich die Flüssigkeiten nicht vermischt hatten sondern, dass das
Collodium eine dünne Haut auf dem Glycerin gebildet hatte, so dass man jetzt das
Röhrchen umkehren konnte ohne die Flüssigkeit zu verschütten. Jetzt verfuhr ich
in derselben Weise bei dem Patienten. Mit einem Augentropfglas liess ich tropfen—
DISEASES OF THE EAR.
weise Glycerin ins Ohr fallen, machte zwischen den einzelnen Tropfen Gehör-
prüfungen, bis ich mich überzeugte, dass weitere Verbesserung nicht erreicht
wurde. War es etwas zu viel geworden, so zog ich mit Watte wieder etwas heraus.
Nun fügte ich in derselben Weise einige Tropfen Gollodium elasticum hinzu und
liess den Patienten, auf die rechte Seite gestützt, eine Viertelstunde sitzen. Der
Erfolg war ein ausserordentlich befriedigender. ‘Während man vorher dem Patienten
laut ins Ohr hineinsprechen musste um sich verständlich zu machen hörte, er jetzt
Flüsterstimme auf 3% Meter und die Uhr, die er vorher beim Andrücken nur
schwach gehört hatte, auf 30 Cm. Irgend eine Empﬁndung eines fremden Körpers
hatte er nicht, war überhaupt in keiner Weise genirt. Nach der zweiten Applica-
tion, die erste war noch nicht so dauerhaft gemacht, konnte ich noch nach vier
Tagen die Dauer des Erfolgs constatiren. Indessen spritzte ich doch das Vor-
handene aus, da ich hinter der Collodiumhaut deutlich Eiter durchschimmern
sehen konnte. Um nun zugleich die Eiterung zu behandeln, setzte ich dem Glycerin
' etwas Tannin hinzu und konnte nun nach weiteren vier Tagen das Fehlen jeder
Eiterung constatiren.
Die Wirkung erklärt sich wohl in 'der Weise, dass die Schallwellen von aussen
auf die Collodiumhaut gelangen, und von dieser durch die Flüssigkeit ohne Be-
nutzung der muthmasslich defecten Gehörknöchelchenkette, und ohne zwischen
Luft und festen Körpern abwechseln zu müssen, auf die Stapesplatte und das
foramen rotundum übertragen werden.
Ich glaube, dass die beschriebene Methode nicht nur zum Ersatz der bisherigen
festen künstlichen Trommelfelle (eine einfache Oollodiumhaut ist vollständig wir-
kungslos) zweckdienlich ist, sondern hoffe in derselben auch ein Mittel gefunden zu
haben, welches uns in den Stand setzt chronische Otorrhöen wirksam zu behandeln.
Bei lang dauernden Otorrhöen mit geringer Secretion, wird es gewiss für viele Fälle
passend sein, die Schleimhaut in dauernden Contact mit einer adstringirenden
oder desinﬁcirenden Substanz zu bringen. Die bisherigen Methoden erfüllen diesen
Zweck in unvollständiger Weise. Die ﬂüssigen Medieamente ﬁiessen heraus,
ebenso die Gelatinepräparate. Die Pulver sind bald aufgelöst oder bilden schwer
entfernbare Krusten mit dem Eiter. Durch Anwendung einer Verbindung des
Glycerin mit einem, dem Fall entsprechenden Medicament wie Tannin, Jod, Jodkali,
Gal-1001 oder Salycil—Säure, und Bedecken mit Collodium sind wir im Stande
zugleich die Schleimhaut von der Luft abzuschliessen und sie der fortdauernden
Wirkung des Medicaments auszusetzen. Mittheilungen über den Effect dieser
Behandlung behalte ich mir für spätere Arbeiten vor.
D3
EI‘
DISEASES OF THE TEETH.
u-—+-_
President.
EDWIN SAUNDERS, Esq.
Vice-Presidents.
J OHN ToMEs, Esq, F.R.S., London. I T. SrENcE BATE, Esq, F.R.S., Plymouth.

Council.
Dr. ANLEIEU, Paris. J. H. C. MARTIN, Esq, Portsmouth.
C. H. BROMLEY, Esq, Southampton. J. R. MUMMEBY, Esq, London.
HENRY CAMrIoN, Esq, Manchester. PETER OErHooT, Esq, Edinburgh.
S. CAETWEIGHT, Esq, London. THOMAS A. ROGERS, Esq, London.
A. COLEMAN, Esq, London. J OHN SMITH, Esq, Edinburgh.
DANIEL CORBETT, Esq, Dublin. Dr. TAFT, Cincinnati.
Dr. HOLLAENDER, Halle. J. S. TURNER, Esq, London.
WILLIAM HUNT, Esq, Yeovil. THOMAS UNDERWOOD, Esq, London.
G. A. IBBETsoN, Esq, London. CHARLES VAsEY, Esq, London.
FRANCIS BnonIE IMLAcH, Esq, Edinburgh. J OSEPH WALKER, Esq, London.
Dr. NORMAN KINesLEY, New York. J. C. WOODBURN, Esq, Glasgow.
Dr. MAGITOT, Paris. A. J. WOODHOUSE, Esq, London.
Secretary.
C. ToMEs, Esq, F.R.S.
-_--§___
INAUGURA L ADDRESS,
BY THE PRESIDENT,
EDWIN SAUNDERS, ESQ.
GENTLEMEN,—Before assuming the duties and responsibilities of President of the Odonto-
logical Section of this great Congress, permit me to thank you for the honour you have
conferred upon me in electing me to that high oﬁice; and let me assure you that it will
be my earnest endeavour to justify your choice, however I may fail to satisfy my own,
and your, well-warranted expectations. And, indeed, were it not that I am sustained by
the kind co-operation of two Vice-Presidents and a Secretary, in whom our profession
feels a just and legitimate pride, I might well feel oppressed by the onus of doing full
lustice to the position on so august an occasion. Nor was it, I am free to admit, until 1
had the permission of the Executive Committee to call around me, as a Council, some old
and tried associates in professional work, that I began to experience the requisite energy
and conﬁdence. And having made this personal avowal and confession, I turn to the
distinguished company before me, who have done us the high honour to visit our too
great, but not too gay, capital, and to become for a short time, and for our signal proﬁt,
our guests at this great intellectual banquet.
Et 2. vous, Messieurs les Etrangers, je désire, an nom des Membres Anglais du Con-
gres, au nom de notre plus grande Société, La Société Odontologique de la Grande
Bretagne, au nom de la profession meme en Angleterre, vous souhaiter la bienvenue.
438 DISEASES on THE TEETH.
Croyez Messieurs, que nous sommes tres sensibles de l’honneur que vous nous avez fait
en visitant a. ce moment notre trop grande, mais pas trop gaie ville de Londres, et croyez
que c’est notre désir de vous rendre la visite, a une fois, agréable et fruetueuse.
Permit me, gentlemen, on behalf of the English Members of the Congress, on behalf
of our largest Society, the Odontological Society of Great Britain, now in the 25th year
of its somewhat chequered, but, on the whole, prosperous existence, and on behalf of the
whole body of the dental profession in England, to oifer you a hearty welcome, and to
assure you of our earnest desire to render your too brief visit both proﬁtable and pleasant.
We hail the happy occasion of our friendly intercourse, and we trust that friendships
begun under such benign auspices may continue and progress in interest through many
prosperous years. Such gatherings as these, with the pleasurable amenities they involve,
do much to soften and reﬁne the manners, to quicken the intellect of all concerned, and
to remove misconceptions of national or individual character, which are apt to be en-
gendered by isolation and want of friendly intercourse. Congresses, such as that at
which it is our privilege at this time to assist, serve a great social purpose, apart from the
intellectual and scientiﬁc aims at which they are more immediately directed. It is much
that they afford an opportunity and a stimulus for intellectual effort, which might other-
wise, with man’s proverbial procrastination, never be called into action. But in these
days of an ever-teeming press, and of facilities for the free inter-communication of ideas,
this is subordinate to the advantage of personal knowledge of the individual, and the
living interchange of thought. The modern Congress, which seems now in high favour,
owes its existence, or shall it not be said, its revival, to the intellectual activity, joined
with a wide ecleeticism, which is a characteristic of our times, and which seeks to assimi-
late to itself whatever is of value in the past or in other lands, whether in social manners
and customs, in matters of dress and daily life, in schools of architecture, or in the realms
of science and art. The generally accepted idea of a Congress is, if I mistake not, more
than a fortuitous assembly of persons engaged in similar pursuits and drawn together by
community of thought and interest. It is the deliberate coming together of distinguished
men, or of experts, of set purpose and for a speciﬁc object 5 the persons constituting the
Congress being invited and selected with a due regard to their knowledge of the subject,
for the consideration of which it has been convoked. This is especially evident in political
affairs, and notably in a recent instance in a northern capital, where the great countries of
Europe, represented by their most distinguished statesmen and dlplomatists, met in
solemn conclave for the rectiﬁcation of national frontier lines, and for the determination
of other questions of vital importance, which must otherwise have been left to the rude
arbitrament of the sword. And may we not indulge the hope, in the interests of an en-
lightened humanity, that this high function may be more extensively employed to interfere
between the unbridled ambition and lawless rapaeity of States, more powerful than just,
and the resolute resistance to subjugation or spoliation on the part of the oppressed, pro-
tracted, it may be, to the bitter end, through years of carnage and misery ? So might the
world be spared the saddening spectacle of “man’s inhumanity to man,” and the fair page
of contemporary history be unsullied by the foul blot of the blood-stained record. Ours,
however, is a Congress of peace, and we are happily not called upon to compose ani-
mosities or to adjudicate upon conﬂicting claims. The triumphs which we are met to
celebrate are those of man’s Skill in limiting and repairing the ravages of disease; our
victories, those over Nature herself, when she 1s forced to yield up another of her secrets
as the reward of patient research or of well-conducted experiment. ()ur international
reunion may be regarded as a periodical taking stock of the gains of science, of improved
appliances, of more accurate means of diagnosis, and of more eﬂieient modes of treatment
in the various departments of medical practice. And for the better and fuller carrying
DISEASES on THE TEETH. 439
out of this intention, it has been found advisable, having regard to the present advanced
state of medical and surgical science, to divide the work of the Congress into Sections.
These Sections carrying on their work simultaneously, and the work of each Section
being complete in itself, greater fulness and accuracy of detail are secured without any
sacriﬁce of the unity of the one grand result, as the work of each Section is the necessary
complement of the whole. In that with which we are more immediately concerned, one
of the youngest departments of surgical practice, and which for the first time enjoys its
own distinct and prominent position, considerable interest will attach to the question of
education, and the regulations which in each country govern the entrance into the profes-
sion. The former part of this very important subject will, I trust, shortly be brought
under the notice of the Congress by one than whom none is more fully informed, and
more entitled to speak with authority, I mean Mr. John Tomes, who has in this direction,
during the last quarter of a century, done much to advance the interests, and to establish
a strong claim on the gratitude of, the profession. Nor would the English sense of
justice and fair play be satisﬁed without an acknowledgment of the more recent services
of his colleague in this good and great work, Mr. James Smith Turner, without whose
unsparing devotion of time and energy it could not have been brought to so successful
an issue. To the joint action of these two gentlemen; to the lawyer-like precision and
forethought of the former, no less than to the vigilance and promptitude of the latter, is
the profession indebted for that invaluable piece of legislation, the Dentists’ Act of 1878.
It must not be forgotten, however, that, to our foreign friends, the nature of the enactment
is of greater interest than the means or the persons by whom it was obtained. By the
provisions of this Act then, which came into operation on August 1st, 1879, it is forbid-
den to any one to use the word Dentist, Dental Practitioner, or other title implying that
he is qualiﬁed to practise Dental Surgery, unless his name appears on the Register of
that body; thus giving to the Dentist the same protection and privileges as are enjoyed
by the Physician and Surgeon in this and other countries. By this measure the oppro-
bium was removed which so long rested on the dental profession in this country, that
it included a large proportion of ill-qualiﬁed practitioners, and in many cases persons
who were unsuccessful in other pursuits, and who were attracted to it by the absence of
restrictions or of preliminary examination. By the provisions of this Act, introduced by
Sir John Lubbock, not only are the public preserved from the extortion and malpraxis of
the ignorant and unprineipled, but a grave discouragement is removed from the educated
and honest practitioner. For it is only in human nature that high aims and honest
zealous work should languish in the atmosphere of indifference and lack of appreciation.
In thus obtaining legal sanction for the organization of the profession, it was desired
strictly to maintain its connexion with the Royal College of Surgeons, as it was rightly
felt that separation from that body would involve abdication of the status which it had
hitherto enjoyed. And when the College had been memorialized on the subject, showing
that the curriculum for the diploma for general surgery, which was the only qualiﬁcation
then open to him, did not comprise certain matters of the ﬁrst importance to the dental
practitioner, that, in fact, the entire subject of Dental Surgery found no place either in
the teaching, or at the examining board, an arrangement was accepted for more fully
meeting the requirements of the case. Accordingly a conjoint board of examiners, con-
sisting of half surgeons and half specialists, was created for the licentiateship of Dental
Surgery, with a corresponding modiﬁcation of the prescribed course of study, eliminating
much that was of little value, and substituting what was regarded as specially necessary
in that particular line of practice. Thus, by varying, not by lowering, the educational
standard, an arrangement has been effected, which if not in all respects perfectly satis-
factory, goes far to meet the reasonable views and wishes of those who have the welfare
44.0 DISEASES OF THE TEETH.
of the profession at heart. With this bare outline of our proceedings, in reference to the
organization of the profession, before us, we shall listen with interest to what has been
accomplished in other countries in the same direction, not, it may be hoped, without
mutual proﬁt and advantage. Gentlemen, I feel that I ought not longer to tax your
attention, but having declared this Section of the Congress open, that we shall prepare
ourselves to listen with appreciation and enjoyment to those varied and valuable contri-
butions to the literature of our speciality with which we are so liberally favoured both
from home and foreign sources. And ﬁrst your attention will be asked for the always
welcome utterances of one whose contributions to science during a long series of years,
many of them having a direct interest for our own speciality, and almost unparalleled
for number and value, have made his name a household word in both hemispheres. I
mean, Professor Owen. We feel grateful for his presence here to-day, which will confer
prestige on our proceedings, and we tender him, with our thanks, our sincere felicita-
tions that he has been able to witness, in unimpaired health and energy, the realization
of his hopes and wishes in the completion of that noble structure, the Museum of
Natural History.
On Z/ze Sez'em‘zﬁe Sz‘az‘us of Medicine.
Professor OWEN, C.B., London.
In response to an appeal from our President, I replied that the subject of an
“ address ” from me would be a general one—via, “ On the Scientiﬁc Status of
Medicine.” It was, in fact, the only one which my leisure, and reﬂections on the main
aim of the “ Congress,” would enable me to prepare for any occasion on which I might
be honoured by a call to take part in the work of the “ Sections ” to be constituted by
the “ General Meeting ” of the International Medical Congress. Having been favoured
by a notice that such subject would be acceptable, and that it would be received at the
present time and place, I proceed to ask the indulgent attention of the Section to a
subject which may seem to be but remotely related to its speciality.
The aim of every student of medicine—and such the true physician never ceases to be—
is to raise the healing art to the status of a science.
The most signiﬁcant testimony that the application of human intellect to comprehend
phenomena has attained its noble aim, is the “ power of prediction.”
When the astronomer foretold the date, to hour and minute, of the advent of an
eclipse, or of a comet, or of a cluster of seemingly vagrant aérolites, his peaceful victory
was manifest. So, when the palaeontologist, on inspection of a new-found fragment of
tooth bone, proclaimed the nature and afﬁnities of the extinct animal which, long ages past,
had left such petriﬁed evidence of its existence, his methods of “ Interrogating and
interpreting Nature ” were acknowledged to be of the rank of a science.
Certiﬁcates of life assurance otiicesﬁf and bulletins issued by the medical attendants
on personages in whose life and health the public have interest, are among the forms of
prophecy in the precise fulﬁlment of which the claims of medicine to a like rank may
be tested. The deﬁnition of disease is the expression of a sum of knowledge and experie
ence by which the constant and essential characters are distinguished from accessory and

at Mr. A. H. Smee, M.R.C.S., F.C.S., &c., in his “Hunterian Oration” of February
9th, 1881 (before the “ Hunterian Society of London”), atﬁrms from his experience as
medical adviser to an “ Insurance Ofﬁce” receiving 1,000 certiﬁcates annually :—“ I have
noticed from year to year the number of cases in which, if the diagnosis of the medical
attendant was right, his prognosis was manifestly wrong.”
DISEASES OF THE TEETH. 441
occasional symptoms; the remedies applied are, in like manner, those which experience
has proved to be most potent to their end. The technical terms of maladies, so discerned,
are, as a rule, “ collective names,” for groups of morbid symptoms.
Permit me to trespass on your patience, and crave your indulgence toward one who
has long ceased to practise the profession—deemed divine by sages of ancient Greece—if
he ventures to submit a few examples illustrative of the dependence of medicine upon a
once deemed unpromising inlet of light ; but of which, in researches connected with the
branch of curative science of the present Section he has availed himself with unlocked—
for advantage in relation to the subjects of the Section of Medicine.
The healer may be called in to one whom he ﬁnds suffering from “loss of appetite,
discomfort and weight in the gastric region, distension of stomach with eructations and
nausea.” To this group of symptoms he applies the name dyspepsia; if aggravated by
aching or burning pain referred to the pit of the stomach, he may term it gastrodynia.
According to such symptoms or indications he may prescribe, for one class, “ car-
minatives,” for another, “ alkaline carbonates in effervescence; ” or he may be led by
special indications to exhibit such drugs as “nitrate of silver,” “ hydrocyanie acid,”
“ bismuth,” and “ opium ”——the latter especially if pain he attended with spasmodic
action.
If the physician be called to a case in which “the alvine evacuations are excessive
in quantity and unnatural in quality ” and sums up such symptoms as “ diarrhoea,” he
may exhibit castor oil or saline “ purgatives ” followed by various “ astringents ”
vegetable or mineral.
But should a patient, whom the healer may see for the ﬁrst time, be suffering, also,
from “ febrile or pyrexial symptoms, thirst and headache, tenesmus and tormina, with
rigid abdominal walls, frequent and uncontrollable calls to defaecate, with little discharge
save of watery mucus of peculiar foetor, perhaps stained with blood,”—-he pronounces the
case to be one of dysentery ;” and may prescribe leeches to the abdomen, fomentations;
and, according to one authority, may exhibit “ purgatives,” but, according to another,
“opiates.” In a late excellent compendium of practice it is written of this disease:
“ Calomel is said to have fallen into disuse and, perhaps, deservedly.”*
An eminent physician, Dr. Trousseau, has conﬁdence in ipecacuanha.
Again, the aid of the medical man may be invoked to abate or banish a group of
symptoms which he terms “ peritonitis.” And, under his treatment there may super—
vene, without the least obvious evidence of causation, another series of sufferings: pain
during respiration, dyspnoea, calling for leeches to the chest, counter-irritants, as mustard-
plaisters, ﬂannel-rollers and compresses, opiates—in short, the recognized remedies for
“ pleuritis.”
And these symptoms may be aggravated by those of “ pneumonia,” requiring other
or added modes of treatment ; moreover, the pulmonary symptoms may become further
complicated by abnormal affections of a more vital organ—the “ bosom’s lord.”
If pain and oppression in the region of the heart predominate, with accelerated
pulse, and, if acoustic scrutiny be superaddcd to vocal and visual interrogations, the
accomplished physician may be able to pronounce the malady to be either “ pericarditis ”
or “ endocarditis.” In either case he will prescribe the appropriate remedies, and form,
according to their effects, his prognosis or prophecy of results.
Should diﬂ'used muscular pains supervene, or be associated with peri- or endo-cardial
symptoms, and these pains be attended with stiffness, loss of muscular power or repug-
nance to exert such power, and the physician happen to be invoked at this stage, he

* Bristowe, “Theory and Practice of Medicine,” 8V0, 1878, p. 683.
442 DISEASES OF THE TEETII.
may pronounce it to be a case of “rheumatismus,” perhaps, “ acutus,” and his treatment
will be guided by the urgency or the predominance of one or other of the symptoms.
But the intractability of the so-cailed malady is signiﬁcantly indicated by the expressions
of one of our most accomplished physicians, under whom I was myself a student, and
whose loss was deeply regretted and is still lamented by his survivors.
Dr. Peter Mere Latham, in his lectures on subjects connected with clinical
medicine—in which in relation to practice and instruction he was a master—-—writes of
acute rheumatism as follows: “ N 0 disease has been treated by such various and
opposite methods. Venesection has wrought its cure, and so has calomel, and so has
opium, and so have drastic purgatives.it
Had Mere Latham, at the date of that “lecture” been aware of a subsequently
discovered cause of “acute rheumatism,” he would have known that at such stage of
the cause’s baneful operation, the so-called malady was beyond the inﬂuence of any of
the proposed and supposed remedies. But, without knowledge or suspicion of such
cause, and noting an abatement of symptoms as time went on, bringing with it a transition
from r/ieumatz'smas acatas to r/zeamatismas eltroizz'cus, the physician might well attribute
the cure of such symptoms to one or other of the remedies which in the then stage of
curative art such experience had suggested.
In a modiﬁed form of muscular malady'to which the term r/zeamatismas art/tritieas
has been applied, and which, at a dropsical stage, proved fatal, a justly celebrated Pro-
fessor of Physiology in the University of Heidelberg observed, in the post-mortem
examination, that the muscular tissues of the defunct were studded with minute white
specks which quickly blunted the scalpel. The chemical analysis by Professor Gmelin
showed the grittiness to be due to deposits of phosphate and carbonate of lime, and
Tiedcmann consigned the facts to Frorieps’ Notizen for1823: the case was held to
be a previously un-noted instance of “arthritis diﬂiusus.” Professor Tiedemann was
little aware how near he was to a discovery to which he might—most probably would—~
have been led by application of the microscope. Some years later, Mr. Hilton, then
Demonstrator of Anatomy at Guy’s Hospital, and Dr. Addison, Physician to the Hospital,
gave a joint account of a similar pathological state of the muscles in a subject brought
in for dissection. They detected the cellular or cyst-like form of the seat of the salts,
which cysts the demonstrator referred to a species of echinococcus, or hydatid, and the
physician, on the results of experiments, to the larvae of some small ﬂy (dipterous
insect).'t
The ﬁnding of a wormlet within the cysticulej in 1835, and the more important dis-
covery by Dr. Zenker, of Dresden, in 1860, of its causative relations to a direful disease,
have demonstrated that the several groups of symptoms to which I have brieﬂy referred,
under their respective technical denominations, may, one and all, be due to the degluti-
tion of the Trichina spiralis. The larva of this wormlet in the ﬂesh of the animal it
infests being introduced into the human stomach, ﬁnds in that warm cavity an environ-
ment of mueo-chymous nutriment, in which it rapidly matures, acquires activities, and
develops its generative organs and products. If permitted to pass into the intestinal
canal it there extrudes its progeny, which, also, rapidly acquire their full size and pro-
creative faculty. But the graver symptoms of their presence are due to the curious
\ migratory instinct of the young trichinae, which impels them to make their escape by
perforating the tunies of the intestine, in the course of which operation the majority
ﬁnd their way into the venous capillaries.

* 0p. cit. Lecture'x. “Diseases of the Heart.”
1‘ Lonolon Medical Gazette, v01. ii. 1833.
1 Proceedings of the Zoological Society of London, 8vo. February 24, 1835.
DISEASES on THE TEETH. 443
Such as wriggle through the meshes of the vascular network, bore their way
through the serous tunic of the gut, and pass into the abdominal cavity : whereupon the
“peritonital” are complicated with the “enterital” symptoms. But the majority are
carried to the right side of the heart, and thence, by the pulmonary artery, to the lungs.
Threading, then, the capillaries continuous with the commencement of the pulmonary veins,
the Trichinae are brought back to the heart. As many as may have burrowed into the
muscular walls of the right or of the left ventricle, or may have made their way into the
cavity of the pericardium, give rise to the symptoms summed up in the terms of art
already cited.
Trichinae which may have strayed into the tissue of the lungs, or which may have
wriggled through the pulmonic serous covering, and from the pleural cavity may have
invaded the serous membrane in their way to the intercostal muscles, add the
“ pleuritic ” and “pulmonic ” to the “ pericarditic ” symptoms.”
;The natural affinity or attraction of the Trichinae is to myonine, or the muscular tissue.
There their wanderings end. They are conveyed so soon and so rapidly by branches of
the carotids to the muscles of the larynx that the Trichinae are there found most con-
stantly and abundantly; but usually, so vast is their number, that they are carried to
the voluntary muscles of the entire body. In the exceedingly delicate connective tissue
of the ultimate bundles of the ultimate ﬁbrils, the young Trichinae coil themselves up to
their larval repose, exciting no other organic change than outﬂow of plasm, which con-
denses with the contiguous cellulosity, and becomes moulded into the shape of an elliptic
case, in which may be seen, under the microscopic compressorium, one or more of the
tiny worms disposed in two or more coils.
The natural history of Trichina spiralis leads the physician, cognizant thereof, to put
a question to his patient, the reply to which would reveal the veritable cause of the
malady at whichever of the stages—dyspeptic, dysenteric, perito'nitic, pleuritic, pneu-
monic, carditic, or rheumatic—he might happen to have been called in. That question
would be, “ What did you eat last before you became unwell?” If the answer denoted
pork in any of its culinary forms, the physician would require a portion of the meat,
or ham, or sausage, and, being practised, as every competent medical man now is
in the use of the microscope—an instrument as indispensable to the consulting-room as
the stethoscope—he would detect the minute parasites, and so recognise the fans er,‘
orig/0 of all and every the groups of symptoms personiﬁed under one or other of the
several before-cited terms of medical art. If, fortunately for the patient, he were called
in at the ﬁrst stage, ere the wormlet had passed on out of the stomach, he might ask
for the mustard-pot, and ‘therewith, or with any other quickly-attainable strong and active
emetic, clear the stomach of its lethal invaders; after which he might administer a strong
dose of calomel, knowing its destructive operation on any lingering Trichinae which
might not have been so dislodged. If the aid of the scientiﬁc healer had not been
invoked until the dysenteric symptoms had set in, still he might see a chance of directly
combatting the cam cause by combining the calomel doses with the remedies which
accessory symptoms would call for. On the supervention of the pulmonary or cardial
trouble the physician would know, with a science enabling him to prophesy, that he could
do no more in the way of cure of the malady,—-z'.e., in eradication of its cause—but that
his treatment henceforth must be merely palliative. He could now predict conﬁdently
to his patient or the friends that symptoms of pleurisy or pericarditis would set in, and
that the chest-symptoms would be followed by rheumatic—probably severely rheumatic
--0nes ; furthermore, that if life were preserved until these symptoms should subside, a
certain deterioration of muscular power, with general stiffness, would long remain, if it
were ever lost.
444 DISEASES or THE TEETH.
The prophet would know that when such stage of recovery was gained, although the
wormlets would die and dissolve, their cysts would arrest and precipitate salts of lime,
such as attracted the attention, but misled the conclusions, of the justly-celebrated
anatomist and physiologist already cited.
My aim, as may perhaps have been surmised by the distinguished members of the
noble profession of medicine whom I have the honour and privilege to address, has been
to exemplify under what conditions and in what proportion medicine may be termed an
art, and under what circumstances it rises to the dignity of a science. In the degree in
which the veritable cause of groups of symptoms summed up as “ dysenteris, pneumonia’,
rheumatismus,” and other species of disease, is recognized, and the remedy specially
applicable to the removal of such cause has been experimentally determined, the applier
of such knowledge to the relief of suffering mankind exerts a power which science
imparts.
The technical terms in which the symptoms of one or other of the four or ﬁve stages of
trichinosis would have been deﬁned prior to the discovery of their veritable causes;
when, also, under the same pre-trichinal condition of knowledge, various causes might
have been assigned, and the then approved legitimate remedies applied to the respective
groups of symptoms, exemplify a stage of medical research which has not risen above
the level of an art. But this is by no means meant to apply to the knowledge and
experience brought to bear upon groups of symptoms independent of a trichinal cause ;
yet a signiﬁcant evidence of the scientiﬁc status of medicine will be manifested when
speciﬁc names of disease indicate the “ cause,” and are founded on demonstrative know-
ledge of such. The recognition of the efﬁcient cause of the several symptoms, and the
relations of these to the anatomical structures affected by such cause, exempliﬁes a rise
to the dignity of a science.
“Knowledge is power :” but what of half-knowledge P
Microscopic discovery of an otherwise invisible parasite has enabled the practitioner
to exhibit the remedies applicable to arrest or annihilate the cause of a direful malady;
such knowledge gives also that of the stage beyond which there is no speciﬁc or direct
remedy. In such phase of medicine he can act with conﬁdence, and prophesy with
certainty.
Finally, I would refer to another test, which, by the analogy of established sciences,
bears upon my present subject. When chemistry was struggling to its goal, a mockery
disguised in its rags obtained the conﬁdence of a maiority, under the name of
“Alchemy,” it was long ere the professors of this pseudo-science lost the patronage
of the rich and great, on whose credulity they fattened.
The extinction of the “transmutors” is an evidence, small, indeed, but signiﬁcative,
of the true and trustworthy status of the branch of knowledge to which the gifted,
single-minded men devoted themselves to raise chemistry to the status of a science.
Prior to and for some time after the promulgation of the Copernican theory, astro-
logy continued to hold its ground against astronomy. The “caster of nativities ” was
patronized by monarchs, State-ministers, men of wealth, and lords of fair estates long
after the period disgraced by the persecution of Galileo and by the cold neglect of
Kepler. Finally arose a Newton, and to the higher evidences of a “ science ” of the stars,
I may add here the lower one of the relegation of the astrological quackery to some
obscure almanack.
Are there, at the present time, practitioners, professors of curative methods, analo-
gous in the actual phase of “ medicine ” to the astrologer and alchemist at given periods
of astronomy and chemistry? Do they, in like manner, obtain countenance and support
as did those empirics from non-scientiﬁc people in eminent social positions?
DISEASES OF THE TEETH. 44 5
In the degree in which the uncertiﬁed dentist, the bone-setter, the mesmerist, the
homœopathist, ma§r ﬂourish and get means of existence, may be estimated the stage at
which inductive medicine has reached in its rapidly advancing career to the status of a
true and established science.
De l’e’lal acme! de la grejê a’em‘az're par reslz'lalz'orz appliquée
a la cure de la pe’e/z'osz‘z'le alvéolaire earem'gae du sommet.
Dr. S. MAGITOT, Paris.
La communication que je vais avoir l’honneur de vous faire est tout entière contenue
dans les trois tableaux que je mets sous vos yeux et qui la résument d’une manière
complète.
Je n’ai donc point l’intention de vous faire ici l’histoire complete des greffes appli-
quées aux dents; loin de la, et mon sujet est beaucoup plus limité.
J e ne veux vous entretenir ici que d’une certaine catégorie de greffes, la greffe par
restitution appliquée aux cas déterminés par notre titre.
C’est encore à. Hunter qu’il faut remonter pour trouver la première mention d’une
semblable opération. Il en indique les termes exacts, et en formule même très
nettement les indications,‘e seulement il ne paraît pas y ajouter une foi bien vive; il
dit même l’avoir vue ordinairement suivée d’insuccès et il ne semble pas qu’il l’ait per-
sonnellement essayée.
La première tentation appartient réellement à Delabarre qui en 1820 ayant pratiqué
l’ablation d’une dent carié d’abcès et de ﬁstule, ﬁt la résection d’une partie de la racine
et la réimplanta avec un plein succès.'i‘
La seconde est due à un chirurgien français, le professeur Alquié de Montpellier.
Ayant, en 1853, reçu, à plusieures reprises, dans son service d’hôpital, un soldat atteint
d’une ﬁstule de la fossette mentonnière rebelle à tout traitement, il eut l’idée d’enlever
une incisive inférieure que le stylet venait heurter au fond de la ﬁstule; il ﬁt la section du
sommet reconnu malade et la réimplanta.
Le malade sortit guéri huit jours aprèsï
En 1870, deux chirurgiens de l’hôpital St. Barthélem;r de Londres, MM. Coleman
et Lyons répétèrent cette opération; leurs observations très courtes et assez peu démon-
stratives, comprennent 14 cas dans lesquels il y aurait eu 9 succès. Les autres se ter-
minèrent par suppuration et élimination de la greﬁ‘e.§
Nos expériences personnelles remontent à. 1875. Les trois premières ont été publiées
à cette époque,” d’autres ﬁgurent dans la thèse de deux de nos élèves, MM. Pietkiewicz
et Davidﬁl Elles comprennent dans leur ensemble une durée d’environ six années, et
reposent sur un nombre déjà. considérable. Mais pendant cette période, d’autres obser-
vateurs en ont signalé des exemples.
Ainsi, notre collègue, M. Théophile Anger l’a pratiquée chez une jeune ﬁlle de 20 ans,

* “ Traité des Dents,” traduction Rochelot, t. xi. des œuvres complètes, p. 109.
1- Annales du Cercle Médical, Paris, 1820. Premiere partie, p. 323.
I Clinique du professeur Alquié de Montpellier. Observation recuellie par le Dr.
Planchou : Bulletin de Thérapeutique, 30 Mai, 1858.
§ Transactions of the Oclontologz'cal Society of Great Britain, London, 1870.
|| Gazette des Hôpicauœ de Paris, 1875, p. 35 et suivante.
1f Thèses de Paris, 1876 et 1877.
446 DISEASES OF THE TEETH.
et guérit ainsi en quelques jours une ﬁstule du menton datant de 2 années.aie
Récemment M. Terrillon a également tenté l’application de cette méthode sur une jeune
ﬁlle atteinte encore de ﬁstule cutanée ancienne du menton. Une incisive grisâtre, mais
sans carie, fut extraite par lui, réséquée dans une étendue de 3 millimètres du sommet
puis réimplantée. La dent se consolida très vite, et la fistule était en voie de guérison,
lorsque la malade fut perdue de vue.'l‘
Enﬁn le Dr. David poursuivant les études consignées dans sa thèse inaugurale, en a
recueilli 20 nouveaux exemples avec un seul insuccèsl‘
Aujourd’hui le nombre de nos opérations personnelles dépasse le chiffre de 100, et
l’on verra plus loin comment se répartissent les 100 premières. Elles constituent en
tous cas une véritable méthode chirurgicale, dont nous pouvons tracer les données prin-
cipales.
L’indication chirurgicale de la greffe, combinée à la résection repose essentiellement
sur le diagnostic d’une lésion spéciale de l’extrémité radiculaire des dents, se caractérise
par la périostite chronique du sommet, inﬂammation du feuillet périostique, dénudation
et nécrose du cément sous-jacent, résorption de l’ivoire, etc. C‘est une sorte de mortiﬁ-
cation partielle de la racine et qui est en dehors de toute tentative directe de gué-
rison.
Ce diagnostic est d’ailleurs ordinairement très facile, en considérant le processus
morbide qui consiste dans une série d’accidents particuliers bien connus des chirurgiens,
ce sont des phlegmons du bord alvéolaire ou de la face, la dénudation et la nécrose par-
tielle du maxillaire, des ﬁstules muqueuses ou cutanées. Nous n’avons pas à insister ici
sur des phénomènes, car il faudrait tracer une description de l’histoire de la périostite,
affection souvent sérieuse, quelquefois grave, puisque par son intensité ou ses compli-
cations, elle peut mettre en question la vie des malades.
Le but thérapeutique en présence d’une lésion ainsi déﬁnie est la suppression du
sommet radiculaire mortiﬁé, qui joue le rôle d’épine inﬂammatoire.
Or, cette suppression n’est que bien rarement réalisable directement.
Nous l’avons faite, toutefois dans un cas, grâce à, un vaste clapier alvéolaire dans
lequel une pince de Liston a pu être introduite, et réséquer en un seul temps le tiers
environ de la racine malade. La guérison s’ensuivit très rapidement.
Dans un cas analogue M. Péan, en 1872, avait pratiqué de même directement la
section d’un sommet de racine dentaire qui entretenait une ﬁstuleä
Plus récemment, un praticien de Lyon, M. Martin, a proposé un titre de méthode
couvant cette résection pratiquée par une ouverture préalable frayée au moyen de la tré—
panation de l’alvéole, il rapporte des observations favorables.“
Le plus ordinairement, une telle pratique demeure impossible à moins de pratiquer,
ainsi que le voudrait M. Martin, de véritables délabrements auprès desquels l’extraction
est une opération bénigne. Une nécessité s’impose alors: l’ablation préalable et tempo-
raire de la totalité de l’organe permettant d’effectuer en dehors de l’économie la résection
de la partie altérée. C’est a, ce moment qu’intervient la greffe en ce qu’elle conduit a la
restitution de la partie restée saine dans son lieu primitif.
Le manuel opératoire contient trois temps :

* Communication personnelle. + Communication personneue_
I Comptes rendus et Mem. de la Société cl’OtoZogée, 1878, 9 Novembre_ Bulletin
PAcadémie de Médicine, 19 Novembre, 1878. Compte rendu des Séances de Z’Acaclémie
des Sciences, 6 Janvier, 1879.
5 Clinique de l’Hôpital St. Louis, communication orale.
H Lyon Médical, tom xxxvii. 1881, p. 35.
DISEASES OF THE TEETH.
1° Ablation totale de la dent chez laquelle le diagnostic d’une périostite chronique
du sommet a été établi et qui présente un état physique susceptible de conservation ou
de restauration ;
2° Résection chirurgicale de la partie altérée;
3° Réimplantation immédiate.
Incidemment, entre le deuxième et le troisième temps, le chirurgien pourra pratiquer,
avant la greﬁ'e, diverses autres opérations : lavage du foyer purulent, ablation des
séquestrés, et sur la dent même en dehors de la bouche, résection de certaines fractions
malades de la couronne obturatoire dans le cas de carie, etc.
L’extraction de la dent, qui comprend le premier temps, doit être pratiquée avec des
précautions particulières. Il faut en effet éviter toute lésion aussi bien de la gencive
que de la dent elle-même. L’emploi du clavier devra être exclusivement adopté.
L’opération se fera lentement, progressivement et sans mouvements de latéralité, qui
risqueraient de compromettre l’intégrité du bord alvéolaire. Il faut dire, du reste, que
l’opération est ordinairement facilitée par l’existence même de la périostite qui a gonﬂé
notablement le périoste et congestionné les parties voisines. Cependant, dans quelques
cas de ﬁstule ancienne, il arrive, au contraire, que les adhérences avec le périoste resté sain
sont d’autant plus serrées et solides, que les produits inﬂammatoires ont une issue facile
par la fistule, et ne tendent plus à. se propager sur les autres points.
Aussitôt l’extraction effectuée,‘et pendant que le malade prend quelques minutes de
repos, on procède à l’examen pour apprécier la nature et l’étendue de la lésion radicu-
laire, puis, au moyen de la pince de Liston, on pratique la section de toute l’étendue de
la partie dénudée et rugueuse. On adoucit alors avec une lime neuve ou très soigneuse-
ment lavée les angles de section, aﬁn de ne laisser aucune arête tranchante ou piquante,
et on place, aussitôt après, la dent dans un linge mouillé d’eau tiède. On fait alors
l’examen de la couronne.
Si la dent est dépourvue de toute autre lésion que celle du sommet déjà. reséqué, on
la réimplante aussitôt que l’hémorrhagie alvéolaire est arrêtée. Si elle est frappée de
carie, on devra, le plus rapidement possible, pratiquer les opérations nécéssaires, c’est-à-
dire, la préparation de la cavité, et appliquer avec l’or ou toute autre substance une obtu-
ration qui donnera parfois des résultats désirables dans la bouche. Ces indications
particulières ne sont toutefois pas constantes, car la périostite du sommet n’est pas
nécessairement liée à une carie antérieure. Un bon nombre de dents réséquées et
greﬁées étaient dépourvues de toute altération de la couronne, la lésion radiculaire
ayant sa pathogénie individuelle, en dehors de toute autre intervention morbide.
Le troisième temps, qui comprend la greffe proprement dite, ne présente pas ordi-
nairement de diﬁicultés sérieuses. Pour les dents uni-radiculaires, la réimplantation est
toujours sûre. Elle est plus laborieuse parfois pour les molaires, dont les racines
peuvent être divergentes, et la remise en place s’accompagne d’un petit bruit sec qui
indique qu’elle a repris sa position première. Cette manœuvre ne cause que peu ou pas
de douleur. Dans quelques cas, cependant, elle a été accompagnée d’une douleur très-
aiguë, mais sans durée.
Les soins consécutifs consistent dans l’application, quelquefois nécessaire, de moyens
contentifs: bandage en huit de chiffre rosière en gutta-percha, &c. Ces procédés sont
surtout indiqués pour les dents uni-radiculaires lorsqu’une résection assez étendue les a
privées d’une grande partie de leur surface d’aﬁîleurement. Il n'en est pas de même pour
les molaires, que la perte d’une racine réséquée n’empêche pas de conserver, parles autres
restées saines, une surface de greffe suffisante.
Les moyens contentifs ne sont d’ailleurs nécessaires, que pendant un ou deux jours
au plus, la réunion, lorsqu’elle s’eﬁ’ectue, étant très-prompte. Ensuite, nous avons
448 DISEASES OF THE TEETH.
l’habitude d’appliquer en permanence dans le vestibule des compresses d’ouate imbibées
d’une solution salinée de chlorate de potasse, fréquemment renouvelées pendant toute la
durée des phénomènes de réaction.
S’il existe une ﬁstule, ce qui est le cas le plus fréquent, on devra en maintenir drainage
soit par un tube de drainage, soit par un cathétérisme fréquemment répété. Le maintien
d’une ﬁstule pendant les premiers soins qui suivent la greffe est même une condition
essentiellement favorable au succès, en ce sens qu’elle favorise l’élimination des produits
ivers dont le foyer est le réceptacle: débris de périoste mortiﬁé, productions fongueuses
fragments osseux détachés, &c. 1
L’utilité bien démontrée d’une fistule nous a même engagé lorsqu’il n’en existe pas
de naturelle, a perforer directement la paroi alvéolaire pour pénétrer dans le foyer et y
maintenir pendant quelques jours un sétou.
Le drainage est particulièrement indiqué lorsqu’il existe des ﬁstules multiples,
comme par exemple un trajet traversant de part en part le maxillaire supérieur et
réunissant deux oriﬁces, l’un situé dans le vestibule, l’autre a la voute palatine. Un mode
e drainage spécial qui nous a donné les meilleurs résultats, est l’installation au travers
de l’os d’un ﬁl métallique en or ou en platine, conduit au moyen d’une aiguille de
Deschamps détrempée, aﬁn de suivre sans se briser les contours les plus sinueux. Cette
application maintenue pendant plusieurs semaines, nous a permis, dans quelques cas,
d’assurer non-seulement le maintien de la greffe et sa consolidation régulière, mais encore
l’élimination complète de tous les produits inﬂammatoires accumulés dans un trajet
osseux.
Les suites de l’opération sont le plus souvent fort simples. Si la consolidation
s’effectue, les adhérences nouvelles sont établies dès les premières heures; la réaction
locale est légère surtout s’il existe par une ﬁstule, drainée ou non, un écoulement libre
du pus a l’extérieur. Peu ou pas de phénomènes généraux. Les ﬁstules se tarissent
et se ferment, le foyer s’oblitère, sans doute par des productions cicatriciclles à la fois
ﬁbreuses et osseusesﬁé et la consolidation complète, ainsi que la guérison de tous les
accidents, survient après un temps moyen de 10 a 12 jours. Cette période, toutefois
se prolonge d'avantage dans les cas de ﬁstules doubles ou triples nécessitant un drainage
prolongé, en raison de la présence de clapiers multiples et de fragments nécrosés dont
l’élimination est nécessairement lente.
Le mécanisme de la consolidation consiste d’abord dans le rétablissement des adhé-
rences vasculaires entre l’anneau du périoste resté sain autour du tronçon de la racine et
la muqueuse gencivale. Ces premières connexions sont bientôt suivies du retour des
liens vasculaires avec la paroi osseuse alvéolaire elle-même. Elles sont amplement
suﬁisantes pom: rétablir, au sein des tissus de la dent greﬂ’ée, le mouvement nutritif
interrompu.
On sait, en effet, par les travaux les plus récents des anatomistes, que la couche du
tissu appelé “ cément ” qui revêt l’extérieur de la racine, est reliée par les ramiﬁcations
des ostéoplastes aux canalicules de l’ivoire, de sorte que ce dernier tissu peut continuer
de vivre et de fonctionner par cette voie. Elle est désormais la seule d’ailleurs, car la
pulpe centrale est toujours frappée de mort lorsqu’une périontite a envahi le sommet de
la racine et détruit le faisceau vascnlo-nerveux qui représente, on le sait, la source vitale
la plus importante entre l’organe et l’économie.
Cette perte préalable, de la pulpe donne précisément la raison de la coloration grise

* Nous n’avons pas vériﬁé exactement ce mécanisme, l’occasion nous ayant manqué
jusqu’à présent, c'est-maire pratiquer l’ablation d’une dent un certain temps après la con-
solidation de la greffe.
'HJZHEL'L HHIL JO SEISVEISIG
61717
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE Rnsnenons ET GREFFES PAR RESTITUTION.


‘III KLIIVCI
No. d’Ordre.
a5
o ‘5
'5 . m a; a:
2x2 4;- 5 . a 3'1
<1 ‘0 $3 :1 .93 .3 5
aOQI. Q Q g "-4 2
»° 2 <1 2'
h
M. 1e Dr. Incis. lat- Sans carie Abcés nom- Double:
C. B. sup. droite breux vestibu-
30 ans laire et
palatine
Mlle. N. Incis. lat. Do. 3 abcés Vestibu-
23 ans inf. droite laircs
M. N. ler prémo- Carie Abcés nom- Do.
32 ans hire sup- pénétrante breux
droite ouverte
Mme. L. Canine Do. Abces gingi- Do,
40 ans sup. droite vaux nom-
- breux
M110. De ler moi. Carie D0. D0.
L. 17 inf. droite pénétrante
ans obturée
M. R. ler prémo- Carie Abcés ves- D0.
23 ans laire sup. pénétrante tibulaires
gauche avec nombreux
suinte-
ment
M. V.‘ Canine inf. Sans carie 1 abces 48 ans droite


8 R q. +5 m. c
. a Q q '— 4 m
g Q Q-rq Q "‘ 0 I0
5 4&2’- eaeé ea I? a
U 3 2 +3»: 5-353 5:5 ,3 '3 Observations.
a’ an “an e; E a E
":3 .0 w“ “3 a p: a"!
,H .-1 PC; QH :3 0
F11 ,5; '° 0
... 28 mai Le sommet est d6- 14 jours Drainage trane- Guérison 6 mOiS
1875 nudé, un peu résorbé ; versal avec un ﬁl de ,
resection de 4 milli- platine passant par
metres les 2 ﬁstules
.. 23 aoﬁt Dénudation; résec- 10 do. 130- “ms
1875 tion de 3 millimetres
.. 5 nov. 3 millimetres de dé- 10 do. Obturation de la Do. 1 d0- Avant l’opération exisiait _un
1875 nudation et de résec- eerie 1101‘8 de "11 large _d<500118m9nt dll maxlllan‘e
tion an sommct externe bouche ' Supéneur.
.. IO doc. Resection do 2 milli- 30 do. Do. Do. 2 (10-
1875 metres nu sommet d6-
nudé ct portant- une
petite fongosité périos-
tique
10 dec. Resection de 3 milli- IO do. Réobturation Do. 3 do- L’opéretion fut Sllivic d’accidents
1875 metres au sommet pos- hers de la. bouche {,{Bnémum ﬁévl‘e, 85%“ d6 l’appm‘i'
térieur dénudé at Don tion d’un nquvel abces gingivalqui
mm, (103 fongositég se reprodlnsit deux fois pour se
- farmer entierement 1m mois plus
tard.
20 dec. Resection de 3 milli- 9 do. Obturation here D0. 2 (10- Un drainage de la earie maintenu
1875 metres a chuque som- de la boucho Pendant 3 ans étalﬁ deveml in-
met; pinteme est dé_ snﬁisant._Ilfallutenleverl’obtura-
nudé, hypertrophié, 91, non; séne do_ petits abcés gingi-
rcxteme porte 1m kyste vaux consécutxis a l’opémtion.
périostique
Sous 18 fev. Resection do 2 milli- 15 do. Do- 8 mois La ﬁsﬁule B’est Plusiem's fois
menton- 1876 metres au sommet dé- M13169 et_1‘éouvel‘te Pendant 198
niére nudé trois premiers mois qui suivirent


l’opération. Elle a ﬁnicependant
par 50 farmer détinitivement.

0517
‘HLŒIŒIÆ CEIHÆ HO SHSVHSICI
’ No. d'ordre. l
IO
II
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RÉSECTIONS
DE GREFFES PAR. RESTITUTION—(Suite)


0 m
ru =1 a5
Ê’c‘â +5 9‘ 0 E
{g ä ë'â É
S? Q 8° 8
c —< > <1
Z <4‘
M. Y. Incis.méd. Sans carie Abcès
19 ans inf. droite revenant à
peu près
périodique-
ment, I fois
par an,
pendant
8 ans
Dr. M. Incis. lat. Carie
:40 ans sup. pénétrante
gauche avec
suinte-
ment
purulent
M. D. 1er prémo- Carie Abcès vesti-
29 ans laire sup. pénétrante bulaires
gauche multiples
Mme. L. Incis.méd. Sans carie Do.
35 ans sup.
gauche
Do. Incis. lat. D0. D0.
sup. droite


33 a; d . .
5 v) _ a o 4-’! m m
à’ â m 5 0.5 à’ =3 ë Ë a‘ ‘a
g 2 si ‘g =~ ce 2’ a» 8 5 à‘ Ê â‘ -
E D 335 gig 3% 5.4:: g a d Observations.
q) .93 a cu 2 3M“ Q Ë ‘a N» >
'3 3 9 o ‘à S E" E m ê:
‘à £2 " “U a ë 8
5 L4
A la 4 mars Résection de 2 milli- :7 jours Un léger allonge- Insuccès La tentative, qui avait d’abord
fossette 1876 mètres au sommet de- ‘ ment de la dent paru. devoir se terminer _par la
du nudé persista. après la guérison, a abouti à l’élimmation
menton consolidation ; en au bout de 2 mois.
ﬁt des cautérisa-
tions è. l'acide chro-
mique, au eautère
actuel; on ﬁnit par
la résection à la
lime
14 avril Résection de 3 milli- Obturation hors Eliminao .. L’insuccès est dû a ce qu’il
1876 mètres du sommet dé- de la bouche tien le restait insuﬂisamment de périoste
nude; la face latérale 6e jour pour la consolidation. La racine
droite est aussi dénudé était dénudée au sommet dans une
dans toute sa hauteur étendue de % centimètre la face
antèro latérale droite, entièrement
«v; dénudée; le périoste restant était
lui-même épaissi, granuleux ,rouge.
Vestibu- 24 avril Résection et dénuda- 8jours Obturation Guérison 13 mois Plusieurs petits abcès gingivaux
laire 1876 tion de 2 millimètres a après l’opération.
chaque sommet
Vestibu- .. 26 avril Dénudationdesmilli- 2 mois .. Do. 5do. Les deux foyers de périostite
laire, 1876 mètres ; résection de 4 communiquaient ensemble et avec
communi- millimètres un vaste clapier situé dans le
quant maxillaire supérieur. Le clapier
chacune fut ouvert sur la voûte palatine, et
avec un un ﬁl métallique fut appliqué
vaste traversant la totalité du bord
clapier alvéolaire. Après 2 mois, la
central guérison fut obtenue.
Do. 1er mai Dénudatîon de 3 milli- Do. ,. Do. Do. Do.
1876 mètres; résection de 41}


millimètres
'HLHELL 'iIH-L HO SHSVHSIG
1517
599
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE Résncnons
DE GnEFFEs PAR REsTrrUTIom—(Suim)

N0 d’Ordre.
14
15
16
x7
0 m
"o s:
' d
.. Q‘ 0 o c:
E 2 Q 8 O
o > I:-
Z 4
Mme. J. ler prémo- Carie
50 ans laire inf. pénétrante
gauche
Mme. X. Dent de Carie
30 ans sagesse pénétrante
inf. gauche obturée
avec
drainage
Mme. B Inc-is. lat. Sans carie
45 ans sup. droite
M. V, lermolaire Carie
24 ans sup. droite pénétrante
M. L. Incis.méd. z trépana-
28 ans sup. droite tions


Accidents.
Fistule Muqueuse.
Fistule Cutanée.

Serie d’abcés
de périostite
sans abces ni
ﬁstule, mais
aceompagnés
de douleurs
tres vives
Suintement
par le drain-
age, accés de
périostite
sans abcés,
douleurs
vives malgré
le drainage
Vaste clapier
osseux
1 abces
palatin
1 abces vesti-
bulaire

Fistula
vestibu-
laire
Fistule
palatine
Fistula
vcsti Ln-
laire


1 5 e e e m
g 0.4-‘; ' ‘0
es ‘2-85 8 $33 =5; :e a
a, c: :J‘” a; m a 3 o '3 a
‘N “5:32-33 5'5 ‘it a e
gig‘ 23132 Q E m 5:’
4 mai Sommet dénudé, ré- 19 jours Obturation hors Guérison 2?: ans
1876 sorbé ; fongosités pé- de la bouche
riostiques ; résection de
3 millimetres
26 mai Sommet dénudé, ré- 20 do. Obturation du Do. 19 mOiS
I876 sorbé; fongosités pé- drainage hors de la
riostiques; resection de bouche ‘
4 millimetres
z juin Dénudation degmilli- 6 mols D0. 14 do-
1876 metres; resection de 3’;
millimetres
Igjuin Sommcl} antéro-ex- gjours Obturation hora Do. P118 rev“
1876 ternc sam ; sommet de la bouche
postéro-externc dénudé,
ct- réséquc de 1 milli-
metre; sommetintcrnc
dénudé et réséquc dc 3
millimetres
29 juin Dénudation et réscc- 36 do. Obturation, hors Do. I an
1876 tion de 4 millimetres de la bouche, deB


deux ouvcrtures


Observations.
Un léger allongement persists
pendant plusieurs mois, sans
amener de douleurs, et ﬁnit par
disparaitre.
La dent oonserva, pendant res
de 3 mois, une grands mobllité
qui ﬁnit par disparaitre.
Traitement long. 11 a fallu
ouvrir lc clapier osseux par la.
voﬁte pal atine, maintenir un drain-
age dc l'ouverture de la ﬁstule
vestibulaire pendant 2 mois puis
dilater l’oriﬁce antérienr pourl’ex-
traction d’nn seqnestre.
Périostite spontanée, abcbs.
Pour éviter la ﬁstule, on ﬁt une
double trépanation qui laissa écou-
ler un suintement fétide. Fluxion,
abces, apres l’opération.
2517
'HŒÆIŒIŒ. HHS!) JIO SHSVHSICI
NH. d'ordre.
I9
20
2!
23
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS
DE RÉSECTIONS
DE GEEEEES PAR Rnsrrrurrou—(S’m‘ta)


Ê '” G3) ‘à; ' a“ g “a
Q a q) :1 a) n-( g U) I
c» se _ d .3 z! s c» _9 Q .9 5 ‘à ‘D ,9 45 A»
sa a :a s a a “sa W28 ë Ë 5‘ 0b t‘
“a. 4.) o a, F3 ä o .53 Êqgä 5.5 :5. g serva lons.
E 2 Q 8 O 8 o '5' Ça 8' 2 L’. a a Q E: :2. É E
"‘ 4::
à’ à < .5 a a s oz; 5 S a
.... {=4 rcx "c U
F74
M. A. 1er prémo- Carie Nombreux 19 juillet Deux sommets dé- 9 jours Guérison II mois
20 ans laire sup. pénétrante abcès vesti- I875 nudés et réséqués de 3
droite ulaires millimètres
M. F 2e prémo- Do. Plusieurs .. .. Igjuillet Sommet interne dé-
Insuccès .. Le 1er août, M. F. souffrant
3 5 ans laire sup. abcès 1876 nudé et réséque de 3 beaucoup, et ne voyant pas la con-
gauche palatins millimètres; sommet solidation s'effectuer, enleva. la
externe portant un dent, non sans quel ues diﬂîcultés.
kyste périostique ; ré- L’insuccès paraît du a ce qu’il n’y
section de 4 millimètres avait pas de communication entre
l’ alvéole et l’extérieur.
Mlle. J. lermolaire Do. Série d’abcès .. 18 dec. Les deux racines ex- I 5 do. Guérison 2 ans
17 ans sup. droite de périostite 1876 ternes portent un kyste
aiguë avec périostique ; résection
suintement, de 4 millimètres; racine
puis résolu- interne saine
tion sans
abcès ni
ﬁstule
laissant un
gonﬂement
de l’os.
Mme. B. Incis. lat. Do. Fluxions et Fistule .. n jan. Dénudation et résec- IO do. Obturation hors Do. 6mois
35 ans sup. droite abcès vesti— vestibu- 1877 tion de 1 millimètre de la bouche
bulaires laire
nombreux
M. K. Incîs.méd. Sans carie 1 abcès .. A la 18 jan. Dénudation et résec- 3 mois .. D0. 6 do. Périostite spontanée ; pendant
15 ans inf. gauche ' fossette 1877 tion de 2 millimètres 2 ans l'oriﬁce externe de la. ﬁstule
du s’était recouvert périodiquement
menton tous les mois d'une croûte d’ap-
parence cornée. Consolidation
lente (après 23 jours). Drainage
de la ﬁstule pendant 3 mois. _
M. R. 2e molaire Carie Abcès vesti— .. 27 jan. Sommet postérieur: Obturation du Insuccès Le drainage n'avait as réussi
28 ans inf. gauche pénétrante bulaires 1877 dénudation et résection trou de drainage et avait laissé revenir es mêmes
obturée périodiques de 2 millimètres. Som- abcès périodiques qu’avant. Con-
aVec met antérieur: dénuda- solidation imparfaite, allongement
drainage tion et résection de 1 considérable de la dent qui em-


millimètre
pèche l’occlusion de la bouche.
Extraction le 2 juin.
2 517 ‘mam am. so sasvsslcr
TABLEAU SYNOPTIQUE nn GENT OBSERVATIONS DE Rlisncrrons DE GREFFES PAR BEsTITmIom—(Saita)


No. d'Ordre.
Nom, Age de
I’Opéré
M.le Dr.
8118
Mme. R.
35 ans
M. C.
30 ans
M1]e.Ch.
20 ans
M. T.,
etu-
diant,
27 ans


m 5 J3 _ _ =5 4: u;
5 a 9 s q, g 8 gé’ 8 8 ..- ,3 -
..- w o a a a w ﬁgs 8 a 5 ‘:3 é a -
5 g ‘g '3 5 0 i3 3 3 ,4 é % i3 :2 .2 a a Observations.
q o o '5 Q, .2 ‘i’ ‘3. Q a m m p E '6. *v E
2 543 '-' 5 ‘no H» a E a P1 8
<1 3 .w -‘--l % “'3 :8 ° “3
.55 Q vg Pd U
m
2e molaire Carie Plusieurﬂ .. .. 3r jan. Dénudation et résec- 16 jours Obturation Guénson 7 m01s
inf. droite pénébrante aecés de 1877 tion de 1 millimetre aux
périostite deux sommets ; fon-
aigué, avee gosités périostiques
suintement entre les deux racines
purulent par
1e canal
dentaire,
gonﬁement
de 1’os
Incis.med. Sans carie Plusieurs Fistule ... 26 avril Dénudation et résec- I do. .. DO- 1% ans Drmllage de la ﬁstule- Pél'slst‘
sup. abcés vesti~ vestibu- 1877 tion de 2 millimetres 4 we: dun léser allonsenpept. ré-
auche bulaires e1; mire sect_10n a la. 111116 de_ 1er millimetre
g ﬂuxions environ du bord hbre de la cou-
ronne.
Canine Carie Abcés et Do. 6 do. Obturation A D0- 18 H1018
sup. pénétrante ﬁstules l’oxychlorure de
gauche ,vestibulaires zinc
zer rémo- Do. Plusieurs ... 11 mai Kyste périostique, 10 do. Obturation DO- 6 d0. 3 Jqm's aprés 1°Pémt1°P> ﬁuxion
1.111% sup. abces de 1877 resection de 3 milli- dqluloue accomléagnée d él'uptwn
' auche périostite métres mllane sur 10 c té correspondant
g aigué. ame_ du visage et de phénomenes géné—
Dani; (ie Vives raux, terminée par resolution.
douleurs,
mais sans
abces, sans 4 juin
ﬂuxions, pas 1877
stule
ze prémo- Do. 2 abces vesti- Fistula ... gjuin Kyste périostique r6- 9 do, Do. Do. 1% M18 Drainage ‘19 111- ﬁstule-
mire Sup bulaires viastibu- 1877 seggion de 5 milli-
droite alre m res _ _
Incis.1at Sans carie Plusieurs Do. .. 26 juin Dénudation et résec- 35 do. Do. 6 m018 , La dent’ ‘Walt été f°rf"e.m°“t
811p ﬁuxions: 1877 tion (1e 2 millimetres hmée Sm‘ “es d9“ cétés“ Dmmage
auche 1 abcés vesti. de la ﬁstule qur a mus longtemps a
g buhire se fermer a cause d an pent foyer


d’osteite.
17917
'HLHELL HHL JIO SEISVHSIG
I
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE REsEcuoNs DE GREFFES PAR RESTITUTION.——-(Suite.)

No. d’Ordre.
31
32
33
34
35
36
M. 1e Dr.
X. 38
ans
45 ane
M. P.
32 ans
Mme. L.
35 ans
Mlle. de
11. 18
ans


2%
m :1
Fl ' 0
+3 3 o: g g‘
g D '2 q; 5
°’ ° d 12 E‘
<1 4 5
E
let: prémo- Carie 1 abces Fistule
13.11‘8 sup. pénétrante palatin Palatine
gauche
Incis. lqt. Do~ 3 ﬂuxions Fistule
sup. droite dont 2 vestibu-
abcédées laire
Do. Sans carie Plusieurs D0.
ﬂuxions; 1a.
demiere
abcédée sur
la. gencive
2e gros. Carie I ﬁllxion, mol. inf. pénétrante suintement
droite par la. carie
Incis. lat. Carie Kyste
sup. droite pénétrante périostique
obtm'ée saillant 5, 1a.
voﬁte
Palatine
Incis.cent. Sans carie 1 abces vesti- Fistule
sup. ulaire vestibu-
guuche laire
ler gros. C'arie Congestions mo]. sup. pénétrante permanentes
gauche sans abces


‘*3 1 :5 4s m-
“) A c Q 51 c:
g "' Q 9.533 Q 0
U 3 u +1); Qhq) Sr: '2
2 =5 ‘2. e “and Q 2 a.
B Q O z I; e 2 B a
ii “” '° ‘is 8‘ 8
3 juillet Dénudation et résec- 3o jours Obturation
1877 tion de toute la. racine
interne—6 millimetres
z4juillet Dénudation et fon- _
1877 gosités périostiques, 11 do. Obturation
resection de 4 milli-
metres
ler aoﬁt Dénudation et 16- ... . .
1877 section de % centimetre
.. 9 aoﬁt Dénudation et résorp- 14 do. Obturation
1887 tion. résection de 4
millimetres
24 aoﬁt Dénudation et résec- .. Ouvertm‘e _ d“
1877 tion de 5 millimetres kyste et drainage
par la. voﬁte
palatine
29 aoﬁt Dénudation et fon- 1 mois Fongositég _du
1877 gosités périostiques; bord gingiyal
resection de 4 milli- touehées par l’acide
metres chromlque
6 cat. Les racines antéro- Igjours Qbturatlon c'i’un
1877 externe et interne drainage anténeur


dénudés, l’interne ré-
sequée entierement,
l’antéro-externe de 2
millimetres


accidentellement
obstruée au mo-
ment du debut des
accidents

4.; )3
d H
+= m
'3 ‘‘ Observations.
ﬁ 2
0)
Pi
Guérison 6 mois Drainage de la ﬁstule.
Do, 8 do. La dent, ayant une grande tend-
ance a descendre, est maintenue
avec un appareil faitfavec de 1
ouate et du collodion. Drainage
de la. ﬁstule.
Do. 5 d 0. N écrose de la paroi alvéolaire.
D0, Perdu du A la suite de la. ﬂuxion tries in-
vue tense survint probablement un peu
d’osteite péri-alvéolaire qui cum-
prima 1e nerf dentaire inférieur,
car i1 s’en suivit une hemia-
nesthesie des parties 01‘1 aboutit ce
nerf.
D0. 16 moi’; Hémorrhagie E1 l’ouverture du
kyste, hémorrhagie secondaire 1e
lendcmain. Le retrait du kyste
demanda. plus d'une année de
traitement, mais 1a. dent conserve.
sa solidité deﬁnitive.
Do. 1 an
D0. 14 mois Cette malade, déjé, opérée pour

une autre dent (Obeer. 5), a subi
ainsi deux operations avec un
succés egai.

SS 17 'Hmsm; HHI. HO snsvnsm
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE REsEoTIoNs
DE GREFFES PAR RESTITUTION—(Suite)

No. d’Ordre.
4o
42
44'
Q) o
0 m g ‘g . a g‘ "3 m' .
rd Ë .3.’ 3 ﬁ c 5 ‘9:5 3 g . ,3
as a “.2 s s s sä T2 a
‘4 3. 5 3 à {g g O 3 ‘3 +3 ..1 3% g .1: g ‘3 ‘3 Observations.
5'‘? Q 30 8 o à’ a 9. É amp?‘ Q Ë ‘E. Ë >-
o" > < '5 4-1 9 ‘23423 E" E M à’
:4 <1 «a .2 H ru °’ 0 :3 o
a En ru 'U U
M. N. I 1er prémo- Carie Nombreuses .. 24 dec. Dénudation des deux 6 jours ... Guérison 6 mois
25 ans laire sup. pénétrante ﬂuxions 1877 racines dans une
droite obturée abcédées étendue de 3 milli-
mètres qui sont ré-
séqués
M. U. 1er prémo- Do. Plusieurs Fistule .. 24 dec. Deux sommets dé- 15 do. Do. Pas revu La dernière ﬂuxion. suivie d’ab-
28 ans laire sup. ﬂuxions vestibu- 1877 nudés ; résection de 3 cès, avait laissé une dénudation de
gauche et abcès laire millimètres :5 millimètres de diamètre sur le
maxillaire, autour de la fistule.
Mlle. de 1er gros. Do. Plusieurs Fistule 25 jan. De‘nudation et ré- 12 do. Do. 11 mois
19 mol. inf. ﬂuxions gmgivale 1878 section de 1% milli-
ans gauche mètres
M. R. Do. Carie _Abçès Do. .. 3ojan. Dénudation des deux 15 do. Obturation de la D0. 7do.
29 ans pénétrante gingival 1878 sommets, résection (103 carie hors de la
millimètres bouche
M. le Dr. Ineis. lat. Do. Fluxions et D0. 28 fev. Dénudation et ré- 2 do. Obturatlon à D0. :0 do. _ Le malade quitté Paris sansaeo
C. 27 sup. droite abcès de la. 1878 section de 2 millimètres l’oxychlorure de cident le 3e Jour de l'opération,
ans gencive zinc mais i a donné, 10 mois après, de
ses nouvelles.
M. B. 1er gros. Carie Fluxion Do. .. 14 mars Résection oblique de 13 do. Obturation mé- D0. 9 (1°-
27 ans mol. inf. pénétrante abcédée 18 % centimètre de la tallique
droite ouverte racine antérieure
M. K. Incis. lat. Sans carie 2 abcès Fistule 22 fev. Résection oblique de 14 do. Do. 6 do. Drainage de la fistule. extraction
' 40 ans sup. double: 1878 3 millimètres du 80m. de Flusieurs séquestres après dila-
gauche palatine met tut on d'un des oriﬁces.
et vestibu-
laire
M. S. 1er molaire Carie Abcès du Fistule .. 27 mars Résection de 3 milli- 6 do. Obturatlon sans D0. 5 d0-
22 ans inf. gauche pénétrante bordgmgival vestibu- 18 mètres de la racine drainage en dehors
ayec lalre antérieure de la bouche
suinte-
ment
purulent
9517
'HL'HEICL HHL JO SEISVEISICI
TABLEAU SYNOP'I‘IQUE DE CENT OBSERVATIONS DE REsEoTIoNs
DE GREFFES PAR REsT1TuT10N.-(Suite.)


q: c:
"U
5 es
re o‘ L.
2 2°
45 M. de N.
23 ans
46 M. B.
43 11118
47 M. L.
21 ans
48 M. C.
23 ans
49 M. E.
40 ans
50 Mme. B.
40 ans
5: Mlle. L.
20 ans
Dent.
Incis. cent.
inf. droite
ler molaire
inf. droite
2e gros.
mol. inf.
droite
Incis. lat.
sup. droite
ler prémo-
laire inf.
gauche
Incis. cent.
inf. droite
ler gros.
mol. sup.
droite
Avec ou sans
Corie.
Sans carie
Corie
pénétrante
avec
suinte-
ment
purulent
Carie
pénétrante
ouverte
Sans carie
Corie
pénétrante
obtururée
sans
traitem ent
Sans carie
Carie
pénétrante
obturée
depuis
4 ans


c) o‘ ' .
8 v» - - * 8 “ w‘
a; (D Q g g o :3 g g , w
*5 5' *‘S g =3 2 ‘e? 8 e a g E E ‘
‘D 5 U ‘D 5’ 3 A Q’ ~53 *‘ 3 8 '3 “ Observatio
:2 E Q "13 ‘8 "3 ":1 pg‘. :5 ‘E :1 an 5 n8
4 5 t2 2-. Q Q "‘ a p:
"'3 "-c 'U Q.) U Q
.52 ﬁr.‘ re: "d O
CH
Abcesoutané Fistule 9 avril Résection de 2 milli- Isjours ,, Guérison 9 mois
de In 1878 metres
fossette
menton-
niere
Abces Fistule du 15 avril Réscction des deux 5do. Obturation com- Do. 8 do. Les accidents avaient cu pour
gingival vestibule 1878 sommets (18318 PH? pl‘ete sans drainage point de depart la suzpressiou du
étcncluc de 3 a. 4 m11h~ en dehors de la drainage de la cariep nétrante.
metres ‘Douche
Abces de la Fistule 23 avril Resection des deux 22 do. Obturation sim- Do. 4 do.
face cutanée 1878 Sommets dimS line ple hors de la
étendue de 2 5. 4 milli- bout-he
metres
Double abcés Fistule 28 avril ‘Resection do 4 milli- 10 do. ,, Elimina-
L’insuccés est manifestemont (it.
du vestibule traversant 1878 ﬁres tion 1e b.1’insufﬁsance de l’évacuation du
ct de la. voﬁte d’avant en ioe jour foyer et 5.1a presence de quelques
palatine arriére 1e séquestres.
bord
alvéolaire
Aboés 6 mars Résection de 3 milli- 9 do. Guérison 8 mois
multiples du 1878 m tres
bord
alvéolaire
Suppuration .. 15 avril Résection oblique de 8 do. Do. 8 do. Cette observation :2. cela de parti-
alvéolaire I878 4 milhmétres ' culier, que la forme de lésion de la
permanente racine se rapproche d’avantage de
l’ostéo-périostite que de la pérl"
\ _ ostite proprement dite.
8:‘noﬂuxions Vestibu- .. 20 mai Simple denudation de 12 do. Do. 13 do. Do.
dont 3 laire 1878 2 millimetres aux 2
abcédées depuis 1e sommets; résection de
dernier 3 millimetres é. chaque
abces sommet


ZS’? ‘HL'HQLL {un no sasvasm
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RÉSECTIONS
DE GEEEEES PAR RESTITUTION.--(Swite.)

No. d'ordre.
S3
54
55
56
57
o , .
w c> .. :1 +7 a;
o m ' :3 *0 . o :1
'6 . g m o c: a 8 °’"'‘ o 8 - ,3
d H up "-4 "J
sa a- sa» “à s s 3-3 sa a s a .
<1 m 5 sa [E g 0 2 2 7;»: 3*» 3.4: .2 z: “’ Observations.
8?. Q 8° 8 o 2 ä‘â 253mm Q ä T5. 53 g
0 > 4 '3 :3 9 (DÈS 5‘ 8 934 Q
z <1 1: É P‘ '° q’ â 5 m
a: Fa '°
M. R. 28 gros- Carie Fluxions 26 mai Obturation hors Guérison I an
26 ans molxsup. pénétrante multiples 1878 de la bouche
etu- droite non abeédées
diant en obturée
droit
M. D. ce gros. Carie Depuis IO Vestibu— 3 juin 2 racines externes 9 jours Ablation d'un D0. 4 mois Après 9 jours, ‘la dent est
27 ans mol. sup. pénétrante mois, 5 ou6 laire 1878 dénudées et résorbées; séquestre consolgdée; le clapier osseux est
gauche depuis ﬂuxions, 3 résection de 4 milli- en ‘(oie de réparation; la ﬁstule
7 ans abcès avec mètres; vaste clapier persiste.
nécrose osseux
partielle
M. A. 1er prémo- Carie 2juillet Tumeurs ﬁbreuse au 3 do. Obturation du Do. 1 an La consolidation est complète
22 ans laire sup. pénétrante 1878 sommet ; résection de drainage après 3 Jours sans suppuration.
gauche obturée, 4 millimètres
drainée
sans
résultat
M. T. 1er gros. Carie Plusieurs Vestibu- 15 juin .Dénudation ctrésorp- 25 do, Obturation en D0. 1 an Corgsolidnﬁon lente. cependant
22 ans mol. sup. pénétrante ﬁuxions laire 1878 tion delaraeine postéro- dehors de la bouche; parfalte au bout d'un mois, malgré
droite 3 abcès depuis externe; dénudation de la réimplantation lamutllation de l'organe ;guérison
dénudation 6 mois l’antéro-externe; ré- oﬁ‘rant des diﬂi- complète de la ﬁstule.
osseuse Section de 3 à 4 milli- cultes on a dû
mètres à chacune; ré- couper entièrement
section entière de la racine interne
l'interne
M. M. 1er gros. Carie Vaste clapier Vestibu- .. 5 juillet Dén‘udation et dé- 12 do. Obturation en de- D0. 6 mois
34 ans mol. inf. pénétrante osseux laire 1878 struction du sommet; hors de la bouche
droite depuis résection de 4 milli-
5 mois mètres
Mme. de 1er gros. Sans carie Do. Vestibu-
rojuillet Tumeurs fongueuses 20 do. Do. Pas revu
A, 42 mol. inf. laire 1878 périostales au sommet;
ans droite depuis périoste partout ailleurs
g mois hypertrophié et fon- .
gueux sur certains


points; résection de 3
millimètres ; section des
fongosités


95v
'HCLEIIELL HHJ} .ElO SEISVHSICI
E5 5%
'2 e <3
0 .58
:c, _ c.
D 8 lo
0 o —'
Z Z
58 M. R.
30 ans
59 M. D.
41 ans
60 M. S.
16 ans
61 M. F.
45 ans
62 M. B.
24 ans


TABLEAU SYNOPTIQUE DE GENT OBSERVATIONS DE REsEcnoNs DE GEEEFEs ma REsTITUmIoN.—(Suite.)


Q) . u
m m ‘D . .. £1 +3 10'
s s é‘; ‘8 o g e as e s ..-
45 m G; E’ 0* S 10;; 2'81: 8 m E 15 .3
q :3.“ o a 1:! a d B‘Q c: w ‘2 g g '5,
e: o ‘a £2 E 0 +3 .3 c; r-l 8 f3 :1 1:3 :2 w
9 a o 8 o .2 a. z 2 i=1 H a H e 35
> <1 '5' .5 .0 Q ‘6’ '9‘ E“ <89
EH
Canine Carie Abcesily a 5 Fistule 19 aoﬁt Racine tres volumi- 60 jours Persistance de la Guérlson
inf. droite post. tres mois de la 1878 neuse; denudation de suppuration par
petite, fossette } de la hauteur; ré- l’extréme étendue
obturée menton- sorption du cément; de la ﬁstule
depuis niere résection de 2 milli-
3 ans metres
Canine Sans carie, Abces tous Fistule 22 oct. Dénudation simple 20 do. DO'
sup. droite chﬁte de les mois longue et 1878 en avant du sommet;
cheval depuis 2ans, ﬁéxuense resection de 2 milli-
endant sensation metres obliquement
a guerre douloureuse
sourde; pas
d’ebranle-
ment
Incis. lat. Caries 2 abces Fistule .. 22 oct. Dénudation simple; 12 do. ... D0-
sup. péné- précédes de perma- 1878 resection de 4 milli-
gauche trantes ﬁnxions nente metres
sur les 2 considér- transver-
faces ables sale an
latérales niveau du
sommet. ‘
ler prémo- Carie Fluxions Fistule 7 nov. Alteration des 2 som-
Tnsllcces
laire sup. pénétrante rares gingivale 1878 mets; résection de la
droite obturée depnis 10 moitié de chacune des
ans avec racines; sorties 4 milli-
fongosités metres
Incis. lat. Carie Fluxions et Vestibu- 26 nov. Alteration du som- 30 do. Extraction d’un Guérison
sup. ancienne abces laire 1878 met; résection de 2 séquestre assez
depuis multiples, millimetres voluminenx sons 10
10 ans clapiers dé- décollement
résequée collements
au moyen
de la lime,
périostite
consé-
cutive
Revu apres
Observations.
15 mois
pas revu
Pas revu

Cette guérison était complete
depuis un an an point de vue de
la greffe; mais la persistance de la
ﬁstule avec un écoulement du
reste lres faible, décida 1e malade
a l’extraction de la dent.
Au 4e jour de la greﬁ‘e, 1e
malade im atient enleve sa dent
quideJa 0 re une certaine resist-
ance.
'HLHELL {EH-LL HO SEISVSICI
6517
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RE'SECTIONS DE GREFFES PAR REsTHUTIom—(Suita)

No. d’Ordre.
64
65
66
67
68
69
a m g ' . ~ g. "E- m’
- o 74 on." C1 .
'3 w . 2 13 g. s w .5 Q 15,5 *5 a, g .2 1-; {-3
$6 a 5.2 55 = 5 '° *3 '56 Ci 3 v» Q *3 s Q. .
_ Q‘ E; o g jg g 3‘; +3 4 33 ‘L535 3 a c: Observatlons.
g 9 Q 30 3 q, g a m 2 girl P‘ Q H '5. w a
*0“ P <4 '3 4;, 2 @132 a a m a;
A <1 "a g g o
m
M. K. ler prémo- Carie Abcés Gingivale 24.1w , Dénudation de 2% mil-
Guérison 1 mois
25 ans laire sup. pénétrante continuels oblique de 1879 llmétres; résection de
droite obturée depuis 2 ans - 3 centi- 3 millimétl’es
antérieure- métres de
ment profou-
deur
M. Y. 20 mol. Carie 3 ﬂuxions Pas de 20 fev. Résection de 4 milli- I 5 jours Do. do. _Le malade, revu ﬁn jnillet, 187g,
28 ans inf. gauche pénétrante considér- ﬁstules 1879 métres 5, 1a racine (ht que depuisg semames seule-
obturée ables postérieure ; résection ment i1 peut se servir de cette dent,
de 1 millimétre 5. 1a. your manger, comme des autres.
racine antérieure usqn’h. cette époque douleur A la
PI‘GSSIOII.
Mlle. S. ler prémo- Deux caries Plusieurs Plusieurs 3 mars Résection de 5 milli- I3 do. Une ﬂuxion 1e Do. 6 do. Sonda es réitérés dn clapier et
17 ans laire sup. dont une ﬁuxions ﬁstules I879 métres dénudés et fon- lendemain deg ﬁstu es. 2 apphcatxons de
gauche pénétrante violentes, gingivales gueux polntes de feu aménent une con-
vastes solidation rapide.
clapiers
Mlle. A. lncis.méd. Sans carie Noyauinduré 19 mars Dénudation de3milli- 18 do. Do. 10 do. Bandage ‘en huit dc; ehjﬁke
17 ans inférieure permanent, 1379 métres; fongosités ; ré- mu1nt0n\l_I$J0m‘S' Cl‘éﬂtlon d “119
remontant section deg 3 mllli. ﬁstule artlﬁcielle avee séton.
2L 4 ans métres aﬁ‘ectés
M. L. ler mol. Carie Fistule 2 avril Résection de 2 milli- 15 do. Obturation hors D0. 3 d0-
24 ans gauche pénétrante :1 I'angle 1879 mébres h chaoun (108 do 19, bouche
non de la sommets
obturée m6,-
choire _
Mlle, Q. ler mol. Carie Fluxion avec Gingivale 28 avnl 2 sommets dénudés et 9 do, Do. I an
20 ans inf. droite pénétrante ﬁstule 1879 {Jrésentant en outre une
ancienne pénétrante égére hypertrophie cé-
obturée. mentaire
Mlle. I‘. ler gros. Carie Vastes abeés, Gingivale 27 juin Fongosités périos- 20 do. Extraction do Do. 5 mois
19 ans mol. sup. pénétrante suppuration 1879 tiques aux 3 sommets ; plusieurs séques-
antérieure trés résection de 3 milll- tres
abondante, métres aux racines ex-
clapier et ternes et (10 I milli-
dénudation


05361188
métreim la racine intcrnc
I
0917
‘HL'ŒIGÏÆ ŒIHL JIO SHSVHSICI
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RÉsEcTIoNs DE Gnnrrns PAR. REsT1TUT10N.-—(Sutte.)


_ a g 4-; (-1; m
s8 sêäê ä .5 g a
"'5 5%? Q’ \3 8 “.3 ﬁ â‘ .
o 2 +1 ,4 4.3% ",3 ‘o :1 Observations.
4533W Ë aäm à E“ "a ~53 E
m8 234-» C3 É: a m 4’
A 'O ‘D; o 0 m
'5 "U U
18 juillet Petite tumeur em- zojours Un peu de ﬁèvre; Guérison ..
1879 brassant les 2 racines; insomnie; ﬂuxion
résection oblique des légère
I‘; centimètres des 2
racines; légère portion
d’alvéole entraînée dans
l’extraction
3 SGPË- Déviation par 211- Obturation en de- Insuccès L’insuccès est dû ici à, la forme
1879 longement et rotation hors de la bouche de la périostite qui rentrait dans
de l’axe en dehors; ré- la classe de l’ostéo-périostite.
section en bec de ﬂûte
de 3 millimètres
13 sept. Obturations en dehors .. D0. ..
1879 de la bouche; résection
de 3 millimètres; ban-
dage double de soie
cirée
22 sept. Dénudatîon de 2 15 do. .. Guérison Pas revu La 2e prémolaire, affectée dela
1879 millimètres; résection même lésion, avait été extraite il
égale y a six mois, mais sans modiﬁca-
tion sur l'état du malade. Cessa-
tion immédiate de la suppuration.
27 sept. Fongosités des som- D0. I an
1879 mets; dénudation - ré-
section de 4 millimètres
20 oct. 2 sommets altérés, Do. Pas revu Une tentative antérieure de
1879 l’antérieur estfongueux; guérison a été faite et a con-

2 'g Ë a; à’
Ë 35€.; 43 g 4.: É g
g îâ ä 3s ë à
0' ËÊ Q §° 3 %
z '2: <1 4 Ë.
F74
70 M. de X. 1er mol. Carie Fistule Gingivale
40 ans inf. gauche obturée gingivale
depuis datant de 3
10 ans ans, abcès
fréquents
71 M. M. Incis.cent. Carie Pas de
3 5 ans sup. droite étrangère ﬁstules
à. l’aﬁ‘ec-
tion
72 Mme. B. Incis. cent. Do. séquestre 2 ﬁstules
37 ans sup. droite éliminé, anté-
accidents meures,
reproduits I poste-
2 fois rieurc avec
clapier.
73 M. de B. 2e mol. Carie Ecoulement 3 ﬁs_tulcs
74 ans inf. gauche pénétrante purulent gingivales
ancienne abondant
obturée
74 M. S. se mol. Carie Empâtement
43 ans inf. gauche pénétrante très étendu
obturée de la région
cervico-
maxillaire
75 M. B. 1er mol. Carie Abcès Gingivale
30 ans inf. gauch pénétrante ﬁstuleux de vestibu-
obturée la gencive laire
avec
drainage
depuis
18 mois
Fistule Cutanée.
résection de 2 milli-
mètres


sisté dans une simple extraction
suivie de greﬁ'e au bout de 6 heures:
mais sans résection. Les accidents
se sont reproduits immédiatement
dans la seconde opération.
I 917 ‘mana; nm; s0 susvusm
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RE’sEoTIoNs DE Gnnrrns PAR. RESTITUTIONr—(Sut'ta)

77
78
-79
Q) . .
ou o a :1 45 ni
0 ä ' g ‘0 ' Ç Q) o g g
PU au F1 c.‘ 0 ‘H Q) ' m
<3. 8 o à :9, E O :3 {.3 âi-Jgs‘â ä-Ë .2 E N Observations.
Ë‘? Q go 3 o ,9 3% z gmü Q r-q ‘E. ~<1> g
a” à 4 :=2 à .0 s33 à: s ' m a
n.‘ "" <9
ä ‘a ,3 vu 0
Mlle. T. Incis. lat. Carie _ Fistule Fistule Fistule 30 oct Résection de 5 milli- 3 mois Consolidation au Guérison 1 an Un drainage est établi entre la
19 ans sup. pénétrante cutanée au gingivale cutanée 1879 mètres environ bout de IO jours; - ﬁstule cutanée et le vestibule;
gauche obturée niveau de au niveau sur- la ﬁstule cutanée par l’oriﬁce buccal, on peut at-
double l’aile du nez du sommet venant ersiste; mais teindre le séquestre. On le dé-
greﬁ‘e persistant de la 6 mois écoulement di- tache à. l’aide d’un excavateur. 11
après une racine après minue; cautérisa- est éliminé quelques jours après.
1er greffe de l’auriﬁ- tions à. l’acide A dater de ce moment l’écoule-
cette dent, cation cliromique; injec- ment devient insigniﬁant, et, à. la
faite sans de la tions à. l’acide thy- ﬁn de janvier, il avait complète.
résection du dent mique: un petit ment céssé.
sommet; 3 séquestre a retardé
ﬂuxions la guérison
M. B. zc mol. Vaste carie 1er ﬂuxion Fistule snov. {altérations caractér- rojours D0. 6 mois La ﬁstule de la racine palatine
24 ans sup. droite pénétrante consécutive palatine 1879 istiques des 3sommets; a été maintenue ouverte jusqu'à
occupant àune 1er résection de à milli- parfaiteguérison.
la moitié obturation mètrca la racine interne
de la le 15 août ; de à aux 2 externes
’ couronne 2e ﬂuxion
obturée après une 1er
précédant obturation
avec drain-
age—ces
2 ﬂuxions se
sont ter—
minées par
abcès
M. M. Incis. sup. Carie Intolerance Fistule 18 nov. Résection de 2 milli- 21 do. D0. 3 mois
50 ans droite pénétrante de l’obtura- gingivale 1879 m tres
avec tion et du inter-
suinte- drainage mittente
ment. Résection complète 20 do. ... Do I mois
M. de P. 1er mol. Carie Suppuration 30 nov. de la racine antéro-
31 ans sup. droite ancienne alvéolaire in- 1879 externe et de 1 milli-
obturée cessante, mètre de la racine in-
accidents terne
généraux
par ingurgi-
tation du


pas
zgt
‘HLHELL 'élHJ} JIO SHSVHSIG
No. d’Ordrc.

81
82
83
84
35
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE REsEc'noNs


0 VJ
1:: :3
we . a s
‘q 9* g o a 53
2'2 Q 8” 8
O
z 2 4
M. 0. 2e mol. Carie Périoslite
26 ans inf. gauche pénétrante ancienne
ancienne ayant résisté
a tout traito-
ment depuis
4 mois
M. B. ler prémo- Carie Série d’abces
36 ans laire sup. pénétrante ﬁstuleux
gauche obturée
depuis
1; ans.
Mme. de Incis. cent. Carie lat. Depuis, 6
N. Z. sup. droite mois, série
32 ans gauche auriﬁcé, d’abces
carie lat. presque
gauche continuels
auriﬁcé.
M. X. ler mol. Carie Abces et
27 ans sup. droite pénétrantc ﬁstules
obturée depuis 3
mois.
M. X. ler prémo- Carie Abces
35 ans laire inf. pénétrante multiples
droite obturée ﬁstules et-
depuis clapier don-
longtemps nant sans
cesse une
quantité con-
sidérable de
pus.
M. B. ler mol. Carie Depuis
18 ans inf. gauche pénétrante l’oblitération
obturée poussées
depuis inﬂamma-
2 ans toires d’une
grande
violence,
adénité sousp


maxillaire
V
g 8 - d‘ 8 ‘5% °"'
8 g Q 8 ®_Q 815 u g
g! 4-‘ IU 33 ;_, m'd 8 a) 8 15‘
e 8 es =sem a» s
2 s :6 gigs “a a
2 ‘a Q 8 Z P‘ 4-": ‘*5 Q E’: g‘
jg 13 ;~ 4§<»j; 5 o
_g ‘T C)
m p '1: 'c
Vestibu- 19 dec. Périostite‘ chronique 18jours. Obturation hors
laire an 1879 des 2 sommets; résec- de la, bouche
nivean tion de 3 millimetres de
de la la racine postérieure et
racine de 1% millimetres de
poste- l’antérieure
rieure
Gingivale 26 jan. Périostite chroniqne 18 do. 1880 du sommet; resection
de 2 millimetres ‘
Vestibu- .. 14 fev. Section oblique en 25 do. . .
laire 1880 arriere de 3 millimetres
du sommet
I
Gingivale 27 fev. do.
1880
Do. 9 mars Resection de 3 milli- 30 do. 1880 metres du sommet
dénudé et résoi be
Do. 25 mars Resection en bec de 18 do. Obturation en de-
1880 ﬂute de 3 millimetres hors de la bouche


des 2 sommets


DE GEEEEEs PAR RESTITUm0s.—(Sm'z‘e)


Résultat.
Guérison
Do.
Do.
Revu apres

ran
3 mois
2 do.
Pas revv.
Do.
Do.
Observations.
Le lendemain de l’opération 1a
dent est completement hora de
I’alvéole, elle est remiee en place.
La malade la maintient avec lcs
dents supérieurs pendant 18
heures. Le troisiémejour la dent
se consolide.
Nécrose du bord alvéolaire ;
ablation de divers séquestres; in-
jections dans le clapier.

'HJÆIŒLL EIHL JIO S’JSVHSICI
€917
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE RÉSECTIONS
DE GEEEEES PAR RESTITUTION—(Suite)

No. d’Ordre.
37
88
89
90
91
92
63 Il)
g... . sa
445 Ë g'z
.. m w c‘!
59 Q go
OP‘ p
'A 4
Mlle. A. Incis. lat. Sans carie
13 ans. inf. gauche
M. B Incis. lat. Carie
18 ans sup. droite antérieure
auriﬁeé
M. de C. 2e prémo- Carie
laîre sup. pénétrante
gauche obturée
et drainée,
continua-
tion des
abcès.
Mme. X Ineis. cent. Sans carie
25 ans. inf. gauche
M. D. 1er mol. Sans carie
24 ans inf. droite
M. R, I m'is.ccnt. Sans carie
22 ans inf. droite
M. P‘. Incis lat. Carie
25 ans sup, obturée
gauche depuis


longtemps
Accidents.

Empâtement
ancien du
bord alvéo-
laire et du
menton
Kyste périos-
tique du
maxillaire
supérieur du
volume d’une
grosse noix
lätat ﬂuxion-
naire perma-
nent de la
fosse canine.
Abcès
multiples
remontant à
4 mois
Etat ﬂuxîon-
naire perma-
nent de la
région men-
tonnière.
Abcès àrépé-
tition depuis
3 ans

Fistule Muqueuse.
Fistule Cutanée.


Gingivale
Vestibu-
laire
Gingivale
d Ë; É m
ê-â 8 g ä Ë Ë
Q E’. 3,4 03% h 3 .° '3 ‘5 Observations.
‘55m ca ""gq 5'3 r’: w :5
g cu 22m Q =.. à ‘<9 >
9 62753 5* Ë ‘3 ê:
.—4 ru '8 r8 o
7juin Résection de 2 milli- 18 jours . . Guérison 1 an
1880 mètres du sommet;
drainage au fond du
vestibule avec un ﬁl de
plomb
7 juin Résection de 3 milli- 2 mois m D0. 5 mois Avant la greﬁ‘e on établit un
1880 mètres de la hauteur au drain de ﬁl de platine au travers
niveau de la collerette du maxillaire, puis dilatation de
de périoste qui corre- l'oriﬁce antérieure application
spond éxactement à du drain d’etain permanent.
l'insertion de la paroi
kystique
Iojuin Résection de 3 milli— rojours m D0. an
1880 mètres; obturation en
dehors de la bouche
r4juin Résection de 2 mîlli- 21 do. . . Do. 2mois Vaste clapier sous-jacent au
1880 mètres sommet.
xsjuin Résection de 1 centi- 18 do. Do. 25 juin L'extraction a été laborieuse.
1880 mètre environ a chaque 188: La réimplantation de la dent oﬁ‘re
sommet d'abord, puis des difiicultés, les racines étant
de 1*} centimètres très longues, et présentant une
certaine courbure d'avant en ar-
rière. Il faut réséquer une partie
notable des racines, pour qu'elles
puissent rentrer dans l’alvéole.
21 juin Résection de 3 milli- 8 do. .. D0- Pas revu
1880 mètres en bec de ﬂûte
9 juillet Résection de rèmilli- 8do. .. D0. 5 mois
1880 mètres


17917
'HJZEIELL ﬁll-LL JO SHSVHSICI
TABLEAU SYNOPTIQUE DE CENT OBSERVATIONS DE Rnsncrrons
DE GREFFES PAR RESTITUTION—(Su ite.)

N o. d’Ordrc.
94
99
100
l
0 É ‘5.’; Cl +5 ou‘
V) o " o m
‘2’, 6 a g‘ 3 Ë ce 5 Æ 2:3 5 E .5 e
620 .. 43 ‘n c; si c" :1 ‘U ‘s A WU 8 ‘D E 5 ‘3 F“
4%‘) c: 55'; <9 5 o œcs swim ‘9o c3 ﬁ c5 Ob t.
_ Q. o) o a g ä o Ë 5 +53»; 3 sa g; 3: ,9 a 5 serva ions.
a? Q 2:0 s o 'a n e me?” 9 ﬁ a v» a
0-! > 4 ‘3 4-‘: SD "3.53. E" a m m
2 <1 «a .52 H ê’ ° q, o 0
-‘—”< ﬁ vu "d Ü
r;
M. A _ 2e mol. Carie Accidents in- 3juillet Résection de 2 milli- 15 jours .. Guérison 8 mois
25 ans lnf. gauche ancienne ﬁammatoires 1880 mètres auxdeuxracines
obturée répétés,
depuis
3 mois.
Mlle. V. Incis. lat. Carie Flnxions Vcstibu 7 sept. Résection de 2 milli— [5 do. Obturation‘ mé- D o. 6 do.
21 ans sup. pénétrante répétés, laire 1880 mètres aux deux som- tallique en dehors
gauche douleurs mets de la bouche
intenses. _
M. S. 1er mol. Carie Fluxion Gingivale 7 sept. Résection de 2 milli— I sdo. D0. 6 do- Obtura’üon en dehors de la
18 ans inf. droite pénétrante gingivale 1880 mètres à. chaque som- bouc e.
obturée gonﬂement met
œdémateux
du maxillaire
Mme. de Canine Do. Fluxions Do: 15 sept. Résection de 2 milli- 25 do. D0. Pas revu
V. 30 sup. droite multiples 1880 mètres
ans.
M. P. 1er prémo- Carie Gonﬂement Perma-
21 jan. Do. :5 do. D0. D0-
25 ans laire sup. pénétrante chronique de nente 1881
droite libre. la région.
M. s. 1er mol. Carie Abcès alvéo- Vestibu-
7 fev. Do. 15 do. Do. s mois L’opération a été suivie de
18 ans sup. pénétrante laires se laire 1881 quelques accidents généraux in-
gauche obturée reproduisant quiétants puis, au bout de 4 jours,
depuis chaque jour l’amélioration fut très rapide.
2 ans et s’écoulant
par un tube
de drainage
poussées in-
ﬁammatoires
. A. Incîs.cent. Fracture Fluxions Do. . . 9 fev. 25 do. D0. 5 do. Application sur la racine d'une
n ans sup. droite acci- multiples, 1881 dent artiﬁcielle avec pivot tubulé
réduite à. dentelle abcès formant drainage. La greffe a
sa seule Nombreux donc eu pour but ici de rétablir
racine une racine de dent incisive
pourvue d'un appareil de prothèse.
C'est le seul cas de ce genre
dans cette série.
M. de T. 1er prémo- Carie Nombreux Do. 8 mars Résection de 3 milli- 20 de. .. D0. 0.
24 ans laire sup. pénétrante abcès dont 1881 mètres
droite le dei'nigr est
rest


ﬁstuleux
DISEASES OF THE TEETH.
465
.SBQSS w ﬂag ._.


03 03 02 02 03 OS 03 8H 03
i
ma 3. ...§ aw w so mm E. .926“. w. w .58 a on b m Q i 3 R 3 an on m w H g 2 H o a 3 § 1‘ E 0 on o»
I,’ III. III In I.
V w
0
a w mm X m m s s s s m w m S m
M. S A S ml 9 m X s V Qu n .m. n I n W. n U .l ob oo o o 0 on a
L9 2 m m 1 "4.0 a u. aw d 3 d m; d J d J a
1 1 Hm“ .d D S S O S .1. B 0 S 9, 9, 9, 9, 8. 9 9, w, _ A
Wm w.“ w M .m. n 0 P $58 485 u e s M raw‘ m. m. .m a a @ am a m a Wm H m
m1 d Ma 3 W m. W a. 9 WW .w, w\ w u S V n m n m m m n m. w m m
m a m u 9 s 0 s m. .Q 5.“ .03 s 1 m I s A u . u . . . .m . o» oo om 0+ on on 0H 0 I. n w
00 9%.. M 9 muv‘ O H p. H mm m. 8 min B W Moo H S
WP u u s n 1 m w? o . b w, s a m. m s . u u .
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4 w m. m w w u .m n 1 W
I a
m. m . ma “3:12: 339,8 w m s m.‘ $38 o8’ 82m
( 1 o 9 S ‘ H - .
. “a 9 8 . EEECE mmﬁqwO .. .
.. s 6mm 85 3254
$.55 323m .
. i540 . .5340 .mamgm
mzogggmﬁoo .mmndnﬂz giéwwm 3 mm mwanzmwwww< an moza .mmwaomﬁg $55 .255 mun “34 amp
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.ZOHHDHHBmEH MAE mmrmmmw 05:1 mzoaommﬁm HQ mzbﬁggﬁmmmmv EZHU HQ HD~§EHH<Z< mgﬁpmwmm
PART III.
466 DISEASES or THE TEETH.
ou bleuatre que présentcnt constamment les dents frappées de périostite chronique du
sommet. Cette coloration est meme un signe important de diagnostic. ‘*
Le sueces de la greil'e par restitution réside done entierement dans l’existenee d’une
étendue de périoste suﬂisante et formant, ainsi que nous l’avons dit, une bande circu-
laire complete autour de la racine. La présence de cet anneau membraneux est une
condition absolue, que tous les cas d’élimination sont dus a l’interruption dans la
continuité de cette surface vasculaire.
Il arrive parfois, en effet, que les phénomenes de la périostite ont amené la production
de quelques fusées purulentes qui se sont fait jour, an bord meme de l’alvéole
auteur du eollet. Le périoste a ainsi subi, dans le sens vertical, une mortiﬁcation ou
suppuration de son tissu, et la eoulée purulente qui en résulte devient la cause presque
absolue d’un insucces.
L’échee de la greﬁe se manifesto ainsi des les premiers jours par une elimination pure
et simple de la dent entrainée par la suppuration de l’alvéole et du foyer.
Quant aux résultats déﬁnitifs que nous a fournis cette méthode opératoire, ils sont
établis sur un ehiifre dc cent observations résumées dans le tableau precedent (v p.p
Mil—41641).
Nous terminons enﬁn eette communication en mettant sous vos yeux le résumé meme
de notre pratique sous forme du dernier tableau, que voici (p. 4165).
Replam‘az‘z'on.
Dr. l/V. FINLAY THOMPSON, London.
The subject of replanting teeth, although frequently brought before the dental and
medical professions, does not seem to have been thoroughly investigated by either body ;
yet it is one in which of late so many instances of treatment, successful or otherwise,
have been recorded, that its discussion is not only permissible, but even necessary 3 and
as the disquisitions of this Congress will undoubtedly bring it into more prominent
favour, or tend to cast it into oblivion, I submit the following questions, hoping that they
may bring out a full expression concerning it :—
I. Shall the system of replanting teeth, under any circumstances, be a recognised
operation in dentistry? and, if so, under what pathological conditions should this means
be employed.
II. What advantages, in contradistinction to the disadvantages, may be claimed for
replanting? Also, what percentage of cases are successful?
Before entering upon the practical bearings of the subject, it would be well perhaps
to brieﬂy consider the structure of a membrane upon which replantation is wholly depen-
dent for its success.
The peridental membrane is an organized tissue which must be considered under
two aspects—its relation to the vascular alveoli, and to the non-vascular cementum ofthe
teeth. Its oliice, however, is similar under either aspect, as it acts as a periosteum or
nutrient membrane to both, though modiﬁed in its action, and even in its texture, to a
degree commensurate with the difference existing between the compact cementum and
the soft caneellated alveolar tissue. Owing to the intimate relation of the peridental
membrane to these two sections, it may—in the absence of pulp irritation—be con-
sidered the important factor in lesions connected with the teeth. It is chieﬂy corn-
posed of white ﬁbrous connective tissue, and has a rich nerve and blood supply, while
nucleated masses of protoplasm are to be found in every part. The wavy character of
the ﬁbres is more pronounced when seen in longitudinal than in transverse section
Their general course is oblique from the bony alvcolus to the cementum, without break
DISEASES on THE TEETH. 467
or interruption. According to Waldeyer, the nerve supply is abundant. The larger
blood-vessels ramify in a general manner; those from the gum and alveolar surface also
anastomose in its substance. The smaller masses of protoplasm are chieﬂy connective
tissue corpuscles, while those near the bone and cementum form the osteoblasts. It is
to the vitality and functions of these histological elements in particular that we must
have the greatest regard in considering or treating any pathological condition of the
dental periosteum.
Reverting to the ﬁrst question, “Shall the system of replanting teeth, under any
circumstances, be a recognized operation in dentistry?” the recorded instances of
success in replanting have perhaps been looked upon as evidences of a certain power in
Nature not practically available, and consequently classed with other curious anomalies
in the transposition of tissues. Want of success, through operating under incompatible
conditions, has discouraged some from following to its conclusion a method which cer-
tainly has, in some instances, been practised advantageously. These remarks must not be
misunderstood; for I contend that the system of replanting should not be introduced in
practice, save in severe and otherwise hopeless cases, and it is to these alone that
reference is now made.
In regard to the physiological action in the reunion of the tooth with the alveolus,
we can only reason from analogy. The evidences, however, of the existence of a perfect
reticulum of connective tissue with ﬁbres and protoplasmic cells are abundantly proved.
In fact, the osteoblasts accumulate in such numbers on the surface of the cementum,
that, in certain inﬂammatory disorders, they act antagonistically, removing part of the
cement, producing characteristic striae and depressions. The otﬁce of protoplasm in the
reparation of dissevered tissues is so well known that I need only call attention to the
existence of this germinal matter in the peri-cementum to at once establish a prima’ﬁzcz‘e
evidence of the probability of the reunion of a tooth with its socket, through the inter-
vention of the alveolo-dental membrane. As we see by an examination of the
peri-cementum, there are, in the healthy condition of the tooth, immense numbers of
masses of living matter in connection with the various parts entering into its compo-
sition. In health, these germs go through their proper changes and perform their proper
functions. In diseased conditions, or in any departure from the healthy state, these pro-
toplasmic bodies are also the principal agents, and, in such departures from the healthy
state, they are excited to action by excessive supply of pabulum, which causes each
individual mass of living matter to live faster than it should—La, it takes up more
pabulum and converts this into more living matter like itself than it does in the normal
condition; it becomes enlarged, it divides and sub-divides, and multiplies to such a
degree that, in the place of the healthy tissue, we have a pus formation. The proto-
plasmic bodies in the blood—or white blood corpuscles—also actively assist in the
inflammatory process. In recorded cases, it is stated that teeth have been successfully
replanted without peri-cementum upon them. The means of union in such cases I shall
not now discuss, but, at the end of my paper, this subject will be indirectly included in
a question I shall then put to the meeting; yet it may not be without interest if I cite
a case which lately came under my care, where the return of the tooth to its socket was,
from various causes, delayed for twenty-ﬁve hours. In this interval, instead of being
kept in a solution of salt and water, it was encased in bibulous paper moistened with
carbolized water. The tooth, after being returned to its socket, appeared for a time to
progress favourably; but was, notwithstanding, ultimately lost. It is a question whether
this destruction of vital power was not in consequence of too long an interval between
extraction and replanting, or whether the carbolized water destroyed the protoplasmic
germs which were to, in part, restore vascular circulation between the alveolus and the
n H 2
468 DISEASES OF THE TEETH.
peri-cementum. I infer that, in the necrosed condition of the periosteum, which was not
tolerated by the plastic effusion from the alveolus, sloughing resulted, rather than any
ﬁbrous connection with the cementum.
There is, even in successful cases, great difference in the stability of replanted teeth.
In some, considerable mobility exists, indicating a lax ﬁbrous attachment; this some-
times occurs in undrained teeth, caused, no doubt, by the retention of septic matter,
or eﬂ'usion of inﬂammatory products into the connective tissue. In others the ﬁxed
condition of the tooth suggests anchylosis. These cases are usually found where
drainage has been provided for, thus permitting egress of the morbid accumulations
from suppuration, as well as the sequelae of organizing inﬂammation. ,
Whether the inﬂammation be acute or chronic, the practice of replantation demands
parallel procedure—via, the removal of all the disintegrated periosteum, the destruction
of the sac at the apex of the root, and the careful polishing of the cementum where the
osteoblasts, from inﬂammatory inﬂuence, have reversed their function and begun to re-
absorb the osseous structure of which they were originally formative. This process
may vary in its intensity from merely causing microscopic pits in and prominences on.
the cementum, to the dissolution of that tissue, and ultimate wasting of the root of the
tooth. It was this condition which suggested to me a possible advantage of capping.
Of the subject of capping I shall shortly treat.
II. What advantages, in contradistinction to the disadvantages, may be claimed for
replanting? Also what percentage of cases are suceessfuli>
Those who have treated chronic alveolar abscess must, at times, have experienced
the uncertainty of their efforts. Day after day, perhaps for weeks, and even months,
have patients been subjected to the inconvenience of almost daily attendance upon their
dentists, with but doubtful beneﬁts being conferred, resulting, perhaps, in only tempo-
rary retention of the tooth. Shall we not consider this a case open for the adoption of
any means promising relief? Then, again, there may be conditions under which the
time required cannot be devoted to the case, as often happens when parties come from a
distance. If treatment calculated to secure a valuable organ can be performed in a
single sitting, shall we not deem it a justifiable procedure P
The operation is one which, from its very nature, must be brought to a quick conclu-
sion. Although, between the intervals of extracting and restoring the tooth again
to its socket, several hours may elapse, no unnecessary time should be wasted in its
return.
It may be alleged that the severance of the contiguous tissues, and the disrupture of
the nutrient vessels, is of such a character as to preclude solid reunion of the cementum,
of the peri-cementum, and the gum and alveolus. That the reunion may partake of the
nature of a “seamed scar,” and therefore be so far incomplete, I shall not attempt to
refute; but that it is sutﬁcient to continue the low vitality required to ensure the reten-
tion of the tooth is now fairly well established by the lapse of years in cases of replanted
teeth, which are apparently sound and us cful to this day. As an instance——
A patient of the late Mr. Edwin Sereombe, who came under my care for general
treatment of the mouth, gave me the history of a second inferior bicuspid replanted
some ten years before by that gentleman. The tooth was not discoloured, and it had
every appearance of being alive. A slight retrocession of the gum and alveolus had
taken place, but not to such an extent as to cause any inconvenience. Numerous other
equally successful cases have been recorded.
Perfect restoration of the tooth can also be made where ugly forms of decay extend
under the gum to almost inaccessible positions, with a perfection limited only by the skill
of the operator, as his ability is not then dependent on the endurance of the patient,
DISEASES OF THE TEETH 469
whose irritability ceases to be an element in the diﬂiculties of the operation. This ad-
vantage, however, should in no way bias a practitioner in the treatment of any case.
The extraction, performed under the inﬂuence of nitrous oxide, is of course, painless;
and when the manipulation of the tooth is complete, gas may again be called into requi-
sition in this the only part of the operation from which any further acute pain may arise.
Once the tooth is established in position and carefully adjusted in respect to its occlud-
ing surfaces, rarely more than tenderness and uneasiness of a few days’ duration are
experienced.
Having viewed one side of the question, I shall proceed to consider the disadvan-
tages that may be claimed in opposition to it.
We have to combat the antagonism which naturally arises from the mere mention of
an operation, the peculiar nature of which is repugnant to the feelings of the patient.
From the limited general information, or, perhaps, lack of personal experience in connec-
tion with the subject, its results are undoubtedly, at the present time, sceptically received
by the profession.
The nutrient structural attachment being ruptured, time will be required to establish
reunion of the parts. For several days the tooth must be considered an object of constant
care. by the patient, who will occasionally be annoyed by its occlusion with the opposing
teeth. Although uneasiness may be experienced as an accompaniment to the operation,
it is doubtful whether the actual pain is in excess of that caused by local applications.
The next restraining inﬂuence in the practice of replanting, is the uncertainty and
known danger of extraction; this is hemmed in with circumstances quite beyond control.
The shape of the alveolus and of the tooth would, in many instances, enable a favourable
prognosis of extraction, yet in some cases it is impossible to accurately predict the result,
for the divergence or distortion of the fangs may be so great as to cause fracture of the
alveolus or of the root itself, while this same distortion may preclude the return of the
organ to its socket.
In considering “ What percentage of cases are successful?” I shall ﬁrst brieﬂy de-
scribe the system of treatment which I have adopted. In cases of chronic abscess and
where the apex of the root has lost its periosteum, the denuded portion of the root has
been excised, and restored with a gold cap, the object being, if possible, to prevent
absorption. To remove inﬂammatory products, instead of drilling through the alveolus,
or cutting a gutter along the roots, a tube has been ﬁxed in the pulp canal, extending
from the apex of the root to the grinding surface. From my experience I do not now
ascribe much of the success that I have had to the cap ; but the tubing, inasmuch as it
permits of drainage, I deem important. How far the cap has met the object for which
it was intended, I am unable at present to give any reliable information, simply from the
fact that, in every case where the tooth has been retained for a period of over ﬁfteen
days,I have had 720 opportunity ry“ again seeing it. That this foreign substance has
been tolerated by the living tissues is a well-authenticated fact, the physiological
effects of which must for a time rest in abeyance.
I have spoken of the diﬁiculty, in some instances, of returning teeth to their sockets.
A case illustrative of this came under my care some two years since, the tooth being a
superior ﬁrst molar, and the palatal fang standing at an angle of about 35°. The tooth
having for a long time been affected by chronic abscess, and the lady being non-resident
in London, with only a limited time which could be devoted to treatment, I decided to
extract, ﬁll and replant it. The tooth was removed at twelve o’clock and returned at
seven RM. same day. Three-fourths of the crown had been destroyed by decay, and
the post-proximate aspect was broken down far below the margin of the gum. This is
undoubtedly a case that I should have failed in again restoring to the mouth had it not
470 DISEASES OF THE TEETH.
been for the kindness of Mr. Woodhouse Brains, who rendered me valuable assistance
in keeping the patient under the inﬂuence of gas while it was both taken out and returned
to its socket. I make particular mention of the gas in this case because I was not able
to re-establish the tooth in its position until I had used almost the same force in its return
that I did in extracting it. The lady called some time since, and, having occasion to
take nitrous oxide again, it gave Mr. Braine an opportunity to examine the condition of
the tooth. The lady stated that it had done the best of service; and, after the ﬁrst few
days, had occasioned her no discomfort. In this case the tooth seems ﬁxed—a condition
that I am not prepared to say is an advantage.
During a visit of Dr. Wm. N. Morrison, to London, replantation was a subject of
considerable discussion between him and myself. I was then endeavouring to investigate
the practical results (if any) that might be obtained by this method; and my conclusions
are drawn from results extending over a period of three years. For the ﬁrst two years
I made it a special point of interest to obtain as many cases as possible. During the last.
year, however, I have only replanted four teeth. My observations have been made prin-
cipally upon people in the lower walks of life. Many cases I have completely lost sight
of, so that my failures may not all be recorded.
Number of teeth replanted (estimated) 80
Lost, as far as known 8
The losses were as follows :—
From non-union .. 5
Imperfect union; three months’ retention 1
Abscess recurring 2
Lost cases, as far as known . . 8
Of the eight lost, ﬁve were not tubed. Of the remaining three tubed, one abscessed
again, and the other two were lost from non-union.
Of the number of teeth replanted, I am not able to state the exact proportion tubed,
but I estimate it as something over 50 per cent.
During the last twelve months, the number of teeth replanted by me has been :—
In private practice 1
Hospitalpatients 3
4
Before closing, I desire to call attention to the subject of transplantation of tissues ;
and, through the kindness of Mr. O. Macnamara, Surgeon to the Westminster Hospital,
I am permitted to refer to a case which has been of considerable interest to me. Mr.
Macnamara seems to have been inﬂuenced in the treatment adopted by what he had
seen in connection with teeth replanted. It is (so far as I know) the second instance
only in which transplanting of bone has been effected of the same nature and of so
extensive a character, and, thinking that it might possess features of interest to this
Congress, I have, with the consent of Mr. Macnamara, arranged for as many to see the
case as would like to do so. The clinical notes handed to me are as follows :——-
“ S. W., aged 6, was admitted into the Westminster Hospital, August 10th, 1880,.
suffering from necrosis of the upper extremity of the right tibia. The inﬂammation
extended to, and destroyed, the shaft of the bone. Mr. Macnamara consequently, on-
June 2nd, 1881, removed the dead bone, that is, the entire shaft of the tibia, the upper
and lower epiphyses being left in situ, and as much of the periosteum as could be saved.
The wound healed, but no new bone formed, so that the child’s leg was useless.
DISEASES OF THE TEETH. 47 I
' “On May 21st, 1881, Mr. Macnamara determined, if possible, to plant small frag-
ments of bone in the situation of the lost tibia, in the hope that they would produce a
new bone. Having a case of amputation of the foot for deformity, the bones of the
tarsus were, immediately after its separation from the body, divided into small pieces,
and an incision having been made along the front of S. W.’s leg, from the upper to the
lower epiphysis, fragments of bone were placed along the situation occupied by the
former tibia; the edges of the wound being then brought together. The operation was
done under the carbolic spray and antiseptic dressings.
“Two days after the operation, on removing the dressings, there was found to be
some tension about the wound, and the sutures were consequently divided and taken
away. On the third day, several of the fragments of bone planted in this child’s leg
were seen to be vascular and attached to surrounding living structures; they have
since grown, and are now covered in by granulations. So far as can be ascertained at
present, there seems good hope of sufficient osseous tissue remaining 'and growing in the
leg to produce a new tibia.”
In sub-periosteal operations, the physiological changes that take place in the mem-
brane to elaborate new bone seem almost incomprehensible. This reproductive power
was strikingly evinced in another case, the particulars of which have been kindly fur-
nished to me by Mr. Macnamara.
“A. L. was admitted into Westminster Hospital under my care on the 26th of
March, 1879, with acute necrosis of the upper extremity of the right tibia, and con-
sequent septicaemia, from which the lad remained in a most critical position for nearly a
month. He then got so far well as to enable me either to amputate the limb or to take
away the shaft of the tibia without removing the periosteum. I determined on the
latter operation, and the section of the shaft of the tibia removed is exhibited in the
Museum of the International Medical Congress, No. 19. The boy recovered well from
the operation; and, from the periosteum I left in his leg, not only has a new tibia
grown, but the bone is larger than we know what to do with. The patient has got a
good knee and ankle-joint, and can walk about perfectly well.”
These two cases possess many points of interest which bear upon the subject of
replantation of teeth. One question, at least, I should wished discussed here, is, what
points of analogy or of difference are there between the nature of the repair and of bone-
formation in such instances as these cited by Mr. Macnamara, and the repair and re-
attachment which takes place between the bone of alveolus and the cementum of a
replanted tooth?
The vivacity of the periosteum, and the reparative action it is shown to be the seat
of, together with the pathological and even destructive functions: it is capable of per-
forming, renders a more perfect knowledge of the structure of that tissue, in its several
positions and relations, a matter of the greatest importance to prevent error even in
such operations as the replantation of teeth.
DISC USSION.
Dr. TAFT, Cincinnati: This is an operation rightly entitled to earnest consideration,
The occasions for the replantation of teeth occur (1st) in the accidental removal of
sound, healthy teeth, by whatever means, from persons of good system and condition, and
under forty years of age; (2nd) in those teeth from which abscesses issue upon the surface
of the face, especially those of long standing; (3rd) in those having abscesses issuing in
the mouth, persistent and unyielding to the ordinary treatment. These I regard as the
only indications for replantation. In respect to the ﬁrst, if there has been laceration of
gum, or fracture of alveolus, there should be adjustment and retention of such parts in
47 2 DISEASES OF THE TEETH.
proper position, before or at the time of replacing the tooth. In the second class of
cases, after the extraction, all débris should be removed from the root, any necrosed
alveolus should be removed, adhesions released, and the tooth replaced. In reference to
the third, the removal of; all excrescences from the root, and freeing the socket from
everything adverse to repair, is a necessity. The means of re-attachment is cica-
tricial tissue, the physiological‘, function of which is much like that of the original
structure, although less resistant, so that disease and wasting is more likely to take place
under the inﬂuence of irritants, mechanical or chemical. Cicatricial tissue is found after
nearly all surgical operations, and is no more objectionable in ﬁxing replanted teeth than
in other parts. In the operation of replanting, the root should be carefully freed from
all extraneous material, the socket must be freed from coagulum, and anything else that
would be an obstacle to the process of repair. The tooth is then to be carefully replaced
and retained in position till union takes place. This should and will take place in
favourable cases without active inﬂammation or suppuration. The operation of replanting
should only be employed as a last resort.
Dr. Jos. ISZLAI, Buda-Pesth; I will relate a case in my practice, which bears on the
present subject. A pretty young lady, ﬁfteen years of age, called on me, wishing absolutely
to have a minor irregularity, but one which she considered as very distressing, corrected.
The second bicuspid was short, and directed against the ﬁrst, near to the border of the
gums. I proposed to extract the ill-situated second bicuspid, while foreseeing the risk of ex-
tractinngmthﬂe ﬁrstgibiwnszpid, the ﬁrst molar behind being less in danger. The lady consented,
and, on extracting the second bicuspid, the ﬁrst one also came out with it. I replanted this
instantly, and observed the lady four days only, during which no symptoms of excessive
reaction came on. I saw the young lady again after half a year, and the replanted tooth
had the same colour, same ﬁrmness, and sensibility, as its healthy neighbour, and the
space was also reduced to less than the half. This case shows also that pulp vessels and
nerves can unite by ﬁrst intention; and Dr. Taft’s case points to the same con-
clusion, as also do the two experimental cases till now known, namely, the one
in the anatomical museum of Bonn, made by Wieseman ﬁve or six decennia ago, and
the other in Berlin, made by Mitscherlich nearly two decennia ago.
Mr. COLEMAN, London; About fourteen years 'ago my attention was attracted
to this subject of replantation in connection with a dental disease, which I might
designate as having almost invariably a fatal termination. I allude to cases of chronic
peri-odontitis of long standing. The operation was a very old one, but, as shown by the last
speaker, had never for certain cases been abandoned 5 but there might be some novelty
in going contrary to the opinion of almost all who, up to that time, had written upon the
subject, and who, with hardly an exception, laid down the rule that a diseased tooth was on
no account to be returned to its socket, and vice versa’. Believing, however, that by the
aid of antiseptic agencies one could bring a diseased tooth, or rather the diseased portion
of a tooth, to a condition in which they would be tolerated by the system, I commenced
treating such cases by removing portions of diseased alveolo-dental membrane, exposing
the diseased portion of dentine to antiseptic agencies, and then returning sucha tooth to
its alveolus. My success was not great, and this, coupled with certain unavoidable
circumstances, led to my ceasing to continue my experiments to any extent. I, however
distinctly laid down my opinion at that period, that I felt convinced that, if the
experiments were continued, and the failures duly investigated, that, under more
favourable and better-recognized conditions, the operation might not only become
legitimate, but positively the most successful, and thus might be likened to ovariotomy,
DISEASES OF THE TEETH. 473
which, in its early adoption from the Continent in this country, was attended with such
fatality that the high authority who presides over the Section of Surgery of this Congress
pronounced it an unjustiﬁable one, but gracefully withdrew his opinion when Mr. Spencer
Wells brought several hundreds of his cases to such successful issue. With regard to the
question of success, that might be looked upon from several points of view; but I
consider an operation a success which prolongs the existence of a tooth in a state of
usefulness and comfort for even a few years. A physician or surgeon would regard a
case successful in which he prolonged the existence of a patient for even a few years.
No life of a patient could be said to be saved; the patient eventually would die; life
could, for however long a period, he only prolonged.
Mr. SPENeE BATE, Plymouth: My earliest experience on this subject commenced
in 1836, when a student in the surgery of a general practitioner. I extracted a
lower bicuspid for a young woman, who, when the tooth was out, regretted that she
should lose one so little decayed. I replaced the tooth, which, after some local irritation,
again united and fulﬁlled its career. My next was in or about 1846, when I was visited
by a gentleman who had had some ﬁve or six teeth knocked out by coming into contact
with the working machinery of a steam-engine. These he picked up and re-inserted in the
mouth. Without again removing them, I secured them in position by the assistance
of a silver plate. They all became in a short time ﬁrmly ﬁxed and useful organs. More
recently a case came under my treatment that exhibits interest of a higher degree. It
was a front incisor that had been fractured by a fall, and complicated with alarge abscess.
I determined to remove and replace it by a rather large lateral incisor that was
irregularly implanted within the dental arch. This I did, and having the opportunity
of seeing it some three, and again eight, years after it was done, I was gratiﬁed to ﬁnd
the re-implanted organ in as good a condition as any other in the mouth. Several
cases I have known} treated as Dr. Magitot has stated to be his plan. In any
case where, either from inﬂammatory action or artiﬁcial agency, the periosteum has
been removed, the exposed cementum becomes necrosed. In fact, if it should be other-
wise, we must be prepared for a total distinction in the surgical treatment of the teeth
from that which we ﬁnd to be the ease in the treatment of bone. For I believe that
no surgeon would ever expect bone to live, when implanted in the living tissue, if he
removed the periosteum from it; neither is it to be expected, in the history of the
dental tissues, that a tooth will live with the periosteum gone. To succeed in re-
plantation, my experience is that the root of a tooth should be well protected with the
healthy peri-odonteum. With respect to the treatment of a peri-odontitis, it appears to
me that the extraction of the tooth and its re-implantation is an extremely undesirable
treatment to pursue, where a less painful one and, in my experience, a more certain,
is available. It has been my practice for years, and with a success that is of a high
average, in cases of peri-odontitis_\that cannot be reduced by external application, to
perforate, with the assistance of a boring-engine and abroad-pointed sharp drill, the
alveolus through the gum, as near the centre of the disease as possible, to follow this
with a pledget of cotton dipped in strong carbolie acid, and the next day repeat the
same with glyeerine, and camphor, and chloral. I do not remember a case wherein the
pain was not relieved and the cure made permanent.
Mr. BROWNE MASON, Exeter : I can bear testimony to the success of replantation
in cases of removal by accident of healthy teeth. One case, in which I have had the
most frequent opportunity of since observing the patient, was a young lady who lost a
lower bicuspid through its being dislocated by the removal of the ﬁrst molar. It was care-
474 DISEASES OF THE TEETH.
fully replaced, and showed, by its sensitiveness to changes of temperature, that union of
pulp had taken place. The replantation was performed at least twelve years since, and the
patient since has had no subsequent trouble. I have never performed this operation on a.
diseased organ, but have found the results were satisfactory in the few cases I had the
opportunity of subsequently inspecting.
Mr. BALKWILL, Plymouth : In replantation, the danger is generally dependent on the
shape of root; if of normal shape, it may be generally successfully undertaken ; but opacity
has sometimes been seen showing death of pulp. lie-establishment of vascular circula-
tion in the pulp wants more conﬁrmation, although probable; in some cases a misplaced
teeth may be forced into the position of an extracted teeth. A case was mentioned of the
successful transplantation of two canines which were crowded out of the arch, into the
alveoli of the ﬁrst bicuspids which were decayed and immediately previously extracted.
It was observed that after replantation for chronic inﬂammation, the periosteum having
been removed, absorption of the root is a not uncommon result. A case was given in
which absorption occurred to a healthy teeth after replantation.
Mr. PERCY MAY, London: The following case occurred in my practice :—The
second right upper bicuspid was extracted (for what cause I could not gather
from the patient) about eighteen months ago, and replaced without further treat-
ment, I believe, than merely removing a portion Of the apex of the fang rounding
it off, rinsing the mouth and tooth in warm water, and then inserting it. A piece of
cotton wool was placed between the back teeth for a “few hours,” and if pain
continued, the patient was directed to “hold warm water in the mouth constantly.”
When I saw her a few months since she desired me to extract the tooth, “ as it was
painful if anything hot or cold touched it, or upon biting hard substances, and it was
accompanied with a constant slight discharge,” I found slight tenderness upon percus-
sion, pus welled up by the side of the tooth upon pressing the gum, which had receded
beyond the neck of the teeth, but it was ﬁrmly implanted, and “ except the ﬁrst few days
had never been at all loose.” The teeth, which was exhibited, showed great absorption
of the apex of the root.
Dr. ATKINSON, New York: My complaint is, that we have before us to-day
only early examinations, without waiting for that ripening of instruction that comes
through the accumulation of observations; and a recording only, under the individual
perception, and not strengthened by the conversational method of many minds com-
petent to examine and decide. We heard yesterday, from the renowned Professor Owen,
that, in so far as professional learning was based upon science, it was-—-those three
beautiful words which he used—viz., “Novelty, utility, charity”; but, when it was only
guess-work, honest men ought to move cautiously. Inasmuch as I have a paper that I
hope to read before this body, on the reproduction of bone, with special reference to
the variable portions of the maxillary bones, I deem further remarks unnecessary.

Evidence of Reﬂex Acz‘z'on, z'n nelaz‘z'on z‘o Constz'z‘nz‘z'onczl Dis—
z‘nnéczncc, z'ncinceci 6y [nz‘ew/npz‘cci Secondary Dcnz‘z'z‘z'on,
and coming nncien an; personal oéserwz‘z'on of an Ant/201'.
Mr. D. OORBETT, Dublin.
It is with no small amount of difﬁdence and hesitation I venture on the introduction
of a subject so complex in its nature, and at times so difﬁcult of comprehension, as
DISEASES or THE TEETH. 475
reﬂex action; but cases will arise in medical practice, where the physician, if he means
to act conscientiously and with beneﬁt to his patient, cannot afford to ignore the advice
and services of the dental surgeon. For some years, reﬂex action in connection with
the teeth has been to me a constant source of study and observation 3 and during the
lifetime of my friend, the late Dr. Hudson, I had several opportunities, through his kind-
ness, for proving the truth of my diagnosis of cases occurring in his practice, when the
symptoms to be combated were anomalous and inexplicable, according to received doc-
trine and authority.
Reﬂex action, as a phenomenon, is perhaps more frequently observable in youth than
in mature age ; at least, such has been my experience; but, practising a speciality, I
may be excused if I be inaccurate in my statement; however, this fact I do maintain,
that the period of secondary dentition is replete in many instances with evidence to
prove the importance of my statement.
The ﬁrst important connexion of the ﬁfth cerebral nerve with the sympathetic is
observable, as you are aware, with the “ Gasserian Ganglion,” the ﬁrst division of which,
the ophthalmic, as it enters the foramen lacerum, receives some sympathetic ﬁlaments.
It then divides into three branches, the lachrymal, frontal, and nasal. I wish you to
remember this particular relationship, as it bears strongly upon the ﬁrst case I shall
allude to.
CASE 1.———Some years since, the late Dr. Stronge called upon me with reference to a
case of, to him, much perplexity. Miss Q., a young girl, aged ﬁfteen years, of nerve-san-
guine temperament, healthy in every particular, was subject to copious lachrymation, on
each occasion that she left the house for outdoor exercise ; there was no outward mani—
festation of organic disease, the eyes looking brilliant and healthy, still, the moment she
went into the open air, the tears poured down her cheeks in a most distressing manner.
Dr. S. tried every plan he could think of to overcome the affection, without any bene-
ﬁcial result. Consultation was had with several medical men in vain as regards improve-
ment. After several months of suﬂering, the case was brought under my notice,
to ascertain if the teeth could in any way inﬂuence the condition of affairs.
On examination, I found the cuspidati of the upper jaw absent, though the dental arch
was perfect. Understanding that no teeth had ever been extractedlfrom the child, I at
once removed the ﬁrst bicuspid at each side. Within one week, a manifest improvement
was observable, and within three months all inconvenience had passed away—when the
cuspidati made their appearance. I have seen this case Within the last year, and can
vouch for the perfect regularity of the dental arch.
CASE 2.——Mrs. A called upon me relative to her ward, a little girl, aged thir-
teen years, of weak intellect from infancy, but docile and tractable, until the period of
the second dentition, when a marked change was observable in her conduct and dispo-
sition: she became at times violent and subject to paroxysmal attacks, causing her to
run about the room biting at everything within her reach, the chairs, tables, and door-
handles. In the street, she would run off from her attendant, and attempt to bite the
lamp-posts. Her teeth appearing to require attention, the child was brought to me for
advice by her guardian, who gave me leave, if it should be necessary, to remove any teeth,
to be prepared for unusual resistance on the child’s part, and act accordingly. I
found the incisors of the lower jaw overlapping each other, as also the cuspidati pressed
forward in a most unbecoming manner. I at once removed the ﬁrst bicuspid at each
side, and directed the child to be brought to me after a month’s interval; this was done,
when I learned that though no improvement had been observed in her mental condition,
the biting propensity had completely disappeared.
CASE 3.—-Dr. R——-— having called on me with reference to some artiﬁcial teeth he re-

476 DISEASES on THE TEETH.
quired at a subsequent visit, incidentally mentioned, as a source of great anxiety to him,
the state of his daughter’s health, aged seven years, which he described as follows.
“ Nothing unusual in her condition since birth was observed, until within a period of two
years, when weakness of the lower extremities showed itself, accompanied with occa-
sional impairment of vision. This state of things gradually grew worse, until the power
of progression was quite gone, unless assisted, and there was complete loss of vision when
she assumed the erect from the sitting posture, though in the latter she could distinctly
see large objects.” _
As her condition had resisted every description of treatment, I asked her father to
allow me to examine her mouth, to which in consultation with her medical attendants
he consented. I found the dental arch in the lower jaw complete as to number. The
dentes sapientiae only partially erupted, the circumference and superior aspect fully
exposed, but still giving unmistakable evidence of severe pressure against the second
molar to the extent of slight lateral displacement outwards. I extracted the second molar
at each side; within one week a slight improvement was observed, which gradually in-
creased, until three months had passed when every iota of constitutional disturbance
save one had disappeared—the power of vision in the right eye was lost, but she is now
in the enjoyment of the most perfect and robust health—I have seen this lady within
the last few days, and have had from her an expression of gratitude for the service I had
rendered her.
To accoiuit for these results, the idea occurs that in the connection of the
sentient ﬁfth with the sympathetic nerve, there may be a recurrent stream of nervous
inﬂuence ﬂowing, which, as it were, by inoculating the whole sympathetic system,
would account for the exhibition of those very anomalous symptoms observable in parts
of the human organism, remote from the primary source of irritation.
012 Erosion.
Mr. ALFRED COLEMAN, London.
I too well remember having said on a public occasion “ that papers written to
order rarely contained anything either original or interesting,” but, at the time, I little
thought how soon I should illustrate my own statements. From those friends, whose
persuasions led me into the scrape, 1 have a right to look for some indulgence, but in
regard to the majority of my hearers I can only throw myself upon theirs.
Erosion or decay by denudation has had, to different individuals, different meanings,
it is therefore desirable at the outset that I should at least deﬁne the subject on which I
propose to treat. Thus some, Bourdet for instance, consider the former to comprehend
what we, in this country at least, comprehend under honeycombed teeth, whilst Wedl
describes it under the title “caries of cementum.” “These carious excavations,” he
says, “usually have sharp edges, are patelliform, and occasionally occur without any
affections of other portions of the tooth.” He also evidently classes the honeycombed
teeth under the head of erosion, as he states in a note with respect to these, “ These
malformations are considered, without reason by many practitioners, to be caused by hot
drinks, sweet and sour articles of food, use of acid preparations for the teeth or other
medicaments . . . . but Bourdet, who treated such deformities under the name of erosion,
considered them due to rachitis, scorbutus, low forms of fever, measles, &c. . . . . The
surgeon Tenon exhibited to Bourdet a series of j aws, by which it couldbe demonstratedthat
the erosion took place while the tooth was still within its capsule. Again, Dr. Murinie,
DISEASES on THE TEETH. 477
an excellent paper, read before the Odontological Society, June 6th, 1870, entitled, “ On
some Abnormal and Diseased Dental Conditions in Animals,” thus classiﬁes the various
conditions under which the teeth incur a loss of substance :—
“Human teeth,” he observes, “may suffer diminution in volume by four separate
processes, which are respectively as follows :--
“ (a) By true absorption, equivalent to the normal healthy process which is witnessed
_ in the passage from the deciduous to the permanent dentition.
“ (6) By erosion, or interstitial change of a chemico-vital character, but differing
from true absorption in being the product of abnormal changes.
“ (0) By denudation, or abrasion, simply slow mechanical rubbing away, either from
contact with opposed teeth, or friction of foreign substances.
“ (0!) By force or piecemeal chopping away of portions, variable in size according to
circumstances.” ,
In this country, both terms have usually been restricted to one condition, as we shall
see in the following short historical notices of it.
Hunter, who appears to have been the ﬁrst to describe it, and who designated it
“ The Decay of the Teeth by Denudation,” says, “There is another decay of the teeth
much less common than that already described, which has a very singular appearance.
It is a wasting of the substance of the tooth very different from the former. In all the
instances I have seen, it has begun on the external surface of the tooth, pretty close to
the arch of the gum. The ﬁrst appearance is a want of enamel, whereby the bony
part is left exposed, but neither the enamel nor the bony part alters in consistence
as in the above described decay; and hence it may be called a denuding process.
The bony substance of the teeth also gives way, and the whole wasted surface has exactly
the appearance as if the teeth had been ﬁled and polished. At these places, the bony
parts being exposed, become brown.” “ I have seen instances where it appeared as if
the outer surface of the bony part, which is in contact with the inner surface of the
enamel, had ﬁrst been lost, so that the attraction of cohesion between the two had been
destroyed, and as if the enamel had been separated for want of support, for it terminated
all at once.
“ In one case the two ﬁrst incisors had lost the whole of the enamel on their anterior
surfaces; they were hollowed from side to side, as if a round ﬁle had been applied to
them longitudinally, and had the ﬁnest polish imaginable. The three grinders on each
side appeared as if a round ﬁle had been used on them in a contrary direction to that on
the incisors—via, across their bodies close to the gum, so that there was a groove running
across their bodies which was smooth in the highest degree. Some of the other teeth in
the same jaw had begun to decay in a similar manner; also the teeth in the lower jaw
were becoming diseased.
“I saw a case very lately where the four incisors of the upper jaw had lost their
enamel entirely on their anterior surfaces, and there was scarcely a tooth in the mouth
which had not the appearance of having had a ﬁle applied across it close to the gum.
“ Those whom I have known have not been able to attribute the disease to any cause;
none of them had ever done anything particular to the teeth, nor was there any appear-
ance particular in the constitution, which could give rise to such a disease. In the ﬁrst
of these cases the person was about forty, in the last about twenty years of age. From
its attacking certain teeth rather than others, in the same head, and a particular part of
the teeth, I suspect it to be an original disease of the tooth itself, and not to depend upon
accident, way of life, constitution, or any particular management of the teeth.”
I have quoted Hunter at considerable length, and for the reasons that, of those who
ever wrote on medical subjects, probably no one ever surpassed him in his remarkable
478 DISEASES OF THE TEETH.
powers of description, and because my so doing will save me from any attempt to deﬁne
what I regard as covered by the designation of decay by denudation.
Fox, some thirty years later, thus writes respecting it, under the designation “ Of the
Removal of the Enamel by the Denuding Process.” This is a disease producing a change
in the teeth by which they acquire an appearance unlike that of caries, but attended with
a loss of substance.
“The tooth does not, as in caries, become softer, nor, like that disease, does it origi-
nate in inﬂammation, but it consists in a removal of the enamel from the bone of the
teeth, as if by solution and gradual abrasion.
“ The ﬁrst appearance is in the enamel of one or more of the incisors becoming thinner,
and appearing as if a small portion had been scooped or ﬁled out, occasioning a slight
depression. This removal of the enamel continues until so much is taken away as to leave
the bone exposed. As this denuding process, according to Mr. Hunter’s term, advances,
the tooth changes its colour, gradually becoming yellower, as the bony part is more ex-
posed. When the whole of the enamel is destroyed, part of the bone is also removed,
the remainder acquires a brownish hue, is very highly polished, and will often remain in
this state for a number of years.
“ In some, it appears near the neck, the cavity extending across the tooth, and the
disease proceeds until the tooth is nearly divided in two; in this case, whilst biting some-
thing hard, the lower part of the tooth usually breaks off, leaving the fang in the socket,
and a small portion of the body of the tooth. The molars are more subject to this dis-
case than any of the other teeth. The incisors of the upper jaw are very frequently
affected by it, whilst the incisors of the lower jaw seldom become decayed.”
Mr. Bell, under the title “Loss of Enamel and Wearing Down of Teeth,” thus
speaks of it: “ Mr. Hunter appears to have been the ﬁrst writer who described the
remarkable and, hitherto, unexplained affection, termed by him “ decay by denudation.”
It consists of a gradual loss of substance, generally without the slightest discoloration
or any diseased appearance. In all the cases in which I have been able to observe its
commencement, it appears to have begun on the surface of the enamel; in most
it attacks, ﬁrst, the central incisors, sometimes removing the anterior surface of the
enamel, either generally or in irregular patches, in either cases making a perfect and
regular horizontal groove, which very gradually increases until it has extended through
the enamel to the bone.” “ The groove is perfectly straight and continuous through its
whole extent, and is often as regular and smooth as if it had been formed by aﬁne
round ﬁle, and afterwards polished; when the bone has been exposed by this process it
sometimes becomes very slightly discoloured; but remains for a long time perfectly hard and
sound and seldom exhibits any appearance of gangrene. . . . , The most obvious solution,”
216., of the question of its cause, “ would be, that it was the result of friction, and I have
seen so many instances in which it has appeared to be produced, or at least increased,
by the use of rough or acidulated tooth powders, that I should not hesitate to assign
to it such a cause, were it not for certain cases which have exhibited this affection to a
considerable extent, without any application of that kind having been ever used.”
On a discussion upon this subject at the Odontological Society, May 2, 1870, in
reference to a case brought forward by Mr. Steele, Mr. Harrison remarked: “ That he
had seen, in the course of his practice, many similar cases to that which had been
brought under their notice by Mr. Steele, and had come to the conclusion, where they
could not be traced to mechanical causes, that they were referable to the cause (be it
what it might) which produced that effect on the teeth generally known in the profes-
sion as “Hunter’s denuding process,” which he believed was a disease—if it might be
called a disease—the cause of which had not yet been discovered. This view of the
DISEASES OF THE TEETH. 479
subject opened, to his mind, a very interesting question for their consideration, but one
which, of course, they could not go into at any length that evening, as they had before
them a paper on a different subject for which the evening had been set apart. He
might, however, perhaps be allowed to state a few facts which had come under his
observation, with reference to this disease, or peculiar condition of the teeth so
frequently met with, as the subject had turned up incidentally, which he thought would
be interesting to the Society, and which he would not occupy much time in doing. It
was, as they all knew, attributed by most modern authors to the use of the tooth-brush,
abrading tooth-powders, and other similar mechanical causes. That they were constantly
meeting with cases of ordinary abrasion of the necks and of the surfaces of the teeth
produced by these causes he (Mr. Harrison) was ready to admit; but he had never
been able to consider the peculiar affection described under this name by Hunter as
being produced by these causes, because they were constantly meeting with cases of it
in which the depressions were so deep, as compared with their breadth, and in which,
moreover, they were sometimes so sharply undercut, that it had always appeared
to him impossible that they could be produced by the use of an ordinary
tooth-brush and any tooth-powder; and he had not been many years in practice
before he became convinced of this, from ﬁnding well-marked instances
of this disease, or peculiar condition of the teeth, in some of the lower animals. After
much consideration given to the subject, he had, at one time, come to the conclusion
that it must be produced by the action of certain absorbents in the teeth themselves,
not yet discovered; and he had nearly settled down into that belief (although there were
almost irreconcilable difficulties in the way of it), when the following curious case
caused him to suspend, if not to relinquish, this idea. A patient of his had worn for
some years a complete upper and a partial set of artiﬁcial teeth, when, in consequence
of having to lose some of her remaining under teeth, he made her a lower row, carved
out of the hippopotamus tusk, to wear temporarily until the gums should be in a state
to receive anew lower set of a more permanent character. She was so comfortable,
however, with this temporary set that, instead of wearing it for a few months only, as
was intended, she wore it for eighteen months or two years, when she came to him to
have the permanent lower set made. On removing this temporary set from the month,
he was at once struck with the appearance presented by its front teeth—they having a
number of transverse lines of indentation running across them, from about canine to
canine, exactly resembling this so-called “ Hunter’s denuding process.” He drew the
patient’s attention to these lines, and asked her whether she had cleaned these teeth
with any particular tooth—powder, or in any other particular way, which could have pro-
duced this effect. Her reply was—-“ That she had not, and that she had merely washed
them with her tooth-brush and water with occasionally, perhaps, a little soap.” He then
asked her whether she had been in the habit of rubbing the front teeth more freely and
with more force than the side teeth; but her reply was--—“ He, that she had rather been
in the habit, if anything, of rubbing the side teeth most freely, inasmuch as they had
soon become the most discoloured.” Struck with the similarity of these lines to what
was known as “Hunter’s denuding process ” (as he had already said), he was set speculat-
ing as to the probable cause of them; and the best conclusion he could come to on the
subject was, that they were in all probability produced by some peculiar action of the
secretion, or of the absorbents, or of both, of the mucous membrane of the lower lip,
and that, if so, “I-Iunter’s denuding process ” might arise from the same cause; and thus
it was that this case went far, at any rate, to upset his previously existing notion that
the latter disease arose from the action of undiscovered absorbents in the teeth themselves,
if it did not entirely dissipate it. He begged to be understood, however, as throwing out
480 DISEASES on THE TEETH.
this latter view merely as a suggestion, and not as a decidedly formed opinion; and
would be glad if, in the interest of science, some enthusiastic physiologist and patholo-
gist amongst them would take the subject up, and endeavour to work it out.
Messrs. J. and C. S. Tomes in a “ System of Dental Surgery,” second edition, give a
good description of the appearances presented in the affection. They say: “Now and
then the teeth are attacked in portions inaccessible to the tooth-brush; thus in the canine’
here ﬁgured, the groove was not only upon the anterior surface, but extended back on
both sides of the neck of the tooth. Moreover, it was distinctly undercut. . . . .
Although the labial surfaces of teeth are usually attacked, the lingual surfaces may, in
some few instances, be eaten away; in the two incisors here ﬁgured this has taken place,
the gum having at the same time receded. The cause of these various forms of erosion
has been from time to time the subject of great discussion; though some hypotheses,
such for instance as that which attributes it to disease inherent in the dentine, may at
once be dismissed. It has been already shown that mechanical abrasion will not serve
to account for all the cases. Absorption cannot be called in to account for the removal
of the tooth substance, for it often takes place at spots remote from any structure
capable of developing an absorbent organ, and it seems that we must fall back upon the
idea that it is an example of chemical solution. But whence the solvent comes, and
why the affected surfaces are not the site of ordinary caries, are questions which remain
unsolved, though it seems probable that mucus, by fermentation or affording a nidus for
fermentation, may provide an acid solvent.” Under the head of abrasion the same
author writes, “Another form of abrasion is that which is occasioned by the action of
the tooth-brush on the necks of the teeth, or upon such parts as are but indifferently
protected by the enamel or the gum. The teeth become very gradually indented by
highly polished transverse grooves.” .
The occurrence of such grooves has been by many writers supposed to be in-
dependent of a mechanical cause. But in many cases, which have come under my own
notice, the grooving could be attributed to the action of the toothbrush, or to mechanical
action, in some other form. The most prominent teeth are invariably the most deeply
cut, or those teeth in which the enamel is obviously defective.
Dr. Magitot thus describes the affection, and suggests its probable cause I “The
cavity then presents the peculiar appearance which may be compared to a saw-cut,
polished, hard, and resistant. Such are the cavities which Duval and several other authors
have designated under the name of ‘ Caries Simulating a Wearing Away,’ and of which the
mode of production has not been explained. They have in effect all the appearances of
true wear, but my observations upon the succession of different periods in the malady
have demonstrated that these clean and polished notches are nothing else than caries of
the neck of the tooth passed to the condition of spontaneous cure or dry caries.”
Salter in his “ Dental Pathology and Surgery ” does not allude to the affection.
From the quotations I have given, from the works of chieﬂy English writers, it will,
I think, he admitted that they do not materially differ in their descriptions of the
appearances the affection presents ; their differences appear when they come to assign to
it a cause, and here no doubt their opinions are worked by their own special views with
regard to dental caries, and with which they, more or less, associate this. In one
respect, however, their differences are somewhat marked, namely, with regard to the
various teeth that are most liable to it. Hunter, whilst stating that it attacks certain
teeth rather than others, does not specify which; but if we take the cases he cites as
typical ones, it would appear to be the incisors and molars. Fox, apparently, contradicts
himself on this head ; thus, he says, in one place, “ The ﬁrst appearance is in the enamel
of one or more of the incisors ;” whilst later occurs the remark, “ The molars are more
DISEASES OF THE TEETH. 48I
subject to this disease than any of the other teeth. The incisors of the upper jaw are
very frequently affected by it, whilst the incisors of the lower jaw seldom become
decayed.” Bell says, “ In most it ﬁrst attacks the central incisors.”
My own observations would lead me to differ somewhat from the above-mentioned
authorities, and to assign to the bicuspides and cuspidati the greatest liability to the
condition. That it is more common to the teeth of the upper than to those of the lower
jaw is the opinion of J. Tomes, and I believe of most who have described the affection.
With the exception of Fox and J. Tomes, none of the above speak of a termina-
tion to the process other than as becoming arrested when the part affected assumes a
brown colour ; nor do they allude to the almost invariable coincident of secondary
dentine, which obliterates the pulp-cavity, and prevents exposure of the pulp. I believe
it to be extremely rare for the pulp to be so exposed ; when it is, it will be generally
found that it has resulted from true caries having supervened upon the denudation
process.
With regard to age, it is certainly an affection more common to middle life than to
any other period. Hunter speaks of his two most interesting cases in individuals aged
respectively twenty and forty. I should say that at about the intermediate period it is
generally met with. If it occur in the milk set, it is certainly rare. I cannot say that I
have never seen it, on the contrary, I believeI have; but what I have seen may have been
only that superﬁcial form of decay so common to the ﬁrst teeth—and which might
perhaps be well designated erosion—which has become arrested and polished by friction.
In looking over a large collection of temporary teeth, I could not ﬁnd a single instance
of it, although the sharply deﬁned line at the limit of the enamel, especially on the
lingual surface of a molar, might, to a careless observer, lead to such an error.
San—Any really careful observation I may have made, with respect to the affection,
dates from so short a period that, if I venture to offer an opinion upon its relative
frequency in the two sexes, it must be regarded as little other than a vaguely formed
opinion, and if I express such, it is that I incline to the view that it is more frequently
met with in females than in males; but my impressions on this head may have arisen
from the fact that we see more female than male patients.
The appearances presented by the affection have been so well described by Hunter
and other writers quoted, that, as before stated, there is no necessity for my recapitu-
lating them ; I could only wish it were as easy a matter to assign to it its true nature and
cause. I have been able to make out but little that is really satisfactory to my own
mind, still, as that may perhaps prove one step further in knowledge gained, I willingly,
'though diﬁidently, communicate it.
I/Vith regard to microscopic observations—and here let me state that without, for one
moment, undcrvaluing that immense means for extending and conﬁrming our knowledge
of both physiology and pathology, yet the appearances presented by highly-magniﬁed
sections are so deceiving, that even the honest inquirer going to them with strong pre-
conceived notions is very likely to make out with his eyes that which his heart longeth
for. With regard to myself, however, I may say that what I might have expected to
see that I could not make out, though it is very probable that what I may describe is
not that which I actually did see.
Section 1, of which with three others I have given illustrations, together with the
outlines of the teeth from which they were cut—and which must be regarded as
decidedly diagrammatic rather than literally correct, as you will see when inspecting the
originals mider the microscope—is from an upper left central incisor kindly sent to me
by Mr. Pearman, of Torquay, and is a well-marked specimen of the affection, but, as is
not uncommonly the case, has suffered at an advanced stage from true caries as well.
PART III. I r
482 DISEASES on THE TEETH.
This is shown in the upper part of the diagram, and which resembles an ordinary though
not characteristic specimen of caries. The tubular structure approximating upon the
carious surface is rather more conspicuous than in the healthy portions, and terminated
in an undefined mass of yellowish broken-down structure, mixed up probably with
micrococci. In the lower portion, and which is not affected with caries, a sharp clear
edge is presented externally, whilst it will be remarked that the dentinal canals are of'
uneven calibre and present a beaded form, the contents being apparently very unevenly
distributed throughout them.
Section 2 is taken from an upper euspidatus of the left side. In this we see the
same varicose and headed condition of the tubuli as in No l, but we see also, that which»
in the small number of sections I have been able to make is as often absent as.
present, that is, some appearance of the “zone of Tomes ;” in no specimen have I found
it so well marked as to be able to say that it was identical with it, and as the nature
of this phenomenon, both as an evidence of antagonistic energy to disease, or a manifesta-
tion of disease itself, is disputed, I feel I shall gain little in insisting or otherwise on its-
appearance in the decay by denudation.
Section 3 I regard as a very interesting one, being a lower left cuspidatus, for a long
while the only tooth in the mouth of an elderly gentleman whom I had under observa—
tion for several years. At the back of this tooth there rested a vulcanitc plate, and its-
continual movements were the tooth half through, the pulp-cavity, which is not quite
obliterated, being protected only by a very thin wall of secondary dentine: besides the
friction of the plate, which has kept the surface as highly polished as in almost any
case of decay by denudation, I think we ought to add the softening action of particles
of food which lodged upon the portion of the plate in contact with the tooth—I regret
the section as cut shows too much of the transverse structure of the dentinal tubuli, but
still I tnink it can be clearly seen that the dcntine appears perfectly healthy, and is.
quite free from the characteristics of caries on the one hand, or the beaded condition of
the denudation cases on the other hand.
Section A shows in a marked degree the beaded contents—or non-contents—-of the-
dentinal tubuli. In some cases this is so marked as to prompt the suggestion that
they may have undergone a fatty degeneration. I am well aware that such an appear-
ance might be produced by other conditions, as the presence of air, or otherwise, in the in-
terior of the tubuli; but, if so, it is difficult to account for its almost complete absence in
the friction-produced specimen, No. 3. The section is obtained from a left lower cuspida--
tus, also kindly sent to me by Mr. Pearman, of Torquay, and is in more respects than one
an interesting specimen; it is more or less coated with tartar upon all portions of the
crown, and fang, excepting the external surface of the former and a special portion
of the latter. The affected portion, at the neck, is well-marked, and might serve for-
a typical specimen of it. But that which is of chief interest is a small, scooped
out, highly polished facet, continuous with, but below, the above-mentioned, and
approximating upon its posterior or distal surface. I should have much liked‘ to
have seen this tooth in sz'in, but even the donor states “ I have no history to give with
them.” -
Section 5, which I have not illustrated by diagram, is from an upper right molar,
most probably the ﬁrst of that order. It presents the affection as a sharply deﬁned notch
at the neck, and chieﬂy above the posterior fang. It is this form which is so highly
suggestive of the action of the tooth-brush, though found in those to whom, if this,
appliance be not unknown, its use is not familiar. It would, however, be interest-
ing to ascertain whether it exists in those who do use, and in those who do not use,
the tooth-brush, in the same proportion. The section possesses much the same charac-
DISEASES or THE TEETH. 48 3
teristics as those before described, only in this one are to be seen faint markings of inter-
globular spaces not met with in the others.
The conclusions I have arrived at, from what I must confess to be other than a deep
investigation of the subject, are ﬁrstly, that the main element in the process is friction,
but that the condition which permits the loss of substance thereby is favoured by a
change or degeneracy in the tooth itself. We will consider these conditions in the
reverse of the order above given.
My impressions, previous to commencing the present investigation in regard to the
affection, were that it arose from the direct action of some solvent furnished by the
labial glands, or those of other parts which were immediately adjacent to the wasted
spots. The application of litmus to both these spots and the opposing glands or sur-
faces, however, has never, in a large number of cases, afforded any greater evidence of
acidity or alkalinity than is to be found in normal saliva in its varying conditions. I am
well aware that solvents of tooth structure might exist having neither of these reactions;
indeed my own views in respect of dental caries point in such direction. But then one
would naturally expect to ﬁnd more or less accumulation of foreign matter at those places,
whereas the teeth there appear more free from deposition than at any other portion of
their exposed surfaces. Again, is it reasonable to suppose that a substance composed of
such material as a mixture of gelatinous matter and lime salts should, when attacked by a
solvent, unless accompanied with considerable friction, present a very hard and highly
polished surface. I cannot avoid the conclusion, but that in the majority, at least of
denudation cases, some degenerative changes have taken place in the tooth structure, and
especially in that of the dentine, and which has the effect of rendering them less capable
of resisting friction than ‘when in a normal condition.
It would be pure speculation on my part to attempt to suggest how this might be
brought about; but if I did so speculate, I might suggest whether, by a fatty degene-
ration of the contents of the dentinal tubuli, and the formation of a fatty acid, the
surrounding phosphates of calcium might be inﬂuenced; or, from another point of
view, which embraces ideas which are more and more ‘growing out of favour, as being
less in accordance with facts elicited by modern research, it might result. from a les-
sening of that power of resistance vaguely termed vital force, which has been supposed
capable of protecting the bodies it pervades from chemical and physical inﬂuences.
A fact of no small signiﬁcance in relation to this subject is the relative liability
in certain teeth to be worn away, or otherwise, under almost precisely the same con-
ditions—viz., such as food, age, habits of life, &c. Amongst a class of people who
reside in a country where a large proportion of grit ﬁnds its way into their food, as in
the case of the Bedouin Arabs for instance, we shall ﬁnd the teeth almost invariably
much worn on the masticating surfaces ; but yet the differences in degree are so
marked as to lead irresistibly to the conclusion that some teeth resist this attrition
better than others. If we were to take a large number of individuals living in this
country under precisely similar conditions, I more than predict that we should ﬁnd
considerable differences in the degree to which their teeth had resisted the friction of
mastication. All of us must have been at times struck with the apparent wear of
teeth at spots and places where, if from friction, it could only have been that from the
tongue or the larger fragments of food. Here are casts illustrating this point, kindly
"furnished to me by an intelligent pupil, Mr. C. E. Truman. It is clear, I think, that
the portion of the surface of the molar marked could never have met an opposing tooth.
But the most marked case of this kind which ever came under my notice occurred in
the person of a clergyman, for whom I constructed a denture, supplying the six front
teeth, and, I believe, also all the bicuspids of the upper jaw. The teeth whose places
I I 2
484 DISEASES on THE TEETH.
were supplied were all so perfectly level with the gum that there was no necessity, I
well remember, for any employment of the ﬁle or other appliance for reducing their
surfaces. The bite was certainly an edge to edge one; but the individual could not
have been past forty. I much regret that I parted with the model of this interesting
case. There was nothing in his history to account for this unusual wearing away of
the teeth, and I think we can only conclude that his teeth, and the teeth of like con-
dition, must be, in certain respects, different from those in other persons.
With regard to the agency by which the friction is, in all cases, furnished, I shall, in
accounting for it, as you will surmise, encounter some difficulty. ' This, however, to my
own mind, has gradually lessened as my investigations have progressed. With regard
to how furnished, this, I think, may be speedily disposed of by the recognition of the
act that all the movable soft structures of the mouth—but the tongue especially—are
capable of reducing in dimensions the dental structures, We well know how soon a
sharp edge of enamel is reduced by the movements of the tongue ; the latter suffers in
the contest, but ﬁnally prevails, in consequence of its powers of repair. This upper
model shows how a tooth may suffer from the constant rubbing of a thumb, in the
evidently gratifying process of thumb-sucking; between cause and effect in this instance
not a shadow of doubt exists. An indirect point in this case is that the individual of
whom this cast is the representative, and who is a child of eight years and a half old,
has, as it will be observed, all her lateral incisors wanting, and hence it may also happen
that the incisors she possesses may be more or less abnormally imperfect in development;
also, it may occur that the degenerative changes that induced the affection may be similar
changes to those which occur in the temporary teeth prior to their absorption. The
teeth, the fangs of which present a horny appearance—5.6., where the tubular appearance
is obliterated—are, we know, peculiarly subject to absorption; and most of the teeth
affected by denudation which I have examined, present more or less the horny character,
some in a considerable degree.
An intelligent friend, if, indeed, I can call the individual “friend,” who chiefly
persuaded me to commit myself to this paper, but who, as a careful observer, is
entitled to much consideration, informs me that he believes he never witnessed the
process in a necrosed tooth. I am sorry I can neither oppose nor conﬁrm Mr. Campion
in this view, although I rather incline to his opinion. In some of the specimens before
you the teeth were most probably dead at the time of their removal, but the process
may have existed only at the time they possessed vitality. If such be the case, I think
it rather tends to support the view of there being a degenerative change in the contents
of the dentinal tubuli affecting the surrounding dentine, and which, ceasing with the
death of the tooth, the process is arrested. A condition not much dwelt upon by
writers upon the subject is the great sensitiveness presented at the denuded spots,
especially in the earliest stages ; when touched by the ﬁnger-nail, or hairs of the tooth-
brush, they give a sharp and peculiar thrill, with a sensation like cold along the region
of the spine. A tooth under such conditions cannot be devoid of vitality. Another
point, also bearing on this opinion, may be mentioned, and it is the only one I will offer
with regard to treatment; for though I believe the plan will invariably, if persevered in,
prove successful in arresting the affection, and causing it to assume the brown colour
mentioned by the earlier observers as the evidence of its cessation, it is of too empirical
a nature to come under the head of a rational treatment. It is the constant local
application of ammonia or one of its compounds. I usually recommend sal volatile—as
being of a suitable strength—to be applied on a little cotton, or brush, three or four times
in the day. If, as suggested, a softened condition in the dentine exists, and if this be
brought about by an acid condition of the contents of the dentinal tubuli, then a limpid
DISEASES on THE TEETH. 48 5
alkali, and such an one as can penetrate the tubuli, would be the most likely to counteract
the condition.
To return to the question of friction—and here I feel I must differ from those who
point to its existence—I mean the affection as clearly described by Hunter—in places
inaccessible to any agent capable of rubbing or touching the same. I believe I have
never seen a case in which it was not possible for friction, either by tooth-brush, tooth-
pick, tongue, lips, or saliva, to have been applied. With regard to the last-named, my
friend Mr. Todd has reminded me of the familiar instances of the stone worn by the
continual dropping of water, and the pebble rounded in the brook; as also of the fact
that all the pebble ornaments, pen handles, &c., produced so cheaply in Germany, are
polished under water. In my own month are some well-marked cases of the affection,
but from their dried surfaces my tongue and lips can at once remove any pigment
applied to them. In respect of those cases which present ﬁne saw, cut-like markings on
their approximal surfaces—molars especially—near to the gum,they could certainly most
readily have been produced by some hard pointed instrument, continuously applied in the
same direction, with the object of pressing food from the buccal to the lingual oriﬁce
of the space existing at the necks of such teeth when the gum has receded. Were such
markings found amongst the teeth of the lower animals, I should then at once with-
draw a tooth-pick origin to account for them; but what does exist, so far as I have
been able to ascertain, of an approach to this affection amongst the lower animals, I will
now endeavour to describe.
Through the kindness of Mr. C. S. Tomes, my attention was directed to the peculiar
markings on the tusk of the female Indian elephants, “ Specimen—2769A in the Museum
of the Royal College of Surgeons.” A history attached to these or similar specimens
will be found in the Transactions of the Zoological Society for the year 1871, p. 145.
The elephants bearing these tusks were shot in Ceylon by Mr. Sclater, and at the time
he remarked the peculiar and unusual markings upon them; also a mass of egg-like
bodies, arranged in regular series, of apparently some dipterous insect, somewhat resem-
bling those of the common blow-ﬂy. On examination of the grooves at the gum no
maggots were discovered. The subject has, I believe, been further investigated by Dr.
Spencer Cobbold, and discussed at the Linntean Society, but I have not been able to ﬁnd
any paper on the subject in its Transactions. Being unable to ascertain at the College of
Surgeons how much of such tooth would be exposed above the gum, I visited the
gardens of the Zoological Society, and there inspected the mouth of a female Indian
elephant, which showed that all the grooved portion was situated below the gum, and
the smooth portion above. The affection, therefore, as shown in one of the casts I was
kindly permitted by Professor Flower to take, was probably, at least some portion of it,
below the level of the gum, and had, I should apprehend, undergone absorption, from
either some altered condition of, or secretion from, that structure or the alveoloidental
membrane ;* but how far this might be due to the presence of the parasites, or the para-
sites owe their existence to it from the presence of some unhealthy secretion, is a matter
upon which I will not venture to offer an opinion. I think I may, however, remark that
the conditions presented by these elephants’ tusks resemble but very slightly, if they do
at all, the condition of decay by denudation as witnessed in man; nor, on the other band,
do they resemble ordinary dental caries. With regard, however, to the teeth of a certain
class of seals, the otaria jubata (sea-lion, or fur seal) the case is different ; here we have,
judging from external appearances only, a condition similar to, or approaching, that seen

* Dr. Murie, op. cit, remarks that it is “ a case where, more truly, erosion from peri-
osteal inﬂammation is indicated.”
486 DISEASES OF THE TEETH,
in the human species. With respect to this condition, Dr. Murie, in the paper before
referred to, remarks : “ To my mind, neither the supposition of inherent disease, nor simple
friction, of a certainty accounts for the uncommon manner in which the otary’s teeth
'have lost substance.” It is possible, he admits, for the dental apparatus to be worn
away by, or denuded of, the softer dentine by the unequally ﬁtting and rubbing of the
teeth against each other; but in the case of the Otaria he believes this impossible; “ for
the abraded surfaces are not those which meet in mastication or closure of the mouth.”
My conclusions in this respect, however, somewhat differ from Dr. Murie’s. The im-
mensely broad condyles of the lower jaw show a great capacity for lateral movement, and
such as would, in the recent state, almost permit the rotation of the lower around the
upper cuspidati, and I think there can be no doubt but that much of the loss of these
teeth, at least, is due to antagonistic friction. It is also a fact, as pointed out by Dr. Murie,
“that seals—notably the species under consideration—swallow mouthfuls of pebbles.”
. . . “ Now granules of sand may be taken up at the same time, and effect an erosion equi-
valent to an injurious dentifrice,” but he considers the staining, regular circular abrasion,
nature of the polish, and the mode in which particularly the great canines are reduced,
~oppose rather than support mechanical friction alone as the agent at work. He does
not believe it can be due to absorption, nor does he see his way clear for accepting in-
herent disease of the tooth-substance as a cogent reason for the removal of the tissue.
‘“ By a combination of them, however, the resultant wearage is more likely to have been
‘brought about.” He suggests “ an inherent constitutional tendency for the teeth to be
.acted on by external agency.” . . . . “ An altered or unhealthy condition of the
glandular ﬂuids,” in which “the lips, gums, and tongue would play a vital part.” . . . .
“Add to this the mechanical inﬂuence of ﬁne particles of sand, grit, &c.” He neither
explains nor contradicts the assertion that certain cases of notching and erosion may be
due to purely mechanical agencies; indeed, he states his belief that such instances do
occur; at the same time he is none the less convinced that examples, both in men and
animals (the Otary to wit) show that dental loss happens through processes other than
friction per se. i '
I am, I confess, at a loss to explain this condition, as occurring in the seal, by any
reference to a degeneracy in dental structure, such as we can justly assign to a being
like man in the civilized condition, and in whom we should almost expect to ﬁnd organs
so imperfectly employed as are his teeth in a state of degeneracy. And in his case, with
regard to the question of abnormal friction, surely the fact of man’s being endowed with
speech must be taken into account. Speak but for a short time with your attention
directed to the rapidly continuous movements of the lips and tongue, and then consider
what that friction under water must amount to in but one year. It is an interesting
fact, that of all animals, the sounds which can be made by the seal most nearly, I believe,
resemble the human voice, so that it has often been called “the talking ﬁsh.” Its
tongue is long and free, and although it appears to swallow its food with but little masti-
‘cation, the tongue, though I have not been able to verify in my examination of the seals
-—which are not the furred variety—at the Zoological Society’s Gardens, may be well
employed in removing the scales of ﬁsh which no doubt at times adhere to the teeth with
some pertinacity. It is such a tongue as can well sweeep round its cuspidati, premolars,
and molars, which have considerable distances between them.
When speaking of the affection as being more common to the female than to the male
sex, I trust my hearers will freely acquit me of having, at the time, this suggested agency
for it in mind, an agency which, if it have a true existence, must be regarded as another
element in our civilization tending to bring the genus lzomo to an edentulous condition.
When I look round upon this assembly and this Congress, numbering so many dis-
DISEASES or THE TEETH. 4S 7
tinguished individuals, and from such varied countries, a temptation arises which it is
difficult to resist.
I can conceive of no grander opportunities than are those afforded by these Inter-
national Medical Congresses, for the general acquiescence in, and settlement of, a universal
nomenclature of the diseases which are common to the countries represented; and if I
may be so bold as to make a suggestion, it is to the fact, that this International assembly,
of dental physicians and surgeons, do herewith decide upon the designation which, in
their opinion, may best describe the affection ﬁrst noticed by Hunter and by him named
“ The Decay by Denudation.”
DISCUSSION.
Mr. GADDEs, London: mentioned a case in which this condition of erosion existed
in a right-handed gentleman. The disease was only very slightly marked on the left
side of the mouth, but very deep grooves from erosion prevailed in the upper and lower
canines, biscupids, and molars of the right side, just where the friction from the
tooth-brush would not be expected to be in greater amount, neither did the patient
consider he brushed the teeth on the right side more than these on the left. The
cavities were very sensitive to the excavator.
Dr. J. TAET, Cincinnati: This is one of the most obscure affections of the teeth
with which we have to contend. There are a number of presentations of this affection ;
it sometimes presents a plain level smooth surface, wearing away the end or masticating
surface, uniformly leaving the enamel slightly more prominent than the dentine. In
other cases, cup-shaped cavities, varying in size, are formed; these, also, are upon the
masticating surfaces of the teeth. Upon the labial and buccal surfaces, this process is
‘frequently shown in the form of plain surface cutting, or in transverse grooves, vary-
ing in superﬁcial extent and depth. Many of these cavities and grooves are so found
and situated, that mechanical attention fails wholly to account for the process. How
much this affection is dependent upon any peculiar condition, either accidental or
original, in the tooth structure, is a problem yet to be solved.
Mr. MAeoR, Penzance: I meet with a great many cases of erosion of the labial
surfaces of the teeth, but I do not ﬁnd these surfaces polished, excepting where the
teeth were habitually cleaned. I meet with other cases where the grinding surfaces are
much worn away by chewing tobacco, such as in the case of sailors and ﬁshermen ; and
perhaps I may be allowed to instance one particular case, that of a Newlyn ﬁsherman,
who, when ﬁrst I examined his mouth, had his full complement of thirty-two teeth, all
worn down almost level with the gums, right into the pulp cavities, which latter were ﬁlled
up with secondary dentine. Another singular case lately came under my observation,
in this patient the cutting edges of the two upper central incisors were worn away
as if ﬁled and polished, so that there was a considerable space between the upper and
lower incisors when the mouth was closed. This is a case which seems to me very dilﬁcult
to account for, but I should like to hear some explanation of it.
Dr. DENTZ, Utrecht: I wish to state, that the opinion emitted by M. Magitot, in the
Section of Diseases of Children, with regard to the nomenclature of erosion, denudation,
&e., does not express the opinion of the Continental professional men as Mr. Coleman
thought. We have mostly studied English works, or their German translations (Ger-
many and Holland), so are generally guided by our English and American colleagues in
our terminology.
488 DISEASES OF THE TEETH.
Mr. C. S. ToMEs, London: I believe that the view entertained in France is, that
erosion is merely caries, rapidly and completely worn away in fact, as it softened “ earie
s‘eche,” and there is the difficulty of accounting for waste of the cutting edges of teeth
sometimes observed. The effect of friction is well illustrated by the difference of loss of
material on its two sides, which can hardly be otherwise accounted for than by the friction
of the tooth-brush.
Mr. COLEMAN, in reply, said: that in having to read his paper in abstract he had not
been able to do justice to his subject, and still less to his audience, as several of the
queries propounded by the latter would be found answered in the former. He was glad
to hear from Dr, Dentz, that Hunter’s term for the affection was more generally applied
to it, on the Continent, than he had supposed. To Mr. C. S. Tomes he was grateful
for the complimentary manner in which he had spoken of that portion of his paper
which accounted for friction in the case of man and the seal. He could not agree
with M. Magitot that this affection was but a variety of earies—“carie seehe”——
but as he had no opportunity for examining microscopically a recent specimen—one
that could be stained—he expressed his opinion with some diﬂidence. The views ex-
pressed by the Chairman and Mr. Gaddes, and which received conﬁrmation at the hands of
the Messrs. Tomes, were much in accordance with his own. Dr. Taft, in no uncompli-
mcntary terms, had expressed dissatisfaction that nothing tangible had come before the
meeting with regard to the subject ; he could only say that that disappointment was
equally shared by himself, but he still trusted that, by further attention to, and a more
thorough investigation of, the subject, he might be enabled to produce, on a future
occasion, something more worthy the attention of an International Congress.
Experz'mem‘s 072 Z/ee Aez‘z'me of some Agents usea'for/ Me
Dew'z‘alz'zaz‘z'ore of Me Toof/e-pulp.
Dr. JOSEPH Anxovr, Buda-Pesth.
The devitalization of the pulp being a daily occurrence in dental practice, it is neces-
sary for the practitioner to be quite clear even about the minute effects of this sort of
treatment.
A considerable number of papers on the subject may be found scattered in the
periodicals, but the manuals of dental surgery only contain general remarks upon
it. We search in vain in the empirical descriptions for an account of the pathological
alterations produced by devitalizing agents, as well as for directions for their use, founded
on a scientiﬁc basis. Perhaps the sole, and certainly the largest, monograph which has
been written on the subject, is by Dr. A. CombeﬁF of Paris; but although attention is
there directed to the mode of application of arsenious acid, the patho-histologieal details
have not been made a subject of special inquiry.
These circumstances led me to commence a series of experiments on dogs, in order
to elucidate, if possible, all the dubious questions which surround this subject.
Before giving an account of my experiments, we should consider the agents on the
scale of the value of their applicability. I think, that every practitioner will agree with
me in stating, that the ideal requirements to be expected of any pulp-devitalizing agent
\
* Anthelme Combe, “ De I’Acide Arsénieux dans ses Applications a la Thérapeutique de
la. Carie Dentaire,” Paris, 1879, translat. Brit. learn. of Dent. Science, vol. xxiii. No. 297,
and subsequent numbers, 1880.
DISEASES on THE TEETH. 489
are—the easy application, sure, and if possible quick action, the least possible causation
of pain, and no interference with the hard substances of the tooth. Now, we ﬁnd only
two agents which answer these expectations 5 arsenious acid and pepsinum.
It is rather curious, that both agents are, especially the former, hardly known as
to their effects upon the elements of the organism; and the investigations made in that
direction (excluding the pretty old practical observations) are of the newest date. We
will take a glance into them as far as they are serviceable to our subject. In 1879
Binz and Schultzif made experiments with arsenic from a chemical standpoint, the results
of which show that, incorporated into the organism, arsenious acid changes into
arsenic acid and vice versct; both changes are executed by the protoplasmic tissue, and
arise from the oscillation of oxygen atoms of the albumin-molecules; the quantity of
these atoms deciding as to the therapeutic or toxic action of arsenic. Under
the inﬂuence of protoplasmic tissue a certain quantity of active oxygen becomes untied,
and that is the real poison producing gangrenous destruction. That the arsenious acid
has a special action upon the nerve centres is a well-known supposition ; and we may
add, after Ringer and Murrell’sj' experiments, that its action paralyzes the conducting
power of nerves quicker than it stops the function of muscles. Another not improbable
statement is, that arsenious acid undergoes a chemical combination with haemoglobin,
as is shown by the spectrum, where we see only one of two oxyhaemoglobin lines.
Pepsinum has not until now been used much for devitalizing purposes, and has been
limited to internal treatment. Once it has been mentioned for this purpose in one of
the English dental journals—I cannot tell which and when—but it was not much adopted.
Its action and the alterations produced by it in the tooth-pulp have not, as yet, been
inquired into.
The experiments, which I now intend to communicate, bring, I believe, some light
into the patho-histological details of the subject, and so, I think, they will be of interest
for the profession.
There are questions which cannot escape the attention of a thinking dentist while
applying devitalizing agents. The ﬁrst of all is, the correct quantity to be used; the
second is, what are the minute changes the pulp will undergo? athird question is,
whether there is any chance of mischief possibly imposed by such an agent upon the
dentine, enamel and cement? fourthly, in what light must we look upon consecutive
periodontitis P
I have made' experiments with arsenious acid as well as with pepsinum, in order to
see the difference of their action, and so be able to state which might be the indications
for one or the other. The experiments have been executed in the pharmacological
institution of the University of Buda-Pesth, on three dogs. The moalzzs operandi was the
following :—
I had an apparatus made for the ﬁxation of the dog’s head, the construction of
which consists of a central iron ring divided into two portions, and provided with two
screws and small leather-cushions to it, so as to keep the dog’s nozzle fast, one serving to
screw in the upper, the other the lower jaw. From the segment of the circle of the ring
there are two branches extending to the maxillary articulation, so that, provided with iron
joints, it may imitate the movements of the real jaw, and make it possible that by screwing

it‘ Experimenteller Beitrag zum Verstandniss der Arsenwirkung von Binz und Schultz
C'entralblatt fra- medicz'm'sche Wissenschaftcn, 1879, p. 17 ; and Die Arsengiftwirkungen
vorn chemischen Standpunkt betrachtet: Archie. f. ewperz'm. Pathol. u. Pharmacol. ix. 200.
+ S. Ringer and W. Murrell : The Action of Arseniate of Soda and Arsenious Acid on
Frogs: Joarn. of Physiology, i. p. 213.
06t-
'HLEIELL III-LI. JO SIHSVHSICI
Too'rn.
Left upper
incisor.
I. and II.
(A)
Right upper
incisor.
I. and II.
(3-)
Right upper
canine.
(0-)
Right upper
incisor.
111.
(D, )
EXPERIMENT (on May 29) YBLLOWISH-BROWN Doe, ABOUT 3% Years On).


Mim- Exrnnnar. EXAMINATION: MIenosoorIoAI. EXAMINATION:
gramm. Pam: on THE Too'rn AT THE— PART or run Too'rn-Ponr AT Inn—-
at I a‘
3* 5‘5 Drill-hole. Crown. Root. Drill-hole. Crown-pulp. Root-pulp.
14 0-1.6
I NO alteration Apical one- _No special destruc- _Diii'use blood At the apical part mode-
in dentine and third of peri- tion; nerve ﬁbres nor- pigmentation. rate blood extravasations,
enamel either dental mem- mal; the blood-corpus- which seem tobe caused by
onlong’or cross brane slightly cles in the blood-vessels capillary embollsms, as seen
sections injected, are to a certain extent in several instances (see Fig.
' a granular detritus. I). Hartnack, cc. 2, obj. 8.
I pinkish pinkish hue, Apical two- Resembling clotted No embolisms.
brown thirds normal, albumen close to the
' drill-hole, while on the
opposite side even the
layer of odontoblasts
intact.
Exrsnmsm (on June 6) Bmcx Doe, 3 Years 01.1).
N 'mal. Brownishred Apical one- The dentinal tubes show
2 ol (pulp), fourth of root- no change whatever ; but
pulp brownish the ﬁbrils in several in-
' red stances seem to be in a state
of granular tumei‘action at
the tinged apical portion.
Normal. Slightly red- Brifrhtly, red- Immediately under Apical one-
3 dcned dentine. dened dentine the drill-hole, cells of third ; blood-


and cementum.

connective tissue en-
larged ; intumescence
of the nuclei of neuri-
lemma ; in the axial part
of nerves the axis-cylin-
ders almost disappeared,
and in some places re-
placed by granular con-
tents. Blood - vessels
normal, rather anaemic.

vessels telean-
giectatic; one-
fourth to one-
sixth of their
normal size.


Srncnu. REMARKS.

The I. incisor diﬁ‘ers from the II.,
inasmuch as here the apical end of the
root-pulp is injected, while it is quite
pale at the drill~hole. In general the
pulp in this instance seems to be less
affected than in the former case.
Sections of the pulp put upon a china
dish, and held over the spirit-ﬂame,
leave a dark black dust (characteristic
of arson), while pulp-particles (normal)
become in the same process only dry
and brown.
The whole pulp-tissue in general is
scattered with arsen. molecules. It is
a very remarkable circumstance, that
while pulp-tissue in toto is suﬁ'used
by blood pigment, the blood-cor-
puscles in the interior of the vessels
are bereft of their pigment, and so
point to the suggestion that the arsen.
molecules form a chemical combina-
tion with the haemoglobin of the
blood-corpuscles.
'HJZH'HJ'. HHJ. HO SEISV'HSICI
1617
Left upper
canine.
Left upper
incisor.
III.
Left upper
molar.
0
Hard substances show no alteration; pulp in
general considerably
upper three-fourths;
change at all.
Alteration
conﬁned o
one-fourth in
its middle ;
dark red; in-
jected.

injected,
especially the
hence, to the apex no
Upper, and, to aeertain extent,
also at the lower end of that
part a demareational line.
Proper crown
Ditto.
pulp unaltered.
In the pulp
chamber 1-2
mgrmm. of ex-
cess of arsen.

Peridental
membrane con-
siderably in-
jected on two of
the roots; one
is specially af-
fected,and even
the dentine
and cement is
brownish - red
from the drill-
hole to the
apex. No nor-
mal art on the
who e tooth.

Granular detritus and
considerable destruc-
tion, where mieroeoeci
may be seen (probably
from the agent itself);
dentine not changed.
Blood-vessels expan-
ded, and full of their
contents; pepsin mole-
cules spread over it.
Dentine seems to be
normal; arsen. particles
not able to invade the
tubes; ﬁbrils unaltered.
Pulp tissue: enlarged
cells blood-eorpuscles
pale (as above).

Hardly any
change; only
in a few ea-
pillaries blood-
eorpuseles in
detritus.

At the demarcational line
the blood-vessels expanded
to four or ﬁve times the nor-
mal size; however,the blood-
eorpuseles did not lose their
pigment; on the contrary,
where they are crowded,
they form purple spots.
Under the demareational
line the vessels are bloodless
and shrunken.
Three millimetres under
the drill-hole, and especially
atthe apical end, ecchymosis
in high degree. The vessels
contain arsen-moleeules, and
are partly collapsed (Fig. 3,
00. 4. obj. 8). Some of_the
vessels form an exception.
Immediatel under_ the
drill-hole t e protoplasm,
as well as the nuclei of the
connective-tissue cells, are
remarkably enlarged, about
three to four times the
normal size (Fig. 4, 00.4.
obj. 8).

At the last one-fourth of the root-
pulp a demareational line is to be seen,
consisting of black-looking, clotted
blood, running all round the body
of 1t; the pulp is, under that line,
colla sed, and does not ﬁll up the root-
cana . In the whole pulp the nerve-
ﬁbres exhibit no alteration.
Some of the capillaries at the affected
part contain in excess pepsine grains,
and only very few blood-eorpuscles
(Fig. 2, obj. 8, 00. 2).
In general, in this specimen the
blood-eorpuseles are disintegrated into
granular detritus ; and we get the im-
pression that such masses produce em-
bolism, and not organized thrombosis;
and hence the pluggin of the apical
vessels. The myelin oft 10 nerve-ﬁbres
is granular (Fig. 5, 00. 4. obj. 8). In
other places the nuclei of the neuri-
lemma are enlarged. The granulation’
does not look like fatty degeneration.
These changes occur mixed with in-
te ral tissue. It is curious and highly
in eresting that, in the least affected
and most peripheral crown-pulp, we
ﬁnd some nerve-ﬁbres with single and
double contour, where the axis-cylinder
exhibits notches of oval shape. They
are sometimes close, and sometimes at
some distance from one another. These
are to be looked upon as tumefaetions
of the axis-cylinder. Yet it is singular
that the neurilemma does not pro.
portionately expand, answering to the
enlargement of. the tumcﬁed parts
(Fig. 6, 00. 4. 0b]. 8.)
‘HI/Hill] [*IHJ'. .EIO S'EISVEISICI
EXPERIMENT (on May 29) YELLOWISH-BROWN Doc, ABOUT 3% YEARS OLD.

Too'rn
Right upper
molar.
II.
H .
EXPERIMENT (on 3 July) BLACK Doe, 11 YEARS OLD.
Right upper
incisor.
III.
Left upper
incisor.
III.
Left upper‘
canine.
An additional experiment has been made with dentine—taken from the three
arsen. trioxyd. ; and the same has been tried with the same
_neither the intertubular substance nor the tubuli underwent
or tnmefaetions, as maybe seen in the adjoining drawing (Fig. 8, cc. 4, obj. 8).
fact—vim, the preparation was covered by a great number of mycelium-threads

SPECIAL REMARKS.

Mllll- EXTERNAL EXAMINATION: Mrenoscorrcnr. EXAMINATION.
gramm PART on THE TOOTH AT THE— Paar on THE TOOTH-PULP AT THE—-
('3
o 5,8 , .
at‘ Q '5 Drill-hole. Crown. Root. Drill-hole. Crown-pulp. Root-pulp.
4 04.5
5 Two-thirds in Pulp slightly Peridental Hyperzemia; blood- Much detritus; The upper part presents
the middle of injected; den- membrane mo- vessels extraordinarily here and there an aspect of almost total
the pulp col- tine close to the derately in- dark red. The pe- unaltered tis- destruction, with detritus
1apsed;brown- pulp moderate- jected; apical riphery of the pulp is sue. and in the greater blood-
ish red, brittle. -ly pigmented. one-third; totally destroyed, re- vessels crowds oft'atty-mole-
slightlyaltered. sembling coagulated eules may be observed.
albumen, while its
I
Slight injec-
Right upper
canine.
tion.
No change whatever.
. _Considerab1y
No change.
injected.
Vehement in-
j ection.


axial part did not much
suffer.

Dentinal tubes; dia-
meter greater.
Vehem ent injection;

(Agents not in direct contact with the pulp, but only
Great quan-
tity of fat
globules seat-
tcred through-
out the right
top of the
crown-pulp.
blood-vessels
expanded ; no other change.
(Fig. 23, cc. 2 obj. 8.) In
gener the whole axial part
of the root-pulp is in a state
of congulation and fatty
detritus ; nerve-ﬁbres par-
take in the latter. The peri-
pherieal partof the root-pulp
hardly underwent any change

The dark red colour (the contrary'
of which we ﬁnd in specimens treated
with arsenic) insinuates the supposi-
tion that pepsinum removes chemically
the water of the blood-corpuscles, and
only the blood pigments remain in the
vessels.
separated by a thin lamella of dentine Section. After three days).
N o .alteration.


The animal having been very young,
the greater diameter of the dentinal
tubes is to be ascribed to that circum-
stance; at the same time, this seems
to give also an explanation of the
real cause of the injection. An addi-
tional cause of this may be the irri-
tation of the foreign body and the
drill-hole. The fatty aspect of the
crown-pulp is not accompanied with
any noteworthy trace of real fatty
degeneration, either of the nerves or
of the blood vessels. ‘
-year old dog—which has been put in one .watchglass full of soft water and ﬁve milligrammes of
quantity of pepsinum. After three days the microscopical examination showed the following: In the ﬁrst instance (As203)
any change; not so the dentinal ﬁbrils, which exhibited (Hartnack’s can]. 4, obj. 8.)—in a few places—longitudinal notches
The specimens in the solution of pepsinum I have found to be devoid of ﬁbrils; but there was a noteworthy
and innumerable very light grains, probably spores of the fungi.
DISEASES OF THE TEETH. 493
open and closing a separate ﬁxed screw on one side, shutting up at the other, not only the
head of the dog will be ﬁxed, but also all desirable dilatation of the mouth will be execu-
table, without permitting the least contrary movement of the animal. To promote this
object the dog receives a sub-cutaneous injection of three and a half cubic centimetres
of tinct. opii. simpl.
In general, I used the trephines with an old White’s engine to pierce through the
sound enameLand dentine of the teeth—mostly the canines, third incisors~and ﬁrst
molars, and always at the gingival margin. When the hole was sufficiently large, the
thin dentin-layer was drilled out too, and either arsenious acid or pepsinum suspended
on a few wet threads of cotton-wool, twisted round a pointed instrument, was brought
into contact with the surface of the tooth-pulp. After this, the cavity was stopped with
Hill’s stopping, and this was again washed with chloroform in order to prevent any escape
of the agent and intrusion of saliva.
All this was executed with the greatest accuracy. The quantity of each agent was
correctly weighed in advance, the smallest amount having been one milligramme, the
greatest not exceeding ﬁve milligrammes. The arsenious acid I used was of the porcelain
quality, and powdered; the pepsinum was the best German preparation. These agents
remained for from twenty-four to twenty-six hours in the teeth.
In one instance—via, in the experiment with the third dog, I inquired into the
effect of these agents, without bringing them into direct contact with the pulp. Here
only a thin lamella of dentin was left to occlude the pulp-chamber, just so thin as to
let the red translucent pulp be seen. At the lapse of the above-named time the dogs
were killed by prussic acid (acidum hydrocyanicu m) and the teeth which had been
operated upon were cutout, together with their bony connections, the agent was at
once taken out of the cavities, and they were then put into a solution of alcohol, water,
and glycerine (2 : 1 : 2) in order that the preparations might not change even in colour.
The statements resulting from the naked eye and microscopical examinations are
put down in the foregoing columns. (Pp. 490-492.)
Now, if we gather and confront the facts which are contained in the above columns,
we may get, I believe, some valuable account of the mode of action of these agents.
The ﬁrst change which we see is the more or less injected state of the pulp‘; the former
in specimens treated with As203, the latter with pepsinum. The injection of the
apical end of the root-pulp, as a sign of inﬂammation or affection in general, is specially
apt to follow action of A8203, while that of pepsinum does not go so far, except when
the greatest quantity (5 mgrm.) is applied, and even then the eifect is rather molecular
detritus and collapse of tissue. The injection in the two instances, arises from different
causes; in the arsenious acid case we see capillary emboli at the apical root-pulp—and
that is even produced by 1 mgrm. of AsgOy—and consequent plugging of blood-vessels;
farther on we see that a surprising change takes place in the blood-corpuscles—viz.,
they become very pale or quite discoloured, owing to the special action of Asgt)3 on
blood in general—as quoted in the introductory remarks—which probably consists in a
chemical combination of it with haemoglobin. We see the contrary with pepsinum; the
blood-corpuscles in the vessels do not diffuse their pigment into the tissue, and are
darker red than normal; this, again, may be ascribed to thc hygroscopic nature of
pepsinum, in consequence of which the water is drawn out, and the hazmatin and haemo-
globin remaining, exhibit their more intense colour. So, in both instances, the action
of the agents is directly upon the blood, and must naturally interfere with the circula-
tion and nutrition of the pulp. Another proof that As2 O3, incorporated into the pulp
remains there either in form of AsgO3 or H3As04, is that thin sections of such a pulp
exhibit on a china disc, held over a ﬂame, the characteristic black soot ; and the conclu-
494 DISEASES OF THE‘ TEETH.
sion to be taken therefrom is, that in a longer space of time its action would extend over
the limit aimed at. Arsenious acid has a special action on the tissue as well, inasmuch
as it enlarges the cells of connective tissue (Fig. 4:.) considerably (3-4 times), and
while it acts in the same way upon the nuclei of the neurilemma, the myelin becomes
granular. There still remains a question, however, as to the mode of action of arsen.-
trioxyd. on the nerve ﬁbres, as to whether we may ascribe this and the more
surprising alteration, which I shall later remark upon, to the primary lesion in general
imposed upon the pulp. Whatever opinion we may form on this matter, it is a fact
that, beginning from‘ 3-——5 mgrms, a certain number of nerve ﬁbres become granular in
their interior (Fig. 5). The same action can be observed on blood-vessels, in specimens
treated with from 3—5 mgrms. ;- their contents are granular detritus and the vessels are,
to a large extent, collapsed (Fig. 3).


I'b


.~\.
3). W I "-


\Y.
//".’ a-
H .’,-~-' /
-ra-ﬂ _. ,,’ ~-
/, . 0/ 4:”
.1‘, L-.-» /
(If, "/5;
- w’: ..¢"'/"
/.‘¢ 2-“-
:r.
Fin .8
ACTION OF DEVITALIZING AGENTS ON THE STRUCTURES OF THE TOOTH PULP.
FIG. A.-—A pulp acted on by pepsin with a demarcational line (macroscopic)
FIGS. 2, 7.--Blood-vessels from a pulp treated with pepsin.
FIGS. 1, 3.—Blood-vesscls from a pulp ‘treated with AS203.
FIes. 5, 6.—Nerve ﬁbres from a similar pulp.
FIG. 4.-—Enlarged connective-tissue corpuscles action of A8203.
FIG. 8.—Dentinal ﬁbrils slightly tumiﬁcd by the action of As203 (see note p. 56.)
Pepsinum even in small, and specially in greater, doses (3—41—5 mgrms.), has a
singular mode of action, as it produces a more or less deﬁned demarcational line, leaving
the end of the pulp really unchanged (Fig. A) ; and this circumstance may be of
value in the discernment of the quantity which should be applied. As opposed to arsenious-
acid it is remarkable that the latter, in no instance, produces demarcation; and
while We see every point of the action of pepsinum in changing blood, in forming a
demarcational line and in producing—and that is the essential of its action—a kind of'
fatty degeneration in capillaries and larger blood-vessels (Figs. 2 and 7), as well as-
changing the living into coagulatcd albumen, the action of arsenious acid is not so
DISEASES or THE TEETH.’ 495.
tr iking at the ﬁrst glance; inasmuch as the destruction of the tissue is not so
plain but is more extensive. Another question we wanted to have lighted up,
concerned the periodontium. In that respect, I think, nothing will be more signiﬁcant in
deciding as to the degree of affection than the condition of the apical end of the root-
pulp. In every case in which this point remained entire or unchanged, there will be no
probability of the action having extended to the peridental membrane. We have
practical reason to avoid the latter, and yet to desire that the action of the agent
should include that end point of the pulp. Our agents act in a totally diii'erent
way in that respect; and while we see a very slight injection already in the
ﬁrst (A) case after 1 nigrm. of A8503 and see the same repeated in the following
(I), G) cases in ascending degrees, we cannot ﬁnd the action to this extent in the
pepsinum cases, where the peridental membrane exhibited no alteration until after the
application of 5 mgrm. (H) In the arsenious acid cases we ﬁnd, in‘ every instance,
a certain degree of affection of the last (apical) one-third or one-fourth of the pulp. On the
contrary, in the pepsin cases this part always remained unaltered, with the exception of the
last (H) ease. Now, the conclusion will thus be obvious that AsgO3 is more liable to
produce periodontitis than pepsinum. Still, a certain part of the value of that state-
ment remains an open question—viz., whether the apical part of the root-pulp will still
be made insensible if left unaltered, and beyond the demarcational line. I
believe that the quick progress of fatty degeneration, which invades the nerve-ﬁbres,
gives support to the proposition, that the sensibility is at least degraded. On the
other hand, AszO3 gives evidence that its action very quickly reaches the peridental
membrane. This latter question has found diﬁ‘erent explanations. Dr. Cruet (as quoted
by Combe, op. cit‘. p. 50), ascribes the periodontitis, in such cases, to the increase of col-
lateral circulation, produced by the suppression of the same in the interior of the pulp.
Dr. Gombe, in his own opinion, rather attributes this effect to the inﬂuence of
arsenic in general. On the ground of our introductory remarks, this inﬂammation must
be due to c/zemz'cal e/zmzyes produced by arsen. trioxyd. in the elements of blood and pro-
toplasmic tissue in general, and for this affection We shall ﬁnd evidences also in our
columns, from which we learn, that particles of A8203 are taken up into the blood-
vessels (Fig. 3), and carried towards the apex, &c.
The consequences produced by arsen. trioxyd. if left lor a longer space of time within
the pulp, may, on that account, he considered as critical for the existence of the teeth
as well as for the health of the socket, and even the body of the maxillary bone.
Therefore, the total extirpation of the pulp, after such an application, must in due time
be considered as absolutely essential.
Now, if we again direct our attention to the patho-histological changes of the nerve-
elements, there we ﬁnd a most singular alteration of the axis-cylinder (G). This con-
sisted in the notchy tumefaction of the axis-cylinder. The notches were partly close,
and again at some distance from one another; they were dark, and looked to be of
homogeneous matter—not granular. The neurilemma was not proportionately widened,
to correspond with the notches. How was this to be interpreted? I soon found
that patho-histologieal fact mentioned in Professor Charcot’s “ Lee-ens sur les Maladies
du Systeme nervcux.”'>"e Gharcot, and before him a few authors, have observed that
tumefaction of the axis-cylinder. Heinrich Miiller was the ﬁrst to recognize this in the
ﬁbres of the retina, associated with fatty degeneration of the connective tissue and
blood-vessels, in cases of nephritis albuminosa (Arc/z. ff Oplzllzalmoiogie,iv.). Afterwards

Tome ii. 3me ed. Paris, 1880. Appendiee iii. “ Sur la tuméfaction des cellulest
nerveuses motriees, et descylindres d’axe des tubes nerveux dans certains cas de myélite j’
496 DISEASES OF THE TEETH.
Zenker, Virchow, Schweitzer, Nagel, and Hadlich had occasion to describe similar obser~
vations, and Charcot, of his own account, in cases of myelitis. All the cases which
have been published on the subject are limited to diseases and traumatic conditions
of the brain and spinal cord; the only one exception being the retina. This circum-
stance seems to me to attribute to these observations a certain importance, inasmuch as
the same patho-histologieal alteration in our case is stated to exist also at the most
peripheral point of the tract of one nerve—via, that of the tooth-pulp.
Whatever the right significance of this affection of the axis—cylinder may be—this
being to-day an open question—we can only consider it as an inexplicable fact, and
an essential alteration in the texture and physiological function of the nerve ﬁbres,
which may be looked upon as a primary change, caused by the foreign body, either
mechanically or by its chemical action.
BEsULT on THE ExPEnIMENTs.
Theoretical Part.
Arserza'ous Acid—I. AlsgO3 brought into contact with the tooth-pulp acts in the
following way: a certain degree of inﬂammatory hyperaemia, total or partial, depending
upon the quantity of the agent applied, sets in; the blood-vessels become expanded
(‘S—A times), of regular diameter, and here have a tendency to thrombosis. This latter
effect may also be in connection with embolism of the capillaries, when the agent is
quickly taken up into the blood-vessels.
II. AsgO3 produces no coagulation of tissue whatever.
III. It has a speciﬁc influence upon the blood corpuseles, combining with the
haemoglobin to form a compound of arsen-haemoglobin, and of this chemical process there
seems to be evidence in the diffuse yellowish tinge of the whole pulp tissue, and in
the discoloration of blood in several of the blood-vessels.
IV. In nearly every case it is taken up in substantia (in form of molecules) into the
‘bloodways; when there it produces, besides the above-mentioned changes, granular
detritus of their contents and anaemic collapse, shrinkage— the latter effect being brought
about nearly exclusively in cases where greater doses were used.
V. The bulk of the pulp tissue—viz., connective fibres and odontoblasts—undergoes
no change whatever ; not so the connective tissue cells, which increase 3-41 times their
'normal size.
VI. The special action of arsen. trioxyd. upon the nerve elements consists in the fol-
lowing : the neurilemma is only so far inﬂuenced that its nuclei are somewhat increased ;
a more essential change takes place in the axial part, where, after the application of more
than one mgrm., granular detritus of myelin sets in, and the axis-cylinder commences
here and there to disappear.
As a very surprising alteration, may be regarded the notchy tumefaction of the axis-
cylinder, described heretofore almost only in cases of central lesions.
VII. All these alterations occur in and amongst normal looking tissue.
VIII. The action of arsen. trioxyd. is microscopically exhibited by a brownish-red
tinging of the whole or of certain parts of the pulp body, as well as of the neighbouring
dentine and cementum—this latter in cases treated with greater doses—viz., 2—5 mgrm.
This alteration is most expressed at‘ the top of the crown pulp, and at the apical %-§
part. This circumstance may be considered as an external evidence of the devitalisa-
tion being completely attained to.
IX. The conditions of the affection of the perideutal membrane should be regarded as
standing in connection with the degree of the above-named (VIIL) alteration, which again
depends upon the quantity used, and the space of time during which it was left in con-
tact. The smallest quantity (1 mgrm.) is able to produce a slight degree of injection.
DISEASES OF THE TEETH. * 497
X. Arsen trioxyd. if not brought into direct contact with the pulp¢-viz., when a thin
wall of dentine lies between, does not produce any of the alterations before men-
tioned even in cases where 5 mgrms. are used. The inﬂammation produced in
the experiment can only be looked upon as a product of the irritation of a
foreign body put close to the pulp, and endowed with different conducting power for heat
and cold.
X1. As203 seems not to have any action upon the dentine ; although if left for a longer
space of time under its inﬂuence, a slight tumefaction of some of the dentinal ﬁbrils
can be seen, while the hard substances do not alter at all.
Pepsz'rzum—I. The action of pepsinum upon the pulp tissue is quite different from
AszOa—via, greater doses (about 4-5 mgrms.) produce well-deﬁned coagulation of
the albumin; but intruded into the body of the pulp a circumscribed coagulation may
be produced even by l mgrm.
II. This coagulation, when greater doses are used, may extend beyond the place of
application, and reach as far as the apical end of the root-pulp.
The details of its action consist in the following changes :—
III. Close to the spot of application an injection sets in, inducing the same at the
crown-pulp. At a certain distance from the drill‘hole (: carious cavity), the inﬂammatory
redness turns suddenly dark and forms a demarcational line, designating the limit of the
action; hence the a ical %-, %, <41; of the root- ul --dependin<>' on the doses—is unaltered _;
P P P r:
the action is total only in cases where as much as 5 mgrms. are applied, and consists in
the above-mentioned destruction.
I V. The blood-vessels become to a certain degree expanded, and their contents do
not lose their pigment; on the contrary, the blood corpuscles exhibit a deeper tint,
which approaches to purple-red. This change may ﬁnd its explanation in the great
hygroscopic power of pepsinum, inasmuch as by this way the water of the blood
corpuscles is drawn out, and their pigment remains in a state of abnormal concentration.
This very eﬂect is also an evidence that the vascular disturbance is to be attributed
to the same cause. So far as the quantity of pepsinum sufﬁces for that purpose, so far its
action will go. Therefore— _
V. It is more probable that, if in such cases peridental inﬂammation ensues, this will
be rather attributable to, and considered as, collateral hypereemia. On the other hand, it
does not seem probable that the disintegrating action of pepsinum should be able to
extend over the aperture of the root canal.
VI. Greater doses (st—5 mgrms.) of pepsinum produce essential alterations in blood-
vessels as well as in nerve~ﬁbres. The former in their continuity become collapsed, or
anaemia, together with fatty degeneration, commences to set in. The nerve-ﬁbres
undergo fatty degeneration only when as much sa 5 mgrms. are applied.
VII. Pepsinum, when not in close contact with the pulp—via, through a lamella of
dentine—produces no effect at all.
VIII. The hard substances if left for several days in a solution of pepsinum do
not alter ; only, perhaps, the dentinal ﬁbres disappear, but the dentine gets covered with
mycelium threads and spores of fungi.
[An investigation into the peridental membrane, and into the maxillary arteries, as well
as the corresponding branches of nerves in the maxillary canal, could not be executed
in the animals, because with the teeth of dogs it is impossible to peel off the alveolar
wall and preserve the integrity of those parts, as would be required for such an inquiry.
_ Practical Part.
Arsenious acid and pepsinum being essentially different in action, the conditions of
their application must also be conducted in a different way.
PART III. R K
498 DISEASES or THE TEETH.
I
I. Neither of the agents has a devitalizing inﬂuence upon the pulp capable of
extending through the dentine, they must be used so as to be in contact with its surface.
II. The quantities of the agents which would produce an insensible pulp are differ-
ent, and the selection decides upon the quantity to be used; at the same time the size
of the individual pulp must also be taken into account. “
III. The smallest quantity to be used of arsenious acid is l mgrm. The greatest
dose should not exceed 3 mgrms.
IV. The length of time arsen. trioxyd. must rest with the pulp should never exceed
twenty-four hours, supposing that a quantity corresponding to the size of the pulp has
been chosen.
V. A dose of arsentrioxyd. even only from 1—2 mgrms. left longer than twenty-four
hours with the pulp, may produce periodontitis; and if still longer, osteitis, peri-
ostitis, and diffuse inﬂammation of the surrounding soft parts may follow.
VI. The swallowing of arsenious acid in such a quantity is not likely to produce any
discomfort to the patient; the smallest poisonous quantity being I centigramme; still
care must be taken not to bring it into contact with the gum, 8:0.
VII. Pepsinum produces remarkable alterations only if a greater quantity of it be
used, supposing this be intended to remain for twenty-four hours. If left for a longer
space of time, for instance, 2—3 days, then even 2-3 mgrms. will do their duty. For
‘24: hours, not less than 41-5 mgrms. will have a destructive effect.
VIII. The smallest quantity (1 mgrm.) of arsen. trioxyd. is more eiﬁcacious in pro-
ducing periodontitis in twenty-four hours, therefore, than 3-4: times the quantity of
pepsinum.
IX. It would be advisable to use this agent in every case where rapidity
is not essential. Special indications for its use would occur (1) in teeth of very young
persons where a large aperture of the root canal may be supposed; (2) in persons who
‘do not keep quiet, in whom a correct application of A8203 would be disturbed; (3) in
teeth with distal cavities where the margin of the cavity is under the level of the gum ;
(4) if the patient wants to interrupt the operation for 2-3 days. I
X. Either of the agents having been used, the total extirpation of the pulp must
follow in due time. If this is omitted periodontitis will result, in arsenious acid cases
sooner, in pepsin cases later. In the ﬁrst instance, directly by the chemical action of
the agent, in the second, partly directly by the agent but principally by the fungi, which
develop after a certain space of time, beginning from three days.
XI. The supposed effect of arsen. trioxyd. upon the odontoblast layer, producing
secondary dentine, does not seem to be well founded, inasmuch as oxygen or hydrogen
is indispensably necessary for its occurrence coming into action at all—and being put
between a lamella of dentine, and the obdurating material (as gutta-percha, &c.) these
conditions are hardly bestowed. It is more likely that break of continuity itself and
additional irritation from any obdurating material would produce that effect.

0% Me Reproduez‘z'me of Bones, wit/e Special Reference z‘o
Me V arz'aéle Pom‘z'oezs 0f the Maxi/la.
Dr. W. H. ATKINSON, New York.
Necrosis has been looked upon as a sudden stroke of death to a given territory of
bone. This is the exact opposite of the truth, in every case that has fallen under my
observation, in my own or the practice of others, be it hospital or private.
DISEASES on THE TEETH. 499
However sudden the privation of nerve-current and blood-current may be, there
must be a period of solution of the lime salts of the part involved, to constitute either
caries or necrosis.
It is to the understanding of this process, that we are indebted for correct diagnosis
and treatment. And just here we enter upon the dispute between the old expectant,
and the modern pragmatic extirpatiye methods.
The old says :——“ Let alone, and await the setting up of the ‘line of demarcation’
before attempting to operate.” ,
The new says :—-“ Extirpate the carious or necrosed portion, just so soon as it is
possible to determine the portion deprived of the nerve and blood circulation.” Thus
limiting and marvellously lessening the extent of the destruction of tissue.
Just how far the solution of lime salts may extend, and the part still be amenable
to re-solidiﬁcation, is not deﬁnitely settled, but that vigorous cutting, at that time,
through the dead and dying portion, well into the healthy adjoining tissues, is considered
to be good conservative treatment, is no longer in doubt.
To comprehend the loss of tissues involves an understanding of their production, nutri-
tion, and maintenance as displayed in embryological histology no less than the alter-
nations of generation of the small bodies which are the elements, the changes of which
constitute nutrition in the adult.
A sort of compromise between nutritional changes in the adult, and tissue meta-
morphosis in the embryo, is present_in all reproduction of tissues, continuity of which has
been broken by mechanical, chemical, or dynamic interruption of function.
All reproduction of tissue (other than that of nutritional maintenance) demands a
utricle, or pocket, to contain the pabulum or protoplasm, from which is then to be
evolved the elements of the new tissue, which is to be built according to the demands of
the type of the destroyed portions of tissue; and this holds good pre-eminently in
bones, nerves, tendons, and blood-vessels. I have not yet seen muscles reproduced in
this way.
The prevailing methods in surgery of treating caries and necrosis by expectant treat-
ment and drainage, should no longer be resorted to. The portions already dead, or greatly
debilitated, should be thoroughly removed, well up to the healthy territory—securing a
pocket to receive the pabulum, out of which to attain reproductions by what has been
called “ ﬁrst intention.”
All tissues arise from protoplasm, if we regard protoplasm as the ﬁrst example of
tissue arising out of pabulum, which is a reduced plasma of food elements. We shall
then regard it as the one tissue. Modiﬁcations of which are presented in the various
tisues composing the human body.
In the light of this view of the subject, we must give the following classiﬁcations of
tissues :—
I. Protoplasm. ’
II. Indifferent or embryonal corpuscles.
III. Connective-tissue corpuscles, nerve-tissue corpuscles, and muscular-tissue cor-
puscles.
IV. Limitary-tissue corpusoles: (this is usually denominated “Epithelium,” and is
characteristic of skin, and some forms of morbid growths).
Limitary-tissue covers the body as a whole, and lines all tracts z—Phono-respiratory
alimentary, genitary, urinary, optical, auditory, and sudoriparous.
To enter into questions respecting reproductions of epithelium from protoplasm, with-
out resorting to the so-called- “ skin-grafting ” method, and discuss the point of a possi-
bility--of attaining a new formation not readily detectable as veritable “ scar-tissue,"
K K 2
SOO DISEASES OF THE TEETH.
would lead us too far from the immediate object of the paper—via, “The possibility of
reproducing the variable portions of the maxillae when the teeth are kept in rate, but
deprived of the alveolar plates constituting their sockets.
The tooth-bearing parts of the jaw-bones are the portions of these structures liable
pre-eminently to caries and necrosis.
Examples of well-formed jaw-bones without teeth, in man, are too rare to afford
comparisons as to liability to deteriorate, as compared to those with teeth.
No case of necrosis of an edentulous human jaw has come under my observation
in history or practice.
Molecular metamorphosis (the commerce of tissues) constitutes the measure of pro-
duction, maintenance, and destruction of tissues, and hence must be apprehended, to
enable us to institute beneﬁcent diagnosis and treatment.
Normal nutritional changes do not attract attention; but when disease (as aberrant
molecular metamorphosis is called) invades the body, the abnormality forces recognition.
The disease is one in origin, and one in mode. Debility is its origin, and modiﬁcation
of tissue its mode, the degrees of which constitute its various manifestations.
Mal-nutrition is always asthenic; and induced by starvation through deﬁciency of
food, or bad food, contagion, or misapplied remedies.
The important point is to be able to distinguish between the cases that are sure to
result in destruction of bone territories, deprived of pabulum, when left alone, and
those in which resolution may be expected before the “periostitis ” becomes “osteitis.”
Bone structure is so low in nutritional endowment, that it is dangerous to trust to
any constitutional or local treatment, other than prompt extirpation of the seat of
inﬂamed bone, from which caries or necrosis is sure to spread if not promptly and
thoroughly removed, quite up to, or slightly beyond, the limit of healthy territory.
To comprehend the reproduction of any tissue, organ, or system, it is indispensable
to be acquainted with its introduction, maintenance, and loss.
The range and variety of method and management is sufficiently extensive to satisfy
the most strenuous advocate for freedom—all the way from expectant or let-alone treat-
ment, to “boiling oil,” “lowered heat,” “ cauterization,” and intermediate modes, down
to the demoniac “imprisonment of the part in plaster bandages,” and other means
of “ ﬁxity,” which may be instanced as the thorough-bass of textbook and journal
doctrine.
If there be one predominant dead-weight in the path of the surgeon, it is the cold
assumption that he knows exactly beforehand all the ins-and-outs of a complicated
operation and how to perform it secandum artem ! ,1
Timidity and reverent regard for textbook authority, and the prevailing teachings
of the medical schools, engendered hesitation and doubt as to the correctness of the
deductions afforded by cases in practice.
Little by little advancement was made, as the light of success added confidence to
the interpretations arrived at, under the inspirations of necessity, in cases pronounced
hopeless by those in authority.
When several of these patients recovered, with little deformity, some of those who
subsequently saw them denied that they had ever been veritable cases of necrosis. But
this question was easily settled by the testimony of competent observers who saw them, and
by, in some cases, producing the bones themselves that had been removed from territory
now occupied by reproductions ; which reproductions were so exactly normal in appearance
and usefulness of function, as to defy detection as new bones, by any who had not seen
them in the course of death of parts, removal, and the procurement of the requisite
receptacle or pocket, in which the new formations were obtained.
DISEASES OF THE TEETH. 501
This pocket, by the way,‘ is the sine qua’ 12012 to success in these undertakings.
The heresy of the vaunted textual statements that “ periosteum is the bone-pro-
ducer ” has now happily been set at rest by the discovery that reproduction of tissues
follows the same course of metamorphosis as their orginal production.
All the periosteum that is still attached to the soft tissues surrounding a necrotic
territory, and which has the uninterrupted supply of blood-vessels and nerves, is of great
importance, and should be sedulously preserved.
But where the blood and nerve supply are cut off, the dead periosteum should be
removed with the necrosed bone; since it is no longer able to perform its functions.
The principal use of'the connective tissue (constituting periosteum) is as a support to
nerves and blood-vessels, by which pabulum may be carried to its inner side next the
bone, there to be converted into : “ 1st, Protoplasm; 2nd, Embryonal Corpuscles; 3rd,
Bone-plates of Osteoblasts ;” which, 4th, become true bone by deposits of the requisite
lime salts; and, lastly, the periosteum then serves as a means of sheathing to bone and
tendon at the places of attachment or insertion of the muscle.
The ado made by surgeons for the necessity of preserving periosteum where repro-
duction of bone is desired, will be superseded upon a close study of embryological bone
production.
Written or spoken directions, howeverjclear they may be, are less instructive than
clinical display of diagnosis and treatment of cases of any sort; but especially of the
simpler ones of necrosis and caries.
Clinical instructions of necessity are limited to the few who can come near enough to
really take in the essential features of the examination, deliberation, and discernment
of the diagnosis upon which the treatment depends.
A rigid adherence to rules in diagnosis frequently tends to render a true one impos-
sible, as it often occurs, that a step in the operation must be taken before the diagnosis
can be completed.
And furthermore, early symptoms are too obscure to be detected by any but the well-
trained observer. Just as soon as the ability to detect to a certainty the departures
from health that are liable to run into caries and necrosis becomes more general among
practitioners, there will no longer be such predominant multiplicity of examples of this
justly-detested disease!
I have a case in point—a case which I present you, showing reproduction of the
alveolar plates, constituting the sockets of the inferior teeth, ranging from the second
molar on each side, all of which are now standing in well-formed sockets, as will appear
upon examination of this cast. The pulps died in the right inferior central incisor, and
the left inferior lateral incisor, but they are now useful and beautiful as the other teeth,
excepting a dark colour.
On April 22, 1865, Miss C. complained of pain in the right inferior ﬁrst bicuspid.
Dr. W. treated the tooth with arsenic, and in a week from that day, excavated and
ﬁlled it. On the evening of April 29th (the day the tooth was ﬁlled), Miss C. suffered
great pain, upon which a physician was called, who ordered hot poultices to the face.
On May 3rd or 4th, Dr. S. C. Munroe was called to see her, immediately ordered
the poultices off, and sent for me in consultation—at this time the plates were so
necrosed that the teeth were very loose—they were secured by ligatures, and the pro-
cesses removed through incisions in the gums. I gave her tonic treatment and
astringent mouth washes—after securing the teeth well in position—and the result is
before you in this cast, the impression for which was taken in May last.
“
502 DISEASES OF THE TEETH.
The Sandy of Denial Surgery, and ﬁre means z‘lzenez‘o.
Mr. JOHN ToMEs, F.R.S., London. -
Dental surgery has, during the present century, with the full consent of the medical
and general public, developed into a well-deﬁned speciality. The medical practitioner
refers all dental cases to a dentist, where one is at hand, and the general public select
him as the ﬁttest to help them in all cases of dental trouble. No apology therefore need
be offered for the separate practice of dental surgery; neither need arguments be put
forward in support of its continuance as a distinct branch of surgical practice. The
necessities of society on the one hand, and the technical requirements of the dentists on
the other hand, have determined the condition of separateness. But this great international
meeting affords a ﬁtting occasion to inquire how the accepted conditions can for the
future be met, so that the public may be best served, for herein rests the sole cause for
our presence, either as special or any kind of practitioners whatever.
Utility alone is the excuse for the dentist’s existence, and the full recognition of this
fact brings us to the question of how and by what available means he can become most
useful. How he can best fulﬁl the trust imposed in him as a specialist, bearing in mind
that on account of his supposed superior special knowledge he is consulted, and that he
assents to the belief that the dentist is far more capable than the general surgeon in the
treatment of dental ailments. Clearly his honour, nay, even his integrity, is pledged to
render himself in the highest degree capable of discharging to the fullest the freely
accepted duties, and to this end the obligations of the teacher are in no way below those
of the student. In admitting the social necessity for the presence of the special practi-
tioner, the need for his special education is acceded, and it is to the wide question
regarded in detail, of what should be the education of the dental practitioner for the
determination and the due development of which we, as practitioners and teachers, are
responsible, that I would call the attention of the meeting.
Before proceeding further, however, let me state that I wish it to be understood that
all I have to say upon the subject of dental education applies only to those who have yet
to be educated, and to those who possess neither unusual ﬁtness or unﬁtness for the
pursuit of dental studies.
And, furthermore, I desire to state that any opinions I express as to what can and
should be done, are intended to apply only to education in this country. It will be for
the representatives of other nationalities to tell us what system of professional education
is most applicable and suitable in their respective countries.
In the ﬁrst and second decade of the present century, dental practitioners were few in
number, and for the most part, but not in all cases, members of the medical profession
who, at the outset of practice, had but slender knowledge of the duties of the dental
surgeon, even as they were then understood, or, at best, had such an amount of special
knowledge as the accident of a good or bad private instructor might impart. In all
constructive matters he depended, from the ﬁrst, on the assistance of dental mechanists.
Other persons commenced their career as young men, or boys, in the laboratory of a dental
practitioner, acquiring therein, in the course of an apprenticeship, extending over ﬁve or
seven years, great manual skill, but whose claim to sound surgical knowledge, at the ex-
piration of pupilage, could not be sustained; yet from this class of persons some of our
most distinguished practitioners, of the last generation, were derived. The one class spent
their years, when to learn is easy and authority in the teacher is effective, in the acquisition
of manual skill ; the other in the acquisition of medical.—I will not say “ surgical know-
ledge ” in the strict meaning of the term “ surgicalff Hence it came that practice was
approached from two wholly distinct sides, and resulted in the production of two distinct
DISEASES OF THE TEETH. 503
classes of practitioners: one competent to advise, the other competent to treat, but
neither fully competent both to say what should be done, and to do it effectively.
Towards the end of the second decade, dentists began to increase in number, and each
year, up to the middle of the century, brought new candidates for practice, the vast ma-
jority of whom came directly from the dental laboratory, and who were, for the most part,
below the surgeon in general education, and in whose medical knowledge they had no
share?!‘
Out of this educational difference arose an inter—professional division, not to say
’ jealousy, in which society took but little interest, each person selecting for himself a
practitioner, from whom he hoped to secure all the advantages treatment could effect, and
the choice as .often fell upon the unqualiﬁed as upon the surgically qualiﬁed dentist.
Among the more intelligent practitioners, it came to be freely admitted, that dental
education, from its one-sided character, was in a very unsatisfactory condition; and after
some years of discussion, the opinion was accepted that the general and special portions
of dental training should go on simultaneously; so that skill of hand and surgical know—
ledge should he acquired in the days of our youth, when the power to acquire is at its best,
and at the only time, indeed, when a high degree of manipulative skill can be acquired.
A consensus of opinion as to requirements having been gained, effective action soon
followed. But we were not the ﬁrst to recognize the necessity of a systematic dental
education. Our American brothers not only felt, but provided for, the want, in the
organization of dental colleges; and in following in their footsteps, and proﬁting by their
experience, we accepted an obligation, which should at all times be freely acknowledged.
The history of the organization, past and present, of the colleges has been published in
“ The History of Dental and Oral Science in America,” 1876. From this work, from
Dr. Eliot’s address, delivered before the American Academy of Dental Science, 1878,
and from the prospectuses of the colleges, I shall take the facts, a statement of which
should be made in acknowledgment of the work of our predecessors, and of those
differences of method, or of requirements in education, which differences of social or of
national wants or opinions have rendered desirable or necessary.
In order to arrive at a right understanding of the constitution of the American
dental colleges, it will be advantageous to refer very briefly to the state of medical
education, and of the medical colleges, upon the lines of which the dental schools were,
to a certain extent, of necessity framed. For this information I am wholly indebted to a
-“ Special Report upon Medical Education and Medical institutions in the United States of
America,” prepared for the United States Bureau of Education, by N. S. Davis, A.l\I.,
M.D., 1776—187 6; and “ The Relations of the Medical Profession to the State,” by
D. B. St. John Rosa, M.D., 1879.

it In May, 1878, the number of bond ﬁde United Kingdom dental practitioners was esti-
mated at about 2000, by persons engaged in Supplying them with instruments and, materials
used in the practice of dental surgery. This estimate did not include either dentists’ pupils
or assistants of any kind, or persons who performed triﬂing operations, or who merely
extracted teeth in connection with the practice of pharmacy, or of any other business.
The initial register, published in 1879, contains the names of 5291 persons, of whom
2049 alleged that they practised dentistry with pharmacy, 50 with medicine or surgery,
leaving 2707 persons who practise dentistry as their sole occupation, 483 of whom are
lioentiates in dental surgery. If a reasonable deduction be made from the remaining 2224
as representing assistants, real and assumed, and of quasi practitioners who are known
to have registered, the entries in the register will support the accuracy of the original
estimate of the number of bond ﬁde practitioners, whose registration was contemplated
when the Dental Practitioners Bill was drawn.
504 DISEASES OF THE TEETH.
In early days, Scotch graduates,who settled in America, organized a university drawn
after our northern model, but it was soon found that educational demands upon the
student, readily met in Scotland, were altogether beyond the powers of the youth in a
newly settled country. Hence, to avoid failure, the standard had to be lowered in favour
of private pupilage. After the War of Independence—according to Dr. Davis——
universities and colleges sprung up in the several States, subject only to the dormant
control of the legislature of the State in which they were situated, and from which they
derived their corporate powers. Neither the dominant feeling of the country in favour of
individual liberty, or the multiplication of graduating bodies, tended to arrest the pro-
gressive lowering of the terms upon which the doctorate in medicine could be obtained;
and “ the fact,” says Dr. Rosa, “that the degrees conferred by the colleges became
practically recognized throughout the whole country, as a sufficient license to practice
medicine in all its branches, gave the student an opportunity of obtaining a degree where-
ever it was granted, upon the most convenient or easiest terms;” fully justifying the
complaint of the president of the Medical Society of New York, in speaking of the
medical colleges to the effect that, “ The present necessary laxity in admission, and in
ﬁnal examinations, fairly overwhelms the land with physicians. Many of them are only
so by title.”
This is but describing a state of things that, in a certain degree, existed in our own
country at no pre-historic time, and against which great efforts had to be made before it
was brought within control, and practically to an end. Its bearing upon our subject is
important, in so far only as it no doubt inﬂuenced the institution and constitution of
dental colleges in America, created in 1840, and afterwards. The distinguished president
of Harvard University, in his admirable address on dental education, divides the subjects
which constitute the ﬁtting education for the dental surgeon into those which are
common to the general and to the special surgeon, and those which are peculiar to the
latter. The general he estimates at three-fifths, and the special subjects at two-fifths,
of the whole education ; and there will be few dissentients to this division. Keeping Dr.
Eliot’s estimate in view, but that the medical degree was often given and taken on such
easy terms, it would, from our stand-point, have been difficult to understand how it was
that so many dental colleges undertook to educate their students in the principles of
medicine and surgery, necessary to the dentist, in the presence of schools devoted to
these subjects, furnished with all the multitudinous appliances necessary to successful
teaching, and provided with teachers of experience and distinction.
The withdrawal of the dental student from association with the general, in the study
of subjects common to general and dental surgery, offers here no educational advantage,
in compensation for the injury his limitation to a special school would probably inﬂict.
The separation might tend to produce a distinction of social position, to the obvious
disadvantage of the dental practitioner, whose claim to the possession of the necessary
amount of medical or surgical knewledge might be challenged by those who studied
under more favourable circumstances, and under the guidance of eminent teachers. For,
however little professional education may be forced upon the individual, there never has
been a time when the diligent and determined student might not readily acquire a
thorough knowledge of his profession in the medical schools of America or of our own
country.
The position taken by the medical graduating schools, thirty-three in number, at the
time (1840) when the ﬁrst dental college came into existence, would inevitably inﬂuence
the organization of the latter. It is not reasonable to suppose that the dental could,
even if they would, exact a higher degree of culture than the medical colleges.
Still, even a casual study of the subject leads to the conviction that our trans-
DISEASES OF THE TEETH. 505
atlantic brothers were, and are yet, strongly and rightly impressed with the absolute
need of a thorough special training, and although not in a position to enforce its
acceptance, yet offer to the student every inducement to acquire a sound knowledge of
the special subject and the skill requisite for its practice.
The general subject appears to receive less attention, or, at all events, occupies in
the dental colleges’ prospectuses, a less prominent position. In some cases, indeed, it would
almost seem that a college faculty considered that a sufficient knowledge of the general
principles of surgery could be gained in the study of the special subjects. It may be so;
but to the English dentist who, bent upon instituting, and indeed insisting upon, a
suitable, and, at the same time, the highest attainable education for his successors, the
order of things described seemed like putting the cart before the horse, and offered an
example which should be followed only after a very careful consideration of all the
attendant circumstances. It was felt in this country that the prevailing medical
education was, in the matter of degree, not in excess of what should be required of the
dentist; but that while it fell short to the extent of ,two-ﬁfths of the whole in strictly
dental knowledge, it exceeds by two-ﬁfths in certain branches of medical knowledge, the
amount which could reasonably be asked of the well-educated dental practitioner. This
conviction was fully expressed in a memorial address to the Royal College of Surgeons of
England in the following terms :——“ The memorialists do not suggest an education and
examination inferior to that required of the medical practitioner, but propose a certain
difference in kind only, not a difference in degree—an education and examination
specially adapted to the requirements of the dental surgeon, as distinguished from that
fitted for the general surgeon.” The value of the foregoing paragraph has not been
fully or rightly estimated, either here or elsewhere. Equality of education, professional
or otherwise, does not necessitate identity of knowledge. A parson, a lawyer, and a doctor,
may be equally well educated. The degree of education may be the same in all; but
some of the subjects embraced in each profession will be different. So it may be with
the dentist and the doctor; the degree of culture may be equal, but the subjects of study
will be in part different. It has been strongly urged that dental should come as supple-
mental to medical knowledge—that the practitioner should be a doctor ﬁrst and a
dentist afterwards. This opinion might perhaps be sustained if the position were
reversed—a dentist ﬁrst and a doctor afterwards, provided all or even the majority of
students were suﬂiciently rich in money and time to extend the educational period from
four up to six years here, or from three to four and a half in America, a condition of
things which obtains neither in Great Britain, or, according to Dr. Eliot, in the United
States. _‘
We allot four years to the study of medicine, and the medical student has not an
hour to spare for any other subject; hence it becomes needful to determine what
subjects in the medical curriculum can be lessened in extent or wholly omitted, so as to
give time within the same four years for the effective study of dental surgery as a
science and a practice.
This problem has not, perhaps, been wholly solved; but as the last organizers of a
complete scheme of compulsory dental education, it is hoped we may claim to have pro~
vided the most perfect curriculum hitherto brought into a nation's use. The details of
this were determined by a committee of the Medical Council, consisting of the represen-
tatives of the several medical authorities which, under the Dentists’ Act, grant dental
qualiﬁcations.
The twenty years’ experience of the College of Surgeons of England being placed at
their disposal, the Committee reported in favour of, and the Council adopted without
material variation, the curriculum originated by the aforesaid College. The subjects
therein embraced will be found appended in a tabulated form.
506 DISEASES OF THE TEETH.
The unconditional entrance upon an attested preliminary education, before a medical
or a dental student is allowed to commence his professional studies, constitutes a feature
of great importance in the» existing regulations, inasmuch as it ensures to him an
amount of knowledge, and of mental training, which renders him able to understand
without diﬂieulty the language of science, and to follow with comparative ease the
methods of scientiﬁc instruction and investigation.
Before this great educational step was taken, pupils not uncommonly entered upon
their professional studies so poorly informed, that much time was lost in attendance upon
lectures which they very imperfectly understood, and consequently to them the ﬁrst
course served the purpose of general instruction, rather than of imparting available
medical knowledge, and thus only of preparing them to take advantage of the second
course of lectures upon the same subject.
Latterly, much has been said against the vast number of lectures students have been
required to attend, and especially against the mere repetition of courses. The objection
is, no doubt, valid, now that preliminary education is enforced, and the students thereby
enabled to learn from one as much as they formerly did from two courses of the same
lectures.
There may be difference of practice, but there can be no difference of opinion, as to
the advantage to the student of an attested preliminary education. Before entering upon
the consideration of the instruction common to a medical and dental education, I will
quote a few sentences from Dr. J. M. Purser’s “ Address on the Study of Physiology,”
and ask you to read therein Dental Surgery for Medicine.* 1
“ I have said your business here is to learn Medicine, and you learn the other subjects
only as stepping-stones to this. You do not come here to be made anatomists, or
chemists, or physiologists. If you want to be an anatomist, you must give your life to it ;
and so of the other sciences. But you learn those parts of these sciences which are
essential in order that you may take the next step safely; so much anatomy, physics,
and chemistry, as are essential to physiology; and so much physiology as is essential for ‘
medicine, of which you should know all that is known.”
I will venture also to bring to your notice the following relevant paragraphs from the
address of Dr. Michael Foster, in which he contends that topographical anatomy, which
has hitherto been studied as in some part a mental training, should now give way, to a
certain extent, in favour of a more complete knowledge of physiologyrf
“ I think I am not overstating the case when I say that, in the two years (or less than
two years) which the medical student devotes to studies other than clinical, 60 or 70 per
cent. of his time—in some cases even more—is spent on the study of topographical
anatomy. That study may be regarded in two lights—as a discipline, and as practical
useful knowledge. The late Dr. Parkes, in a remarkable introductory address which he
delivered at University College, London, many years ago, insisted most strongly that its
value as a discipline was far higher and more precious than its direct utility; and I
imagine that the more one reﬂects on the matter, the more clearly this will appear. The
details of topographical anatomy have this peculiar feature, that, though they can only be
learnt with infinite pains and labour, unlike other things hard to learn, they vanish and ﬂee
away with the greatest ease. I would conﬁdently appeal to my audience of practical men,
how much of the huge mass of minute facts, which in their youth they gathered with so
much toil, remained fresh in their minds two years after they passed the portals of the
College ; and how much now remains to them beyond a general view of the parts of the
human frame, and a somewhat more special knowledge of particular regions, their acquaint-

* British Medical Journal, November 13, 1880. 'l‘ 16%., August 21, 1880. ~
DISEASES OF THE TEETH. 507
ance with which has been maintained with more or less frequent operations. I would
conﬁdently ask them what is the ratio, in terms of money or any other value, which the
time spent in those early anatomical struggles—say over the details of the forearm—bears
to the amount of that knowledge remaining after twenty, or ten, or even ﬁve years of active
practice, or to the actual use to which that knowledge has been put.
“ No, it is as a discipline, and not for its practical utility, that anatomy has been so use-»
ful; and this, indeed, may frequently be recognized in the questions set at examinations.
When the candidate is expected to describe, within the error of a few millimetres, the
structures traversed by a bayonet thrust obliquely through the neck, or is invited to re-
produce written photographs, no less exact, of the parts which, from skin to skin, underlie
a triangle or quadrangle drawn in ink on the front or back of the thigh, it is clear that
the examiner has in view, not the needs of practical life, but an easy means of testing the
proﬁciency of the student in mnemonic gymnastics. Of the value of anatomy as a discipline
there can be no doubt. In past years it has served as the chief culture of the medical
student—as the chief means by which the rough materials coming up to our great medical
schools were trained to habits of accuracy, of exactness, of patient careful observation;
and their memories strengthened by exercise for the subsequent strain which would have
to be put upon them by more strictly professional learning. In this aspect the very
sterility of the subject was a virtue. The mere fact that the separate details seemed to
hang loosely, isolated in mental space, held together by no theory, by no ideas, inasmuch
as it made the learning a harder task, increased its disciplinary value. Most wisely did.
the leaders of our profession insist that no trouble or expense should be spared to afford
the neophyte this preparatory scientiﬁc training; and that, as far as examinations and the
like can go, no pains should be spared to compel him to avail himself of the opportunities
offered. Indeed, viewed as a branch of education, the machinery of anatomical instruc-
tion has for many years past not been equalled by any.”
Dr. Burdon Sanderson, in his introductory lecture, saysﬁ'r “The precious years
which immediately precede a man’s entry on professional duty, are far too valuable to be
wasted in learning anything he does not intend to retain.” If we keep in mind the lately
expressed and published opinions of these distinguished teachers, we shall be qualiﬁed to
form a just estimate of the current dental curriculum, regarded as a training in the prin—
ciples of medicine, and of its relations to the current medical curriculum.
Without substantial differences there are some slight variations in the divisions, and
even in the designations, of the lectures recognized by the several surgical colleges.
On this account it will be convenient, in making a comparison, to take the respective
courses of study of the English College; and the more so, as its dental curriculum has
been in successful operation for the best part of twenty years. If, then, we refer
to the tabulated statement in the Appendix, it will be seen that the dental student is
required to attend one winter course of six months on anatomy, in a recognized
medical school, and a second like course, or, in lieu thereof, a course on the head and
neck. He is required to have dissected for nine months—in other words, during a
winter and a summer session. The medical student, on the other hand, must attend,
with no alternative, two winter sessions of anatomy, and dissect during a like time—or
twelve months, In fact, the dental student is relieved of part of one course of lectures
and of three months’ dissections. But if any credit is to be given to the opinions
I have quoted, enough surely remains even for the education in anatomy of the medical,
and certainly for the dental, student.
We know quite well that the knowledge of a subject got up merely for the purpose

* British M edical Journal, October 9, 1880.
508 DISEASES or THE TEETH.
of a pass will not be retained; and who will contend that a minute knowledge of the
anatomy of the foot will be of suﬂicient practical worth to the dentist to ensure its
retention in his memory? and if not to be retained, then, precious time, Dr. Burden
Sanderson says, should not be wasted in its acquisition. That which is true of the
foot is true, also, of the minute topographical anatomy of many other parts of the body,
with the treatment of which, in disease, the dental surgeon is not directly or, indeed,
indirectly, concerned. ' ,
A winter six months’ course of lectures on physiology is required alike of each, but
the dental student is excused the thirty lectures, or meetings of the class, on practical
physiology compulsory on the medical student. But the former will do well to decline
this exemption: for a full knowledge of physiology is equally required for the intelli-
gent practice of any and each branch of surgery.
It is of all subjects the most interesting, and time cannot be misspent by any
manner of student in its study. Neither need we fear that the knowledge of
physiology will be lost either to ourselves or to those who may seek our services. '
The attendance upon one six months’ course of lectures on surgery during one winter
session is required in each curriculum, but the attendance upon a six months’ course of
practical surgery, that is, of handaging, the application of splints, &c., is not required of
the dental student. A course of lectures on chemistry, and a three months’ course upon
practical chemistry, are required in each curriculum, together with a course upon materia
medica and a six months’ course on the practice of medicine.
The lectures upon forensic medicine, midwifery, pathology, practical pharmacy, and
vaccination are, in the dental curriculum, replaced by other subjects. So much for the atten-
dance at a medical school. We now come to the practice of a general hospital. The medical
student attends the surgical practice three winter and two summer sessions, while the
dental student attends two winter sessions. The former is required to attend clinical
lectures on surgery during two winter and two summer sessions, but two winter courses
only are required of the latter. And here the pupilage of the dental student at a medical
school and general hospital ends ; for he is not required to attend the six months’
dressership, the post-mortem demonstrations, the practice of medicine and clinical medi-
cine of the medical curriculum. But counting all omissions in attendance, can it be said
with any show of truth that the dental student has not had ample opportunities—oppor-
tunities which within living memory were considered suﬂieient for the general surgeon
-—-of gaining a sound knowledge of the principles and practice of surgery i’ and if in the
individual case that knowledge has not been acquired, it will be for the surgical section
of the Board of Examiners to refuse the qualiﬁcation of which they, with the dental
section, are the constituted guardians in the interest of the public.
The all-important special subjects comprised in the dental curriculum now claim
our attention.
In these, the medical student takes no part, while it is in ,the exercise of them under
the direction of his general medical knowledge that the dentist takes and holds his place
in society.
The conditions imposed are that he shall, subsequent to his having passed the pre-
liminary examination in general knowledge, have devoted four years to the acquirement
of professional knowledge, have been engaged during a term of three years in the ac-
quirement of a practical knowledge of mechanical dentistry under a competent instructor,
have attended and taken part in the practice of a dental hospital, or the dental depart-
ment of a general hospital, during a period of two years; have attended two courses or
twenty-four lectures on dental surgery; a like number on dental physiology, human and
comparative; one course on mechanical dentistry; and one course on metallurgy.
These, then, are the subjects and conditions which take the place of those remitted
DISEASES OF THE TEETH. 5 09
from the medical curriculum, and who can justly say they do not impose a tax
equal to the one remitted upon the intelligence, the industry, and the time of the student P
It may, indeed, be contended that even a greater load is substituted for a lesser.
For it is the opinion of those engaged in instruction, and those recently instructed, that
nothing can be remitted from the special division of the dental curriculum. The hospital
attendance must be exacted almost day by day in order to gain adequate manipulative
skill, without which the practitioner would be as the musician who cannot play, the
artist who cannot draw, the sculptor who cannot use the modelling tool or the chisel,
or the dental critic who should be, but is not, able to equal the work he condemns. It
is one thing to know the scientiﬁc principles of an art, but it is quite another to carry
them into effect. This requires an amount of skill of hand which can be attained only
by long and careful practice under competent teachers. The ﬁngers must become uncon-
sciously obedient to the will; they must follow it automatically as the ﬁngers of the skilled
pianofortist execute the mental reading of the work he is playing, or as the hand of the
sculptor produces the form the mind has conceived. Short of this unbidden obedience of
hand, the performer would be but an amateur, and his professional life one long apology-—
a life of words in the stead of work.
It will be admitted by all that skill of hand can be attained only by long
practice, and few will contend that one time is as good as another for the training.
Mr. Fawcett, has told us that the blind may, in their youth, he taught a bread-winning
trade, but adults who lose their sight cannot gain sufficient skill to secure indepen-
dence. We know that successful musicians and artists commence their studies while
young, and give promise of power before they attain to manhood. If we turn to the
artisan class, it will be found that he who fails to acquire skill of hand during his
apprenticeship seldom attains excellence afterwards. There is no reasonable ground for
doubt that the young hand develops anatomically in the direction of its exercise, and
acquires thereby a power in that exercise to which the adult hand seldom attains.
These facts have an important bearing upon the question of the time at which the dental
student should proceed with his practical education; for the skill needed by the dentist
in the beneﬁcial exercise of his calling is inferior to none other.
The results of professional examination fully establish the fact that the medical and
dental curricula cannot be fulﬁlled honestly in the same four years. Yet it has been urged
that the entrance upon the special division of the dental curriculum should be delayed
until the surgical education has been completed, thus putting oil’ the manual training to
a period when the attainment of excellence is diﬂ‘icult, and of the highest degree of
excellence perhaps impossible. To devote the days of our youth to the acquisition of
knowledge we do not intend to exercise, to the exclusion of knowledge by the exercise
of which we propose to gain our bread, is, I contend, a very grave error, and the graver
as the remitted portions of the medical curriculum can, without disadvantage, be taken
up after the dental education has been completed.
My strong advocacy of the special must not however be interpreted as indifference
to medical qualiﬁcations. I would give every encouragement to the attainment by
students of the latter, not however as a substitute for, but as a supplement to, the dental
degree. Educationally, the relations of the membership to the dental licentiateship may
be regarded much in the same light as are regarded the relations of the fellowship to the
membership. This view of the position of the two qualiﬁcations will, and indeed does, take
effect in certain appointments. In many of our hospitals, although the membership of
the College of Surgeons is a full qualiﬁcation for practice, the governing bodies require
that the surgical oiﬁcers shall be fellows of their College. And when the fellowship of his
college is required of a candidate—provided the fellowship betokens a higher degree of
surgical knowledge than the membership—it may justly be required of the dental
510 DISEASES OF TIIE TEETH.
candidate for office that he shall possess the membership in addition to the dental license
of his college.
Upon the question of examinations and of examiners I need say but little. The former,
being conducted by the same bodies, will follow in their character the lead of medical
examinations, and it is provided in the Dentists Act that should the much talked-of
conjoint scheme comeinto operation in medical, it shall do so in dental examinations.
Parliament has ordered that the examining boards shall consist of surgeons and dentists
in equal numbers. The examiners are the guardians in the public interest against incom-
petence, and should, as a matter of course, be independent of the pecuniary success of the
schools, and collectively irresponsible for the professional instruction of the individuals
they are called upon to examine.
In this connection the profession may be congratulated upon the recent determina-
tion of the Medical Council to enter in the Dentists Register surgical qualiﬁcations as
additional to dental qualiﬁcations, on the ground that they indicate a further pursuit of the
science of surgery than the licentiateship implies. It may be said that this step should
have been taken at the onset; but those who have practical experience in bringing an Act
into full operation know quite well that to succeed requires the free exercise of patience ,
perseverance, and last, but not least, of forbearance.
In reviewing the task imposed on the student, it may be asked whether I have not
overstated the amount of special training needed to ensure the acquisition of the neces-
sary manipulative power? I should answer no, with all the emphasis of which I am
capable. For I contend that a high degree of skill of hand is absolutely necessary to
professional competence—that competence is necessary to self-respect—and that self-
respect is necessary to that professional rectitude without which personal comfort in
practice would be imperilled, and professional status would be but a shallow ﬁction.
Furthermore, that, with the existing opportunities, a high degree of skill can be
gained by perseverance and the due expenditure of time in pupilage, and that it is the
bounden duty of the teacher to press for, and the examiner to demand, its possession.
Sutﬁcient reasons for the study and the practice of dental surgery as a speciality are
recorded in the ﬁrst pages of this address, to which a statement of the obligations and
the scope of specialism will form an appropriate ending. In no other way can I more
perfectly fulﬁl this latter purpose than by borrowing the very words used in his pre-
sidential address by our great master of thought and of speech—Sir James Paget—who
therein says :—
“ Many of us must, for practical life, have a fair acquaintance with many parts of our
science, but none can hold it all; and for complete knowledge, or for research, or for
safely thinking out beyond what is known, no one can hope for success unless by limiting
himself within the few divisions of the science for which, by nature or by education, he is
best ﬁtted. Thus our division into sections is only an instance of that division of labour
which in every prosperous nation we see in every ﬁeld of active life, and which is always
justiﬁed by more work better done.
“ Moreover, it cannot be said that in any of our sections there is not enough for a
full strong mind to do. If any one will doubt this let him try his own strength in the
discussions of several of them.
“In truth, the fault of specialism is not in narrowness, but in the shallowness and the
belief in self-sufficiency with which it is apt to be associated. If the ﬁeld of any speciality
in science be narrow it can be dug deeply. In science, as in mining, a very narrow
shaft, if only it be carried deep enough, may reach the richest stores of wealth, and ﬁnd
use for all the appliances of scientiﬁc art. Not in medicine alone, but in every depart-
ment of knowledge, some of the grandest results of research and of learning, broad and
I I 5 ‘Hanna; aim; to sasvasici
DENTAL CURRICULUM.


Grammar. Mn'mcan SUBJECTS To an ATTENDED u: a RECOGNIZED Scnoon AND CERTIFICATES :ro BE
HosrImL. PRODUCED
c: m . . I; , vat’
d g m a as 63 6 Q74; 0 a g G) . ivy-was - -m P . p555 os man “a” E
Lmm 5mg, >- ‘iig E g s 3 55h h . o 8 H h dams; g _ g as _ 2 g g XAMINL'IIONS SINK
Bonus. g “az‘gjgg E %5 g’ g g Egg)?‘ ,5 g; g] g: $5152 CURRICULO.
‘a h ""‘§$ 3 '51" M2 "‘ g 08 dNQ .2 and .HUQ‘B'U Clo-sq
g gtgcqg m kg 8 F1 '3 u-l do 'ZS'E W13‘; QM >903 ‘QTY-*3
<1 4-10'383 .2 =8 g 5 5; 3 53:4 =oo°g ~50 ,ggn-m e55
gsge‘g Q m5 o *5 0 £853.51 n we}: is»:
4155:; B s a see 6 05-" Q "i r.
, 08
Royal College Not less I course 9th I course 1 course I cgurse 1 course 1 course’ I course lglotless 21 years 4 years 1 edggizrllggiaggsDgvlﬁos 1Zigrere in practice or who commenced their
of Surgeons than I men s of 6 etc o 6 o 6 an 1
of England. Winter months months months months year Before Sept. 8, 1859,
Session and who at the time of the passing of the Dentists Act were
practising in Englang, or; admitted to examination, on the
, production of certain e_rti cates.
Royal College Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Cﬂndldates who were 111 Frame6
of Surgeons _ Before August 1878,
of Edinburgh. and apprentices who commenced their education as Dentists
d m d t Before Augillst 18175, f t C
are a in e o examination on t is pro when 0 oer ain er-
Fwmy of Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Candidates who were In practice Etiﬁcates-
Physicians Before August 1878,
and Surgeons and apprentices who commenced their education as Dentists
of Glasgow a M a t Beforte August 1875, f t C
are a mi 0 o examine ion on t_ e promotion 0 cer ain er-
Royal College Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Candidates are admitted to examination [tiﬁcates.
of Bar eons Up to August 1881,
in Ire and. on the production of certain Certiﬁcates, provided they have
been in practice ﬁve years before the date of this applicationcl'
SPECIAL SUnJiio'rs.
” “ ‘H i I ‘d ' 1- N .B.-—-Evei successful Candidate ‘actions to
>2 . q) '5 the i 9 In
ﬁg‘??? ggﬁgd-E “5323 amid; receiving the Lg‘ense, shall declare that he will not
3573 ﬁg Dental Me ha i 1 $52? $3 g 33.35 5 gig advertise, or pursue any other unbecoming _mode of
LICENSING BODIES‘ 4g“ :5 S ‘ Metallurgy. D00 mute“ 3h gﬂqiatii 8 g Dace-:55 attractmg business, so long as he holds the License an
'35 5 g urgeiy n s ry. a 5W3 0E 55 on? g 2. 2'5)» Dentistry of the College.
‘isms iii-‘2583 Etta-titers?
Q “3 Q (‘15> 0;‘ aw
Royal College of Surgeons of England Not less than Not less than Notless than i2 lec- Not less than 2 years 3 years
24 lectures 20 lectures tui'es, unless spe- 12 Lectures or
cially included in Demonstra-
Pi'actical Clie- tions.
_ mistry
Royal College of Surgeons of Edinburgh Ditto Ditto Ditto Ditto Ditto Ditto
Faculty of Physicians and Surgeons of
Glasgow . . . . . Ditto Ditto Ditto Ditio Ditto Ditto
Royal College of Surgeons in Ireland Ditto Ditto Ditto Ditto Ditto Ditto


51 2 DISEASES OF THE TEETH.
deep, are to be found in monographs on subjects that to the common mind seemed small
and trivial.”
Such, then, are the lines upon which the study of dental surgery have been drawn, so
drawn to secure adequate knowledge and skill in the practitioners, and with the view, there-
fore, to a certain difference in kind, but to equality in degree, between the compulsory
education of the medical and of the dental practitioner.
If in this imperfect sketch I have entered at certain points too far into details, or
occupied too much time in their description, extenuation for my prolixity may he
pleaded on the score of the high degree of satisfaction, not to say pardonable pride,
which the surviving members of my generation feel in seeing an educational scheme, in
the origination of which they took part, completed and rendered national, and thereby a.
calling, heretofore of undeﬁned position, elevated by the Legislature to the rank of a
learned professionﬁt _
The following table, drawn up by Mr. S. J. Hutchinson, shows the extent to which
the Dental follows in the line of the Medical course of study.
A COMPARATIVE STATEMENT of the respective Courses of Study required by the Royal College
of Surgeons of England of Candidates for the lllembershlp and for the Ltcent'lateshtp
in Dental Surgery.
Curriculum for the Membership. Curriculum for the Ltcentiateship in Dental
1. An examination in Arts. SW19”!!-
2. Being 21 years of age. 1- The Same.
3. Having been engaged in acquiring pro- 2' The Same-
fessional knowledge during four 3- The Same- _
years. 4. The same or second special course on
4. Anatomy Lectures : 2 Winter sessions. the head and neck.
5. Dissections: 2 Winter sessions : 12 5- 9 months-
months. 6. The same.
6. Physiology: 1 Winter session. 7- (Say) Metallurgy, 1 Course-
7. Practical Physiology. 8. The same.
8. Surgical Lectures : 1 Winter session. 9‘ See 18~ _ _
9. Practical Surgery : 6 months. 10- The Same (Imperative).
10. 1 course of Chemistry (optional). 11- The Same-
11. 1 course of Materia Medica.
12. 1 course of Medicine.
13. 1 course of Forensic Medicine.
14. 1 course of Midwifery.
15. 1 course of Pathology.
16. Practical Pharmacy and Vaccination:
6 cases.
17. Practical Chemistry.
18. Practice of Surgery: 3 winters and 2
summers.
19. Examination of patients : 3 months.
20. Clinical Lectures on Surgery : 2 winter
and 2 summer courses.
21. Dressership: 6 months.
22. Post-,mortem Demonstrations.
23. Practice of Medicine ; 1 winter 1
summer. Clinical Medicine.

12. The same.
13. 2 courses Dental Anatomy and Phy-
14. siology.
15. J 2 courses Dental Surgery and Patho-
16. logy.
17. The same.
18. 2 winters. And 2 years’ practice at
a Dental hospital.
19. (At a Dental hospital.)
20. 2 winter courses.
21. 2 courses of Lectures on
22. Dental Mechanics.
23. 3 years Practical Mechanical Den-
tistry.
The subjects common to the two courses of study must in each case be attended at a
recognized General Hospital and Medical School, and the subjects special to Dental

*1‘ Dr. Butler (Cleveland, USA.) and Professor Sheppard (Harvard University) ex-
pressed their unconditional approval of the British Dental Curriculum, and of the
opinions advanced in the paper. Dr. Hollander described the state of dental education in
Germany ; and Dr. Taft (U.S.A.), gave a short account of the early proceedings of the
American Dental Colleges. Report of discussion. The Journal of the British Dental
Association, October 15, 1881.
DISEASES or THE TEETH. 513
Surgery at a recognized Dental Hospital and School, or the recognised Dental depar t~
ments of a General Hospital and School.
Four years is the time allotted tr study for the Membership, and for the Dental
Licentiateship, and six years will not be more than sutﬁcient for the acquirement of the
two qualiﬁcations.
Re‘sz‘omz‘z'on 0f Contour Me only way 10 keep the Margins 0f
Enamel of 1/26 Pmxz'maz‘e Sui/fares 0f the T eat/z per/72a »
nem‘ly Separate and PVéZ/éiil‘ RecuW/erzce 0f Decay.
Dr. 1\’IARSHALL H.WEBB, New York.
For full restoration of contour it is necessary to gain space to prepare the cavity, pack
the gold, and ﬁnish the ﬁlling. This must be done either by wedging at the time of
performing the operation, or by previously placing or pressing wood, linen, tape, or
cotton between the teeth. When the necessary space has been made in this manner,
particularly between the incisor and cuspid teeth, white gutta-percha should be placed
in the cavity or cavities, and in the space, to remain a day or two, or till the irritation
incited by the wedging has passed away. Rubber ought not to be used for pressing
teeth apart, for the reason that it excites far more irritation than other substances. It
is otten best to place a wedge of orange or box-wood between the teeth, even after
having pressed them apart, not only to gain more space, but to arrest their tendency to
approach each other, and to steady the organs for the performance of the operation,
particularly if the irritation from the slow wedging has not passed away, so as to admit
of the insertion of all, or almost all, the gold by the aid of the mallet.
When the cavity extends almost to the margin of the cementum, the gold should be
built into and from the starting-point, along the cervical wall and grooves, and to the
part where the convexity of the ﬁlling must be gradually increased, and when this much
of the gold has been inserted with the mallet, and smoothly ﬁnished with ﬁne separating
or other ﬁles, the wedge of hard wood ought to be placed between such gold and the
tooth adjoining, and sufficient space thus secured to so complete the ﬁlling that there
shall be no space between the teeth, excepting at and near the necks.
A. cavity within the proximate wall of a bicuspid or molar tooth should be opened
into from the masticating surface (excepting in rare instances), because even when but
little tissue appears to be decalciﬁed, this surface would be almost reached upon the
perfect removal of the disintegrated tissue, and the plate of enamel be liable to fracture
if hard substances were to come in contact with it during mastication of food. By
cutting away the enamel between the cavity and masticating surface, a clearer view is
thus had, and the entire operation can be performed in a satisfactory manner, with
certainty of good result. The sulci and ﬁssures are usually imperfect, and they should
be prepared and ﬁlled in connection with, and at the time of, the performance of the
operation within the proximate wall. The margins ought to be evenly and smoothly
ﬁnished with ﬁne, sharp burs and chisels or ﬁles, and emery-cloth carefully used (the
edges of enamel should be slightly bevelled in some cases, but never rounded), and a
groove should be cut in the dentine along each wall of the cavity. This groove should
be about a sixty-fourth of an inch deep, and must be made in the dentine just within
and near the line of both the buccal and palatal or lingual portions of enamel, and ought
to extend from the masticating surface to the cervical wall. A groove should not be
out along the cervical wall (excepting in some cavities in the incisor teeth), because of
PART III. 1, I,
5I4 DISEASES OF THE TEETH.
there not being suﬁicient tissue at that part as to make it safe to remove any of it for
this purpose. In the preparation of a cavity between bicuspids and molars, enough
enamel toward both the buccal and palatal or lingual walls must be cut away to free the
edges, thus enabling the operator to so restore the contour of the parts, and ﬁnish the
ﬁllings, as to keep the whole margin from contact with the tooth adjoining. This is the
only way to permanently separate or keep apart the margins of enamel, and prevent
recurrence of decay.
When a cavity has been prepared as described, a starting-point should be made in
some part of the cervical wall, usually toward the palatal or lingual surface, and in that
portion of the dentine which shall not endanger the pulp. This point, in which to start
the ﬁlling, should only be deep enough to retain the small pieces of gold ﬁrst introduced
while others are being built upon them, and the ﬁlling is carried along to the groove in
each wall of the cavity. The gold ought to be built against every portion of the dentine,
packed as nearly perfect as possible along the enamel, and a little beyond its margins,
and carried fully to the line that originally deﬁned the contour of the part. To thus
perform an operation, it is necessary to build that part of the gold nearest the buccal
and masticating surfaces against the proximate surface of the adjoining tooth. By per-
forming this operation with the electromagnetic mallet, the passing of the packing-
instrument from off the edge against or over which the gold is being placed, may not
only be avoided, but the surplus material can be so trimmed away during the performance
of the operation, that comparatively little trimming is afterwards necessary. Cohesive
gold foil (about Nos. 30 and 60) for large, and foil, folded to No. 16, and 20 or 2%, for
small ﬁllings, and which is not touched with the ﬁngers, ought to be used in the perform-
ance of all operations, especially in the cases just referred to, and those where frail edges
of enamel are to be supported and protected 3 and the gold should be made compact by
careful malleting—preferably by the aid of a properly-adjusted electro-magnetic mallet.
All gold should be cohesive, particularly where a mallet is used, so that each piece may
remain just where it is placed, and also that the ﬁlling may always be one and insepa-
rable. I/Vhen foil has been so built in place that the substitution for lost tissue is
complete, a thin broad saw, or a ﬁne suitable ﬁle, should be used to trim down the
surplus material to the prepared edge of enamel, and to aid in shaping the ﬁlling like the
original contour of the part; after which, narrow strips of emery-cloth or paper out a
line or an eighth-of-an-inch wide, should be so manipulated as to properly ﬁnish the
surface of the gold. When this has been done, and the rubber-dam is removed, the ﬁnish-
ing should he completed by the use of ﬁne pumice and silex on linen tape. The gold at
the masticating surface should be trimmed down with ﬁne burs, and made concave, or
ﬁnished to represent the original contour or the outline of the part operated upon. The
gold should be so placed in the cavity as to be ﬂush with the prepared margins of the
enamel, and made concave when such concavity is indicated. Restoration of contour
prevents contact of the margins of enamel, and this prevention is necessary, especially
when the tissues of the organ operated upon are not fully calciﬁed. The contour of the
tissue that is missing ought always to be so restored with gold that the enamel of one
organ may be free from contact with that of the next in the arch, and that a part of the
gold in one may be in actual contact with a small part of the normal tissue of, or with a
ﬁlling (if one has been inserted) in, the adjoining teeth. In such cases solution of lime
salt does not take place, because of the freedom from proximity, and the cleansing (by
the saliva, or ﬂuids taken into the month, if by nothing else) of the margins of enamel
against which the gold has been placed.
When operations have been so performed as to entirely prevent ﬂuids or semi-solids
from entering between gold and enamel, and all discoloration has been removed from the
surface of remaining tissue, the gold-tint may be seen through the light walls or edges
DISEASES OF THE TEETH. SI 5
of the translucent enamel soon after the removal of the rubber-dam and completion of ‘
the operation. If an opaque or dark line or spot be visible at or near the parts where
gold ought to be, in contact with the dentine or enamel, the operation has been imper-
fectly performed, and if not re-performed, as it ought to be, chemical action may soon
follow, and the entire ﬁlling prove a failure.
Solution commences at, and often near, the parts of enamel that are in contact, and
soon takes place along the surfaces that touch each other, and extends to the dentine
where decay makes rapid progress. In those cases where the system has been maintained
in normal condition during childhood and youth, and the tissues are ﬁrst-class, disinte-
gration takes place slowly, and does not usually become extensive, so that where enamel
is dissolved superﬁcially, it can be removed, and, after a ﬁnely ﬁnished surface is made,
decay will not be likely to recur. In no case should a permanent space he made or left
between the teeth, however, for even in such cases as those just referred to, food may
so wedge against the gum as to bring about its recession, and exposure of the necks of
the teeth, and ﬁnally lead to the formation of a cavity of decay at that part. Per-
manent separations ought not to be made, for the reasons that they interfere with masti-
cation, annoy the patient, and, with few exceptions, do not prevent disintegration upon
or about the surfaces that have been cut. The teeth again come in contact almost invari-
ably excepting where antagonists prevent them ; food, wedging between them, undergoes
fermentation, and solution and decay takes place, and that, too, in a part of the tooth
where it is difficult to perform a ﬁrst-class operation. This may not take place, how-
ever, till long-continued pressure of food paralyses the nerves in the papillae throughout
the gum tissue pressed upon, and breaks the nutrient circuit or obstructs the movement
of the molecules of living matter through that ﬁne reticulatcd line between the gum and
the brain, and the patient is therefore not notiﬁed of the presence of such obstruc-
tion to the neural and vascular circulation. This condition of the gum tissue as inevi-
tably leads to the return of the elements to their embryonal state, as does interference
with the nutrition of any other part of the system.
In those cases where tonicity is at normal standard, the gum is so close to the necks
of the teeth as to prevent the lodgment of foreign matter beneath the margins; not
only this, but the tissue ﬁlls the space between the teeth almost entirely, and protects
the parts it covers. The gum should therefore be protected by full restoration of the
contour of the enamel that is missing, and the gold ought'to be ﬁnely ﬁnished at all
points, that there may be no obstruction to the gum tissue again closing around the neck
of the tooth operated upon. In this manner the margin of enamel at or near the neck
of the tooth is protected by the gum, and, if the whole operation has been properly
performed and ﬁnished, recurrence of decay at that part is prevented. If decay does
not extend to or beneath the margin of the gum, both the enamel and dentine of the
proximate, as well as the buccal surfaces of the teeth, especially those in which calciﬁca-
tion of enamel is imperfect, ought to be cutaway with ﬁne burs to about the thirty-
second or nearly a sixteenth of an inch above the part where the gum closes around the
tooth, so that when the operation is completed, this part may be protected from particles
of foreign substances. When the necks of the teeth are kept separate, as in Nature, and
the gum is in normal condition, it protects the portion of enamel, and covers the well-
inserted and ﬁnely-ﬁnished gold, which may be beneath its margins, so well, that disinte-
gration and even discoloration of the surface is prevented. In after years, however, there
may be lack of nutrition to the gum, or the circulation may not be full nor free in the
capillaries of the part, and the tissues may not therefore close around the necks oi the teeth
so tightly, but become less ﬁrm in texture or commence to return to their embryonal state.
It, then, there be such condition as to bring about decalciﬁcation of the enamel, decided
L L 2
51 6 DISEASES or THE TEETH.
decay may take place above or about the cervical margin of the ﬁlling. Such cases
are rare, however, because deﬁcient nutrient action usually takes place at an age when
there is least derangement of the saliva, and when deposit of caleiﬁc matter is likely to
take place beneath the lax margin of the gum. Though there may then be no recurrence
of decay, peri-cementitis sometimes follows, and the deposition of such calciﬁc matter
prevents the rebuilding of the gum-tissue, and keeps irritated or breaks the net-like
arrangement of living matter between the epithelial and connective tissue—corpuscles.

—
Des Lz'mz'z’es de [a C uméz'lz'z‘e’ de la C m/z'e Dentaire.
Dr. E. lVIAGITOT, Paris.
La carie dentaire est, ainsi que nous le savons tous aujourd’hui, une aﬁ‘ection curable.
Mais il convient d’établir avant tout ce qu’il faut entendre ici par guérison.
Or on doit entendre par guérison: 1° La cessation complete et déﬁnitive des acci-
dents divers qui occasionnent la carie; 2° Le rétablissement de l’organe malade a ses
usages normaux, c’estua-dire, le retour de l’intégrité fonctionnelle.
C’est d’ailleurs sur ces deux termes que se pose aujourd’hui tout problème qui a .
pour objet la thérapeutique d’une lésion déﬁnie qui intéresse à la fois la substance
anatomique d’un organe et son rôle physiologique. Ils sont de tout point applicables à
la carie dentaire, laquelle consiste, comme on sait, en une destruction progressive, c’est-à-
dire, en une perte de substance accompagnée d’une série de phénomènes variables de
caractère et d’intensité, suivant les phases mêmes de cette destruction et la nature des
tissus qui sont atteints.
Or, cette maladie, qui est aussi vieille que l’humanité, puisque nos ancêtres des âges
préhistoriques en étaient déjà affecté,’6 a dû susciter, dès les origines de la science, des
tentatives thérapeutiques. C’cst ainsi que les auteurs de tous les temps et de toutes les
écoles ont proposé des moyens de guérison qui consistaient surtout dans l’emploi de
divers médicaments propres a calmer les douleurs, et quelques autres substances desti-
nées a la réparation de la perte de substance par l’obturation. Mais ces indications
étaient nécessairement bornées aux périodes initiales de la maladie, c’est-à-dire, au plus
petit nombre des cas, aux formes les plus simples enﬁn, au delà. desquelles apparaissait
invariablement le procédé radical et déﬁnitif, la suppression de l’organe malade,
l’extraction.
Aujourd’hui les tendances conservatrices de la chirurgie moderne doivent protester
contre toute pratique qui n’aurait pas pour objectif la thérapeutique rationnelle et la
restauration physiologique, reléguant l’ancienne opération de l’extraetion pour les cas
relativement très rares de complications extrêmes et atitre de procédé d’exception.
Les méthodes thérapeutiques sont d’ailleurs d'une simplicité très grande, elles sont
à la fois précises dans leur emploi et sûres dans leurs effets. Elles apparaîtront belles du
moins a tout médecin éclairé qui entrera dans cette voie. Nous n’avons pas ici a les
exposer, cela a été fait a diverses reprisesrl" Notre but aujourd’hui est d’établir, parles
chiffres d’une statistique rigoureuse, les limites même de cette eurabilité, et l’on verra à
quels résultats véritablement inespérés nous avons été conduit.
L’enquête a laquelle nous nous sommes livrés, a été faite publiquement et au grand
jour d’une clinique ouverte. C’est ainsi qu’elle a eu pour témoins et aussi pour collo-
borateurs un certain nombre de jeunes médecins qui, depuis quelques année, ont bien
voulu s’associer à notre pratique et écouter nos leçons. Nous dirons tout-a-l’heure la

* Les restes humains des temps quaternaires contiennent une notable proportion de
dents cariées.
+ Voir “Traité de la Carie Dentaire,” 8vo, Paris, 1867. Art. Carie des Dents, du
“Dictionnaire Encycl. des Sciences Médicales.” -
DISEASES OF THE TEETH. 517
part importante qui revient a quelques-uns d’entre eux, lorsque nous aurons abordé plus
directement notre sujet ; mais nous croyons devoir, au préalable, rappeler dans un court
résumé, quels sont les caractères, les formes diverses, les aspects variés que présente la
maladie au sujet de laquelle nous avons entrepris ces études statistiques.
Or, on sait que la carie dentaire consiste en une destruction progressive des tissus
durs de l’organe dentaire et que, procédant invariablement de l’extérieur à. l’intérieur de
la couronne, elle envahit et désorganisejles couches successives qu’elle rencontre en
suivant, d'une manière générale, comme trajet, une ligne verticale représentée par le
rayon de cette couronne même.
Dans cette marche qui n’est que très secondairement modiﬁée par les circonstances
accidentelles, la maladie peut se diviser en trois phases ou périodes successives, dont la
distinction est de la plus haute importance au point de vue thérapeutique, et d’un grand
intérêt à. l'égard de la statistique.
1.-Prémière périoda—Elle comprend l’altération de la couche d’émail isolément;
c’est le début de la lésion, et ce premier degré a pour limite profonde la couche superﬁ-
cielle de l’ivoire dentaire. .
Cette forme est ordinairement indolente, aussi passe-t—elle le plus souvent inaperçue,
et lorsqu’elle a été diagnostiquée par un praticien attentif, elle peut être, dans le plus
grand nombre des cas, curable sans autres moyens thérapeutiques, que la simple résection
au moyen de la lime ou l’obturation immédiate. Ces deux opérations, qui ont leurs
indications spéciales, réalisent l’uudes termes de la curabilité de la maladie, c’est—a-dire,
l’isolement sans traitement préalable nécessaire. C’est la d’ailleurs une méthode employée
empiriquement depuis très longtemps, et qui a donné toujours d’excellents résultats.
Aussi n’est-ce pas pour cette forme élémentaire, pas plus que pour les premiers degrés de
la période suivante, qu’ont été instituées et préconisées les règles de thérapeutique
rationelle. Les recherches modernes n’ont fait ici que consacrer les résultats utiles de
l’ancienne pratique.
Deuæz'ème perioda—Elle répond à. tous les degrés de carie qui occupent l’épais-
seur de l’ivoire dans l’intervalle compris entre le revêtement intérieur d’émail et la
couche qui tapisse directement la pulpe centrale.
Dès le début de cette période, apparaît la nécessité de la division des règles théra-
peutiques qui comprennent d’une part la cure des accidents douloureux par les agents
modiﬁcateurs appropriés, et d’autre part, la ﬁxation et le maintien de la guérison par
l’obturation, c’est-à-dire, l’isolement déﬁnitif et complet. Or, les accidents douloureux
varient singulièrement suivant le degré plus ou moins profond qui a atteint la destruc-
tion. Ils sont ainsi tantôt simplement provoqués, tantôt spontanés, et les agents
thérapeutiques appropriés apparticndront a la classe générale des astringents: acide
phénique, créosote, tannin, et parfois aussi, mais a dose faible, le chlorure de zinc, l’acide
arsénieux, &c.
Le but de cette thérapeutique est de provoquer une excitation ménagée des fonctions
de la pulpe, c’est-à-dire, la réparation moléculaire des couches altérées de l’ivoire par la
production dentaire secondaire. Cette méthode, basée sur l’emploi rationnel des
astringents ou des caustiques superﬁciels, précédés, dans leur application, de pansements
anesthétiques ou narcotiques, prépare en déﬁnitive les couches d’ivoire a recevoir, après
une réparation moléculaire suiﬁsante, l’obturation terminale.
Troisième période.—Elle commence avec la pénétration de la cavité centrale et la
mise à. nu de la pulpe pour se prolonger jusqu’aux dernières limites de cette cavité et
aux canaux radiculaires. Les accidents douloureux nécessitent l’emploi de bien des
agents sur lesquels nous n’avons point à. nous étendre ici, mais le but thérapeutique
essentiel est la destruction de la pulpe. Ce résultat se réalise par diverses méthodes,
518 DISEASES OF THE TEETH.
soit l’ablation directe ou la destruction par diverses manœuvres mécaniques, soit la
destruction par des agents caustiques et en particulier l’acide arsénicux. C’est a ce
dernier procédé que nous avons eu presque constamment recours dans les faits que nous
avons recueillis. Mais la thérapeutique est ici très complexe, car elle doit répondre aux
indications les plus nombreuses et les plus variées. Eu outre cette dernière période de la
carie est celle qui marque le début d’apparition des complications les plus ordinaires
comme aussi les plus graves. Tels sont les faits de cloisonnement de la cavité de la
pulpe, la périostite, &c.
Hâtons-nous de dire, cependant, que ces complications sont elles-mêmes les plus
ordinairement curables. La plus redoutable d’entre elles, la périostite elle-même,
lorsqu’elle n’apparaît pas sur une dent dont la couronne est absolument détruite, n’est
pas au-dessus des ressources thérapeutiques. Si elle est simple, subaigu‘e‘, sans retentis-
sement de voisinage, les caustiques, les émissions sanguines locales en ont facilement
raison. Aiguë et phlegmoneuse elle ne représente pas, selon nous, une contre—indication
au traitement. Chronique et localisée au sommeil elle peut encore être guérie par l’inter-
vcntion de la méthode de drainage de la carie.âÊ En cas d’insuccès de cette pratique,
il subsiste une dernière et extrême ressource dans la greffe par restitutionj” Seuls, les
cas relativement rares, où une périostite prend la forme de phlegmon diffus de la face
ou des régions voisines, relèvent formellement de l’extraction, procédé également appli--
cable aux débris sans retour possible à. un rôle physiologique quelconque, et qui-
provoquent des accidents inﬂammatoires du voisinage permanents ou répétés.
Nous venons d’indiquer ici brièvement les différentes étapes que parcourt l’aﬂ'ection
qu cu désigne sous le nom de carie dentaire, et du même Coup nous avons déterminé les
limites de curabilité de la maladie. Les études statistiques que nous allons exposer ont
été entreprises dès le début de 18711, et les résultats comprennent cette première année
entière, soit douze mois. Devant cette période, tous les cas de carie, sans exception, qui
se sont présentés à. nous au hazard de la pratique, ont été soigneusement relevés et
enregistrés dans les tableaux statistiques uniformes. Ces tableaux mentionnent toutes
les conditions multiples relatives au sexe et à. l'âge du sujet, au siège de la lésion à la
période d’altération, aux procédés thérapeutiques appliqués, à la durée du traitement, et
enﬁn a la nature et aux particularités diverses de l’obturation ﬁnale.
Enﬁn les cas considérés comme au-dessus de toute tentative de guérison possible,
ont été enregistrés dans un relevé spécial; c’est la part proportionnelle de l’extractionï
Les résultats généraux de ce travail sont les suivants :
Les cas de carie dentaire observés et traités pendant le cours de l’année 187 4 ont
dépassé le nombre de deux mille. Nous nous sommes cependant arrêté a ce chiffre aﬁn
d’éviter un fractionnement dans l’une des données fondamentales de ce problème.

* Du Drainage Chirurgical dans ses Applications à. la Thérapeutique de la Carie Den—
taire: Bulletin de Thérapeutique, 30 août, 1867.
‘le Voir les documents sur la Greffe par Restitution appliquée a la Périostite Chro-
nique du Sommet : Gazette des Ï'Iôpitauæ, 1875, p. 35 et suiv. : Bull. et Mém. de la Société de
Chirurgie, 187 9 : Comptes Rendus de Z’Acad. des Sciences, 6 Janvier, 1879. Voir aussi
David: De la Greﬁ‘e Dentaire: Thèse de Paris, 1877, et Revue de Thérapeutique, 1880.
De l’Etat Actuel de la Greffe Dentaire par Restitution appliquée à. la Cure de la
Périostite Alvéolaire Chronique du Sommet : “Comptes Rendus du Congrès de Londres,
1881, p. 445.
I Nous ne voulons point dire ici que les seules extractions pratiquées dans le cours de
l’année 1874 soient celles qui ﬁgurent dans cette statistique. Nous ne parlons ici que des
extractions effectuées pour des cas de carie dentaire, passant sous silence, bien entendu,
les ablutions pour causes de déviations, d’anomalies, cl’acciclents de dent de sagesse.
\
DISEASES OF THE TEETH. 519
Sur ce chiffre de 2,000, les guérisons ﬁgurent pour le nombre de 1,980, les extractions
sont au nombre de 20, soit une proportion de 99 pour 100 pour les guérisons, et de 1
pour 100 pour les extractions.
Tel est le premier fait essentiel, qui se dégage tout d’abord, mais il se décompose à.
son tour en un certain nombre de conditions diverses que nous devons analyser:
Ainsi à. l’égard du sexe des sujets observés, nous trouvons 1,138 femmes et 862
hommes. Nous ne saurons cependant inférer de ces chiffres une prédominance de la
carie chez la femme. Ce qu’il faut conclure d’un tel rapport, c’est qu’au point de vue
particulier de la thérapeutique, les femmes y apportent plus de souci que les hommes, et
viennent plus souvent réclamer les soins spéciaux.
L’âge des sujets observés, depuis la naissance jusqu’a soixante-dix ans, montre que
la période de plus grande fréquence des traitements entrepris est celle de 20 à. 30 ans;
vient ensuite celle de 30 à. 50 ans, puis de 12 a 20 ans, &c. Enﬁn, ou trouve une
période infantile de 0 a 6 ans, pendant laquelle 12 caries seulement de dents temporaires
ont été traitées et guéries.
Les considérations de sexe donnent des résultats très intéressants que nous devons
détailler ici, et qu’on trouvera dans le tableau d’ensemble; nous relèverons toutefois cer-
tains chiffres principaux.
Considérant la carie dentaire au point de vue de sa répartition aux deux mâchoire s
nous observons que la mâchoire supérieure est plus fréquemment aﬁ‘eetée que l’infé-
rieure, la proportion est de 1,225 caries pour la première et de ‘775 pour la seconde-
D’autre part le côté gauche est au côté droit dans un faible rapport de 992 à. 1,008.
Un autre problème se présente a l’égarl du sic’gc relatif: c'est le degré de fréqizrm
de la carie, suivant les diverses espèces de dents. Nous avons établis déjà dans un
travail antérieur, une statistique de ce genre, qui portait, sans préoccupation thérapeu—
tique quelconque sur un total de 10,000 caries.* Nos résultats actuels au sujet du.
traitement sont sensiblement conformes. Nous les reproduisons ici a titre d’éléments de
comparaison. i
STATISTIQUE DE FRÉQUENCE A L’ÉGARD DU SIÈGE


Statistique 1867. Statistique nouvelle
10,000 caries. 2,000 caries.
Nombre ProportioÏl Nombre Proportion
absolu. pour 100. absolu. pour 100.
1re molaire inférieure 1,810 18‘1 317 158
1re molaire supérieure 1,510 151 251 125
2c molaire inférieure 1,016 104 236 11-8
1“ bicuspide supérieure 910 9'1 160 8'0
2c bicuspide supérieure 810 8'1 139 7'0
Incisive latérale supérieure 715 74 191 9'7
2e molaire supérieure 690 _ 6-9 139 7.0
Incisive cent. supérieure 612 6'1 167 84
2e bicuspide inférieure 500 5'0 70 3 5
Canine supérieure 115 1'1 112 56
1‘re bicuspide inférieure 370 3'7 55 2'8
3e molaire supérieure 220 2'2 62 3.1
3° molaire inférieure 110 1'1 67 84
Canine inférieure 70 0-7 25 1-25,
Incisive cent. inférieure 30 03 2- 0'1
Incisive latérale inférieure .. _ m u _ 30 0-3 3 0-15
Total .... .. 10,000 Total .... .. 2,000
* Voir “ Traité de la. Caire Dentaire,” Paris, 1867, p. 18.
520 " DISEASES OF THE TEETH.
L’étude des périodes de la carie a donné, au point de vue de la guérison proportion-
nelle, les résultats suivants:
Guérison de la première période 22
Guérison de la deuxième période 1360
Guérison de la troisième période ’... .. 598
Extraction pour des cas de troisième période accompagnée de
complications graves 20
Total 2000
L’examen des moyens thérapeutiques appliqués fournit les données suivantes:
Dans les cas simples de première période, l’obturation immédiate sans traite-
menta étépossible 18 fois.
Les pansements simples destinés à calmer une douleur légère en à, produire
un simple écartement devant favoriser l’obturation ont été employés 412 ,,
L’emploi des astringents, tannin, acide phénique, irritants superﬁciels divers 1147 ,,
Les applications caustiques, acide arsénieux, chlorure de zinc, cautère actuel 370 ,,
La résection pratiquée au moyen de la lime ou des gouges spéciales a
l’etfet d’effacer une carie de début 25 ,,
L’amputation, qui consiste a réséquer complètement une couronne de dent
cariée, dans le but de conserver dans la mâchoire un moignon, d’ailleurs
indolent, qui sert de soutient aux parties et d’aide aux fonctions de la

bouche 8 ,,
Enﬁn l’extraction se retrouve encore ici comme ressource des cas incurables 20 ,,
Total 2,000 ,,
La durée totale du traitement, extrêmement variable, bien entendu, suivant les périodes
mêmes de la maladie, a donné un temps moyen de quinze jours. Cette durée, nulle
pour les cas d’obturations immédiates au nombre de 18, a été parfois très considérable
pour les cas de troisième période. Plusieurs semaines ont été souvent nécessaires pour
amener la guérison à. travers les complications les plus diverses. Enﬁn, les caries
moyennes réclamaient le plus souvent cinq à huit jours de thérapeutique astringente.
Les chiffres relatifs à ce point de Vue ﬁgurent encore dans la colonne des moyens théra-
peutiques.
Voici maintenant les chiffres, qui concernent les procédés d’obturation, c’est-a-dire
l’opération qui termine le traitement et qui est destinée, d’une part, à restituer al’organe
guéri sa forme physique compatible avec son rôle physiologique, et d’autre part, aassurer
la persistance de sa conservation, par l’application du principe déjà énoncé de l’isolemcnt.
A cet égard, les obturations métalliques ﬁgurent pour le plus grand nombre des cas,
et elle comprennent :
1° Les obturations faites de divers alliages(argent et étain; argent, étain, or;
argent, étain, zinc, &c.), mélangés avec quantité suﬁisante de mercure;
leur nombre est de 1,059
2° Les auriﬁcations proprement dites, représentées par le chiffre de 420
Cette disproportion entre les obturations métalliques ordinaires et l’cmploi
exclusif de l’or provient de diverses circonstances dont la principale réside
précisément dans l’intensité même de nos tendances thérapeutiques
actuelles. Un très grand nombre de caries, en effet, soit par leur étendue,
soit par leur siège, leur direction ou leurs susceptibilités aux réactions
inﬂammatoires, ne se prêtaient que très rarement aux manoeuvres longues
et aux pressions énergiques que nécessite l’auriﬁeation. Nous avons
DISEASES OF THE TEETH. 521
donc été forcés de renoncer souvent à ce dernier procédé, malgré toutes
les préférences que nous lui accordons en principe.
Pour des raisons analogues, l’emploi de certains ciments composés soit d’oxy-
chlorure de zinc, soit plus récemment de certains pyrophosphates de
chaux et de zinc a dû être préféré pour un nombre de cas que représente
le chiffre de 400
Enﬁn des caries, le plus souvent des dents antéro-supérieures ä. parois très-
friables, et auxquelles ne pouvait convenir aucun des procédés précé—
dents, ont été obturées par un mélange de gutta-percha blanche et de
silice ﬁne. Ces cas sont au nombre de l8
D’autre part, ﬁgurent encore dans cette colonne des opérations terminales,
les cas traités par simple résection ou amputation: leur nombre est de 33
Viennent enﬁn les extractions, dont la proportion doit ﬁgurer de nouveau ici 20
Total
Un dernier renseignement doit trouver place dans le relevé relatif à l’obturation en
général, c’est celui qui ﬁxe le nombre des obturations complètes après guérison de tous
les accidents quelconques comparé au cas dans lequel un suiutement séreux ou séro-
purulent, provenant d’une périostite chronique, a nécessité l’intervention d'une particu-
larité de procédé opératoire, l’installation d’un tube a drainage ﬁxe et permanent’?
Ces cas ﬁgurent sous les chiﬂ’res suivants :
Obturations simples, complètes 1,9l8
Obturations avec drainage 32
Extractions 20
Nombre égal 2,000
Ainsi s’achève l’exposé général de tous les détails que comporte une semblable sta-
tistique, et il ne nous resterait plus, pour clore cette enquête, qu’a donner le tableau
d’ensemble qui en résume tous les éléments (voir ci-contre). Mais nous avons ici un
devoir à remplir, c’est de signaler la participation qu’ont prise à. ces patientes et délicates
études pldsieurs de mes élèves. -
Le travail de répartition générale nécessitait une attention soutenue et une grande
persévérance; le docteur Pietkiewicz, qui était en 1874: notre chef de clinique, voulut
bien l’entreprendre et y consacrer tous ses soins. Le même travail s’est continué pen-
dant les années suivantes, et avec des résultats semblables, par le concours de plusieurs
jeunes praticiens, parmi lesquels nous sommes heureux de citer les docteurs David
et Cruet, de Paris ; Piotrowski et Ciunkiewicz, de Varsovie ; Quinet et Lambert, de
Bruxelles ; et plus récemment les docteurs Redier, de Lille ; Aguilhon, Combe, Chauveau,
de Paris, 850. _
Plusieurs de ces médecins ont d’ailleurs contribué par leurs travaux personnels et par
plusieurs thèses de doctorat à la démonstration aujourd’hui complète de la curabilité de
la carie dentaire. Mentionnons, par exemple, le mémoire du docteur Gaillard, “ Sur la
carie dentaire, sa nature et son traitement ;”‘I‘ un autre du docteur Manrel, médecin de la
marine, “ Sur le traitement de la carie ;”1: la thèse du docteur Cruet, sur le “ Traitement de
Caries Dentaires compliquées ;”§ celle plus récente du docteur Combe, sur “ l’Acide Arsé-
nieux dans ses Applications à la Thérapeutique de la Carie Dentaire,”|| &c.

* Voir a cet égard notre travail, cité plus haut, Sur le Drainage Chirurgical dans
ses Applications à. la Thérapeutique de la carie dentaire : Bulletin de Thérapeutique, 10e. cit.
1‘ ‘.‘Essai sur la nature de la carie dentaire.” Lyon, 1867.
I Archives de médecine navale, 1877. § Thèse de Paris, 1878. [l Thèse de Paris, 1879.
00
b0
'HLEIELL ‘HILL JIO SHSVEISICI
TABLEAU STATISTIQUE DE 2000 OBSERVATIONS DE CARIE DENTAIRE.
Relevées au point (16 we t/zérapeutz'qzze.


sExE AGE IDES
DEs MALAZDES. MALADES.
NGHIBRE DE 02s \
2°°°- /—*——-—\ /-———-*——-\ SIEGE DES CARIES.
'IHom. Fem.
IAnnées. (J as. I
2 Incisivcs cent. ............. ..
I 0-6 5 8 Incisivcs latérales ....... ..
lg Canines ...................... ..
6-12 88 g‘ 110 prérnolaire ............. ..
m 28 ,, . . . . . . . . . . . . . . .
1 2-20 460 ,5 we molaire ................ ..
<5 2e ,, ................ ..
,4 38 ,, ................ ..
Guérisons. 1080 8 50 1130 20-30 814 |
- 0 Incisives cent. ........... E Incisives latérales ....... ..
Canines ..................... 3°-5° 553 E9 lre pl‘émolaire ............. ..
.5 2e ,, ............. ..
50-70 57 __.__j Ire molaire ................ ..
\ 5; 2e ,, ................ ..
7o 3 :5 3e ,, ................ n
2 Incisives cent. ............. ..
5 Incisives latérales ....... ..
I 0-6 11 Canines ...................... ..
YD -
12. Ire prémolan'e ............. ..
6-12 5’; 2e ,, ............. ..
4.3 lre molaire .............. 12-20 2 g 20 ,, ................ ..
g Q g I I I I l o l I l I I on...
20-30 16 I
Extractions. 20 12 8 3 Incisives cent. ............. ..
g (Incisives latérales ....... ..
‘Z Canines ...................... ..
30-50 2 <3 lre prémolaire ............. ..
\ --_ 2e ,, ............. ..
50-70 .5 Ire molaire ................ ..
\ <2 ze ,, ................ ..
70 E 30 ,, ................ ..
862 1138 I
Tot. égaux. 2000 2000 2000 i
.2 25
ND 00
O U
87 80
102 91
59 53
8‘ 77
7° 69
129 118
67 71
3° 29
1 1
2 1
10 14
25 30
3° 39
I59 155
117 117
28 38
1
1
1
2, I
2 2
1
3
1
1
2 1
2
1
1008 992
W
2000
TOTAL
DIES D'BNTS.
H uaH-pHr-i HH
“Nun-1
2000
a: v5
3 g OBTURATIONS
,, 5 _ MOYENS MODES simples on
g m PEBIODES. THERAPEUTIQUES. D’OBTURATION. compliquécs
0 2 de drainage.
8 N
H
m Simples ....... .. 412 Métallique: Obtnrations
E simples ..... 1948
lrcpériodezz Q Amalgames
2 % Astringcnts .1147 de métanx
I 13 g divers .... .. 1059
C3
2e - 1360 9" Caustiques .... .. 370 Auriﬁcation... 420
. ' Obturations
| Ciments di- avcc drainage 32
Amputations ....... .. 8 vers, oxy-
3e — 598 chloruresde
Réscc-tions .......... .. 25 zinc,etc. 450
767 Obturations immé-
314 diatcs sans traite- Gutta-percha
234 mcnt ................ .. 18 silicée .... .. 18
6
Amputations
etreséctions 33
Extractions ..... .... 20
12
m a
c: +1 . .
g g Extractions... 20 Extractions .... .. 20
Extrac- (I; 8 .
tions 3 Q ,
pour Q, Q s
compli- ‘2 “:3 --°-.
8 cations 5 -§;’ ‘,2
graves... 20 v
2000 2000 2000 2000
DISEASES OF THE TEETH. 523
Ajoutons, pour terminer, tous nos remerciements partieuliers au docteur Chauvsau
qui a patiemr rent rassemblé et résumé sous nos yeux les documents qui ﬁgurent dans le
tableau général par lequel nous résumons cette série d’études statistiques.
Conclusions .- De l’ensemble des documents qui precedent nous nous croyons auto-
risés a déduire 1es conclusions suivantes:
1° La carie dentaire est une affection curable dans l’immense majorité des cas ;
2° Les proportions que donne a eet égard la statistique sent que la guérison est
possible dans le 99 per cent, ce qui réduit l’extraction a 1 per cent;
3° Ces résultats s’obtiendront couramment dans la pratiquejournaliere, a la condition
d’établir une the'rapeutique rationnelle fondée sur un diagnostic exact des périodes et
des formes de la maladie, et sur une notion pre’cise des indications thérapeutiques que
réelame chaque eas partieulier.
Arc [aoesz‘zgaz‘z'mz z'm‘o Z/ze Eﬁ'ecz‘s of Organisms upon Z/ze Teet/z
aaza’ Alveolar par/Zions of 6/26 jaws.
Mr. ARTHUR S. UNDERWOOD, London, and Mr. W. T. MrLLEs, London.
Mr. PRESIDENT AND GENILEMEN,——Ml‘. Milles and myself approach with some diﬁi-
deuce the task of laying our views, in their infancy, before a body of representative science
from all parts of the world. In the presence of so many illustrious members of our pro-
fession, whose own well-established researches have so materially advanced Surgery in all
its various departments, we should scarcely have ventured to address you without some
apology or excuse ; we have only one to oll'er, yet we think it is one you will all sympa~
thize with and appreciate. It is a ﬁrm and rooted belief in the truth of our theory, and
a hope, almost amounting to a conviction, that it will prove serviceable to humanity.
Without further preface we will proceed to discuss it.
INTRODUCTORY.
The effect of the presence of septic organisms in various parts of the body has been
for some years the subject of vigorous discussion and inquiry. Up to the present time
certain main facts have, we consider, been placed beyond doubt, and accepted by the
general body of scientiﬁc men as incontrovertably established. We shall therefore
assume, as axioms in our present inquiry, the main principles of the antiseptic theory.
The object of our inquiry (undertaken some four years ago) has been to determine, as far
as possible, to what extent germs were present in the dental tissues when in a state of
disease, and to deduce conclusions as to the effects of their presence. The method we
have pursued has been threefold;
1.-—-Mz'croscopical.— The observation of numerous sections of morbid dental tissues
stained in such a manner as to render the germs plainly visible. ’
2.—--~Flasl: Erperz'menta—The exposure of dental structures in a healthy condition to
the action of septic and aseptic ﬂuids.
3.—-Clz'm'ca/ Erperz'memfa—The treatment of morbid conditions of the dental tissues
with antiseptic agents.
The results of this threefold investigation have uniformly led us to the conviction
that germs play an important part in the production and maintenance of morbid conditions
of the dental tissues. With regard to the principal calciﬁed dental tissue, dentine, and
its destruction by caries, it is necessary to allude, for a moment, to the most commonly
received views of the etiology of the latter disease. The old, “vital theory,” may be
passed over, as completely disproved by the successful experiments of M. Magitot and’
many others, who have produced caries in teeth not in connection with the living body»
524 DISEASES oE THE TEETH.
With regard to the purely chemical theory, we cannot accept it as wholly satisfactory, for
the following reasons :—
1.-Beeause the destruction of dentine effected by the action of acids alone under
aseptic conditions does not resemble caries, either in colour or in consistency, it being
colourless and gelatinous, the process uniformly attacking all parts of the surface.
2.-—Beeause sections of dentine so destroyed show uniform destruction of the matrix,
but not enlargement of the channels occupied by the ﬁbrils; whereas the true caries ﬁrst
attacks the soft tissues—ale. the ﬁbrils—and encroaches from that point d’appm' upon the
surrounding calciﬁed structure, thereby producing the characteristic enlargement of the
channels, until two channels break into one, the intervening matrix being wholly destroyed,
3.—That although artiﬁcial caries has been produced exactly resembling true caries,
we have failed to discover any record of an experiment in which this has been the
case when septic inﬂuences were excluded. Two experiments have, indeed, been
recorded in which the teeth were protected from septic agencies, in one by the addition
of creosote, in the other by hermetic sealing of the ﬂask, and in neither of these did caries
occur. We assume, therefore, that two factors have always been in operation (1), the
action of acids, and (2) the action of germs. Further, our own ﬂasks show that malic
and butyric acid, with saliva in a meat infusion, have not, under aseptic conditions,
produced caries.
It may be asked, if a tooth can be decalciﬁed by acids out of the mouth, and
these acids are constantly in action in the mouth, then, if they produce caries, why can
they not produce simple decalciﬁcation? To this it may be replied, that acids alone do
not destroy a living tissue, that the stomach is not digested by its own acids until it has
been removed from the body.
4.—Lastly, we would urge that when caries occurs in the mouth, it is always under
circumstances more favourable to the action of germs than to that of acids. There is
always, ﬁrst of all, a minute pit or haven where germs can rest undisturbed and attack
the tissue. We cannot, upon the purely acid hypothesis, explain why the same acids
that originally caused the decay, gaining access through some minute imperfection of the
armour of enamel, do not in the same mouth, or under the same condition, attack the
wounded enamel at the edges of a ﬁlling. The germs cannot rest there; they are con-
stantly washed away if the surface is fairly smooth, but the acids literally bathe the
part (during the intervals between the acts of mastication, when the alkaline parotid and
submaxillary saliva neutralize their action). '
These considerations led us to seek for signs of the presence of organisms in carious
dentine, with results that far exceeded our expectations, some of which are here this
morning.
This theory which—for the sake of distinction, may be called “septic”——is rather an
ampliﬁcation of the chemical theory than a contradiction of it. Most probably the
work of decalciﬁcation is entirely performed by the action of acids, but these acids are,
we think, secreted by the germs themselves, and the organic ﬁbril upon which the
organisms feed, and in which they multiply, is the scene of the manufacture of their
characteristic acids which, in turn, decalcify the matrix, and discolour the whole
mass.
From our observations on cementum, to which caries has extended, we conclude that
the process is very similar; the bioplasmic contents of the lacunae and canaliculi aﬂ‘ord
board and lodging for the organisms, which multiply, and, when sufficiently numerous,
decalcify the surrounding bone, so that the lacuna loses its outline and extends in all
directions.
With regard to the pulp, its inﬂammation does not materially differ from that of any
DISEASES OF THE TEETH. , 525
other cellular connective tissue. The inﬂuence of germs upon such tissues, when
inﬂamed, has been already demonstrated by Professor Lister. One peculiarity dis-
tinguishes this from kindred tissues, and that is, that a tooth being an absolutely shut
box, its contents are singularly amenable to antiseptic treatments. Having once
rendered them aseptic by means of a penetrating agent, it is easy to keep them
absolutely so, by sealing the only opening of the cavity with a ﬁlling. With a view
of testing this fact, the theoretical accuracy of which we could not doubt, I have
repeatedly allowed the gangrenous contents of a pulp cavity in which suppurative
inﬂammation has gone on, to remain in the tooth covered by a ﬁlling.
All that is necessary to prevent further disturbance is to soak them in apowerful
antiseptic. Ihave chosen for this purpose a combination of iodoform and eucalyptus
oil, because it is the most powerful and the most permanent in its effects. After a
certain period, during which the cavity has been sealed with a temporary ﬁlling, if no
disturbance has occurred, I have substituted a permanent ﬁlling, and with almost invariably
the most satisfactory results. This treatment is, I think, eminently conservative surgery,
and based upon sound surgical principles.
M. Magitot, in a recent most interesting article upon development of teeth, lays
great stress upon the fact that the odontoblast layer is very essential to the health of
the tooth ; and if we can, by this method of dealing with the matter, avoid the otherwise
necessary alternative of removing it together with all dead matter, we certainly give the
tooth an extra chance. The more of the natural vital contents of the pulp cavity we
can preserve in siz‘u the better for the tooth.
Further, we would propose for your consideration a theory as to what is the probable
course of behaviour of a tooth pulp under these circumstances, a theory at present only,
but one which we hope to establish shortly by ocular demonstration, and lay before you
in a mature form. Suppose a tooth, with alarge cavity communicating with the pulp-
chamber ; suppose that gangrene and suppuration have extended down two-thirds of the
pulp-chamber, and that the extreme periphery of the pulp (membrana eboris), and the
contents of the apex of the fang alone remain alive ; suppose the cavity cleared, and a
small portion of the surface of the slough removed, and the rest carefully soaked with
eucalyptus oil until all the existing organisms are destroyed, and the cavity then ﬁlled with a
permanent and effectual stopping: what becomes of the slough? In every other part of
the body a slough, that has been rendered and kept aseptic, is gradually absorbed by the
neighbouring vessels, while new cicatricial connective tissue is laid down in its place ; this
has been repeatedly demonstrated in sloughs of the limbs, treated antiseptically. We there-
fore suggest that the same thing that happens in other parts of the body, under similar cir-
cumstances, happens in the pulp-chamber : the slough is removed gradually by absorption
while its place is supplied by healthy cicatricial tissue; like all scar tissue, it is of a
lower order than that which it replaces, but it is a living tissue. After a lapse of time,
then, we imagine that, if the tooth in question were extracted and split open, its contents
would be found to be a healthy connective tissue, and not a slough at all.
Exrnamnnrs on THE LIVING SUBJECT.
Taking, then, for granted the facts established by Lister and others, relative to the
eifects of the presence of organisms in other tissues, we were convinced that the course
of an alveolar abscess was profoundly modiﬁed by their presence also. An aseptic or
a septic alvedlar abscess seemed to us to differ very much in the same way as a simple
and a compound fracture.
To render such abscesses aseptic, we have injected them with eucalyptus oil and iodos
form, and dressed them with lint soaked in these substances.
5 26 DISEASES on THE TEETH.
By means of constant and careful dressings and injections, we have been for the last
two years very successful in inducing extensive, and often old-standing alveolar, abscesses
to run a rapid aseptic course of recovery. Wherever we have failed we have been able
to trace our failure to the presence of a sequestrum, which has afforded an inaccessible
refuge for organisms, and which, until Nature has rejected it, or surgical skill removed it,
has kept up the mischief despite all applications. Mr. David Hepburn, in a recent able
paper upon such obstinate cases, read before the Odontological Society, urged this fact
very strongly and clearly, and we quite agree with him that, while dead bone is
present, antiseptics may mitigate, but are powerless to annihilate, the disease.
Mrcnoscorrcxn.
The sections upon which our observations have been made have been cut from fresh
teeth, very shortly after extraction, and without the use of any decalcifying or softening
re-agent.
We have subsequently stained them with an aniline dye (methyl violet), following as
closely as possible the process recommended by Koch—a process which renders
micrococci fairly distinct under a a lens, with proper illumination. A few typical
slides we have been enabled to show you, owing to the kindness of our friend, Mr. Nelson_
I need scarcely add that as the powers are very high oil immersions (E15, ,1,, 215-), we
shall ask you to refrain from touching the adjustments. We have also prepared some
diagrams illustrating upon a larger scale the appearance of the objects. In dentine,
which has occupied most of our attention, we have invariably discovered the channels
containing the dentinal ﬁbrils more or less inﬁltrated with germs—for the most part
micrococci, oval and rod-shaped bacteria. These germs we ﬁnd penetrating at ﬁrst in
Indian ﬁle, then more thickly, along the course of the ﬁbrils. As they accumulate and
choke up the channels they encroach upon the matrix, diminishing the distance between
the ﬁbrils until the matrix entirely disappears and the neighbouring channels join, and
the whole tissue becomes one conglomerated mass of organism. Beyond the sphere of
visible decay, sections cut from apparently healthy tissue show here and there a narrow
line of micrococci or bacteria, like an advance guard, and such isolated tubes or germs
probably penetrate far into tissue which the naked eye would pronounce sound.
In decay, which has appeared in blocks of hippopotamus ivory worn on a plate, we
have observed very similar appearances (see ﬁgure) 5 also in some. caries which we have
produced ourselves in a ﬂask, by exposing a sound tooth to septic agencies.
In cementum hitherto we have experienced some dilﬁculty in obtaining sections of
tissue into which caries has penetrated; but where we have succeeded we have found the
lacunae ﬁlled with germs. In some lacunae the protoplasm of the osteoblast cell is
slightly stained, the nucleus very deeply, and a few germs are seen scattered about in
little groups. In others the protoplasmic contents of the space appear to have been
totally destroyed, the outline lost, and the whole lacunae crowded with germs.
SUMMARY.
The preceding observations, together with the experiments with ﬂasks and upon the
living subject above referred to, have led us to adopt certain views which may be
regarded as an extension of the views previously held upon the matter.
l.—-We consider that caries is absolutely dependent upon the presence and pro-
liferation of organisms. That those organisms attack ﬁrst the organic material, and
feeding upon it, create an acid which removes the lime salt, and that all the differences
between caries and simple decalciﬁcation by acids is due to the presence and operation
-of germs. This view we propose to call the “ septic theory.”


x 1200 diam.
Cementum. Three lacuna: containing a faintly-stained
osteoblast with dark nucleus and micrococci.
. 0
Q . O
Q .. ‘Q I ‘C . ‘Q
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x 1250 diam.
Transverse section of dentine ; mierocoeci in tubes.


x 2500 diam.
Three dentinal tubes enlarged by the presence of organisms_—
one tube is full of microeocci, the other two rod-shaped
bacteria.
0 '. -
‘. I .0.
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x 1250 diam.
Longitudinal section of dentinal tubes containing microeocci
and rod-shaped. bacteria.
DISEASES OF THE TEETH. 527
Q.-—That suppuration of the pulp audits sequelac, such as alveolar abscess, depend also
upon the successful working of organisms.
3.-—We feel justified in concluding that the successful exclusion of germs would
prevent the disease, and that their exclusion is quite easy and practicable by the use of
powerful and penetrating antiseptic agents, such as eucalyptus oil.
We have found that the space of time allotted to a paper rendered it quite impossible
to enter into all the details of treatment and experiment we could have wished. These
experiments have extented over three years, and cannot be condensed into a half-hour
paper. All, therefore, that we have been able to do has been to lay before you the main
facts and a few typical results, and in doing so we have been very kindly assisted by Mr.
Nelson, whose microscopical arrangements have enabled us to show you our result in a
more perfect manner than would have been otherwise possible.
DISCUSSION.
Dr. TAFT, Cincinnati: The experiments detailed in the paper just read are very
interesting indeed, and are fraught with instruction to all; but they can hardly be re-
garded as accounting for the production of caries of the teeth. The conditions that
attend and surround the teeth in the mouth cannot be simulated nor imitated artiﬁcially,
The experiments here given were conducted under a uniformity of conditions that is
never found, and does not exist. The temperature in the mouth is ever varying; the
substances in the month are changing constantly; and the agents produced by their
decomposition or fermentation will be various, and subject to constant change. The agents
producing decay are subject to change, both in kind and degree. In the month there are
ever present substances that will produce coloration, more or less marked, and various
in kind. In regard to parasites, I do regard them as active agents in dental caries, and
not a cause, but a result, of decay; they are not a primary, but a secondary, element in
the process. The cause of dental decay must be sought in some other direction, of
which I will not speak.
Dr. DENTZ, Utrecht : It appears to me that the experiments carried out by Messrs.
Underwood and Milles, although exceedingly interesting, nevertheless lead to results
identical with those obtained by Leber and Rottenstein, whose conclusions have already
been sutﬁciently controverted by, amongst others, Messrs. Wedl and Tomes.
Mr. C. S. TOMES, London : In answer to the suggestion that the paper before us has
been anticipated by older writers, and that it is inconclusive, I may be permitted to point
out wherein it appears to me that the especial value and the thorough originality of the paper
lies. Caries has been produced artiﬁcially many times, and by many observers, but with
no special thought of septic agencies taking any part in the process ; consequently they
have always had their full ﬂing. Mr. Underwood and Mr. Milles have shown, by many
experiments, that the other conditions remaining precisely the same, in an aseptic ﬂask
caries never occurs; in a septic ﬂask it always and speedily occurs. Whatever interpre-
tation we may put upon this, it remains as a fact, contributed to our knowledge of the
artiﬁcial production of dental caries, which can never be left out of consideration by any
subsequent observer or writer on the subject. -
Mr. WALTER Col-‘FIN, London : described a treatment of extensive alveolar abscess
by the evolutjgn of oxygen rapidly, within the sac, by the injection into it of peroxide of
hydrogen, forming with the secretions a thin froth, and strongly distcnding and
thoroughly evacuating it. There is a complete antiseptic disinfection without coagulation.
528 DISEASES on THE TEETH.
Mr. COLEMAN, Streatham= said that the interesting and valuable paper they had just
listened to was——whether it should lead to the adoption of the views of the writers
or the rejection of their opinions—still a step, and a valuable step, towards our knowledge
of the conditions or complications which are to be met with in the affection termed
dental caries. There was this difference, that in the one case—in the mouth—the
affection occurred in structures closely connected with living tissues, which was not
the case in the artiﬁcial experiments. Mr. Coleman further said it would be very
interesting could they follow out the ultimate results of abscess cured by antiseptics
He had thought the matter much over, and considered it probable that the parts
so treated might assume the condition of the carbolized catgut. If so, it was more
than probable they would undergo the same changes as the latter did when introduced
into the body—via, to become gradually absorbed, and have their exact place supplied by
new and healthy tissues.
Mr. S. I. HUTCIIINSON, London: thanked Mr. A. Underwood and Mr. Millcs for
their most valuable labours, and believed they had got in the right groove for elucidating
the action and cause of caries; but he must protest against the threatened abandonment
of the term “ dental tubules.” The authors admitted that there were ﬁbrils, that these
ﬁbrils ran in channels in the calciﬁed tissue of the dentine, then, why should they be so
ready to give up calling those channels—tubes ? Mr. Hutchinson then read an extract
from Dr. George Harley’s paper in the Pathology Section, which went far to conﬁrm the
authors in their views: he says that “all disease germs tend to produce local as well as
constitutional disturbance.”
The debate was continued by Mr. SrENcE BATE, Plymouth.
Mr. A. S. UNDERWOOD, London: I have very little to add to Mr. Charles Tomes’
speech, by way of reply 5 he has expressed my idea of the scope of my paper more clearly
than I could have done myself. Dr. Taft has asserted that germs are net primary, but
secondary, causes of caries; this assertion Ijmust meet by simply saying that they are
never secondary, but always primary. One assertion carries probably as much weight as
another. Both Dr. Taft and Dr. Atkinson have misunderstood the drift and scope of
my paper. We did not profess in the short space of twenty minutes to give a succinct
account of the ultimate and elementary causation of everything connected with the teeth.
The allotted time is scarcely sufficient to discuss the effects of germs, and we had no
desire to enter into any other question. Dr. Taft must remember that the varieties of
caries are just what we shquld expect from the varietiesof the germs, hundreds of different
forms having been already demonstrated. Dr. Atkinson asks me what “septicism ”
means. In England, we understand it to mean a condition in which germs are present.
He also complains of the use of the terms organic and inorganic. I can only say that
we are obliged to employ these terms in their ordinary sense, for simplicity ’S sake. Mr.
Hutchinson asks an important question, afterwards repeated by Mr. Spence Bate, why
are bacteria more lively now than 2,000 years ago, when decay was less rife? I answer
that we are all more lively ourselves; we eat things and drink things that are not- good
for our enamel, and we contract diseases, traceable to civilization, that are not good for
the enamel of our children, and thereby give the bacteria an opportunity to employ their
energies on the weak ppints. Our progenitors ate simpler food and lived more simply,
and therefore their enamel was better : and the progenitors of the modern bacteria had
no chance of showing what mischief they could do. The primeval micrococci that dwelt
in Mr. Bate’s primeval skull were as powerful as those that swarm in the mouth of a
modern dog (and even dogs are beginnning to have decay now). I must heartily thank
DISEASES OF THE TEETH. 5'29
Mr. Bate for his clear and candid criticism. I hope he will investigate what we have said ;
we shall do so ourselves. We do not take it for granted or blindly believe it a bit more
than you do, and if our further rcscachcs disprove it we shall be the first to say so. We
quite feel, with Mr. Bate, that it would have been more satisfactory to have enlarged at
greater length upon our experiments ; but there is plenty of time before us for that, and
we promise to do so. Do not expect too much all at once; we had an embryonic theory,
and as you had a Congress we determined to breach it to you; of course, time alone
can establish it, but we cannot give you a new theory, and, at the same moment, one
sanctioned by time. Our bantling is in his cradle ; we must wait to see what he will
grow up to be. Dr. Dentz has also paid us a compliment I cannot pass over, in coupling
our names with those of his distinguished countrymen, Leber and Itottenstein. I must,
lastly, thank Mr. Charles Tomes for his clear exposition of our views. I do not think
you have heard the last of them, and I confess to a suspicion that our endeavours to
convince our very candid critic, Mr. Spence Bate, will be crowned with success ; and
I am sure that if we can prove our point to his satisfaction, he will be the ﬁrst to confess
the fact. One thing I think you will all agree upon, that, whatever the merits of the
paper, it has produced a very animated discussion, for which, in the name of my col-
league, Mr. Milles, and myself, I heartily thank you.
Remaw/es on ﬁre Admz'm'sz‘mz‘z'mz 0f AvzrzzsZ/zez‘ics at 5/26 Denial
Hagm'z‘czl of Lumiere, from 1868 zfo Z/ze present‘ lime.
Mn. A. COLEMAN, London.
A reference to the records of the above-named institution shows that anaesthetics
have been administered, within its walls, a little over twenty thousand times.
In the majority of cases nitrous oxide has been the agent employed; the next in
frequency has been ether, used in conjunction with the former, upon the plan introduced
by Mr. Clover. Ethylene-dichloride probably comes next in order, whilst chloroform ,
bichloride of methylene, and other anaesthetics, have been employed occasionally.
In reply to queries, Mr. Clover has kindly written to the following effect : “ I continue
to prefer dichloride of ethylene to other or chloroform, in cases where the pure nitrous
oxide does not keep up the anaesthesia for asuﬂicient length of time. The apparatus I use
is the gas and ether apparatus I have had for several years. This enables me to begin
with gas, and add the other gradually, without the supply of any more gas. I have had
no dangerous cases attributable to the anaesthetics—none serious enough to require arti-
ﬁcial respiration; but a few have been attended with the nausea and vomiting with which
we are familiar after chloroform.”
Mr. Braine also kindly states : “At the Dental Hospital of London I have, in by far
the majority of cases, administered nitrous oxide alone. When a longer period of anaes-
thesia has been indicated, I have then employed that agent in conjunction with ether. I
have never, during the period of my appointment to the above-named institution,
encountered a case that has given me more than a few seconds’ anxiety. In a few cases,
where respiration has failed, I have had to forcibly compress the thorax with my hand ;
but have never had to employ artiﬁcial respiration otherwise.”
Mr. Bailey also kindly supplies the following—that he very rarely uses anything else
than nitrous oxide at the Dental Hospital. In the only dangerous case, he had required
to employ artificial respiration for three-quarters of an hour before complete recovery.
In the larger proportion of cases of administration, on the Thursday mornings
PART In. M M
530 DISEASES OF THE TEETH.
(when the anaesthetic is usually administered by myself) a little ether is combined
with the nitrous oxide. This is done with the objects of economizing the gas and pro-
1onging the anaesthesia. The mixture of gas and ether is also, at a certain stage, respired
over and over again, which reduces the consumption of both to a minimum; thus, a fifty-
gallon bottle of compressed gas may be employed for sixteen to nineteen eases. From
the time anaesthetics were ﬁrst used at the Dental Hospital, to the present, only one really
alarming case occurred, and that within the present year, when a young female ceased
to respire during about ﬁve minutes, whilst artiﬁcial respiration was being kept up.
That so large a number of administrations of anaesthetics should have taken place at
one institution, without any serious consequences, is a source of much congratulation and
thankfulness to all connected with it ; but there is, perhaps, another point for satisfaction
hardly less important—via, the immense advantage that the students at such a hospital
must have, in witnessing anaesthetics administered so frequently and so elliciently as they
are, by the distinguished gentlemen, Mr. Clover, Mr. Brainc, and Mr. Bailey, who hold
the post of administrators of anaesthetics, and who most regularly attend on their
appointed days. No other hospital in this or any other country can, probably, present
similar advantages.

A Zveolm/ A éscess.
Dr. M. S. DEAN, Chicago.
Mr. PRESIDENT AND GENTLEMEN,—The causes of alveolar abscess and its pathology
have been so minutely and accurately described by several learned authors that it
would only be a waste of time for me to dwell upon the etiology of this disease, or upon
its history. I will, however, state at the outset that I shall denominate as alveolar
abscess no lesion except that which is associated with a teeth, the pulp of which has
become devitalized; no matter whether the devitalization be of recent or remote occur-
rence. In other words, the death of the pulp will be regarded as the remote or indirect
cause of the disease. The immediate or exciting causes, then, of alveolar abscess
(properly so-called) are, the various matters and their products that ﬁnd their way from
the root canals, through the apical foramen. These irritating agents may arise either
from the decomposition of the pulp tissues, or, at a later period, of the exudations that
may have entered the canal through the apical foramen, or from the matters that may
have entered the root canal from external sources; or, indeed, in some cases even,
from the passage of liquids or gases through the canaliculi of the dentine and cement
of the root. Any of these agencies, acting mechanically or septically upon the tissues
surrounding the root, would cause inﬂammation, and, as a consequence, might terminate
in alveolar abscess.
This is a very general statement indeed of the causes of the lesion which is made the
subject of this paper. To trace its progress from its incipieney to its climax would be,
as before intimated, only a waste of time, since its different progressive stages are well
known to every dental pathologist.
The pathogeny of this disease being thus condensed within these narrow limits, it
remains only for me to proceed to the practical question, its treatment. I shall in this
confine myself to a few of the ordinary cases that are of the most frequent occurrence,
of which some are regarded by many writers as incurable, and, unfortunately, are treated
as such by many practitioners.
Alveolar abscess with ﬁstulous outlets, whether of long standing or recent develop-
ment, are the least difficult to treat, and are the most speedily brought to a favourable
termination. Indeed, the treatment of such cases is exceedingly simple; and if the
remedial agent is properly and thoroughly applied, a single operation usually results in
DISEASES or THE TEETH. 5 3 I
a permanent cure. To illustrate the mode of treatment in detail, we will take an example
in practice. A ﬁstulous abscess associated with a superior bicuspid having a large cavity
on its distal surface—the gums somewhat inﬂamed and turgid. The ﬁrst step in the
treatment of this case—whether the abscess be acute or chronic—consists in adjusting
the rubber dam to this and to the adjacent posterior tooth—if there be such. The
decayed parts should then be removed, and a convenient entrance made into the root
canal or canals, which should be enlarged, if necessary, with a Gates’ drill, or other
instruments suitable for that purpose, and thoroughly cleansed. A steel breach should
then be passed gently through the apical foramen to remove any obstruction to the
passage of liquids. This last operation sometimes requires considerable patience, espe'
eially so when the end of the root is somewhat curved. The next process consists in the
injection of creasote through the apical foramen into the abscess. This operation should
not be discontinued until the whitened oriﬁce of the ﬁstula gives evidence that the
remedy has reached this point.
A simple method of accomplishing this, and one that has proved entirely satisfactory to
myself and to others, is this : Fill the root-canal with a light pledget of cotton, saturated
with ereasote; then introduce a soft ball of vulcanite into the cavity of decay ; new, with a
few quick and forcible impulsions, with a round-headed instrument upon the soft rubber,
the creasote will be forced through the apical foramen and the mouth of the fistula.
The injection of the abscess and ﬁstulous tract having been accomplished, the root-
canal or canals may now be ﬁlled tightly with cotton, slightly moistened with ereasote,
and the cavity of decay scaled up so securely as to prevent the entrance of the ﬂuids of
the mouth. If the details of this simple operation are carefully carried out, no additional
treatment will be necessary in a great majority of cases to effect a permanent cure.
After the lapse of ﬁve or six days, the ﬁstula will be found closed, and the pulp canal
should now be completely ﬁlled with some durable and impervious material. But
before the temporary stopping is removed, the rubber dam should again be applied to
the tooth in order to prevent the possibility of any contaminating matter entering the root-
canals. This last point is so essential that I wish to strongly emphasize it here; for a
successful result would generally, if not always, be thwarted by any infectious matter——
the ﬂuids of the mouth even—that might enter the root-canals subsequent to the ﬁrst
step in the treatment of the case. (No matter how badly broken down the crown of the
teeth may be, or swollen the surrounding parts—an alveolar abscess of the character
just described Wlll readily yield to the treatment above indicated—as a rule.
The treatment of the teeth anterior to the bieuspids is, in some respects, still more
simple; the roots being straight, and the canals more cylindrical. In these teeth it is
sometimes better—if not too much weakened thereby—to make a direct opening into
the canal from the lingual aspect. In other respects, the treatment of these teeth is
the same as in the case just described. It is hardly necessary for me to state that this
treatment applies equally well to abscessed roots upon which artiﬁcial crowns are to be
secured.
The treatment of ﬁstulous abscesses, that are associated with the molar teeth, is some-
what more complicated, inasmuch as it is more diﬂicult to obtain free access to the
root-canals ; but when these are once opened up, a cure is generally quite easily effected
by adopting, essentially, the same method as that described for the single-rooted teeth.
In the foregoing I have had in view those alveolar abscesses in which ﬁstulous open-
ings had been already established. We will now brieﬂy consider the treatment of those
abscesses which are generally far more diﬂicult to mam ge. Having no ﬁstulous
outlets they are sometimes called “blind” abscesses; some of these yield readily to
treatment especially if they are not of long standing, yet they require more cautious
M M 2
5'32 DISEASES or THE TEETH.
management. The cavities of decay and root-canals should be cleansed, as in the cases
just cited, but greater care should be exercised in the manipulation, lest some of the
debris he forced through the apical foramcn. It will be readily seen that this care is
more necessary in the treatment of the lower teeth than of the upper. After the opera-
tion of cleansing the cavity and root-canals is completed, if the pus does not alreadyr
flow into the canal, a breach should be passed through the foramcn. and the pus and
serum that follow the withdrawal of the instrument should be removed or wiped out
until it ceases. Then make a piston by winding cotton around a suitable instrument——
the head of a Gates-drill does very well—and saturate it with eucalyptus oil or phenol
sodique. With this as much of the pus as possible should be forced or pumped from
the abscess. Of course the cotton should be removed from the instrument and renewed
many times. By this means the remedial agent will be forced through the foramen
and drawn out again, bringing with it a mixture of purulent matter. By repeating this
operation several times nearly all the contents of the sac will be removed. I prefer
the eucalyptus oil or phenol sodique to creasote or carbolic acid in this operation,
because the latter, by coagulating the albuminous ingredients of the pus, affect its
ﬂuidity, and thus increase the difficulty of drawing it through the apical foramcn. After
the contents of the sac are measurably exhausted, a little ereasotc may be injected into the
abscess, and the root, or roots, be ﬁlled with a light pellet of cotton, and the cavity be
scaled up. If there is not a sufficient quantity of ereasote in the canals to saturate the
cotton, a little should he added. On the second or third day subsequent to this treat-
ment the temporary stopping, and the dressing in the canals, should be removed. To a
practised eye, the appearance of the dressing taken from the canals will often indicate
the condition of the parts beyond the apex. If pus should be found in the meshes of the
cotton, or if serous ﬂuid, or pus in small quantities, should in a few minutes ooze through
the apical foramen, or, if we ﬁnd there has been a leakage of the temporary stopping,
the same treatment should be repeated. The second treatment will, as a rule, be
sufficient to cure the abscess. But, in most cases, I would advise the removal of the
second dressing after about a week’s time, and again to pack the root-canals tightly with
cotton moistened with creasote; and then to securely fill the remaining cavity with a
trial ﬁlling that might remain for a month or more.
This is all the treatment that is required to cure the great majority of cases of this
class. But occasionally we meet with a case that will not yield so readily. In such a case,
after a faithful course of treatment with crcasote and eucalyptus has proved ineffectual,
it would be well to substitute aromatic sulphuric'aeid. The effect of this remedy in
these stubborn eases, though somewhat painful, is often truly wonderful; and one appli-
cation is frequently sufficient to arrest the secretion of pus. The subsequent treatment
would be the same as that adopted in milder cases. In some of these cases—especially
those of long standing—when the external wall of the abscess has become thin and
yielding, the quickest, and perhaps the least painful, method to pursue, would be to
produce an artiﬁcial ﬁstula with a trcphinc, or any other instrument.
The lesions may be then treated as before described for ﬁstulous abscesses. Of
course, if there be necrosis of the osseous parts, the removal of the sequestrum, and the
substitution of aromatic sulphuric acid, will be indicated, and will generally result in a
speedy cure.
Abscesses, with ﬁstulae opening externally upon the face, yield readily to this treat-
ment, without the loss of the teeth that are associated with them. Even those of many
years’ standing, may often be cured by a single injection of ereasote or carbolic acid. You
are all aware that abscesses of this nature quite frequently arise from the death of the
pulp in the inferior incisors that are entirely free from decay; the cause being frequently
Diseases or run 'rnuru. S33
overlooked by the medical, and sometimes even, by the dental, practitioner. Cases of
this kind, which had been treated. externally for a series of years, have come under the
observation of many of you. By applying the same principles recommended in the ﬁrst
case described, an abscess of this character may be cured almost invariably by an
operation requiring thirty minutes’, or at most an hour’s time and the tooth retained in
its usefulness.
Perhaps it may not be amiss, here, for me to suggest that the opening should be made
posterior to the cutting edge of the teeth (I speak of the inferior incisors), and in as
direct a line as practicable with the longitudinal axis of the root canal. This is easily
accomplished by the aid of the dental engine, and a right-angle attachment armed with a
triangular spear-pointed drill, having a small and slightly ﬂexible shank. I need not
detain you with the further details of this operation, as they have been fully suggested
by the foregoing treatment of the bicuspid. I will bring this imperfect sketch of the
details in practice to a close after a few words concerning the treatment of incipient
alveolar abscess. Of course it is often diﬁicult to distinguish an incipient abscess from
periostitis when the latter is occasioned by the mephitic gases or other irritating
matters that ﬁnd their way through the apical foramcn. But this is of no practical
importance, since the same treatment that is adopted for the one is applicable to the
other, In cases of incipient abscess the rubber dam should be applied as in the cases
before named, and after having removed the parts softened by decay, the dead pulp or
other matter should be carefully removed from the canal. It would be better not to
thoroughly remove the debris at the ﬁrst sitting, lest in the attempt to do this we force
matter through the foramcn, and thus aggravate, rather than ameliorate, the trouble.
After this partial cleansing of the cavity, a pledget of cotton, saturated with eucalyptus,
or dilute creasote, should be delicately introduced into the canal, and the cavity scaled
up with cotton and sandarach varnish. In this operation pressure should be carefully
avoided. The margins of the surrounding gums should then be touched with a solution
of iodine in creasote. This may be conveniently done with a small spatula that will pass
between the circumjacent gums and the neck of the tooth. After three to ﬁve days the
cavity of decay, and the root canals, should be thoroughly cleansed, and the latter now
tilled densely with cotton moistened with a little creasotc, and the former with gutta-
percha or some other impervious material. For an incipient abscess—or periodontitis
from the cause already named—this treatment will (with very careful manipulation)
generally prove all-sullieicnt. It is, of course, understood that the ﬂuids of the mouth
must be absolutely excluded from the cavity, from the commencement of the treatment
until the cavity is permanently ﬁlled.

Civilization 2'12 223 re/az‘z'on Z0 Z/ze Decay of 5/16 Teri/z.
Dr. NORMAN KINGSLEY, New York.
rl‘hc most important undetermined problem nowr confronting the dental profession is
embodied in the inquiry made daily by anxious parents in substantially the following
form:—“ Why do my teeth decay more rapidly than my father’s or mother’s did, and
why are my children's teeth decaying at an earlier age than mine i’ ”
'l'his inquiry does not come from those who neglect their teeth and who never consult
a dentist until a throbbing pain betrays an exposed nerve. It does not come from the
lower classes of society, the ignorant, or the depraved, who are as habitually careless of
their teeth as they are of every other personal attention.
It is not conﬁned to any race or nationality, nor is it affected by the seasons, climates,
0r locality; but it does come from a class which is the most intelligent, the most cultured,
5 DISEASES OF THE TEETH.
and the most ﬁnely organized in any community, irrespective of race, locality, or climate,
from people who appreciate the importance of hygienic laws, who give much care to the
preservation of their bodily health, and who are attentive to their teeth.
This inquiry, when put to the professional adviser, frequently betrays great anxiety
for the present condition, and alarm for the ﬁnal results. It is useless to treat it lightly,
or attempt a denial of the premises ; for although the inquirer may have no statistics to
sustain hisimpressions, he has a knowledge and a memory which is almost equivalent to
a record, and his opinions are conﬁrmed by the observations of most of his acquaintances.
The cases are exceedingly rare, if they exist at all, where the teethzof the children are
sounder than the parents’, and we must admit the conclusion that with each succeeding
generation the dental organs are becoming more and more degenerate.
The dental practitioner holds the position of one in authority to his patients, if he be
anything more than a mechanic, or makes any pretension to scientiﬁc attainments; but
what response has he to their inquiriesi>
It is not difficult to formulate an answer that will satisfy many. It requires but little
tact, and less knowledge, to give a reply that appears to impart information, but which
really only covers ignorance and paciﬁes the patient. Even those who are well versed in
other branches of science are often satisﬁed with an answer that will not bear investiga-
tion, and may even be absurd.
In this way is heard daily a repetition of the theories and speculations of a generation
which have just enough foundation in truth and just enough plausibility to escape being
challenged.
Probably the most universal idea among cultivated unprofessional people of the cause
of the decay of teeth, especially among children, is “candy.” At least, nine-tenths of
parents seem to think there is no other cause, and half believe that, with all their efforts
to keep candy away from their children, they must be eating it surreptitiously, or their
teeth would not be found decayed.
There is probably no more fallacious idea so generally believed. How it should have
obtained such wide-spread credence is difﬁcult to conceive; it has just sufficient plausi-
bility to save it from rejection.
But pure candy, in modcratequantity, never harmed any healthy child or adult. Pure
candy, which is only sugar in a fanciful form, is as legitimate an article of diet, within
moderate limits, as pastries, pickles or_ preserves, or a hundred other inventions for
gratifying the palate, and if all other factors were eliminated from the problem, candy
might be eaten with impunity.
Another speculation which has gained some credence is contained in the discovery that
ice wal er, hot drinks, or hot cakes are the cause of all the mischief. It was even gravely
asserted, at a gathering of professional men a few years since, by a gentleman who had
no mean pretensions to scientiﬁc acquirements, that the common habit among Americans
of drinking hot coffee or tea, to be followed by ice water, caused a sudden alternate
expansion and contraction of the enamel, which produced cracks, which ultimated
in cavities of decay. It is vcrytdoubtful if a cavity of decay ever originated from that
cause, and certainly it is not possible that such a cause can have any very considerable
direct inﬂuence. Neither ice-water nor hot drinks are any perversion of Nature’s
provision for man’s health or comfort.
If there are any pernicious results following their use, from which the teeth suffer, it
is not in their directly causing caries or other injury to these organs.
Another favourite theory held by some professional gentlemen is that of “living
upon soft food instead of that which requires mastication.” It has a seeming plausibility
from the fact that the principal tissues of the body become strengthened by the severity
nrsEAsEs or THE TEETH. 535
of their use, and are atrophied by neglect. But among the opposing arguments to this
theory may be noted the fact that the Esquimaux living on whale blubber, the tropical
Oriental with a rice diet, and the savage with his forest nuts, grains, and dried meats,
have each and all equally good masticating organs—the difference appearing not in
structure, nor liability to decay, but in the abrasion of those which have the most severe
use. Food has unquestionably a most important inﬂuence upon the dental organs, but
the beneﬁts come not in the rejection of soft food and the substitution of hard.
Neither is the “ bran-bread ” theory, which has been so persistently advanced, a
much more solid foundation upon which to rest.
Bread made from unbolted ﬂour, or that which contains the husk of the grain, possesses
certainly more of the elements which go to make up healthy tooth-structure than where
these elements have been eliminated. But mankind do not live upon bread diet alone, it
forms but a small part of the bill of fare of the more luxurious classes, and it is very
doubtful if the experiment were tried of feeding a family from birth to maturity upon bran
bread, they would show any marked improvement in the dental organs, if that were the
only means relied upon to produce that result. It savours of the experiment of feeding
phosphates into the stomach, in the expectation of thereby making solid bones.
The food theories may be among the secondary sources of decay, but no one of them,
nor all combined, form the primary cause of the present increasing degeneration of tooth-
structure.
Still another theory persistently advocated by a professional observer, is embodied in
the statement that “ Contact always produces decay.” That teeth frequently decay when
they are in contact must be admitted; that they are more likely to decay at such points
than in more exposed portions, is also borne out by every observer; but that contact is
anything more than an incident to the real cause cannot be shown. If contact be a cause
operating independently of other causes, then are we confronted with the fact that a
different, but equally independent and potent cause, is found operating upon another
surface of the tooth where there is no contact ; and, furthermore, an examination of the
most solid dental structures ever presented for professional inspection, show all the teeth
in absolute contact, and no evidence of decay. This condition is also universally found
in the jaws of savage races of good physique.
The contact theory must be relegated to its proper place among secondary causes, and
simply a coincident factor in the great problem.
Another theory which has been ably maintained as the sole cause of such vast dis=
traction of dental organs, is the want of cleanliness.
This proposition becomes more forcible when put in the uﬁirmative form—via, that if
the teeth are kept absolutely clean they will not decay. '
It is not probable that so simple and so direct a statement, so broad, so comprehensive
and so complete, can be made embodying any other idea, or the different ideas which havd
been advanced.
It is upon the face of it unquestionably true, and would seem to prove that the con-
verse statement of want of cleanliness was the real cause underlying tooth degeneration.
But this is not true. Want of cleanliness is only a factor associated with many others to
give it any potency. With all other factors eliminated, it is not at all likely that teeth
would ever decay, simply because they were not cleaned.
The cleaning of teeth, as it is now conducted with lotions and pastes, with powders,
brushes, and silk, was unknown to the ancients, who were innocent of any thought of such
a necessity, and besides we are even now frequently seeing perfect dental structures, which
have never known cleanliness as at present understood.
Should we accept want of cleanliness as the sufficient answer to our inquiries, it would
5 36 DISEASES or THE TEETH.
dispose of the necessity of any discussion of the agency of “ Electrical Conditions,”
“ Chemical Solutions,” “Acid Secretions,” “Fungi ” or “ Parasites,” by whatever name
they might be called ; for whatever might be the agency, external and foreign to tooth sub-
stances, which was aeting detrimcntally, absolute cleanliness would prove the radical cure.
Nevertheless, this most plausible of all practical theories is more important in its remedial
character than as an explanation of the primary cause.
Each and all the theories thus far noted may be classed among secondary causes, any
one of which may have some direct application in certain individual cases, but neither
one, nor all together reach the root and foundation of the difficulty.
“ Climate inﬂuences” is the cause, says another, and still another, “Intermarpiage, or
the Mixing of Types.” These terms, although not altogether meaningless, have probably,
in the minds of those who use them, only a vague and indeﬁnite relation to the subject.
The more one reﬂects upon it the less is he inclined to adopt the idea that climatic con-
ditions are anything but a coincidence.
Climate, per 80 cannot, possibly inﬂuence directly the disorganization of tooth struc-
ture; the changes from heat to cold, from damp to dry, from high barometer to low, do
not in themselves affect tooth substance, no matter how frequent or how sudden. Nor
does the prolonged continuance of any one of these conditions, with or without any of
the others, produce any visible change. The inhabitants of the torrid and the frigid zones
have equally sound mastieating organs, and so have those of high altitudes, under a pre-
vailing low barometer, as well as those at the sea-side, under the other extreme.
Districts may be malarious to the unacclimatized, and the whole system poisoned, but
tooth-structure suffers, if at all, only as a secondary result.
Intermarriagc, interbreeding, or crossing the different types of the human race, ought
not to result in defective tooth structure, Reasoning from analogy, in the crossing of
different breeds of animals improvement should be looked for and not degeneration.
Interbreeding among diseased, deformed, or unsound subjects, carries with it its own
antidote, and would very shortly exterminate the race, but the fault would not lie with
the principle involved, but with the subject chosen. Interbreeding, in its highest application
and essence, involves that only sound and healthy subjects be brought together, and a
superior quality, rather than inferior, is the natural result.
While this applies to structure, it may not be equally true of arrangement. The mix-
ing of sound,but inharmonious, types, may result in deformity of arrangement, but not
in disorganization or deterioration of structure.
Interbreeding of unsound and diseased subjects with the sound and healthy, is equally
a perversion of and an abuse of the principle.
Other vague theories—used, often, without much understanding, but of general appli~
cation—are formulated as “ Constitutional Conditions,” “Violations of Hygienic Laws,”
or “Hereditary Predisposition;” but the most comprehensive of all agencies, and the
most intangible withal, which has been made sponsor for this growing curse of the human
race, is—“ Civilization.” What is civilization ?—--and what has civilization to do with
decaying teeth? '
Civilization means—out of barbarism, into reﬁnement; out of ignorance, into know-
ledge; out of bondage, into liberty; out of privation, into comfort.
Civilization expands the intellect, represses vice and savage instincts, cultivates virtue
and noble aspirations, encourages the growth of the emotional nature, and enlarges the
domain of human sympathy. Civilization includes a life of luxury and case, the accu-
mulation of wealth, the development of the arts, and the gratiﬁcation of the appetites and
the aesthetic tastes. Civilization deﬁes and controls the elements, organizes commerce,
builds cities, railways, telegraphs, and factories, and brings to our vision the most in-
ﬁnitesimal organisms, as well as the mighty worlds of boundless space.
DISEASES or run TEETH. 537
Civilization is the divinely-appointed method through which mankind derive their
greatest blessings, and by which they reach their highest possible state of intellectual,
moral, and social development. Through civilization is to come the grandest achieve-
ments of the race, the possibilities of which are so much greater than have even been
conceived, that if now presented to the mind they would be regarded as proceeding only
from the Inﬁnite ; and only through civilization will the millennial, or ideal, existence of
the human race ever be attained.
Civilization, therefore, is a normal condition of mankind, entirely consistent with
perfect health and development, and is the agency of evolution from a lower to a higher
grade. Nevertheless, while civilization thus contains within itself the elements of the
highest attainable ﬁnite perfection, it is made the author of nine-tenths of the disorders
which now affect mankind. 1n the rude and barbaric state disease is as uncommon as
among the brutes; the sickly and feeble must go to the wall; the ﬁttest only can survive.
But with reﬁnement and culture comes enlargement of human sympathy, and the weak
and suffering are cherished with fostering care ; the sickly child is nurtured tenderly and
carefully into manhood, to become the progenitor of a tainted family, and the seeds are
sown which bear fruit for generations.
Civilization is not responsible for the disorders of civilized communities ; but disease,
deterioration, degeneration, and decay, arise from the neglect of, or abuse of, the re-
sources, the agencies, and the products which civilization brings. Crowded communities,
ﬁlthy abodes, vitiated atmosphere, hunger, privation, and exposure—among the lower
classes—breed diseases which sap the foundations of life. But neither of these, nor all
combined, tend to produce the disastrous effects which follow the habits and mode of
life of the more intelligent, the more wealthy, and the more cultured classes.
The increasing tendency to the degeneration of the dental organs of these days, and
which has now become alarming, is exceptional among the lower classes, while they re-
main in that class; it becomes distinctly marked when, by the accumulation of wealth,
they are enabled to adopt the practices of the higher classes, and thus become subject to
the same deteriorating influences.
Caries of the teeth is only incidentally connected with the diseases which prevail
among a class inured to constant physical labour, whose minds are fully occupied in
solving the question of daily bread, and who are content when food, clothing, and shelter
are provided. Fevers, inﬂammations, or epidemic diseases, do not, necessarily, cause
teeth to decay. People are constantly passing through these various complaints, and the
teeth remain intact. But, passing out of this condition in life, into the more reﬁned
and luxurious, we ﬁnd physical labour exchanged for mental; strain of mind takes the
place of strain of body; muscular tension ceases, and nervous tension takes its place;
the vices of luxury supplant the virtues of privation ; the individual, no longer content
with having satisﬁed his daily wants, enters the struggle to obtain a higher place in the
social scale, to accumulate wealth, and to he envied by his former associates.
Reﬁnement and culture create new ambitions, new responsibilities, and new anxieties.
Every added anxiety brings an additional mental strain. The mind—and the mind only——
is constantly on the alert. The brain has no rest. Nutrition of muscles and bones is
diverted to repair the undue waste of nervous tissue; and sooner or later come, inevit-
ably, to parent or offspring, the long list of nervous diseases which now so threateningly
confront us. The testimony of the most distinguished 11eurologists—especially in
America—is uniform and undeniable, that diseases of the brain, the spinal cord, and the
nerves which issue from them, or the sympathetic system, are alarmingly on the increase.
The causes which tend directly to produce such results are more potent, and more active,
in the Northern United States than in any other locality upon the face of the globe.
S33 DIsEAsEs on THE TEETH.
Causes and results which might pass unnoticed in other localities, from their infre-
quency, are there exhibited in their most pronounced forms; and thus better oppor-
tunities are then afforded for the study of these phenomena than anywhere else. The
reasons for this (which time will not permit us to discuss) have their foundation, pri-
marily, in the institutions of the country, which permit every one to indulge his wildest
political and social ambitions. Add to this, opportunities for accumulating wealth
unparalleled in the history of nations, together with the influence of railways, steam
printing—presses, and telegraphs—whieh bring a whole nation into a common bond of
sympathy-and we find every excitement, and every stimulus, for the intensest mental
activity. For these reasons causes multiply and results develop with far greater
rapidity in the New World than in the Old ; but testimony is not wanting, that the same
thing, in kind, but more limited in extent, is now going on in Great Britain; and even
heretofore stolid Germany is developing a like transition.
Decaying teeth and nervous diseases are correlated—each, in a measure, resulting
from the other, and both symptoms of a common cause. Neurasthenia, or nervous ex-
haustion, is the almost uninterrupted condition of large numbers of the most highly
cultivated and most charming people of modern society. I use the term, “nervous
exhaustion,” not in a positive, but in a relative, sense. Thousands, among the classes
referred to, may not show the positive symptoms of nervous exhaustion ; but they have,
nevertheless, no reserve nervous force.
With watchfulness and attention to their health, and from long habit in a beaten
track, they may be quite equal to a systematized daily routine, but any undue excite-
ment, any excessive emotional strain, any unusual physical labour, becomes a drain upon
a nervous system without a reserve force which breaks it down, carrying it beyond the
point or possibility of immediate recuperation.
Every intellectual faculty developed by civilization, every emotional excitement of a
ﬁnely strung nervous organization, contains within it the possibilities of the highest
enjoyment, but when stimulated to excess or abnormally used, impairs with unerring
certainty other bodily functions.
The teeth require as constant nutrition as the muscles, the bones, or any other organs
or tissues of the system.
Teeth decay, primarily, because the nutrition of their organic structuresbeing with-
drawn, retrograde metamorphosis ensues; and, secondarily, because the agencies born of
diverted, improper, or inadequate nutrition, are capable of producing their chemical
solul ion.
Caries is simply solution or disorganization of tooth constituents by agents which are
always external, but which would be quite inert under other constitutional conditions.
The vitality of well organized tooth-structure in a healthy body is quite sufficient to
counteract the effects of any active external agents which might be temporarily present ;
but when nutrition is insullicient or diverted, the resisting power of its vitality inade-
quate, and destructive agents present, the teeth will yield at their weakest points, and
caries result.
Herein we find the explanation of many cases {which are seen of caries having made
considerable progress and then ceased, the causes which produced it having evidently
spent their force, or rather the conditions which permitted caries to advance having
terminated.
Parents whose teeth are decaying because ofdiverted nutrition, and exhausted nervous
force, transmit, by the inevitable laws of inheritance, this condition to their offspring
and it becomes in them constitutional. '
Children born of parents whose physical health is barely equal to a continuance of
their mental activities, enter the life-race handicapped.
DISEASES or THE TEETH. 539
That which was possibly but a temporary state in the parents, which might pass of
itself, leaving no trace, or, at least, without serious effects upon the teeth, may become
the ﬁxed and permanent characteristic of the child, to be fought against and combated
through life.
A child entering lite under such unpromising and predisposing circumstances, will
almost inevitably show frailty of physique, with poorly organized teeth and a certainty ol
their early decay.
Unless active and constant effort is made to arrest the result, the steps on the
downward grade are as inevitable as mathematical law. Every mental or emotional
excitement, every intellectual stimulus in early childhood, only aggravates the inherited
and constitutional tendency, and the teeth succumb to destructive agencies which would
otherwise be harmless.
The physiological law and its rationale are very simple. Excessive mental or
emotional activity impairs digestion and diverts nutrition to the brain to repair undue
waste 5 from lack of nutrition the teeth become degraded, and fall an easy prey to the
aggressive agencies generated by the same disordered and defective assimilation.
The organic condition of the tooth, resulting from the want of proper nutrition, is
thus the primary cause or essential element, either directly or originally, which gives
potency to other causes which are superﬁcial.
Given an unimpaired nervous system, in a sound body without inherited taint, and
teeth would never decay so long as that condition was maintained, and that, too, irre-
spective of climate, peculiar kinds of food, or any external agents which might be present
in the natural course of nutrition. Even cleanliness, now considered so essential, would
be unnecessary as a preservative of the teeth, and need be practised only for its comfort.
We thus recognize the relation and the inﬂuence of the many secondary causes, which,
by one or another, have been invested with such importance.
The radical remedy for these evils, and the salvation of the race from degeneracy and
destruction, would seem to involve a return to a habit of lite more consistent with
hygienic laws, but in the present irresistible march of civilization, a return to a primitive
condition of lite would be impossible; but a recognition of. and an adaptation to, a new
condition of society is not only possible, but practicable.
A pessimistic view of the tuture is without reason, for while degeneracy of the teeth
is certainly on the increase with certain families and classes, there are equally certain
signs of its abatement. With increasing wealth in families comes less care, less anxiety,
less nervous strain, more ease, more attention to hygiene, and better habits of life. De-
struction of dental organs is arrested in childhood, and transmission ot‘ tendency is to a
considerable extent stamped out.
The intellectual activity of today, the driving energy and intensity of modern
thought, is not inconsistent with sound constitutions, u ith perfect health in all the
tissues, and with long life. It is the worry which wears out the nervous system, and
not the work.
Civilization, the glory of mankind in their matin'ity-—which has rapidly and largely
advanced at the expense of the best life-blood ol' the race, is, nevertheless, in no wise
responsible for the incidental etl'eets which have resulted from a violation of her true
principles, for out of civilization ought to, and must come, the grandest examples of
physical beauty the world has yet seen, without spot or blemish or taint of disease.
DISCUSSION.
MT. SPENeE BATE, Plymouth: It was my intention to have read a paper on “ The
Tendency to Variation in the Ultimate Structure of the Dental Tissues,” but I have
540 DISEASES 0E THE TEETH.
been precluded from want of extended opportunity of obtaining specimens. I have
already examined the teeth of man taken from ancient tumuli, but these have been
mostly obtained from my own locality, and these I have compared with teeth of the
Esquimaux, Flat-headed Indian, New Zealander, and Ashantee, and the examination
has led me to the conviction, that both in form and ultimate structure, the teeth of the
recent civilized man have undergone, and are still undergoing, a change. If those friends
who may have the opportunity of obtaining specimens of various races, both ancient and
recent, will assist me, they will confer a favour and help me in the research.
Mr. OAKLEY CoLEs, London : pointed out that the teeth referred to by Mr. Spence
Bate, as having remained undeeayed for 2,000 years, although they had been the seat of
decay during the life of the patient, would again take up the process of decay if they
were inserted in an ivory denture and worn in the mouth, thus proving that decay was
extrinsic rather than intrinsic in its origin, and depended for its development upon the
conditions under which the teeth were placed.
Dr. MAeIToT, Paris : It appears to be the conclusion advocated by Dr. Kingsley, that
dental caries is on a rapid increase. I am far from participating in the opinion, which
could only be proved by means of statistics, which are wanting. In reviewing the
history of caries in the past, one would infer that it was as frequent as it is today; in the
time of the Egyptian civilization I have found the same indications ; and going still farther
back, we arrive at prehistoric times, where, as is well known, many of the crania present
evidence of caries. To explain the frequency or the searceness of caries in particular
parts of the earth, the inﬂuence of race must be considered ; for it is certain that at- the
present time many diseases attack certain races more speedily than others, and dental
caries is amongst the number. I endeavoured some time since (in a table published
in a treatise upon dental caries) to show what has been the part played by race in the
distribution of dental caries in my own country.
Dr. GEORGE M. BEARD, New York, said that he was present by invitation of Dr.
Kingsley, that he was not a dentist, but had given much time to the study of the
effect of civilization on the nerves, and had treated of it especially in his works on
“Neurasthenia and American Nervousuess.” Dr. Kingsley was sound and verifiable
throughout, and he was glad to have heard his paper. It was carrying philosophy into
dentistry. fl.) Nervousness was mostlya modern condition. (2.) It was most marked
in America for two reasons: (a) Greater intensity of life; (0) Dryncss of air and
extremes of temperature. (3.) All the special organs of the body have been reasoned
upon in the same way as the teeth, that is, by giving excessive prominence to local and
secondary cause. Hay fever, for example, was formerly considered to be local and
parasitic, it is now proved to be a constitutional, a functional nervous disease.
Nervous dyspepsia also, was once supposed to be purely local, it is now known to be
constitutional, and to be treated constitutionally; just as dentists attributed decay of
teeth to “ sweets,” &c., just so physicians attributed nervous dyspepsia to “rapid
eating,” “ice water,” &c. Savages and semi-savages can eat anything in enormous
quantities, or go without eating, and they do not have dyspepsia, or bad teeth or rarely;
also, they can bear bad air and almost all other evil inﬂuences, and be unharmed;
their descendants also are unharmed. Alcohol and tobacco do not hurt savages. The
temperance agitation is made necessary by civilization. The tendency of evil is to cure
itself, within certain limits ; and Dr. Beard agreed with Dr. Kingsley, that there would
be in the future some improvements.
DISEASES OF THE TEETH. 541
0% Me Causes of Denial Caz/2'65.
Mr. J. R. MUMMERY, London.
The question is perpetually recurring—To what causes are we to attribute the admitted
degeneracy of the teeth, and contraction of the maxillary arch, at the present day?
Many theories have been advanced upon the subject, but a sufficiently extended and
systematic accumulation of reliable data, remains still a desideratum. Nearly twenty
years have passed away since I commenced a series of investigations into the conditions
of the teeth and maxillaa of the races who have successively inhabited this country, and
of the ruder existing races of mankind.
In pursuance of this object I visited, in the course of nine years, every known collec-
tion of skulls, between the museums of Netley Hospital, in the south, and that of New-
castle, in the north. '
More than 3,000 skulls passed through my hands, but a large proportion were without
a reliable history ; I selected nearly 2,000, and recorded the results of a careful
examination in a tabular form ; appending such information as could be attained, from.
their cemeteries, their weapons, and from historical notices—with reference to the food
and social advancement of ancient races in England.
"With regard to existing uncivilized races, I have derived much valuable information
from military and other gentlemen who had resided in, or had travelled through, countries
inhabited by half savage tribes.
In the year 1869 I had the honour of reading a paper upon the subject, at a meeting
of the Odontological Society of Great Britain.
With regard to the ancient inhabitants of this country, I found a very striking in-
frequency of caries, and no instance of irregularity, among the earliest races (whether
Palaeolithic or Neolithic), who were unacquainted with the use of metals. A marked in-
crease is observable in the tendency to caries in the Celtic race who succeeded them, and
whose possession of bronze instruments, and considerable progress in civilization , is proved
by evidence from many sources.
After the Roman conquest, the instances of extensive caries andirregularities, arising
from contracted jaws, are very frequent, bearing the surprising proportion of ten cases of
caries to one case found among the earliest race of people ; and we have abundant historic
proof of the luxurious habits and advanced mental culture introduced by the conquerors.
The inﬂux of the mighty hordes of Teutonic race, or half savage people of simple habits
of life, was followed by a very remarkable diminution in the number and severity of cases
of caries, and irregularity of the teeth.
It is generally admitted that civilized life, with its high mental culture, has a tendency
to stimulate the development of the brain, whilst the maxillary bones, in the absence of
the severe employment of the teeth, in savage conditions of life, suffer a proportionate
diminution in size and power.
It should, however7 be noticed that destructive attrition of the grinding surfaces of
the teeth is singularly prevalent among people, whether in ancient or modern times,
whose food is imperfectly cooked, and, consequently, tough or hard, when compared
with people of civilized habits.
It would be out of place to occupy the Section by further reference to a paper read
some time ago; but it appeared necessary to make a brief mention of my too limited
investigations by way of introduction.
The gathering of such an unprecedented number of scientific men at this great
Congress, has afforded me an opportunity of enlisting efficient aid in research which
542 DISEASES OF THE TEETH.
should not be lost, and I offer the following list of questions, proposed for distribution
by authority of the Congress :M
1. Have you any opportunity of comparing the teeth of mountain dwellers with
those of a kindred race of ‘people who inhabit marshy plains or insalubrious valleys ?
2. Have you observed any injurious eli'ects upon the teeth attributable to the
impregnation of drinking-water with sulphurous acid gas, in volcanic or in coal-mining
districts ?
3. Have you any facilities for comparing the condition of ,the teeth among factory
operatives, with those of an agricultural population in a neighbouring district ?
11-. Have you an opportunity of noticing any especially healthy state of the teeth,
and a fuller development of the maxillae—among sailors, whose diet of hard biscuits and
tough meat demands cificient mastication, thus of necessity approaching the habits of
uncivilized races, and similarly experiencing destructive attrition?
5. Have you observed, among communities in a similar rank of life, who subsist on
a mixed, and often unwholesome, diet, that requires “but little mastication—a less
favourable condition of the jawbones and teeth?
(3. Have you seen any remarkably healthy state of the dental organs among people
who subsist upon oatmeal, pure wheat meal, maize, or lcguminous food, as compared
with those living upon potatoes, or other food, deﬁcient in albuminoid elements P
7. Are you of opinion that the frequent sucking of sweets—especially when com-
bined with citric or other acids-may be regarded as one cause of the increasing pre-
valence of dental caries?
8. Have you observed any nstances of the alleged injurious effect of camphor as an
ingredient in tooth-powder?
9. In instances of the emigration of families, who, quitting a highly artiﬁcial state
of life, have settled in a healthy district or country, adopting simple habits and diet;
have you in such cases had the opportunity of comparing the diseased state of the
teeth in the elder children with those of the children born under the later, and more
salubrious conditions?
10. Have you observed in certain families, who, for a long series of years, have been
under your professional care, a progressive deterioration of the teeth, in each succeeding
generation '9
11. Have you known instances in which the cumulative inﬂuence of hereditary
disease consequent upon repeated intermarriages, has manifested itself in contracted
maxillary arch and extensive dental caries P
12. Have any cases come under your notice which led you to conclude that injury
to the teeth may sometimes be traceable to the over-tasking the intellect of young
children—seeing that the brain is undergoing its most rapid increase in volume at the
precise period of life in which the whole of the permanent teeth, with the exception of
the third molars, are in process of development?
——___-0
A Generalized T rem‘mem‘ 0f [WeguZm/z'z‘ies.
Mr. WALTER H. Corrrn, London.
The possibilities of regulating are known, but on any case of irregularity presenting
for treatment, the practical question will be, What isthe best to do, and what is the best
way to do it?
A classiﬁcation and analysis, in even their inﬁnite variety, of a sufficient number of
instances, and the results of their treatment by every possible means, should afford at
DISEASES OF THE TEETH. 543
least an approximate answer to these and the no less important questions, What not to
do, and how to avoid doing it?
The few models shown have been selected as fairly representative from a collection
of several thousands, recording the attempted treatment of perhaps a larger proportion
than usual of the ordinary irregularities met with in an average practice, and as extend-
ing over more than twenty-five years, illustrating the evolution within certain limits of an
almost generalized method.
A peculiar system thus developed in use for many years, and now more or less fami-
liar, is no longer a novelty ; but as it has been imperfectly made known, for which
perhaps its advocates are responsible, and a misconception exists as to its real object,
those in whose hands it has been an invaluable aid, feel that some account of what they
conceive to be its capabilities and limitations may not be unwelcome.
Classifying any large series, most conveniently by the mechanical exigencies of each
case, in certain of them extraction of possibly sound teeth may of course be necessary,
though these are somewhat less numerous than usually imagined, and a possible alter-
native in many instances affords, as shown by casts submitted, satisfactory results.
A large class, uncomplicated by crowding, in which aberrant teeth are easily replaced,
admit of direct and immediate correction by suitable means (a simpliﬁcation of which will
be further alluded to). Of the remainder, the majority are cases, of every variety, in
which the teeth, not really too large or numerous for the jaw they might symmetrically
occupy, are, by some chance of their eruption, irregularly disposed, interlocked and
crowded. Of these it may be affirmed quite generally, that rectiﬁcation necessitates
the movement of many teeth, or all, and with their changed positions an altered shape or
outline of the dental arch, for any attempted direct adjustment of individual teeth, will
be accompanied by such a disturbance more or less extensive.
This will be found to be the chief diﬂiculty of regulating in the usual way, especially
with a rigid plate. But in the most intricate, or the simplest of these cases, the per-
missive control of the general tendency of movement during regulation, reduces their
successful treatment to comparative ease and certainty. This mechanical anticipation
of favourable conditions may be illustrated by assuming that an incisor has to be moved
in a crowded arch by any means applied by a plate, rigidly embracing the bicuspids and
canines, when a certain force in a certain time may complete the operation; but if the
plate were either abolished, or its two symmetrical halves partly independent and free to
move relatively in the plane of the arch, less time and force would sutﬁce ; and further-
more, if its two halves tend but slightly to separate by an elastic spring reaction, the
operation in some cases will require very much less time and force to be exerted on
the tooth. The action thus stated in its simplest form, is obvious from c? priorz' consi-
derations, but was observed, it is believed, for the first time, by a singular accident.
S0011 after the introduction of vulcanite my father was employing an ordinary plate
of that material to move an incisor by the swelling of wood in a dove-tailed notch in the
plate. Successive increments of force were resisted, until not only was the tooth quite
suddenly in position, but other front teeth were found to be slightly separated, where
previously in overlapping contact, the wood which was nearly on the median line by lateral
expansion having cracked the plate down the centre. In this instance, as will often be
the case, previous “ expansion” by the means usually applied, was certainly not indi-
cated, and therefore not resorted to, although just the slight amount of spreading
required was prevented by the rigid construction of the plate.
A conviction of this led to a particular mode of treating various irregularities, the
adoption of which has been abundantly justified by experience, and which, as anticipating
changes common to them, usually expansive, has been called somewhat indeﬁnitely an
“ expansion treatment.”
544 DTSEASES OF THE TEETH.
The troublesome and delicate operation of “ expanding the arch,” as usually
performed, if attempted by the ordinary “jack screw” direct, must be accomplished
before other regulating action can be commenced, and may then prove to be- either
excessive or unnecessary. The screw is applicable with care to severe contraction,
though inferior to other means; but undivided plates however thin, and elastic, or
hinged plates, however actuated, have not the freedom of movement and self-adjusta-
bility desirable, and the screw is entirely unsuitable for a split plate.
The little device my father called an “ expansion plate,” whether used for direct ex-
pansion or not, is intrinsically of extreme simplicity, while of’ complex regulating
action, comprising a means, easily embodied in any plate, of conveniently permitting or
assisting, instead of hindering or preventing during regulation, the inevitable changes of
the arch naturally accompanying it, and supplementing ordinary expedients with an ex’
pansive characteristic.
Its distinguishing function depends on the principle of permitting a relative motion,
or maintaining a particular controllable reaction, between two semi-independent parts of
it, usually its symmetrical halves.
Any force, however small, is suiﬁeient, if only exerted continuously, with not
too rapidly diminishing intensity. Mere repulsion, however, between two points on a
split plate is an unstable system, and uncontrollable. Allowing a certain freedom of
motion, means must be provided for restraining it, and maintaining by a yielding guidance
any desired degree of parallelism.
Difficulties attended the ﬁrst realization of these conditions, but it is found that a
metallic spring of certain form, if a constructive, part of the plate, will itself meet all
requirements. Trials of the metals and their alloys proved the superiority of apparently
so undesirable a material as steel.
Modiﬁcations of the arrangement found most convenient and satisfactory are
exhibited, some after actual use, others in ditterent stages of construction. The general
form may he described as a rather thin ordinary vulcanite plate, capping and clasping
some or all of the hiscupids and molars, ﬁtting the lingual surfaces of anterior teeth, but
divided completely along the median line into two distinct halves, connected, however
by a slight steel wire, so disposed that, while guiding and limiting their relative motion,
its tension, exerted between them, may be perfectly determined and varied in direction and
magnitude.
When necessary in such a plate to establish the spring reaction, a surprisingly small,
almost imperceptible stress, even so distributed, and against a wide-spread resistance,
if continuously maintained and suitably applied, sutﬁces to produce any degree of motion
desired.
The perfection of the model must he insisted upon. An entire plate may ﬁt Well and
securely, and yet both its halves be so loose when divided as to be useless, while, on the
other hand, the halves of a split plate from a good model may be easily ﬁtted, which
before division could not pogssibly be inserted. The best impressions have been obtained
with the elastic preparations of gutta-pereha or ballata gum, no other material aifording
with ease the absolute ﬁt essential for a split plate. The peculiarity of gutta-percha,
when in good condition, is the physical property at the right temperature of yielding to
slow pressures, and being elastic and recoverable to rapid changes, whereby when inserted
slowly and removed quickly the most intricate undercuts may be copied, and the slight
contraction in cooling just al’fords enough shrinkage for a thin hard rubber copy to ﬁt
tightly. A delicate and elastic vulcanite plate, from a good gutta-pereha impression,
will generally spring over the teeth with so absolute a ﬁt that its removal may even be
embarrassing, but until divided its insertion should not usually be attempted. A good
DISEASES on THE TEETH. 545
model should be vulcanized upon direct, and not require to be touched to accentuate
undercuts or correct imperfections. The almost insuperable difficulty of satisfactorily
tempering bent soft steel, without deformation of shape, was obviated by the use of
pianoforte wire, possessing very uniform texture, temper permitting it to be fashioned
and used without heating, and a surface hardness and burnish which greatly tend to its
preservation. Attempts to coat this wire with other substances were found unnecessary
and undesirable. The behaviour of steel to the ﬂuids of the mouth is such that (after
certain constructive precautions to be described) if hard and bright at ﬁrst, and con-
tinuously immersed in average saliva, it generally assumes a black polished surface, the
smooth, fairly-adherent tarnish being apparently insoluble.
A diameter of between three and four hundredths of an inch, or about 00% inch is
most suitable, as of this a convenient length of from 1 to 2% in. exerts an appropriate
tensionjin average cases. The force, varying inversely as the length, may be thus
determined within those limits, beyond which a different size is required. The
extremities being buried rigidly in the vulcanite, the uncovered and active portion of
the wire, emerging from selected points in the alveolar region, should be entirely on the
lingual side of the plate, nicely ﬁtting, but free to move upon its surfaces. The
wire, between its attachment, may be in a simple curve, when, for localized action (as
exclusively posterior expansion), it will urge a relative motion or rotation about some
point, but that every kind of motion may be established, one or more reversals of
curvature must be made; by either a single couple of opposite curves, or any number of
alternately contrary ones, preferably odd, approximately balanced, and as large and
symmetrical as possible.
Small bends or angles being avoided, the disposition of the wire may otherwise
entirely conform to its most convenient adaptation to the particular plate.
A serviceable form for an upper general expander, is a three or ﬁve-curve serpentine
ﬁgure, like a rounded capital W.
The spring, when in shape, must be free from tension, and attached in the vulcaniza-
tion to the plate, which is made entire and afterwards divided. The spring being shaped
to ﬁt, as nearly as may be, the palatal surface of an upper model, or the lingual surface
of a lower, has its ends, for half an inch (without being softened), slightly ﬂattened
and roughened, and so bent towards the model as to raise it equally from the surface
to a distance of about the desired thickness of ‘the plate, and the portion to be inserted
in the rubber, tinned or coated with common solder.
To several points, upon its exposed part, short ends or loops of binding wire are
twisted, to better secure it in the plaster investment.
The plate being modelled in the usual way, the spring is placed on the surface of the
wax, with its ends buried within,‘ and when removed by the counterpart, protected
from the rubber by tinfoil before packing. Finished in the usual manner, entire, the
plate is divided with a ﬁne saw, the edges and corners of the cleft being well rounded
and smoothed. This, with care, may be done without imparting any tension to the
spring, which is important. The plate should be inserted and worn in the month
without tension for a day or two, to ﬁrst eliminate causes of irritation not due to its
expansive action, and sooner induce toleration of its presence.
Any expansive force required may then be established, and its right direction secured
by stretching the two halves, with a slight exaggeration, into the relative positions
towards which it is desired they should tend to move. This, however, may require
correction and modiﬁcation by observing its effects in the mouth. The amount of
stress, which is not so conveniently diminished as increased, should be small at ﬁrst,
especially in plates whose expansive function may be simply permissive or auxiliary to
Pam III. ~ N N
546 DISEASES or run TEETH.
other regulating action. It may safely be entrusted to the patient (even quite young) to
frequently remove, clean, and replace, after duly cautioning, without fear of disturbing
its adjustment.
The experience gained of steel wire has led to its almost exclusive adoption for
ordinary regulating purposes, as spring levers acting directly on the teeth for pulling,
pushing, or rotating; and being ﬁrmly ﬁxed to the plate, their convenience, adjusta-
bility, and many adaptations are remarkable.
Combined with a split plate it is found to replace with advantage, screws, inclined
planes, wedges, levers, and ligatures, in many of their local uses, and moreover is
practicable where nothing else can be applied. In fact, by the gradual simpliﬁcation of
means, and the elimination of uncertain devices, a delicate split plate, with perhaps one
or two short lengths of small wire, closely ﬁtting its surface, is often now, to those who
use it, the representative and substitute of the wondrous combinations of nearly all the
known “mechanical powers” that once exercised their ingenuity. Where, in'simple
cases, the use of a plate is unnecessary, with an inch or two of steel wire and rubber
tube, efficient expedients may often be improvised.
When direct expansion of the arch is indicated, the thin spring reaction plate, ﬁtting
closely the palate and tissues covering the alveolus, and not ﬁlling the mouth or impeding
any of its functions, will, with the minimum of trouble and attention, effect any desired
degree of that spreading and moulding of the month which it is well known may, to a
surprising extent, be rapidly and almost painlessly produced. So easily is this done, that
caution must be exercised not to inadvertently exceed the intended results, and the
temptation to so readily make room for crowded out teeth, though often with most
gratifying effect, must sometimes be :resisted. Indeed, the extreme facility and rapidity
of general expansion by the split plate, has, in the hands of some without experience of
its limitation and abuses, been to the prejudice of the method.
Among the uses of direct expansion, its interesting application to the operative treat-
ment of caries, and to slightly overlapping incisors, may be discussed together.
In young mouths, where interstitial decay of incisors closely in contact almost deﬁes
successful treatment, any operation attempted, whether of separating, shaping, or ﬁlling
cavities, or restoring contour, will of course be facilitated by gaining ever so small a space
between the teeth. Paradoxical as it may seem, it is actually less painful and troublesome
to secure ample space between all the front teeth at once, than to wedge two of them
apart in the ordinary way; with the advantage of easily maintaining their separation, with-
out irritation, during any course of treatment.
A plate exerting anterior expansion will rapidly, and usually, almost painlessly, separate
the incisors, and by a suitable adjustment of the bearing surfaces may readily be caused
to distribute spaces equally between all the front teeth. Their slight tenderness soon dis-
appears if held by the same or another plate, and they may be kept apart without fear of
their not coming together again. In cases of nerve inﬂammation, caution will suggest
itself, but an accident has not occurred from that cause. Models are submitted of this
effect. If the incisors are overlapping, slight expansion, with just suitable disposition of
the bearing surface afterwards, usually permits the natural action of the lips to straighten
them.
In some of these cases it may be necessary to partly maintain the expansion of pos-
terior teeth by a suitable retaining plate exposing their articulating surfaces till the bite
is re-adjusted by those of the other jaw accomodating themselves.
I/Vhere the expansion in one jaw is considerable, the correction of the bite may re-
quire a slight mechanical expansion of the other, which for this purpose, and assisted by
the articulation itself, is easily attained. Expansion, where posterior teeth wrongly
DISEASES OF THE TEETH. 547
articulate, presents little difficulty when the conditions are symmetrical on both sides;
when otherwise, or conﬁned to one side only, a differential or even a unilateral effect may
be produced, according to the number and kind of teeth the action of the plate may be
distributed or concentrated upon, and the arrangement of its articulating surfaces. In
differential expansion (which may occur unexpectedly), the relative [motions appear
disproportional, that is, seem to vary (inversely) more than the estimated resistances.
Lastly, the obvious application of expansion to narrow misshaped months with high
contracted roofs, unfortunately also presents the greatest difﬁeulty. Many of these cases
admit of very great improvement, as illustrated by model's exhibited, where circumstances
are favourable for expansion, as when the bite can either be kept normal or made so, and
the jaw is not really as contracted as the dental arch makes it appear, but these must be
treated with caution. In several cases accompanied by prominent incisors, after only
slight posterior expansion, considerable spontaneous recession of the incisors has occurred,
probably by the action of the lips, before any special mechanical means were employed.
In the models of some cases treated will be observed the profound alteration in shape the
palate vault appears to have undergone. Inﬂammatory symptoms observed along the
median line corresponding to anatomical relations, but possibly caused by the edge of the
cleft plate, have suggested certain bone disturbances, but though the extensive damages
seem otherwise almost inexplicable, interosseous action can only be conjectured. While
expansion is most readily performed in young mouths, especially under sixteen, the only
limitation in age would seem to be the diminished power of restoring ﬁxity after movement
which must be inferred of advanced age, though in a case of considerable expansion at f orty-
ﬁve, the teeth became perfectly ﬁrm afterwards. It is hardly necessary to dwell on the
desirability of the greatest simplicity of regulating devices, in principle and details, and
the self-maintaining adjustability of plates, that they may be as independent as possible
of any control by the patient, whose co-operation should be conﬁned to maintaining their
perfect cleanliness only, and the health and comfort of the month. But it may, perhaps,
be pointed out, that greater beauty and ﬁnish of plates than is customary, is not without
effect in assuring care and attention to their good condition by arousing interest in their
perfedtion. Great credit is due for working out certain details of expansion plates, to
Mr. Peter Headridge, of Manchester, for many years assistant to my father. This gentle-
man even obtained a patent for some constructive particulars, which he very advisedly
allowed to lapse. The curious are referred to Speciﬁcation 1101—1869. In ﬁnal justi-
ﬁcation, the advocates of means that simplify, extend, and may revolutionize the treatment
of irregularities, appeal to the records of their results, as matters of fact, with the con-
viction that, whatever their real importance or value may be, they would have been diflieult
or impossible to otherwise attain, and venture at such length to detail their procedure in
order that their conclusions may be conﬁrmed or criticized by others.
DISCUSSION.
Dr. ROSENTIIAL, Liege : Fearing that the method of Mr. Coﬂin may not be appre-
eiated, I feel it my duty to communicate to you, that eight years ago Mr. Coﬂin explained
his method to me, since when I have employed it, with a success that I had never obtained
so easily by the methods that I had formerly employed. I have been able to undertake
my cases without having recourse to the extraction of sound teeth ; besides, his theory
is correct, most irregularities proceeding from the narrowness of the dental arches, which
his apparatus enlarge, so that the teeth come into position naturally. I ﬁnd it easv to
carry out, rapid in its results, and but little distressing to the patient.
NNZ
548 nrsnasns on ‘THE rnn'rn.
Causes of fa/rcgwlm’z'tz'es of Position of 1726 Tact/z.
Dr. Tnonxs BRIAN Genuine, New York.
GENTLEMEN,—I premise that after deciding to offer this, and when looking into what
had been done in the past, I found, in the New For/l: Dental Recorder for 1811-7, a trans-
lation of the “ Reﬂections of M. P. A. Grandhomme, on the Methods used in Regulating
the Teeth,” and, to my surprise, I saw that, before 1840, he had, in Germany, practised
the regulation of the teeth as soon as they appeared, and by means of a new method,
which was, in principle, the same as that now used by myself. To his arguments in its
favour, and in condemnation of the ligatures, metal straps, &c., even still in common
use, there is little to add. His experience dated back at least to 1828, when he made
the numerous apparatus offered in that year, by Professor Carabelli, to the University of
Vienna, intended to illustrate the subject. He criticized, most intelligently, the methods
of M. Catalan, M. Delabarre, and M. Desirabode'; and condemned the adjustment of
teeth by forcible luxation, as introduced by M. Uudet. His views were published in
Paris, in 1845, and translated as above, by Dr. E. Baker.
I agree with this cultured writer in his estimation of the importance of this branch
of practice. I, however, differ with him in his rejection of M. Grandhomme’s early re-
duction of irregular positions of the teeth in children. I have long practised this, and
supposed myself to be the ﬁrst who had written in favour of it, until, as above, I came
across M. Grandhomme’s able presentation of the different methods known in 1845.
Since that period practitioners have had for their guidance the investigation and dis-
coveries of Owen, Nasmyth, Goodsir, Tomes, Saunders, Lintott, Cartwright, Mummery,
and others ; and, in this kingdom at least, the great advantage of association with those
in the other branches of medical science in renowned hospitals and dispensaries.
But their most trusted teachers and writers upon “ Irregularities of the Position of
the Teeth” ignore the facts of Nature, and teach others to work, not only outside of, but
in opposition to, her processes.
This paper cannot consider the special traits in the jaws of different races or nations,
nor attempt to account for abnormal conditions which are hereditary or congenital.
Discussion upon irregularities of the teeth which result from fault in the jaws will
be more useful when remarking upon the features it is desirable to improve, and showing
the means to accomplish it. This, especially, as the relations of the jaws to the teeth
and their alveolar processes will be explained, because they are not only imperfectly un-
derstood, but misrepresented, it being asserted that the jaws are developed in advance
and independently of the teeth and alveolar process, and that these may be removed
without affecting the jaws.
Normal growth is sometimes interrupted by disease, which checks nutrition, and
parts may be lost by necrosis, or adhesions form which obstruct the movements of the
lower jaw. The limits of this paper, however, prevent remark upon these lesions, except
to say that mere stretching will not release the jaw ; the knife, saw, &c., must be used ;
and if a false joint is required, it should be made, if possible, in the ascending ramus,
about one-fourth down from the top of the condyle to the angle; thus the external
pterygoid muscle of the other side will depress the jaw readily.
At the seventh week of foetal life the germs of the teeth begin to start from the
mucous membrane, which lies between folds somewhat ﬁrmer than itself; and by the
thirteenth week the papillae of all the deciduous teeth are enclosed in open follicles. At
the ﬁfth month, the germs of the ten anterior and of the ﬁrst molar teeth of the per-
manent set start; and as the deciduous teeth with the sacs of the ten permanent ones
grow, and take up more space, the permanent molar is forced into the tuberosity of the
DISEASES OF THE TEETH. 549
upper jaw, or into the eoronoid process of the lower. They occupy these positions until
the eighth or ninth month; during these two months, the basilar portion of the lower
jaw, which supports the alveolar process and teeth, and also gives attachment to so many
muscles, is rapidly developed; yet at birth it is comparatively incomplete.
In nursing, the upper jaw is supplemented by the lip, the nipple being held against
the roof of the month by the stronger and more active lip, assisted by the less-developed
jaw. This keeps the lower jaw back, and the upper jaw projecting, in accordance with
the earlier development of its teeth in foetal life. In general, the central incisors of the
lower jaw appear ﬁrst; but when those of the upper come, they are soon joined by their
lateral neighbours, the lower lateral incisors emerging later from the jaw, which is still
without bony union at its symphysis. Thus, the lower teeth are kept back inside the
upper. The lower jaw is more easily observed than the upper ; it is, therefore, referred
to in preference.
The deciduous set of teeth which begin to appear about six months after birth, are
by three years of age arranged in the mouth. At six years the lower jaw is seen to be
much deeper and larger in every way, as it holds the temporary set of teeth and also
the permanent, so far as developed.
The jaw generally lengthens until three large molars have come through on each
side behind the semicircle which held the deciduous set. The third molars come down
like the second and ﬁrst molars into the dental range, the horizontal portions of the
jaw growing an inch or more in front of the ascending ramus in the lower jaw, and an
equal length in the upper jaw.
It is apparent that from the start the vital force is specially exerted to perfect
the teeth, and form thejaws for their protection and arrangement in the mouth. The
alveolar process develops with the teeth, and the basilar part of the lower jaw, which
grows rapidly just before birth, continues to enlarge in proportion to the develop-
ment of the teeth; this is shown clearly in its growth to admit the permanent molars.
N ow all this change of the jaw from before birth until adult life is in connection with
the development and arrangement of the teeth; and enough has been shown to prove
that the growth of the jaws is generally controlled by the development of the teeth.
It is now necessary to inquire ,how the jaws are affected by the loss of the teeth;
for if the jaws are out of proportion, one, especially the lower, may be too large or
otherwise deformed. From a short time after birth, even with both jaws normal,
conditions may arise which tend to deformity, but they are so well known as to require
no special explanation. The permanent front teeth, when about to replace the
temporary ones, are packed in the alveoli and in a somewhat smaller circle than the roots
of the deciduous teeth ; therefore the central incisors of thelower jaw come up to the back
of the deciduous incisors with their mesial sides projecting, and their distal sides kept
back by the unshed laterals; the permanent laterals come with their distal sides
projecting, the mesial resting behind the centrals; and the canines come up outside
and turn in the laterals which turn the centrals into range. This is when the parts
are regularly developed, and the deciduous teeth shed naturally. If the infant teeth are
lost too soon, then the permanent eentrals may be turned out too much by the laterals,
and the last turned in too much by the canines. This, however, is not the whole injury;
for the cutting edges of the incisors will project forward too soon, and develop their
roots towards the inside of the jaw, instead of forming their alveoh in a larger circle
nearer to the front of the mental process. Again, the growing permanent teeth are not
so likely to expand the parts as when assisted by the deciduous roots. The effect of
premature loss of temporary teeth is proved by loss of the deciduous molars; a bicuspid
grows between the roots of each, and if these roots are lost early, the bicuspid teeth
SSO DlSEASES OF THE TEETH.
are not wide enough to keep the large molar back. New this forward movement is
common to all the permanent molars while anyone of them is still up behind the
dental arch; they often crowd the bicuspids, and make even the lateral incisors close
too much on the eentrals. '
When the way is open to them through early loss of the teeth, they develop and come
into range sooner; and in proportion as they ﬁnd room forward, their alveoli require
less growth of the basilar portion of the jaw in front of the ascending ramus. It is thus
clear that loss of teeth contracts the alveolar process, and also tends to shorten the
jaws.
I submit two examples, one, which originated before birth, shows defect of jaw from
a want of teeth; the other, lateral deformity through the loss of a teeth from one side
only. The ﬁrst was taken from a boy ﬁfteen years and a half old ; only seven teeth of
the infant set were in the upper jaw, the lower had ten; but in both jaws the incisor
teeth were pointed. No permanent teeth had developed, nor were there any indications
of their being in the gum. The upper jaw was very small. His mother thought the
deformity was caused by a fright she received from an animal. The boy’s health and
intellect were good. I lost sight of the case over twenty years ago.
The second case is that of a patient eighteen years and a half old, who had the
right lower permanent ﬁrst molar extracted when between nine and ten years of age.
In May, 1877, I began to widen the roof of the month, between the bicuspids, to
remove the pointed form of the upper jaw; this was accomplished by December.
The fourteen upper teeth then articulated well with the thirteen lower, but during
the last three years the lower wisdom teeth have enlarged the jaw, so that the lower teeth
project outside the upper all around, but more so in front where the jaw is out of centre,
the chin being a quarter of an inch over to the right, through the left wisdom tooth get-
ting room to come down by the growth of the jaw; while on the right the wisdom tooth
came into the place of the second molar that had moved forward to the bicuspid, the jaw
not growing so much on this side which lost the molar. The wisdom teeth are even with
the second upper molars, while the left lateral incisor is up to the division between the
upper centrals ; there is as yet no indication of the upper third molars. The jaw is ﬁrmly
jointed in the gienoid cavities, the left angle is out a little, but the great deformity is in
front.
In these anatomical and physiological condition and processes, we should seek for a
way to counteract the abnormal departures ; and the way to modify the relations of the
jaws and teeth will be still more apparent, after some suggestions as to the effect of pre—
mature loss of the deciduous teeth upon the position of the permanent set, and some
remarks upon the effects of diseased teeth. These suggestions are made more particu-
larly to aid in the selection of appliances.
As the lower permanent teeth usually appear before the upper ones of the same class,
so the expansion of the lower jaw is somewhat earlier than that of the upper. Con-
sequently in the time between the completion of the ﬁrst set and the appearance of the
six-year-eld molars, the lower jaw may grow too large, and its incisors strike on the
edges of the upper front teeth, and this so that it is uncomfortable, and in order to rest
upon the back teeth the muscles in such cases hold the jaw and the front teeth forward.
Or the jaw may be held out through the too early loss of its infant incisors, allowing the
permanent ones to get in the way, and they are held in front for comfort.
Now when an infant tooth remains too long unshed, the permanent one may be kept
out of range, and the jaw even be misplaced by it; this should be corrected, but as the
alveolar arch will not be diminished in front, nor eneroached upon behind by the molars, to
extract unshed teeth and bring their successors into place is but a simple matter, corn-
DISEASES OF THE TEETH. 551
pared with the trouble caused by want of room through the too early loss of infant teeth
allowing the permanent ones to develop the points of their roots backward into a smaller
circle. The forward action of the lower jaw may also commence through a tender front
tooth of either jaw ; or if a side tooth is painful, the muscles may hold the jaw out of centre:
and it may grow deformed, or its joints with the glenoid cavities may alter and perma-
nently displace it. This deformity is also occasionally quite convenient for the time,
Where the abnormal position of the jaw gives a more comfortable position to the teeth; so
that when the jaw moves out of centre, it brings its teeth on one side more in articulation
with those of the other jaw. -
Thus in 1865 I was called to a patient sixty-two years old,whose jaw had for years been
held out to fit his teeth. He was now under treatment for fracture through the neck of
each condyle, having fallen on the curb-stone, so that his jaw was driven back and the
overlapping teeth snapped off. The bandages were removed, and the jaw proved to be
unbroken.
In a child which has been fed by the bottle, or which has ahabit of sucking its tongue
or linger, we frequently see projecting upper gum and teeth; this displacement should
teach us that teeth may be moved early, and that they need not be left out of place until
ﬁrmly held by their full grown sockets, as is generally practised. The teeth press each
other into or out of regular position, without causing pain or injuring each other,
and if, when cutting the gum, they are out of place, they may frequently be made to
regulate themselves by the use of proper appliances while growing.
At any time after four or ﬁve years of age, a rubber plate which ﬁts and covers the
teeth of the lower jaw, running down on the gum inside somewhat, will restrain undue
enlargement, while, with appropriate projections above, the upper teeth will keep the
lower teeth and jaw in place. It will do this by retarding the growth of the lower
alveolar arch, and perhaps by spreading the upper teeth, and it frequently breaks up a
temporary holding of the lower jaw out of position, which if left alone might cause
permanent distortion.
A lower incisor often comes with its cutting edge turned, so that it will be pressed
more out of range when the next tooth appears. This can be corrected by letting it grow
into a channel cut in a plate such as just described, or in a mere skeleton plate, which
allows the tops of the teeth to appear and strike the upper ones as usual. In this way,
or a modiﬁcation of it, the teeth may be put in place before the next is so far up as to
block the way. This is but a simple following of what is often seen in the gums when
a piece of an old root, &c., turns a growing teeth out of line.
In cases of projection of the lower jaw, caused by muscular action drawing the con—
dylcs toward the eminenthe articulares, a plate, which projects out from under the upper
incisors down in front of the lower, will generally press the jaw back, and, at the same
time, it may be used to correct the positions of the teeth which caused the jaw to come
forward. Or, if required, a plate on the lower teeth will throw the jaw back.
A projecting jaw, which is well seated in the glcnoid, cavities, cannot be pressed
back by any apparatus in the mouth, nor by any outside around the head and jaw,
whether as pictured in the books or otherwise. If the condyles were pressed back from
their natural position, the cars would be closed.
In families with a tendency to long lower jaws the children should be carefully
watched, for much may be done to modify the relations of ‘one jaw to the other, and of
each to the teeth within it, by carefully discriminating between teeth to be extracted
and those to be saved, especially if observation is afforded in early life, and operations
are made to conform to what is indicated by the quality and condition of the teeth, in
connection with their relative value, and in respect to hereditary tendencies.
552 DISEASES on THE TEETH.
Except for the relation between the teeth and jaws, and for the changes which are
usual to them in the earlier years of life, the most intelligent treatment could be of little
avail in preventing or in remedying malformation.
The fact that when the teeth are lost the jaws are still able to act in functions other’
than mastication is no justification of the misleading statement that the teeth and jaws
are independent of each other.
If the teeth, as awhole, are too large for the jaw, they should be kept in to encourage i
the growth of the jaw, as long as this can be promoted, and then such of them extracted
as can be best spared to make room for the others. If a jaw is too large prospectively,
remove the necessity for its growth, whether in the least important teeth, or in their
position, and especially guard against habits which tend to this deformity.
If irregularity be treated by appliances, they should act naturally; those just
described press the teeth either through their own growth, or similarly; when the jaws
close, they give the shock usual in natural movements, but upon the intervening appli-
ance. Thus, if the teeth are moved, they are never lifted from their sockets. The teeth,
as a whole, support each other, or are affected naturally, and are not moved unnecessarily
in other functions. This is especially so with these regulating plates, they having gold
hooks imbedded in them, and being used without anything more elastic than hard wood,
which drives each teeth by direct pressure; in this way the apex of its root is carried
out with its crown, especially in the lower incisors and the upper laterals, whose thin
roots move readily in the alveolar process, when their crowns are held back by the
adjoining teeth, or their cutting edges restrained by gold hooks.
Dental practitioners enjoy, at this time, great facilities for the manufacture of their
various contrivances, while periodicals and books are numerous, to which they may refer,
and in which many have shown their peculiar methods; but careful scrutiny gives no
assurance that they regulate teeth any better than men of good standing and skill, in
Germany and other parts of Europe, fifty years ago.
012 Z/ze Origin and T Veaz‘mezzz‘ of Car/mm Forms of
[VVeguZm/z'z‘z'es off/w Teal/z.
Mr. J. OAKLEY‘CoLEs, London.
In my classiﬁcation of the deformities of the upper jaw I have endeavoured to
establish the theory that a large number of cases of irregularities of the teeth are due to a
malformation of the jaws, rather than to a mere displacement of the dental organs. In
other words, I have asserted that the arrangement of the teeth is but the expression of a
profound morphological change. In continuance of my investigations in this direction,
I desire to call attention on the present occasion to that variety of the brachoid jaw in
which the region of the bicuspid teeth is the seat of lateral compression. It is a fact
that will scarcely demand proof or veriﬁcation, that at birth all upper jaws are normal in
size and outline. At this date the antra are little more than rudimentary, and occupy
but a small space between the base of the alveoli and the floor of the orbit. The
intermaxillary articulation is generally normal in character, and the position of the lower
jaw in relation to the upper rarely affords any evidence of the changes to which they
will afterwards be subjected. Whatever may be the influence of heredity, such influence
ﬁnds expression during the period of growth, rather than that of development, and
structural and functional dcrangements are manifested and intensified chiefly at a date
subsequent to the shedding of the deciduous teeth. In the perfectly healthy subject the
face and jaws will have arrived at a normal state of development at about the age of

DISEASES on THE TEETH. 5'53
puberty. The features of the‘ face will have become permanently marked out by the
gradual growth downwards and forwards of the upper maxillary bones and adjacent
structures. The chief factor in the production of these results is the growth of the body
and wings of the sphenoid. By the agency of this bone the intermaxillary region is
carried forward, and space provided, posteriorly for the increased length of the true
maxillary processes. The two glenoid cavities become more widely separated from each
other, and the direction of the long axes of their articular surfaces and of the
corresponding eondyloid processes of the lower jaw become subjected to important
modiﬁcations. During the time that these changes are taking place, the antra will have
become considerably increased in size by the lengthening, in a vertical direction, of this
portion of the upper maxilla. Although the maxillary sinus may vary in capacity from
one to eight ﬂuid drachms, it should still physiologically bear a deﬁnite relationship to the
facial angle. To compensate for the advanced position of the maxillary bones, the palate
bones grow in such directions as to ﬁll up the gap that would otherwise exist between
the posterior extremity of the dental arch and the pterygoid processes of the sphenoid.
If all the parts involved in the formation of the upper and lower jaws have grown in
proper proportions to each other, the teeth will only be subjected to such forms of
irregularity as may arise from some purely mechanical condition conﬁned to the
normal area of the dental arch. If, on the other hand, the jaws themselves have been
subjected to any irregularity or inequality of growth, the entire dental arch will be the
seat of well-marked deformity, and the teeth themselves be but an integral, and not
independent, element in the production of the conditions we are discussing; or, to put
the case in another way, the teeth are in the one instance the cause of the dental
irregularity, whilst, in the other, they only give expression 'to a general maxillary
deformity in which they are involved. For the purposes of the present paper I now wish
to call attention to that form of brachoid jaw in which the bicuspid region gives
evidence of lateral compression, rat her than of lateral expansion. In such a case the six
front teeth are crowded together, whilst the second bicuspids are implanted, in a severe
example, with but a space of ﬁve millimetres between them in the transverse direction.
The ﬁrst bicuspids, although inside the dental circle, are not so seriously disturbed. If
the deformity has been allowed to progress unchecked until 21 years of age, the grinding
surfaces of the bicuspid teeth are frequently on a lower horizontal plane than the
remaining dental organs of the upper jaw; or, in other words, in the case of the four
bicuspids, we may say that the bite is raised.
The external alveolar wall will show compression corresponding to the teeth as
measured from side to side, and in a well-marked case pass vertically upwards, or even
outwards, towards the level of the ﬂoor of the antrum. In many instances, the lower
jaw will be of unusual dimensions, not merely in comparison with the upper maxilla,
but also in comparison with a normally developed jaw at the same age. The interdental
articulation is, of course, destroyed, but beyond this the horizontal rami and body are
unusually thickened, and at both the alveolar and inferior borders present a curious
thickening and rounding. The inferior dental arch passes outside the superior dental
arch at all points. The mental outline is almost rectangular ; whilst the outline of the
ascending and horizontal rami are generally obtuse-angled. The soft palate is generally
short, as measured from the posterior wall of the pharynx; the vertex of the hard
palate is apparently above the normal plane; and the tonsils are almost in every case
considerably enlarged. Externally the face presents certain well-marked and charactcr~
istic appearances. There is a peculiar flatness and squarencss from the root of the nose
to below the mental eminence, which I can only describe, in the langu. 0'e of an artist,
by saying that there is an absence of drawing in these parts. The lines produced by
5 54 DISEASES on THE TEETH.
the muscles passing from the superior border and angle of the orbicularis oris are not as
strongly indicated as they should be, and the face generally is noticeable as being devoid
of those lines which are generally regarded as myologieal landmarks. The nose is usually
small, whilst the forehead, with the remaining frontal outlines, gives a good facial angle.
The cause which I venture to suggest as an explanation of the origin of this deformity is
the irregular and excessive growth of the external wall of the antrum on either side.
From the fact that the transverse measurement of the second bicuspids normally
corresponds with a similar measurement between the posterior deciduous molars, it is
manifest that in the cases under consideration, where we ﬁnd the second bicuspids
within ﬁve millimetres of each other, that this region must not only have failed to
preserve the outline presented in the infantile arch, but must also have been subjected
to very considerable mechanical forces during that period of growth in which the antra
have become developed to their normal size. I have before alluded to the influence
exercised by the body and great wings of the sphenoid, and to the operation of the latter
in carrying back the condyloid cavities, and with them the condyles of the lower jaw,
and to this we must I think attribute its abnormal size. Whilst in the evidence
afforded by the texture of the hair, teeth, and nails, as well as the enlarged tonsils, we
may assume that strumous condition of the. constitution which is generally held to
explain the development and irregular growth of the cranial and facial bones, Professor
Humphreys has observed that the prominence of the forehead is proportionate to that of
the chin, and that the antra in negroes are small, and bear a deﬁnite relation in size
with the angle of the face. It is, therefore, not unreasonable to infer that in the cases
we are discussing, in which the frontal bones are vertical, and the mental region of the
lower jaw correspondingly, if not abnormally developed, that the antra should be abnor-
mally large.
My clinical observations do not at present permit me to discuss the relationship
between the enlarged tonsils and the increased capacity of the maxillary sinuses, but I
trust we have present with us on this occasion those who may be able to contribute to
our knowledge on this important point.
In connection with the subject of the influence of the superimposed structures on
the dental arch, I have elsewhere endeavoured to show that the prominence or dimi-
nished size of the intermaxillary region is due to either the increased or diminished force
exercised through the vomer by the body of the sphenoid; and a case under the care of
my friend, Mr. Rose, of double hare-lip and cleft palate that had remained unoperated
upon till the patient was thirty-five years of age will afford corroboration of the sound-
ness of this theory.
The accompanying diagrams show the long and well-arched nose, and the inter-
maxillary bones carried forward with the rest of the nasal septum ; and this affords very
strong evidence in favour of the assertion that intermaxillary prognathism is the pro-
duct of excessive growth of the sphenoid operating through the vomer. In the Museum
of the Royal College of Surgeons (Teratological Section, 238), there may be seen an
interesting specimen, illustrating the peculiar form of the walls of the antrum and upper
maxillary outline, that I believe we may ﬁnd in the compressed brachoid arch as well
as the enlargement of the lower jaw, to which I have already referred.
In a paper read before the Royal Society of Edinburgh, some twelve years ago, by Dr.
Smith, some inter-bicuspid measurements were given of a series of cases of congenital
cleft palate; and the author of that communication attributes the lateral compression
in such instances to “ a misdirection of growth dependent upon the absence of the mesial
structures, while the superior maxilla is becoming as age advances elongated downwards
by the expansion of the antrum.” At that time, I dissented from such a conclusion; but
DISEASES or THE TEETH. 555
my later investigations have induced me to think that Dr. Smith was right and I was
Wrong, and I gladly avail myself of this opportunity of saying so. And it will be seen
that I have adopted the same explanation for the origin of the compressed hrachoid
arch. Time will not permit me to enter at any length into the question of treatment,
and I would submit the following point :—
(1) That if expansion is tried it should be expansion of the jaw with the teeth in aim
in the ﬁrst instance, and regulation of the teeth individually as a subsequent operation,
rather than’ expansion of the dental arch by pressure applied to the teeth and their
alveoli. (2) And next the desirability of extracting the teeth that are out of position, and
then restoring the contour of the arch by expansion. This treatment, of course, apply-
ing only to the more severe cases.
I am induced to bring this point forward for discussion, as there seems to me the
danger that we may, in the pride of our professional skill, submit our patients to greater
pain and risk by saving the teeth than by extracting them.
[Zlusz‘mz‘z‘ve S/az'zzevz zu Camöellz’s “ .Mw/a’ex paw/ms” und
dessen V eﬂzéilz‘m'ss ZZH/ sagen. “ Proguat/zz'a eZ/molagz'ca ”
zum’ Maya/‘s “ Cmm'a pzogenrea.”
Dr. JOSEPH ISZLAI, Buda~Pesth.
Zweifellos sind allen Zahnärzten und Anatomen diejenigen teratologischen Formen
der Zahnreihenschliessung, oder des sogenannten “ Bisses ” bekannt, bei welchen während
einer zwanglosen Aneinanderlagerung der beiden Zahnreihen, das Vordertheil der oberen
Reihe übermässig weit vor das untere Vordertheil zu stehen kommt, oder andere der-
artige, weiter unten naher zu beschreibende Unregelmätssigkeiten wahrzunehmen sind.
Es sind diejenigen Zustande, welche Carabclli, mit Einschluss selbst eines massigcn Vor-
trittes der unteren Vorderreihe vor die obere, in seiner “ Anatomie des Mundes,” 8.133,
unter dem Namen “ Mordcx prorsus ” zusannnengefasst hatte.
Diese Benennung ist jedoch in der Odontiatrie und überhaupt in der Odontologie
nicht heimisch geworden, insofern ‚man kaum in irgend einer anderen h‘achschrift sie
wiederﬁnden kann. Dafür werden öfter die verschiedenen Ilauptarten der, durch
Carabelli zusammengefassten Zustande, getrennt durch besondere Namen in den betref-
fenden Nationalidiomen, oder auch ohne Specialnamen durch hlossc Umschreibung
bezeichnet.
Ich will nun im Nachfolgenden zu erörtern versuchen, wie weit die Umschreibung
der Carabellischen, als auch die anderen, litterariseh in Verwendung gekommenen Aus-
drücke und die, an sie geheftetcn Begriffe, den theoretischen und praktischen Fach-
werken entsprechen.
Was die Umschreibung anbelangt, so kommt es allerdings in den verschiedensten
Doctrinen, und auch in der Odontologie vor, dass einzelne Specialititten, wenigstens
bis jetzt, keine eigene Benennung erhalten haben. Dies kcmmt aber meist nur bei nicht
häuﬁg ﬁgurirenden und weniger wichtigen Gegenständen vor. “Tenn nun doch hie und
da eine Ausnahme hieven entdeckt werden kann, so ist das meiner Ansicht nach eben ein
Zeichen dafür, dass ein solcher Gegenstand bis jetzt nicht ganz gebührlich verarbeitet
worden ist. Es wird doch wohl einem jeden, der sich mit irgend einem wissenschaftlichen
Gegenstande intensiver befasst hat, genügend bekannt sein, wie sehr die Unstetigkeit der
Bezeichnungen und die Priteisionslosigkeit der, daran gekniipften Begriffe, die Handha-
bung eines solchen Gegenstandes, wenn nicht geradezu verhindert, so doch zum Ueberﬁuss
556 DISEASES er THE Tnnrin
langwierig macht und sogar die Aneignung desselben, besonders für jüngere Studirende,
bedeutend erschwert. Bei der mir gewiss scheinenden Wichtigkeit des gegenwärtigen
Themas, ist also meiner Ansicht nach eine blosse Umschreibung der betreil‘enden Spe—
cialitäten ohne wohl deﬁnirte Nomenelatur ungenügend. Wir vernehmen doch auch
Kingsley auf S. 28 seiner “Treatise on Oral Deformities,” welche in mannigfaeher
Beziehung zu meinem gegenwärtigen Thema steht, folgenden Satz, sichtlich im Bedürf-
nissgefühle, malmend ausrufen: “In entering upon an investigation of this kind with a
view of demonstrating a fact in science, it is of the utmost importance, that there be no
ambiguity of language or terms.”
Es ist eben ein Merkmal des Fortschrittes, dass bei ihr, nebst der immer mehr specia-
lisirenden Objectforschung zugleich auch in der Klärung und Präcisirung der Begriffe
und deren Nomenclatur eine immer mehr vervollkommte Correctheit, besonders in jedem
solchen Fache, welches in irgend einem Grade auf WVissenschaftlichkeit Anspruch haben
kann und will, angestrebt und bemerkbar wird, wobei bezüglich des Ausdrucks mit Rück-
sicht auf die internationale Natur der Wissenschaften überhaupt ein Streben nach——
wenngleich hie und da etwas barbarisirtem—Altclassischem, meiner Ansicht nach nur
erwünscht sein kann, denn dadurch gewinnt man zugleich an Sicherheit der Namen-
stabilität.
Derartige Erwägungen ermunterten mich das, im Titel bezeichnete Thema, vor ein
internationales, als besonders in solchen Angelegenheiten eompetentestes, Forum zu.
bringen, indem ich hiemit meine diesbezüglichen, meist unabhängig eigenen Ideen vorzu-
führen, und dadurch wenigstens zu weiteren, perfecteren Parallelarbeiten anzuregen
trachte.
Um nun auf unser Thema zurückzukommen, kann ich angeben, dass ich unter den
Ursachen, welche die erwähnte mindergünstige Aufnahme der Carabelli’schen Auffassung
und Nomenclatur bedingten, die drei folgenden für die wichtigsten halte.
1.—Nach S. 13A des erwähnten Werkes, war Carabelli in dem Irrthume befangen,
dass immer eine blosse Vorwärtsneigung des vorderen Alveolartheiles, d. i., beson-
ders des es intermaxillare die Ursache seines oberen oder beide Kiefer betreffenden
"Mordes: prorsus” ist. Nun wurde und wird aber bei weiterer Prüfung der Sache
immer gefunden, dass ein solches Vorstehenaus verschiedenen Zuständen resultircn
kann. Die vollkommene Auseinanderhaltung dieser Ursachen aber ist trotz einer
erkannten solchen Nothwendigkeit bis jetzt nicht durchgeführt werden, wie aus dem
Weiteren erhellen wird. Die Nichtbefolgung einer absoluten Auseinanderhaltung führt
noch jetzt zu mancher irrthümiichen Auffassung und führte Carabelli zur Vermischung
teratologischer Zustände mit normal etlniologisehen.
2.——Da Carabelli einem solchen Inbcgriil' der als “ Mordex prorsus ” bezeichneten
Zustände in seinem “ Morde}; retrorsus ” nur zum geringen Theil entsprechende Gegen-
sätze entgegenstellt, so fehlt dabei der symmetrische Antagonismus der Begriffe.
3.—-Das Wort Morden selbst wandte Carabelli nach seinem eigenen Geständnisse nur
mit einer gewissen Lieenz an, wie dies aus seiner Bemerkung auf S. 126 1. e. ersichtlich
ist. Sollte auch “Morden” wirklich Gebiss bedeuten, so muss nach der moderneren,
präeiseren Auffassung nicht für die Specialität des ganzen eigentlichen Gebisses, sondern
nur für die Art der Aneinanderpassung der beiden Zahnreihen, und zwar besonders ihrer
Vorderparthie, ein möglichst internationaler Ausdruck gesucht werden, was ich weiterhin
bei dieser Gelegenheit zu erstreben traehte.
In VVedl’s Auffassung dieser Angelegenheit ﬁndet nach seiner “Pathologie der
Zähne” die Carabellische Idee selbst gleichsam nur eine Bestätigung, nur meidet er
hierbei die Carabellischen und überhaupt die altclassischen Bezeichnungen, und sondert
den “ Mordex prorsus” Carah, natürlich auch nur durch Umschreibung, in drei Arten.
ü
DISEASES OF TUE TEETH.
1m übrigen fügt er den, von Carabelli aufgestellten Specialformen—abermals nur mit
umschreibender Bezeichnung— zwei andere bei, nämlich das “ vorn abgeplattete” und das
von Professor Langer in Wien beschriebene “ unten zu weite Gebiss.” l
‘Um nun einen umfassenden Ueberblick des heutigen Standpunktes dieser Angelegen-
heit zu gewinnen, Wlll ich auch einige andere, diesbezüglich crwähnenswerthere Auffas-
sungen anführen, nach welchen nämlich die, von Oarabelli zusammengefassten, Zustände
schon mehr gesondert werden, und da ich schon mit den ebengenannten deutschen
Autoren begonnen habe, will ich zunächst mit den, in deutscher Sprache vorhandenen
Systemen fortfahren.
Mühlreiter lehnt sich zwar mannigf ach an den Carabelli-Wcdl’schen Standpunkt an,
bringt aber dadurch eine klarere Uebersicht in sein System, dass er den Mordex retrorsus
von Carabelli gänzlich eingehen lässt, welcher unter andere, hauptsächlich unter die
“ geraden Gebisse ”” sich eintheilen lasst, und mit dem Namen “rückstehendes Gebiss ”
(was lateinisch “Morden retrorsus ” wäre), diejenigen Falle des Carabelli’schen Mordex
prorsus bezeichnet, bei welchen die untere vordere Zahnreihe vor die obere tritt; seine
Bezeichnung : “ Vorstehendes Gebiss ” aber reservirt er nur für diejenigen Falle, wo die
obere Vorderreihe übermassig vor die untere beisst. Das überm'zissige Vor- und Bück-
stehen beider Kiefer zugleich, ob teratologisch, und also accidentell, oder ob physiologisch-
ethnologisch, lasst er unberührt.
Die unmittelbar causal-cssentielleni’G Zustande ﬁnden wieder bei Mühlreiter eine
umfassendere Berücksichtigung, als bei Carabelli ; freilich ist von einem genügend
ersehöpfenden, specialisirten Systeme in dieser Beziehung, auch bei Mühlreiter keine
Rede.
Dass man auch bei den Mühlreiter’sehen Auseinandersetzungen nicht stehen
bleiben konnte, beweist schon der Umstand, dass gerade Banme, obwohl er in seinem
trefﬂichen Lehrbnche der Zahnheilkunde eben diesem Gegenstande nicht seine ganze
auszeichnende Aufmerksamkeit gewidmet zu haben scheint, dennoch für das Mühl-
reiter’sche “ rückstehcnde Gebiss ” den Ausdruck “vorstehender Biss” substituirt; dass
er also einerseits die Bezeichnung Gebiss für diesen Gegenstand nicht annehmen konnte,
und andererseits ihm nicht passend schien, eine solche Art des “ Bisses” rückstehend
zu nennen, wobei ein auffälliges Vorspringen, nämlich das, der unteren vorderen Zahn-
reihe, als Hauptmerkmal in die Augen fällt, und auch thatsäehlich in vielen, nämlich
solchen Fallen nicht nur scheinbar, sondern wirklich vorhanden ist, wo die essentielle
teratologische Ursache dieser Erscheinung nicht etwa in einer minderen Evolution des
Oberkiefers, sondern in einer übermässigcn Evolution des Unterkiefers besteht. Da
nun Baume auf diese Weise das Vorspringen für diese Falle auf brauchte, blieb ihm nichts
besseres übrig, als die andere, nur auf die eine Vorderreihe beschränkte Art des “ Mordex
prorsus ” als “ vorstehende obere Zahnreihe ” zu bezeichnen, da er zur Vermeidung von
Verwechselung und wegen des wirklichen lVIaugels eines richtig klappenden Bisses in
diesen Fallen das Wort “ Biss ” auch nicht anwenden konnte.
Im Ucbrigen kann von Baume’s Darstellung dasselbe gelten, was bei der Anführung
lVIühlrciter’s gesagt wurde. I
Was nun die englischen und amerikanischen Autoren betrilft, so scheinen dieselben auf
die Nomenclatur kein besonderes Gewicht gelegt zu haben, dabei leisteten sie aber um so

* Ich Verstehe hier unter Camsal-Essentialitéiten die abnormen, also schon patho- oder
teratölogisehen Zustande, Welche zwar die mehr oder Weniger unmittelbaren, jedoch
nicht primären, also eigentlich aetiologischen Ursachen diesartiger Deformitaten sind.
Unter diesen Causal-Essentialitaten nun sind auch die Weniger unmittelbaren als
“ mediate” von den ganz unmittelbaren oder immediaten zu unterscheiden.
558 DISEASES OF THE TEETH.
Gediegeneres im Wesen der Sache. So z. B. ﬁndet sich unter anderem in dem “ System
of Dental Surgery ” von J. und Ch. Tomes, S. 117 eine werthvolle und ganz eorrecte,
eausal-essentiellc Unterscheidung, indem daselbst die Zahnirregularitäten im Allgemeinen,
also auch diejenigen, welche Bissanomalien bedingen, einerseits in solche, bei welchen die
Wurzeln der Zähne am richtigen Orte sich beﬁnden, und welche also nur durch eine
Zahnneigung entstehen, andererseits in solche, bei welchen die betreffenden Zähne im
Ganzen, d. i. sammt ihrer Wurzel unrichtig stehen, unterschieden werden.
Hinwieder findet man die populär-englische, allgemein als “underhung bite” oder
“ jaw ” bezeichnete Irregularität auf S. 4:50 und S. 4-52 (der 10. Aufl.) der “ Principles
and Practice of Dentistry ” von den amerikanischen Autoren, I-Iarris und Austen in zwei
Gruppen getrennt. In die eine Gruppe werden nämlich diejenigen Fälle zusammen-
gefasst, bei welehen kein Evolutionsmissverhältniss des oberen unteren Alveolarbogens
zu einander nachzuweisen ist, sondern die Deformation angeblich nur durch eine Abnor-
mität in der Glenoidalarticulation, nämlich durch einen subluxationsartigen, übermässigen
Vortritt des ganzen, sonst normalgrossen Unterkiefers vor den oberen—wie das auch schon
von Gynnel nach Wedl’s “ Pathologie der Zähne” S. 80 angenommen wurde—bedingt
wird 3 und welche auch zur besseren Unterscheidung unter dem besonderen Namen
“ Protrusion of the lower jaw ” zusammengefasst werden. In der anderen Gruppe aber
werden die übrigen Fälle des “ underhung jaw ” vereinigt, bei welchen nämlich bald ein
Missverhältniss in der Entwickelung beider Alveolarbögen, bald eine blosse Stellungs-
und Richtungsanomalie der betreifenden Zähne die causal-essentiellen Momente sind,
was auf S. 450 des ebenerwähnten Werkes folgendermassen ausgedrückt ist : “ It (näm-
lich die gedachte Deformität) may result from a want of correspondence in the develop-
ment of the teeth and alveoli of the two maxilla, the upper jaw being defective in size,
while the lower jaw is natural; or the former being natural, the latter may he in cxeess.
It may also arise from a simple eversion of the lower teeth or inversion of the upper.”
Hier wird also unter Inversion eine blosse Einwärtsneigung verstanden. Salter
gebraucht aber diese nämliche Bezeichnung in einem anderen Sinne, wie dies aus folgen-
den Worten, auf S. 51 seiner “ Dental Pathology and Surgery ” erhellt: “ Inversion of
the tecth is another and very rare form of irregularity. I have seen both superior lateral
incisors completely inverted and growing upside down; the crowns of the teeth appeared
in the nostrils, from which I removed them.”
Es liegt also schon hierin ein Beweis der Unstetigkeit der Begriffsbestimmungen und
Bezeichnungen in diesem Zweige der odontologischen Deformitätslehre, was besonders
für jüngere Studirende eine überﬂüssige Erschwerung bedingt, und was bezüglich
anderer, als der jetzt in Rede stehenden Kieferdeformitäten aus dem Umstande noch
melir erhellt, dass Kino‘sley, in seinem nur vor kurzer Zeit publieirten obengenannten,
Werke, zu dem Geständnisse gedrängt erscheint, dass er mit Dr. Langdon Down darüber
nicht einig werden konnte, welche Fälle von den, durch die beiden Herren gemeinschaft-
lich untersuchten unter die übermässig hohen und engen Gaumen zu zählen wären und
welche nicht, wie dies aus folgendem Originalwortlaute von S136 des schon erwähnten
Kingsley’schcn Werkes zu ersehen ist: “In this way only is to be accounted for the
dilfercnce of opinion, which existed between us upon many cases, which seemed to him
an unduly high vault to the palate, narrowed arch, or irregularity, but which to my eye
come clearly within the limit of normality.”
Wären aber diesbezüglich ﬁxe, international vereinbarte Indexe vorhanden gewesen,
so hätte man einfach nur die Maasse zu bestimmen gehabt und damit wäre der Aus-
schluss oder die Beherrschung jeder Meinungsverschiedenheit für alle Zeiten gegeben.
Wenn wir nun unser Augenmerk noch auf Frankreich richten, so begegnen wir, als
diesbezüglich wichtigstem Werke: dem “ Traité des Anomalies du Systeme dentaire ” von
DISEASES or THE TEETH. 559
Magitot. Dieses Antors Auffassung betreffs des gegenwéirtigcn Themes stimmt nach
dem V. Kapitel des gcnannten Werkcs mit dcr Miihlreiter’schen darin iibcrein, dass er
dieselben Féille unter seine relative “rctroversion totale on complete” subsummirt,
welclic Miililreiter ails riickstelicndc Gcbisse bczeichnete, und cbenso verhéilt es sich mit
der relativon “antcversion compleic ” und dem “vorstchenden Gebiss.” Er geht aber
insofern weitcr als Miihlreiter, dass or, wie Carabelli und W'edlstct, aucll die sogenanntcn
“ Prognathismen,” 11nd zwar ausfiihrlicher als die beiden letztgenannten, bespriclit. Er
untersclieidet n'ztmlicli ansdriicklicher den “Prognatisme téra/cologique” und zwar eo
ipso “accidentcl ” vom “ Prognatisme ethnologique” und begrenzt anch diese beiden als
‘ absolut” im Gegensatze zu scinen completcn odcr totalcn “ Antc- nnd Retroversioncn”
Welche er als “ relatives ” bczeiclmet.
Betreifs der wciteren, diesbeziigliclien Darstellungcn Magitot’s, will ich in mogliclister
Kiirze wenigstens noeli folgcnde, annlytisclie Bcmcrkungcn machcn.
1.-—Mit seiner Deﬁnition dcr accidentellen “Anomalies de Direction absolues ou
totales,” Welclie auf S. 142 seincs genannten Werkes l'olgendermassen lautct: “ \Tous
entendons par ce titre les deviations dans la direction comprenant dans un mouvement dc
projection double et uniforme 1cs dcux arcades dentaires, qui rcstent ainsi dans lenrs
rapports ordinaircs dc rencontre” scheint—wenn niclit etwa Druckfehler im Spielc sind
---folgender Passus auf S. 140 l. c., “Tclles sont les deviations dc direction dites ‘absolues’
du systome dentaire ; elles occupcnt soit la région antcro supc'rieurc, soit l’antero infé-
rienre,” 820., nicht in eincr gonz absolut vollkommencn Harmonic zu sein.
2.-—Indcm-Magitot bei seincn diesbeziiglichen Bestimmungen, die dnrch irgcnd cine
blosse Zehnncigungsert bedingtcn “Ante- und Retroversioncn ” von den durch fiber-
méissige oder zu geringc, blos Ober- oder blos Untcrkiefercvolutionen bedingten eben-
solclicn Versionen sclbst saclilich nicht geliorig, und nominell gar niclit untcrscheidet,
erfolgt cine unvortlicilhafte Vermischung und nngerechte Vertheilung von zwei verschie-
denen Objcctzustétnden: niimlicli einerscits von der in blosser Ersclicinungsform
bestellcnden Bissart; andcrerseits von den causal-essentiellen Bcdingungen dieser
Erscheinungsform, und zwar hauptsiiclilich der Zahnncigungcn blos fiir die “ Rctrovcr-
sion.” Dieses Verfahren schcint mir abcr insofcrn ungereclit als z. B. cine von diescm
Autor sogenanntc Anteversion vorhanclcn scin kann, ohne dass die Vorderziilme allein
oder sonst mit dem cntsprechenden Alvcolartheile, einc schiefere Riclitung zcigten, als
bei gewohnliclien Fétllen mit normalem Biss, indem aucli cine iibermiissigc Obcrkiefer-
entwicklnng mit sonst richtig geneigten Zitlinen cine sogenanntc “Anteversion ” verur-
sachen kann, Wie dies am nachtritglich zu demonstrirenden Schitdcl zu crsehen scin wird.
Und umgekehrt kommt es gewiss vor, dass ein blosscr Zahnncigungsfchlcr oline Evolu-
tionsfehler cine sogenanntc “ Retroversion ” selbst ini Magitot’schen Sinne bedingt, wie
das schon ans den bisherigen Ausfiihrungen anderer, wenn nucli Weniger Autoren erhellt,
und ebenl'alls aucll an eincm mitgebraclitcn, nachtriiglioli zu dcmonstrirenden Sch'ztdel zu
ersehcn scin Wird.
3.--Beziig1icli der Ausdriicke “ absolu” und “rclatif ” ist Wolil zn bcmerken, dass
Broczi schon friiher und bcsondcrs in seiner “ Instruction cranialogique,” S. 53 die
Epitheta. “ simple” und “ double ” fiir die Prognathie der Zitlinc angewendet hat, 11nd
Topinard in seiner Abliandlung “Des diverses especes de Prognatisme,” S. 5 und in
seiner “Anthropologic,” S. 286 oline Anwcndung des W ortes “rclatif ” einen “ progna-
tisme dcntairc supérieur et inférieur ” anfstellt, freilich mit dcm Ausdruck des Zweifcls
iiber die Existenz des “ prognatisme dcntairc ethnologique ” iiberhaupt. Ich glaubc
nun, dass die Anwendung des “ dupplex ” im Falle der glcicligeurtetcn Irregularitiit beider
Kiefcr im Gegensatze zum “superior und inferior” cine allgcinciner verwendbere und
sicherere Bezeichnungsweisc abgcben wiirdc, und so konnten anch die Ausdriicke
560 DISEASES OF THE TEETH.
“ absolutus ” und “ relativus ” fin‘ andere, ilmen entspreohenderé, weiterhin anzugebonde
Verhaltnisse zweokm assig aufgespart Worden.
Bei all der Wenigkeit dieser An~ und Ausfiihrungen glaube ioh dennoch, dass i011
mit Riieksichi; auf die hier bemessene Zeit, die nooh unerwahnten, jedoch ganz gediegenen
ante und post Carabelli’sohen Autoren wie Hunter, Fox, Bell, Linderer, Maury, Taft,
Garretson, O. Ooles, Coleman und andere nicht weiter zu bespreehen brauche, indem
dllI’Cll das Gesagte der gegenwartige, nicht eben besonders giinstige Standpunkt dieses
Thomas genﬁgend beleuchtet sein diirfte. Auch wird hoﬁ‘entlich—nach den diesbeziig-
lichen Leistungen der angefiihrten Autoren zu urtheilen—geniigend ersichtlich sein, dass
wohl in praktisoher, besonders therapeutisoher Hinsicht Erkleokliches geleistet Worden
ist, aber in der theoretisoh anatomischen Systemisirung, Deﬁnition und Nomenolatur
konnte bis jetzt von einem gleiohen Fortschritto nicht die Rode sein.
DIE BISSARTEN UNLD 11mm BEZIEIIUNG ZUR “Pnoona'rnm ETHNOLOGICA.”
lVas nun meine diesbeziigliohen, eigenen, zu Weiterer Anregung bestimmten Positiv-
ideen anbelangt, so halte ioh es v01‘ Allem fi'u' hoohwichtig und nothwendig, dass—wie
erwiihnt—j a niolit versoliiedene Objeotspecialitaten und Zustande untereinander gemisoht
oder auoli nur miteinandei' vereinigt betraohtot werden, sondern jede Ersoheinungsform
von allen Causal-Essentialitaten '* gesondert, und selbst diese, sobald sie irgend welohe
wesentliohe, mehr generisohe Verscliiedenheiten zeigen, auoh getrennt in Betracht gezogen
und benanat werden. Ohne eine genaue solohe Sonderung wird es nicht nur sohwer,
sonde1'n,ich wage es auszusprechen, geradezu unm'ciglioh, die wiinsohenswerthe Exaotheit,
Klarheit und Ueborsioht in dieser Angelegenheib zu erreielion.
Nun sind aber—abgesehen von j enor schon erwahnten Gynnel- Harris’sehen Protru-
sionen—bei den Bissanomalien dreierlei Hauptmomente zu beriioksiclltigen. Das eine
ist die unmittelbarste aussere Erscheinungsform des Bisses selbst. Die beiden anderen
sind unmittelbar causal-essentiell in Bezug auf den Biss. Es sind dies einerseits die
Stellungs- und Riohtungsanomalien der Zahne selbst, und andererseits die Evolutions-
vorhaltnisso der Alveolarfortsatze, besonders der Kiefer und der Unterkieferaste.
Zunaohst ist also nothwendig', dass einstweilen ohne Riicksicht auf irg'end ein
bedingendes Essoni-iolmoment die Arten dor blossen Aneinanderlagerung der boiden
Zahnreihen in ihren gegenseitigen Lagenverhaltnissen in Betraeht gezogen, specialisirt und
benannt werdon. Hierbei orsoheint es mir orwiinsoht boi der eben dargestellten Unzugan-
gliohkeit bisheriger AuITassungen und Systems nothigonfalls auoli ganz unabhiingig von
dem Gewohntcn und bisher Bestandenen vorzugehon. So orschoint cs mir nicht unzweck-
massig, dass sogenannte Vor- und Riickstohon odor Springen nicht mehr als bestimmen-
des Hanptmerkmal zu betrachtcn, da ja dooll bei diesen beiden Arten relativ der eine
Theil stets von, Wahrend der andere Thoil stets zuriicktritt, so dass man eigentlich in
beiden Fallen sowohl von oinem Vor- als Riiokstelien odor Springen reden konnte. Viel
zweokmassigor ersohoint cs mir, den Oborkiofer oin fi'ir allemal gleiohsaln als den ﬁxen,
und nur den Untcrkiefer als don lageiindernden Theil-wio es auoh relativ wirklich der
Fall ist——zu botrachten. Man braucht dann weiterhin nur fiir die Ancinandorpassung
oder Sollliossung dcr beiden Zahnreihcn cine passende, womog'lich altelassischo Stamin-
bezeielmung zu suclien, welohe sich duroli passende Zusatze zn spocialisii'endon Zusam-
mensotzungon gut eig'net. Fiir eine SOlGllO halte ich das gricchische Wort c'z'ppoows, also :

Ich verstehe unter Causal-Essentialitaten die abnormen, also patho- odor tera-
tologisehen Zust'zinde, Welche zwar die mehr oder weniger unmibtelbaren, jedoch
nicht primaren, also eigentlich atiologischen Ursachen diesartiger Deformitaten sind.
Unter diesen Causal-Essentialitaten nun sind auch die weniger unmittelbaren, als
“ mediate,” von den ganz unmittelbaren oder immediaten zu unterscheiden.
DISEASES OF THE TEETH. 561
ööovßdpnoaw. Es stammt von äpaog‘ew, fügen, zusammenpassen. Hieraus stammt auch
äpuös und dpproyn, Fuge, welche auch unter Umständen angewendet werden kann,
aber in ‘gewöhnlichem, mehr activem Sinn halte ich das Wort “Harmose” für das
zweckmässigste. Da nun im Griechischen für “an-, ein- und entgegenpassen oder
fügen ” die Wörter egl>-, ev- und vrpos-appocew, sowie auch die Participialadjective an,
ev- und z-por-apnoaros existiren, so kann ebensogut auch 611-, e¢- oder 7rpoa'app0m9
gesagt werden.
Wenden wir nun diese Wörter auf die drei Hauptarten der Zahnrcihenschliessung mit
Rücksicht auf die relative Fixität des Oberkiefers an, so haben wir mit der “ Enarmose ”
die Einpassung des Unterkiefers, nämlich den sogenannten normalen Biss, mit der “ Pros-
armose,” die Entgegenpassung, nämlich den geraden Biss, und mit der “Epharmose”
den sogenannten unten vorstehenden oder rückstehenden, oder sonstwie genannten Biss
nach meinem Dafürhalten genug zweckmässig bezeichnet. Hierbei müssten natürlich
nur diejenigen Fälle berücksichtigt sein, bei welchen die Aneinanderlagerung ziemlich
genau passend wäre. lm entgegengesetzten Falle, wo nämlich bei der Schliessung min-
destens ein Raum von drei Millimetern zwischen den vorderen Zahnreihen verbliebe,
hätte man entweder eine “Phaulenarmose ” (von dmühos, fehlerhaft), welche dem
bekannten, häuﬁgen oben vorstehenden Gebiss, oder eine “Phaulepharmose,” welche
dem nach den Sitzungsberichten der Kais. Wiener Akademie vom 1. Juli 1869 durch
Professor Langer demonstrirten Fall entsprechen würde, wie solche übrigens auch in den
anthropologischen Sammlungen in Berlin und Paris vereinzelt zu ﬁnden sind. Eine
fehlerhafte Prosarmosc fände meist nur in der “Anarmose,” nämlich im sogenannten
“offenen Gebiss” einfacher, gewöhnlicher Art Ausdruck. Wenn ferner eine Vex‘
mischung der Schliessungsarten vorhanden ist, lässt sich auch diese bald als “Haplo-
mixarmose ” (von ä’vrhovs, einfach), wo nur die ganze rechte und linke Hälfte der Vorder-
reihen miteinander abwechseln, und bald als “Tyrbomixarmose” (von rvpäa, durch-
einander), wo mehrere Zähne bei einem gewissen Individuum in verschiedenen, miteinander
abwechselnden Harmosearten zu ﬁnden sind, bezeichnen. Wenn aber nur ein Zahn aus
Reih’ und Glied wäre, so könnte das eine “Monarmose” und zwar entweder eine
Moneph-, oder eine Monenarmose heissen.
Alle diese Bezeichnungen könnten sich ohne dem Epitheton “posterior,” natürlich
nur auf die Vorkommnisse in den Vorderreihen, welche nämlich die wichtigsten und
häufigsten sind—aber auch auf diese nur für die labiolingnale Richtung—beziehen. In
derselben Weise lassen sich aber mit “ ne’ra,” also als “ Metharmosen ” auch die selteneren
Fälle der mesio-dittalen Abweichungen, und zwar auch als “anteriores” und “poste-
riores ” bezeichnen. Eine solche hintere “ Metharmose ” vereint mit vorderer "Ephar-
mose” wäre die vorhin nach Gynnel-Wedl und Harris-Austen angeführte Art von
“ underhung jaw,” welche durch die beiden letzteren Autoren “Protrusion of the Lowel‘
Jaw ” bezeichnet wurde.
Das eben Gesagte enthält beiläuﬁg meine Neuerungsideen bezüglich der äusseren
Erscheinungsform des Zahnreihenschlusses oder Bisses.
Nun sind die beiden wichtigsten causal-essentiellen Momente in Betracht zu ziehen,
wozu ich hier von Vornherein bemerken muss, dass während die Anthropologie hauptsäch-
1ich mit normalen Fällen zu thun und also schon die mindest abnormen Fälle auszu-
scheiden hat oder hätte, nachdem sie die abnormen Fälle mehr nur in zweiter Reihe
nebenbei zu berücksichtigen braucht, muss die praktische Odontiatrie und Odontologie
sich hauptsächlich mit abnormen, und nur zur klärenden Beihilfe auch mit normalen
Fällen, befassen, wobei die fast unendliche Mannigfaltigkeit der patho- und teratologischen
Verhältnisse eine grössere Schwierigkeit bedingt. Deshalb müssen auch von den ethno-
anthropologischen abweichende, auch für abnorme Fälle sicherer verwendbare Bestim‘
PART III. 0 0
562 DISEASES OF THE TEETH.
mungsmetlioden und selbst eine verseliiedene Nomenclatur in Anwendung gebracht
werden, wobei eine besondere Aufmerksamkeit fiir die Gaumenlange und ihre Beziehung
zur Hirnsehadelcapacitat als am meisten zweckdienlieh erweist, was in der Anthropo-
resp. Ethnologie zur Bestimmung der Grade der sogenannten “ Prognatliie ” viel weniger
der Fall sein diirfte.
In erster Reihe nun treten bei diesel‘ Betrachtung der Causal-Essentialitaten die
sogenannten Versionen oder Neigungen der Zéiline, respective ihrer Kronen und Wurzeln
oder aueh ihrer Alveolen entgegen.
Diesbeziiglich kann gleich jetzt bemerkt werden, dass zur Beurtlieilung des Neigungs-
grades von irgend eineni Zahne getrost die Direktion der Kronenaxe als massgebend
angenommen werden kann, da die Kriirnmungen beim Zahnhalse oder noch tief'er, néimlioh
an der Wurzel, nur Ausnahmsfalle representiren, und wenn dies auoh nicht der Fall ware,
fiir die Art des Bisses doch immernur die Kronenrielitung, soferne diese als bedingendes
Moment fungirt, entsclieidend ist. Aus diesen zwei Griinden ist es nioht notliwendig,
ferner von den Wurzeln 11nd Alveolen zn spreclien, indem fiir die iiberwiegende Mehrzahl
ihre Richtung als gerade Fortsetznng der Kronenaxe, oder sonst als diesbeziiglich bedeu-
tungslos, angenommen werden kann.
Die Zalinversionen sind nun am hauﬁgsten labiolingual, d. h., naeli Aussen oder naeli
Innen. I-Iier waren also unabhangig von der Art der Zalmreihenschliessung die Bezeieh-
nungen Ante- und Retroversion aueh so ziemlieh verwendbar. Ich lralte aber die, irn
Englischen iibliolien Ausdriieke, “ eversion ” und “inversion ” fiir vortheilhafter, Weil sie
kiirzer, plastisclier und aueli saehlich zweckentsprechender sind, indern sie'mit der so
ziemlieh allgemein verbreiteten distalmesialen und labiolingualen Auifassung iibereinstim-
men, und demgeméiss selbst fiir die selteneren Zahnneigungenin distalrnesialem Sinne, als
“ deversio ” und “ adversio,” ja sogar fiir die ganzliclie Umkeln'nng eines Zahnes um die
'horizontale Axe als “ reversio ” (statt Salters “inversion ”) verwendet werclen konnen, so
dass hievon nur die “torsio ” ve'rsehiedener Grade fiir die Dreliung um die verticale Axe—-
wie reell, so auch nominell—ganz abweiellen wiirde. Die genaueren Specialisirungen
m'irden mittelst der Epitheta “ relativus et absolutus,” “ abruptus ot oontinrus,”
“simplex et dupplex,” “anterior et posterior” und “superior et inferior” eﬂectuirt
werden.
Beziiglich der zwei letzteren Paare ist, glaubo ieli, jedos weitere Wort iiberﬂiissig.
Uebcr das “dupplex,” ini Gegensatze zum “simplex” spracli ieh meine Ansieht zum
Tlreil schon vorhin bei Gelegenheit der Ausfiilirung von Magitot’s diesbeziiglicher Dar-
Stellung ans. Ferneres hieriiber ist aus dem zu entnehmen, was writer iiber das
“ absolut ” und “ relativ ” gesagt werden wird. Die Ausdriieke “ abruptus et contineus ”
innerhalb der Gronzen des anterior und posterior Wiirde ich dem “ partialis” 11nd “ totalis,”
oder “oompletus” darum vorziehen, weil diese letzteren zu selir an die Totalitétt des
Gebisses oder wenig-stens an eine ganze obere, oder untere, oder aber zugleieh auf die
obere und luntere, wenn auoli nur vordere Reihe erinnern. Es bleibt also nur das relativ
und absolut nalier zu bespreclien iibrig. Ich wiirde mit “ relativer” Zahnneigung eine
solohe seheinbare oder wirkliehe Version bezeiclinen, welche sclion bloss dureh den Anblick
bestimmt, aber nur im Vergleioh zu richtig 'stehenden, iiberwiegenden benachbarten
Zalinreihenpartnien sieher als eine Direktionsabweiehung orscheint. Eine absolute Version
muss dann jede'lAbweiehung von der bei einem gewissen Volke als vorhersehend und
also relativ riehtig erkannten Direktion der Zahnkronenaxen heissen. Die erstere Art
hat eine sofort einleuohtende, praktische Bedeutung, und létsst Sieli leielit schon beim
ersten Anbliek bestimmen, selbst wenn sie eine ganzo Zahnreihenpartliie betreﬂ’en
wiirdefxNidhtus'ondie-lle'tvztere Art, welche auf den ersten Anblick keine praktisolie
Beaeutung zu haben seheint, und deren Bestimmung gar nicht einfaeh ist. Indessen
DISEASES on THE TEETH. 563
kann selbst in praktischer Hinsicht unter Umstz'inden wiinschenswerth ersclieinen, eine
zweifellose Constatirung ilires Vorhandenscins zu erlangen, so 2. 13., wenn cine “ Eversio
dupplex ” der Vorderreilien nicht dnrclr den Anblick mit Bestimmthcit crkannt werden
kann, wie das an einem der mitgebrachten anatomischen Praparate zu ersehen scin wird.
{ch halte es dalier fiir gut, hieriiber noch folgendes mitzutlieilen.
Zur Bestimmung des N eigungsgrades von ganzen Vorderreihen—denn es kann sich
ja, wie eben erwiihnt, hicr nur um diese handeln--ist bei der hicnach vorausgcsetzten
Continuitéit der Version geniigend, die bcidcn Ccntralincisoren, oder bei vorliandener
Symmetric auch nur cinen derselben, zu bcriicksichtigen. Man kann nun zur Messung
des Neignngswinkels entweder die Anthropologie, resp. ihre Bestimmuugsmethode der
sogcnannten Prognatliia ethnologica iiberhaupt znrn Muster nchmen, indem man die
Horizontalrichtung der natiirlichen Stellung des Kopfes sucht und die bei einzelnen Vol-
kern allgemeinsten Neigungsgrade zu dieser Horizontalen bestimmt; oder unabhangig
hievon die leicht zu einer geraden sehematisirbaren Alreolarrandlinie als ﬁxe massgebende
Grnndlinie bctrachten und die Zahnneigungen zu dieser Linie messen. Ich, meines-
thcils, lialte vom praktisclien Standpunkte aus die letztere Methode fiir die besserc, denn
die massgeloende Grundlinie derselben ist so ziemlich ﬁx und lasst auch cine bequeme
Vergleichung mit anderen Saugethieren zu, da bci den meisten derselben, den Menschen
nicht ausgcnommen, anerkannter Maassen die Alveolarrandlinie, resp. die Gaumenaxe in
den meisren Fallen cine solche (relativ) ﬁxe Richtung darstellt, worauf die Axen der
mcisten Zahne—wenigstens gewiss fast immer die, der Hauptreihc, namlich der Kau-
zalme irn Normalzustande—senkrecht zu stehen pﬂegcn, walirend man zur Bestimmung
der Prognathien, nach jetzt iiblichcn anthropologischen Methoden, wie es allgemein aner-
kannt ist, znerst die Kopf'e, resp. dic Scliadcl—conditio sine qua non—in die verrneint-
lich richtigste Natnrlage bringen muss. Nun besteht aber beziiglich dicser “ richtigstcn
Naturlage ” cine solche Meinungsverschiedenlieit unter den ersten Autoritaten der
Anthropologie, dass solehc sogenannte riclitige Grundcbenen nach S. 271 von Topi-
nard’s Anthropologie nicht Weniger als 15 angegeben wurdcn, sowic auch als Endpunkte
der Schenkellinien des Prognathiewinkels fast ebenso vicle angenommen werdcn, als
bedeutendere Autoritatcn hicriiber geforscht und geschrieben habcn.
Um also solche Unstetigkeit, und auch sonst um Verwechselungen mit der anthropo-
ethnologischen Prognathie zu vermeiden, wahlte ich die andere Methode, und construirte
zur bequemen und sicheren Ausfii'nrung der Messung ein Messinstrument, welches ich
ad vocem Stomakace mit dem ans wohlbekannten griechischen Wortern zusmnmen-
gcsetzten Namcn “ Stonialneter ” benennc, und desseu Anwendung ich nach Beendigung
dieses Vortrages samnit dem Instrumente zu demonstriren beabsichtige.
Das Princip der Entsclieidung dariiber, ob nach der Messung eine absolute Versions-
anomalie anzuerkennen sci oder nicht, berulit darauf, dass man die, fiir ein gewisses
Volk, oder cine Hauptmenschenrace als Mittclscliwankung gefundcnen Grenzwcrthe zur
Richtschnur nimmt, und das darnnter beﬁndliche als “ invcrsio,” das dariiber bcﬁndliclie
als “ eversio ” namlich “ dentalis ” und zwar “ absoluta” bezcichnet.
Die Bestimmung der niittleren Scliwankungsgrenzen ist eigentlich Sache eines mehr-
seitigen Uebercinkommens und Priifens. Indessen will ich zur vorliiufigen Richtsclnnu'
anfiihren, dass ich nach meincn bisherigen Resultaten—denn Untersuchungsserien nn'issen
liier wegen Kiirze der Zeit wcgblciben—die Scliwankung bei Europacrn zwischcn 90°,
d. i., dem rcclitcn Winkel und 10° als Mittelstandarte gel'undcn habe, so dass, Wenn man
Zahlenangaben gebrauclien wollte,——der rechte Winkei gleiclisam als 0 betrachtet—die
iibrigen Werthe beziehungsweise mit + oder —- bczeichnet werden konnten, und
natiirlicli inclusive bis zum + 10. Grade selbst bei Europaern von keiner Versions-
abnormitétt die Rede scin diirfte.
o o 2
564 DISEASES OF THE TEETH.
Hiezu muss ioh aucli sehon hier vor der Demonstration bemerken, dass als Messobject
der mesiale Rand der Labialoberﬂaclle der centralen Inoisoren oder aueli nur von einem
derselben zur Bestimmung geniigt,und zwar ans Griinden,welohe ans dem friiher Gesagte-n
zu entnehmen sind.
Nooh ist zu erwahnen, dass bei vorausgesetzter angebogener, also gehoriger Form
des Zahnganzen (wie es auch in dem eingangserwahnten Tomes’sehen Werke ausge-
sprochen wird) es nothig ist anoli anf die bei gerader Form aus der Kronenriohtung zn
folgenden Wnrzelstellung zn achten. Denn Wenn bei einer solitaren oder abrupten
Abweiohnng zngleich die Wnrzel nnriclitig steht, ist nicht, oder niclit blos eine Versions-
anomalie, sondern—sagen wir bei minderer Entfernnng ad vocem Diastem—ein “ Endo-”
oder “ Ekto-stem ” fiir die labiolingnale Richtnng, und ein “Metastem” fiir die mesio-
distale Richtung vorhanden. Fiir entferntere Stellnngsanomalien passt das im Gebranch
beﬁndliehe Wort Heterotopie. Fiir die Richtigkeit sowohl der Stellnng als der Rich-
tung konnte man etwa das Wort Orthostem anwenden.
Die Wnrzelstellungsanomalie ganzer Reihen ist natiirlich mit der, im Nachfolgenden
zn bespreehenden, Anomalie identisch. Bevor ich aber auf diese iibergehe, will ich noeli
erwahnen, dass anch die Neignng des vorderen oheren Alveolartheiles (also der, dem Os
intermaxillare entspreehenden Parthie) zur Alveolarrandlinie, d. i., gleichsam eine Art
von ethnologischer Prognathie aneh nach demselben vorangefiihrten Principe und mit
dem von mir oonstruirten Stomameter gemessen Worden kann, ohne dass man erst die so .
viel gesnohte, vermeintlioli natiirlichste und beste Horizontalstellnng des Kopfes, resp.
Schadels, branehte. ‘
In zweiter Reihe sind nun diejenigen essentialen Bedingungsmomente zu besprechen,
welehe ebenfalls verschiedene abnorme Zustande des Bisses hervorbringen konnen und
deren Wesen aber nur in irregnlaren Evolutions-, oder einfacher gesagt, Grossenverhalt-
nissen der Kiefer, resp. ihrer betreﬂienden Theile, so, z. 13., in einem basalen Uebermass
oder Mindermass des Alveolarbogens, besonders vorne, besteht. Diese letztere ist zwar
dnrohaus nicht mit dem Wachsthnm der Kiel'erkorper unloslieh verbnnden, jedooh in
dieser Hinsioht insofern damit gleichwerthig, als eine blosse Grossenveranderung des
Alveolarfortsatzes allein, ohne dass dabei die K ieferdimensionen selbst verandert
erschienen, diesbeziiglich entweder keine Bedentung hatte oder nur als eine blosse Zahn-
neigungsanomalie, welche zu der vorherbesprochenen gehort, zum Ausdruok kame. Um
nun diese Zusammenfassung knrz auszudriicken, gebranche ioh die Bezeichnung, “ basale
Grossenverandernng des Alveolarbogens,” Womit ioh natiirlich auf die Basis des Alveolar
fortsatzes, zugleioli aber—fiir die meisten h’alle—anch anf den betreﬁ'enden Kieferkoiper-
hinweisen will.
Was nun die basalen Grossen- oder Evolutionsverhaltnisse am Qber- oder Unter-
kiefer anbelangt, so kann natiirlich—abgesehen von der normal richtigen—entweder nur
eine zn geringe oder iibermassige Evolution derselben, und zwar entweder des einen von
beiden, oder beider zugleieh vorhanden sein. Ich halte es fiir zweokméissig, diese
Zustande auoh mit besonderen Namen zn bezeichnen, und zwar ans den bishor und
weiterhin angegebenen Griinden mit solohen, welehe mit denen der ethnologischen Pro-
gnathie nieht identisch sind. Ich sehlage z. B. fiir einen zn wenig entwickelten Kiefer
den Namcn “Endeognathia,” von 31186179, diirftig; fiir den iibermassig entwickelten,
“ Perissognathia,” von wepiao-os, iibermassig, und fiir den normal riohtig entwickelten,
“ Kairognathia,” von Karpés, das rechte Maass, vor. Dem “ superior” oder “inferior ”
als simplex wiirde anoh hier das “ dupplex ” entgegenstehen.
Diese Nomenclatur an sich Wiirde hoffentlieh keine Schwierigkeit, sondern ehor eine
erleichternde Klarheit bedingen. Einige Sehwierig'keit liegt auch hier nur in der Be-
stimmung der Grenzen des Mittelmaasses.
DISEASES OF THE TEETH. 565
Diesbeziiglieh muss nun besonders bemerkt werden, dass hier die Prognathia. ethno- -
logica als maassgebende Aushilfe noeh weniger verwendbar ist, als bei den Zahnneigungs-
anomalien; und zwar aus folgenden Griinden, welche ausser den schon gesagten zugleich
die Meidung der anthropologischen identischen Benennungen rechtfertigen.
1.——Selbst der Winkel des Topinard’schen “ Prognatismc alveolo-sousnasal,” welcher
noeh am Sichersten zu sein seheint, bestimmt ja doch hauptséchiieh bloss die Neigung
jenes Oberkiefertheiles, welcher beiliiuﬁg dem in friiher Entwickelung unverwaebsenen
Os intermaxillare entspricht. Und wenn man aueh annehmen wiirde, dass selbst eine
wirkliehe Vergrosserung des Os intermaxillare und m'cht zugleich und besonders immer
auch seineNeigung—Was iibrigens nicht derFall sein kann—im Maassstabe der Prognathie
Ausdruck féinde, so Wiirde doch in dieser Messung ein zu kleiner Theil des Oberkiefers
als Anzeiger des ganzen ﬁguriren; w'alhrend ieh der Meinung bin, dass bei den friihesten
Messungen der l’rog'nathie selbst die urspriingliche Grundidee fiir die weiteren Folge-
rungen darin bestnnd, class je léinger, oder eigentlich grosser der Kiefer, resp. der diesen
representirende Gaumen im Vergleieh zum Hirnschéidel ist, desto kleiner der Prognathie-
winkel und desto tief'er die Stellung des betreffenden Thierindividunms in der hyerarehi-
schen Reihenfolge; und wenn man sich nun bloss auf die Betraehtung des Os inter-
maxillare, beschr'z'rnkt, so kann man durch den Einﬂuss seiner blossen Stellungs-
oder Neigungsversehiedenheiten, dann aber bei den nicht Topinard’schen Prognathien
such in Folge der blossen Gestaltversehiedenheiten des Hirnschiidels, namentlich ihrer
Héhenverh'ztltnisse bei gleieher Capaeit'alt, zu Irrthiimern geleitet werden. So zum Bei-
spiel Wi'u'den manehe Neger mit abwnrtsgeneigtem Os intermaxillare hoherstehend
erscheinen, als manche Carnivoren mit geradevorstehendem Os intermaxillare, wie z. B.
die Canida, Viverrida, und selbst die meisten Ursida. Nun ist es zwar auch mb'glieh,
was die Anthropologen wissen mégen, dass bei Menschenracen die hyerarcbische Abstu-
fung 11ichtnach der verhéiltnissmnssigen Kiefcrgrosse, resp. nach der diese represen-
tilenden Gaumenlétnge sich richtet, sondern eben nach der blossen Neigung des dem Os
intermaxillare entsprechenden Oberkiel'ertheiles zu beurtheilen ist. Dies kann wohl fiir
die Anthropologie gelten, aber die praktische Odontiatrie und Odontologie haben eine
directe Bestimmung und Vergleichung der Gaumenliingen selbst nothiv.
2.-—Gesetzt aber, dass die Grosse des Intermaxillm‘theiles anch als Anzeiger fiir den
Entwickelungsgrad der ganzen Gaumenl'zinge, ja selbst des ganzen Oberkiefers dienen
kénnfe, so glaube ich doeh, dass eine directe Bestimmung der Ganmenliinge, im Falle
ihrer Moglichkeit, f'nr den gedachten Zweck doch immer vorzuziehen ist, welche (VOID
Os infermaxillare zum Zweeke des Ausschlusses von dem Einﬂnss ihrer N eigung sogar
mogliehst isolirte) Bestimmung auch eine Folgernng auf die Grosse des also ausgelas-
senen Intermaxillartheiles viel eher zuléisst, als umg‘ekehrt.
Auf diese Erwétgungen hin habe ieh folgende Ideen wenigstens fiir die odontiatriseh-
odontologisehen Bestimmungen fiir zweckdienlich erachtet.
Die verhiiltnissmﬁssige Kiefer-, resp. Gaurnengrosse irgend eines Individuums, liisst
sieh, nueh ohne den Vergleieh der Gaumenléingc zurganzen Korpergrosse, oder etwa zur
ganzen Kopfgrosse, durch den Vergleieh dieser Liinge—nicht etwa z¢1r Léinge einer
einzig'en Axe seines Hirnschéidels, wie fiir manche einseitig bestimmte Prognathiearten
geschehen ist, sondern—zur Schédelcapaeitiit bestimmen, und die Angabe von hierdureh
gewonnenen Beziehungsindexen erseheint mir nieht nur wohlbereehtigt, weil der Gaumen
ein Schddeltheil ist, und nicht nur mit Riicksieht auf friiheren Branch, sondern um so
bereehtigter, weil Oakley Ooles (“ Deformities of the Mouth,” p. 95) und Dr. Claye
Shaw (Journal qf Mental Science, 1876, p. 200) sowie Meyer und nndere diese Verhiilt-
nisse beobaehtende Autoren ein evolutiv-eorulatives V‘erhéiltniss zwischen Hirnschéidel
und Gunmen nachgewiesen haben.
566 DISEASES OF THE TEETH.
Dass hierbei ein Kubikinhalt mit einem Linearmaass verglichen wird, macht aus dem
Grunde gar keine Schwierigkeit, weil nach den Lehren der Stereometrie das Verhältniss
von Kugelinhalten schon mittelst ihrer Durch- oder Halbmesser vollständigen Ausdruck
gewinnen und jeder beliebige Kubikinhalt als Kugelinhalt gedacht werden kann, dessen
Radius mittelst einfachen elementar-stereometrischen Calculs nach der Formelä (d. i. ‚c,
3 TS—
nämlich K'Ußüs‘ und 0', nämlich 0‘(I>17p1]S‚ also) 5 = 1;; r 3 7r, und hieraus r =\/_4nr—
leicht zu bestimmen ist. Die Zahl (oder der Exponent) nun, welche diesen Radius auf
100 gesetzt, das Verhältniss der Gaumenlänge zum betreifenden Radius ausdrückt, kann
als “Index craniognathicus ” bezeichnet werden.
Von der ganzen Gaumenlänge aber ist nun, wegen des möglichen, schon erwähnten
Neigungseinﬂusses vom Intermaxillargebiete, nur die Strecke vom vorderen Rand des
Eckzalmes bis zum hinteren Gaumenende in Rechnung zu nehmen; während—wie
gesagt—das Gebiet des Os intermaxillare mit dem Haupttheil des Gaumens in stetig
annähernd gleichem Verhältnisse zu sein vorausgesetzt werden kann. Beim Fehlen
sowohl der oberen Eckzähne, als auch der lateralen Incisoren kann man die Grenze
zwischen Os intermaxillare und eigentlicher Maxilla durch Abrechnung der abschätz-
baren Incisorenstrecke bestimmen, oder solche Fälle bei nothwendiger, grösserer Genau-
igkeit eliminiren. Uebrigens können, da nicht directe, sondern bloss Verhältnisszahlen
gebraucht werden, nach dieser Methode überhaupt keine bedeutendcre Fehler vor-
kommen.
Auf diese Weise muss nun die Mittelstandarte für ein gewisses Volk, oder wenigstens
für die drei Hauptracen, von denen nämlich die, der Internationalität wegen so zu
nennende “ albide ” myoprognath, d. h. weniger prognatb, die so zu nennende “ ﬂavide”
aber schon mesoprognath, und die “negroide” plio oder plistoprognath, d. h., meist
prognath ist, gesucht werden, und die Kiefermaasse, welche diese Mittelstandarte bei
einer gewissen Race nicht erreichen oder übertreffen, sind je nachdem, bald “ende0-”
und bald “ perisso-gnathisch.”
Bis zur Bestimmung durch mehrseitiges Uebereinstimmen kann ich hier für den vor-
läuﬁgen Gebrauch angeben, dass meine bisherigen Untersuchungen bei der albiden
Race auf eine Mittelschwankung des Index craniognathicus zwischen 7 2 und 741 also im
Mittel auf 73 führten. Nur zum Vergleich ohne für europäische Praktiker irgend ein
Interesse dafür zu supponiren, gebe ich an, dass ich bis jetzt diese Mittelschwankung
beid’er Flaviden beiläuﬁg gleich der der albiden Race,9g bei der Negroiden aber zwischen
7 6 und 78, also im Mittel 7 7 gefunden habe.
Diese Methode lässt sich nun nicht nur zu Bestimmungen der Kieferverhältnisse an
präparirten Schädeln, sondern auch mit ziemlicher, man kann sagen, mit eben solcher
Genauigkeit zu diesartigen Bestimmungen am Lebenden verwenden, so weit man über-
haupt am Lebenden Skeletmaassbestimmungen zu bewerkstelligen vermag. Ich habe
nämlich mit einer Modification der Broeaischen Capacitätbestimmungsmethode für Schä-
delabgüsse und defects Schädel (s. “ Instructions craniologiques,” S. 113), indem ich die
drei I—Iauptaxen des Hirnschädels, resp. des Kopfes am Lebenden mittelst eines einfachen
von mir construirten, später zu demonstrirenden Messinstrumentes gemessen, und so die
erforderlichen drei Hauptdimensionen des betreffenden Parallepipedons und dreiaxigen
Ellipsoids erhalten habe, Capacitätbestimmungen auch an Lebenden ausgeführt, und so
den Index craniognathicus in einzelnen betreffenden Fällen der Praxis verwerthet.

* Ein genug interessanter Befund, welcher mit der Correlation zwischen Gaumen
und Schädelgestalt nach Olaye Shaw I. c. zusammenzuhängen scheint.
DISEASES OF THE TEETH. 567
Die Angabc einer gcnaueren Ausfiilirnng konnte viellcicht zu weitlauﬁg werden, ich
unterlasse sic daher bei dieser Gelcgcnheit.
Nur nebenbei soll hicr nocli gcsagt scin, dass dicsc Art der Bestimmung von Endco-
Pcrisso- und Kairogriathie viclleicht cbcnso gut auch zur Bestimmung der by erarchischcn
Rcihenfolge der Anthropologic sich cignet, als die bishcrigcn Prognathicwinkelbcstim—
mungcn; man miisstc nur natiirlicli diese Mcthode dann zur Bestimmung der ganzcn
Reihe normaler Saugethicrschadcl anwenden. Einc kurze Scrie von Saugethiers-
chadeln lautet z. B. folgcndcrmasscn :—
Leo. Ursus. Sus. Ovis.
Gapacitas cranii: 321 265 207 150 (Topinard, “ Anthro-
pologic,” p. 46).
Index craniognathicus 2641 282 450 300 (mcinc Fundc).
Mcrkwiirdig ist hicr, dass das Schaf nach dcm Index craniognatliicus hoherstchcnd
erschcint, als das Schwein, was—gcgen die Anzcigc der Scliadelcapacitat—nach mcinem
Dafiirhaltcn richtiger scin diirftc, und so sind nach der Scliadclcapacitat allcin manchc
andere cclatante Widcrspriichc zu ﬁndcn.
Was nun die Bcstimmung des Untcrkiefers anbelangt, so riclitet sich diese nach dem
Befund des Obcrkicfcrs. W enn cs jcdoch manchmal nothwendig erscheincn solltc, aucli
den Unterkicfcr direct zu bestimmcn, wie zum Beispicl im Falle, dass man bei iibcrmas-
sig klcinem Gaunzcn aucli wissen wolltc, ob der Untcrkiefcr nicht nur rclativ zu gross,
sondcrn olo er nicht zuglcich absolut iiberm'zissig cntwickclt ist, so miisstc man auch fiir
den Untcrkicfer auf ahnlicbc Weise cinen “ Index craniognathicns secundus ” aufstcllcn.
Die Messung dcs Unterkicfcrs ist an sich am Lcbendcn unschwcr, indem man von»
Gonion zum Punctum mentalc und die Linea, seu Axis bigonialis lcicht messen kann,
welche Linien abcr die Seiten eines gleichschenkcligcn Drciecks bilden, dessen Hohc als
uuterc L'alnge entwedcr direct dureh Zcichnung oder mathcmatisch bcstimmt werden
kann. . ‘
Diesc Bestimmungen betreffcn nun mchr die basalc Langc des Untcrkicfers ; da abcr
auch die Langc des Untcrkicferastcs und die Grosse des W inkcls, wclclicn dieser mit
dem Unterkicfcrkorper bildct, cinen Einﬂuss auf die Bissform liabcn konncn, so will ich
auch iiber dicse soviel sagcn, dass sic lcicht durcli ansclilicsscndc Diagnostik und dircctc
Untcrsuchung brevi manu bcstimmt wcrdcn konncn. Am préiparirtcn Scnadcl sind sic
nach den bekanntcn VVcisungcn der Anthropologic zu bestimmcn. Wolltc man nun
auch fiir diesc Falle bcsonderc Namcn anwcnde'n, so konntc man fiir die Grosscm, resp.
Langenvcrhaltnisse dcs Astes sclbst die W orter Ende0-, Pcrisso— und Kairoklonia, von
KMov, Ast; und fiir die Winkclvcrhaltnissc die IVertcr Nio-, Kairo- und Pliogonia, von
bckanntcn griecliischen Wertern anwendcn.
Die Falle von Zahnverlust oder von iiberméissigcr Hohc der Zahnc, wclchc untcr
Umstanden ebenfalls Causal-Essentialitiilcn, und zugleicli primal‘ iitiologischc Momcntc
der bctrcﬁenden Bissanomalien scin kounen, sind tlicils durch ausscliliesscndc Diagnostik
und theils durch die Datcn des Status praesens sehr lcicht bcstimmbar, und bei ihrcr sons-
tigcn minderen Bcdeutung liier nicht weiter zu besprcclieu.
In lctztcr Reilic wiiren nocli dicjenigen Fallc zu bcsprcchcn, bei wclchen nacli Gynncl-
Harris nicht cine Evolutionsanomalie, sondcrn cine blossc, mcist fiir crcrbt gclialtenc
Vorschicbung gleichsam cine Subluxation des Untcrkiefers vorlianden ist. Die Erkcn-
nung solchcr Fallc wird durch den Umstand ermoglicht, dass ohnc cine Vergrosserung
des Unterkicl'ers oder cine Vcrminderung des Gaumcns cine Epharmosc zu linden ist,
wobci die Spitzen und Einsclinittc der gegcniibcrstchenden Kauzahnrcilicn nicht gut
zusammcnpassen. Diese Falle gebeu kcine wcitcr einthcilbare Spccialitaten ab, und fiir
\— U’
568 DISEASES OF THE TEETH.
sie wiirde, wie sohon oben erwahnt, nach der hier vorgesohlagenen Nomenclatnr der Name
der vorderen Epliarmose bedingt dlll‘Cll eine hintere Metharmose passend sein.
Hiermit héitte ich nun die Darstellnng meiner diesbeziiglichen Positivideen beendet.
Indessen haite ieli es, trotz der fiir jetzt knrz bemessenen Zeit, fiir Qpportnn, hier noch
einige I'Vorto iiber die Form des Gaumengewolbes zn bemerken, da 2. B. eine nngewohnte
Hohe desselben bald als Folge und bald—wenigstens nieht ganz selten—als Ursache mit
den angeliihrten Anomalien, besonders den Zahnversionen, in essentiell-eansalem Nexus
stehen kann; und da die maassliclien Bestimmungen der Holio des Ganmengewolbes
iiberliaupt eben auoh mittelst des, von mir jiingst constrnirten, erwalinten Stomameters
bis jetzt am siohorsten bewerkstelligt werden konnen, wahrend solche Maassbestimmungen
i'riilier—wie das selion ans Kingley’s obenoitirtem Bekenntniss seiner Disharmonie mit
Langdon Down zn ersehen ist—bis anf die Bestimmnngen von Dr. Claye Shaw ganz
felrlten, die Messmetliode des letztgenannten Psychiatren aber als Wenig praktisoli auoli
"Wenig Eingang gefunden hat. Dr. Claye Shaw’s Maasse sind namlich, wie dies in dem
Journal of llfem‘al Science, July, 1875, p. 200 zu ersehen ist, nicht in Indexi'orm
gebraolit, indem kein vergleiehendes Verhaltniss zn irgend einer anderen Dimension des
Gaumengewolbes gesuolit wurde, was jedocli nnnmganglicli nothwendig ist, da sogar ein
ziemlich lioher Alveolarfortsatz nocli immer keinen eigentlich hocherscheinenden Ganmen
bedingen muss, sobald besonders eine entsprechende Ganmenbreite vorhanden ist, und
ebenso umgekehrt. Aneli sind in Glaye Sliaw’s Bestimmnngen keine Mittelschwanknngs-
grenzen angegeben.
Wie die Messnng der Gaumenhohe mittelst des Stomameters am Lebenden oder am
Skelet actuell auszufiihren ist, lasst sich ganz gut nur bei der praktisclien Anwendnng
des Instruments selbst darstellen, wie ich naehtraglich zn versuchen beabsichtige. Es
sei jetzt vorlanﬁg nur beziiglioh des Principes der Messungsweise erw'alhnt, dass es
daranf berulit, eine durcli die als ziemlich gerade laufend vorherrsehenden Partliieen
der Alveolarrandlinie gelegte Ebene darznstellen, wie das mittelst dieses Instrnmentes
gesolielien kann; und dann von dieser Ebene ans verschiedene, zn gewissen Pnnkten
der Gaumenmittellinie senkreoht emporgericlitet gedaohte Hohenlinien zn messen.
W enn man nun die gefundenen Hollen mit den entsprechenden Breitestellen mittelst
sogenannter Indexe in Beziehung bringt, so wird man ein ziemlich branchbares nnd
bestimmtes, fiir die Praxis genug wiehtiges Bild von Form und Grad der Ganmen-
wolbnng orhalten. Ein soleher Index kann vielleicht genng treffend als “ Index
rgnathorophicns,” von 3poq50s, Dacli, und zwar der des hinteren Ganmentlieiles oder
Endes als “ Index gnatliorophicns posterior,” der des vorderen Ganmenendes als
“Index gnathorophicns anterior” und der des wiehtigsten mittleren Gaumontheiles
‘in der Gegond zwisohen dem letzten Bienspis und dem ersten Molarzalin als “Index
Ignathoropliicns medins” bezeiclinet werden. Znr Bestimmnng dieser Indexe Wéihlte
icli fiir die Vergleichnng mit der Holie darum die Gan menbreite und nicht die Lange,
weil hanptsaclilioli die Ganmenbreite nnsere Vorstellnngen von der Gaumenconformation
und besonders der Wolbungshohe beeinﬂnsst. Ja icli mochte sogar behanpten, dass
der ebenverzeielinete “ Index gnathorophions medins” aneh solion allein eine geniigende
ldee davon zn schaiien vermag.
Um nun aueli fiir die Hohengrade des Ganmengewolbes nnmerische und namentliolie
Maassansdriicke Zn erhalten, habe i011 eine Mittelstandarte gesncht, und bis mehrsoitiges
Uebereinkommen diesbeziiglieli eine deﬁnitive Richtschnur ﬁxiren Wird, fiilile ioh
micli naeli meinen bislierigen Messnngen bewogen, den “Index gnathoropliious me-
dins” eines normalen Gaumens auf 30, oder eigentlicli zwischen 25 und 35 sehwan-
kend zn setzen; eine Gaumenliohe zwischen diesen Schwanknngsigrenzen ware also
“mesoroph;” nnter diesem Mittelmaass bis abw'arts 15 \vareder Ganmen “sn btopi-
DISEASES OF THE TEETH. 569
noroph,” und unter 15 were er “tapinoroph;” ﬁber 35 bis 45 ware er “subhysoroph”
und iiber as “hypsoroph” zu nennen, durch welche Bestimmungen jede kiinftige
Meinungsdisharmonie fiir immer verbannt wiirde. Statt dieser Benennungen die
Brocaischen Allgemeinausdriicke der “ Meso-, Mega-” und “ Mikrosomie” zu gebrauchen
halte ieh nicht fiir zweckmassig, weil mit diesen nieht so bequem die fiinf nothwen-
digen Abstufungen bezeichnet werden konnen; und weil zu viel Aehnliches leicht eine
irrthiimliche Verwechselung verursacht.
Endlich will ich noch aut'merksam machen, dass Professor Ludwig Meyer in Grit-
tingen die, auf eine gewisse, von ihm beschriebene Weise deformirten Schadeltypen von
gleiehfalls zusammengehorig eigenartigen Idioten, “ Crania progenaea ” genannt hat.
Bevor ich aber weiteres hieriiber sage, muss ich zuvorderst bernerken, dass hier
oﬁ'enbar ein ethymologischer Fehler unterlaufen ist. Diese “ Crania” sollten narnlich
nicht “progenaea,” sondern “progenia” heissen, da griechisch das Kinn ye'vaov und
nicht yévawv heisst, wie Meyer auf S. 90 des im Jahre 1868 erschienenen I. Bandcs
vom Arc/zz'vﬁir Psychiatric angiebt, und immerfort iiberall “ progenaea ” gebraucht, wo-
naeh also ein Druekfehler ausgeschlossen werden muss.
Also diese “Crania progenia” konnen ohne eingehendere Priifung leicht—wie es
wirklieh auch sehon in der Literatur vorgekommen ist—durch ihren Namen, namlich
durch die Bezeichnung, “ mit vorstehendem Kinne ” (vrpo'ye'vews) zu dem Glauben fiihren,
dass Meyer hiemit immer solche Schadel bezeichnen wollte, wobei die untere vordere
Zabnreihe vor die obere beisst. Dieses ist indessen fiir Meyer wohl ein hervorragendes,
jedoch nieht absolut essentielles Merkmal dieser Schadeltypen, wie das nach seinen ein_
zelnen Beobachtungen, so 2. B. naeh Beobachtung Nr. 6, S. 101, Nr. 7, S. 102, Nr. 8,
9, 10, S. 103 und Nr. 11, S. 104, l. e. zu erschen ist.
Sornit sind eigentlich die “Crania progenia” von Professor Meyer in keinerlei
Zusammenhang mit dem “ Mordex prorsus ” Uarabelli, und also nicht hieher gehorig.

Conform’ Resz‘omtz'ovz of Z/ze Super/2'01’ Ceyzz’ral [1202'307/5.
Dr. E. PARMBY BROWN, New York.
Statistics taken by two dentists, extending over about ten years, in their daily practice
in remote localities from each other, accounts of which appeared in a dental journal some
time ago, harmonized in one particular—that the upper central incisors were more liable
to decay than any other teeth. My own observations lead me to believe the correctness
of the statement. The ﬁrst caries appeared there in my own mouth, the ﬁrst ﬁllings
there inserted by hand pressure and non-cohesive gold, by one of the leading dentists in
New York City, in two or three years failed, only to be repeated the same way, with the
same failure soon following. Then came the loss of one pulp, the loss of the corner of
the tooth—the corner restored by wooden mallet with sponge gold—broken off in one year ;
replaced and broken oif again in one year; work done by another New York dentist—
the best I knew of. Another expert operator chosen—graduate of Phila. College: corner
replaced with cohesive foil and 6,700 blows of the lead mallet. Stood seven years; then
tooth and gold shaft entering the nerve channel, snapped off while eating, leaving only
a pulpless root behind. The two original ﬁllings of hand pressure and non-cohesive gold
failed, probably for want of thoroughness and lack of the means of those days to save
more than a small percentage of teeth worked at. Failure of the two corners restored by
sponge or crystal gold, due to poor material for such work, to improper mode of
operating, and to defective adaptability of gold to tooth substance. Last corner, by foil and
lead mallet, failed in seven years, on account of improper mechanical union of gold to
57.O DISEASES on THE TEETH.
enamel at cutting edge, which by crumbling of the enamel at the point of contact with
the gold, and the gradual forcing away of the gold by the rotary action of the jaws
during mastication, permitted the decaying inﬂuence to make progress.
We may have seen many failures 3 there are many. They come from three causes :—
lst. Not knowing how to do them. ‘
2nd. Not doing them thoroughly when knowing how.
3rd. Not using good gold and proper appliances when capable of performing them.
Some men may be able to build up a golden incisor with hand pressure; but how
many can do it, and do do it successfully and proﬁtably P N ot one ! I venture to say,
and challenge contradiction.
The secret of the greatest success, in this line of operating, is a great number of light
and rapid blows, in harmony with tooth structure and the living organism to be
operated on.
Dr. Atkinson and I timed and counted the malleting then in progress by his student.
Finding that nearly one hundred thousand blows could be struck on a gold ﬁlling in a
single day, by a hand-mallet, I deduced from the experience of the heavy lead mallets
(6,700 blows on my own teeth), that I would prefer to take more of them, and take
them lighter and livelier. I preferred to take, say three times as many, one-third as
heavy, and have them laid on three times as fast. And 110w to accomplish this has
been my earnest study. Since then we have counted ﬁfty thousand blows on a single
ﬁlling, occupying ﬁve hours. We—by means of a steel mallet—lately had occasion
to replace a large corner on central incisor, pulp alive, for New York City Dentist,
which had failed ﬁve times—the last time operation done by college graduate—taking
ﬁve hours to perform 5 and was broken off entire at the supper-table, the ﬁrst meal eaten
after it was put in. Two years ago a dentist, from New Jersey, had two golden corners
put, on his central incisors, at the New York Clinic, by the heavy lead mallet. One
year after, he showed me, at the same place, a pivot tooth, where one tooth was, and a
score of nicks on the enamel margins of the other corner, where the great force of the
blows had bruised the tooth. Contour restoration has, for more than ﬁfteen years, been
particularly attractive to me, which has led to making it somewhat of a speciality; and
I have built up on incisor teeth, in the last twelve years, upwards of three thousand of
these ﬁllings, with the gold running to the cutting edge of the teeth. This makes about
ﬁve a week only, or less than one a day—when I sometimes do several, and, on one
occasion, as many as ﬁve, in one day. And, to balance this, several days may pass without
any of that class of work. _ ~
The record says that less than thirty of these ﬁllings have failed, as far as known.
Careful examination of causes of failures prove that the principle is a success, and that
the failures were due to reasons which can be avoided as a rule: improper anchorage,
improper condensation of gold, imperfect margins, &c. I can think of many months
where many tooth restorations have stood upwards of ten years, and not a defect has
come—mouths of young and old; teeth with and uithout pulps living—teeth of both
good, bad, and indifferent structure.
Suppose the failures to be ten times greater than ascertained, by some patients moving
away, or not reporting, this would only make a ten per cent. failure running twelve years,
which would be as good as any class of ﬁllings in the teeth.
The author then proceeded to elucidate by means of models and diagrams various
minutiae which would be unintelligible without ﬁgures.
DISEASES OF THE TEETH. I
Denial SaWgeVy in the Army.
Mr. THOMAS GADDEs, London.
Cognisant of the notable fact that the executive of the International Medical Con-
gress have, for the ﬁrst time, so recognised dental surgery as to set apart a special
Section for that branch of surgery, likewise that this Congress is scientiﬁc, not only in
the common acccptation of the term, but scientiﬁc also in the medico-social sense, it may
not be inopportunc to solicit the opinion of this Section—so weighty and so inﬂuential
——upon the question of Dental Surgery in the Army.
The regular forces of the British army consist of 191,000 men; the average number
abroad being 103,000 ; the average number at home, 88,000.
For this great number of men, who are the units of Her Majesty’s power, there is
provided a specially trained and examined medical staff. The special subjects of study
and examination of the Army Medical Department are Medicine, Surgery, and Hygiene.
Therefore, we may infer that the health of the soldier is the immediate consideration of
that department.
I need not, before this Dental Section of the International Medical Congress, set forth
the relation of the teeth, and the importance of dental surgery to the general health.
Their association is too well known, not only to the specialist, but also to the observing
physician and surgeon. Yet, in the face of these facts, the army medical oﬂicers have
not to receive, neither, as a rule, do they obtain, any instruction or experience in the
treatment of the common, and often very painful, diseases of the teeth.
In 1858 the Royal College of Surgeons of England recognizing the special nature of
dental surgery, and the inadequacy in this respect of the education for the fellowship
and membership of the College, instituted a speciﬁc dental curriculum, examination and
diploma. Furthermore, the Council of this College decided not to accept the signatures of
teachers of dental surgery unless they possess the license in dental surgery—the certiﬁcate
of a fellow or member only is not recognized. The speciality of dentistry has also been
recognized by the Royal College of Surgeons of Edinburgh and in Ireland, and by the
faculty of Glasgow. These bodies, under the powers of the Dentists Act, 1878, have
adopted the dental curriculum recommended by the General Medical Council, and now
hold examination and grant degrees in dental surgery. By the Parliament of 1878, by
the General Medical Council, by the Royal College of Surgeons of England, and the
other‘ surgical corporations, has the necessity for, and the special nature of, dental
education and examination been sanctioned. Yet dental surgery is totally ignored, and
enters into no part of the special training required by the Army Medical Department.
The result of this is that the non-commissioned officers and men of the British army
receive from the Army Medical Service, as a whole, such treatment as must, from the
nature of the case, be far inferior to the skill in medicine, surgery, and hygiene, dis-
played in the highest degree by members of that service. And, where treatment for
diseases of the teeth, from which of a certainty nine-tenths who are sufferers, is not
given by the army surgeon, relief is not unfrcqucntly sought and obtained at the hos-
pitals of the charitable, maintained for the nccessitous poor only. Furthermore, how
many teeth are lost which might, in these days of conservative dental surgery, be saved 8
How much suffering before their loss, and also after their loss, is endured by the brave-
hcarted, for the want of the administration in the army of an organized system of dental
surgery ?
That there is a necessity for such an administration all must agree; but the question
how such is to be accomplished will require careful consideration.
Several members of the Army Medical Service, wishing to improve their knowledge
572 DISEASES on THE TEETH.
and skill in dentistry, have attended the special course of instruction at certain of the
dental schools, and have qualiﬁed themselves by taking the diploma in dental surgery.
Though these are very exceptional instances, they indicate the feeling of want of
knowledge in dental matters, which is truly the general feeling of the Army Medical
Service.
In October, 1859, there was presented to the Military Department of the Madras
Government, a Report on Dental Surgery, by Acting-Garrison-Surgeon H. W. Porteous.
That Report showed that the Honourable the Governor in Council had, in May, 1859,
under his consideration the fact of the European soldiery being inadequately provided
with any dental assistance, beyond extracting teeth when the cause of toothache: That
it was resolved—“A medical oﬁiccr in every European regiment be instructed in Dental
Surgery.” That “The Commander-in-Ohief is requested to issue such subsidiary in-
structions on the subject as his Excellency may consider necessary for giving it effect.”
Dr. Porteous at once made arrangements for carrying out, in H.M.’s 44th Regiment,
stationed in Madras, the provisions of the former resolution. Practical instruction was
given by him to the assistant-surgeons twice a week. For one group of 66 patients,
108 teeth were stopped, and 203 roots extracted. The success of the system pursued
was, in that instance, so far satisfactory that it was only necessary to ,extract three teeth,
“two of these on account of alveolar abscess, and one in which the ﬁlling had induced
more irritation than the patient was inclined to bear.” The Report continues--“ By the
extension of the present system of instruction in dental science to assistant-surgeons of
the army generally, it is hoped that the practice of extracting every aching tooth will be
reduced to within the narrowest limits, and that the arrest of decay in teeth soon after
. its detection will be the means of preserving many of our soldiers’ teeth which, under
the present system, are sacriﬁced whenever they begin to be painful-and troublesome.”
In March, 1857, the Director-General of the Army Medical Department issued a
circular to the Medical Ofﬁcers of the Service. In that circular Director-General Dr.
A. Smith instanced the advances made in Conservative Dental Surgery, and said, “ There
is no occasion for me to enlarge on the important inﬂuence, advantageous or the reverse,
on the functions of digestion and nutrition which the sound or defective condition of the
teeth exercises; and I need not dwell on the fact that their conservation is especially of
consequence to soldiers, as their absence or defective condition found a very possible
cause of impaired digestion and consequent loss of health ; and, moreover, occasionally
constitute a direct cause of ineﬁiciency and unﬁtness for military service. . . . .
“I am of opinion that a considerable gain to the Service, besides comfort to
individuals, would accrue from a more improved practice in dental surgery than that
which has hitherto obtained in military life. . . . . .
“I therefore hope that medical officers of the Service will co-operate with me
in endeavouring to introduce into military medical practice the improved modes of
treatment, now all but universally adopted in civil life.”
In reply to the above-quoted circular of the Director-General, the medical officers
pointed out that they had not received any practical instruction in a branch so absolutely
requiring it, and that they were not supplied with the requisite instruments.
Notwithstanding the success which attended Dr. Porteous’ experiment of two
seasons, and the valuable support this excellent movement had in Sir Charles Trevelyan,
at that time Governor of Madras, and of the Director-General of the Medical Depart-
ment, the Government took no action.
In 1865 Surgeon-General Balfour was requested to inquire into and report upon the
health of the troops, stationed at the extensive barracks at Secundcrabad. In an ex-
haustive letter of December 26, 1866, he stated that instances occurred of impaired
DISEASES OF THE TEETH. 5
assimilation from imperfect mastication, and a good dentist would preserve the teeth of
many soldiers. \
Defective teeth are a cause of rejection among recruits, and it may be interesting to
mention the numbers refused from this cause during eight years :—
l 1871 . . . . 12'54
. 1872 . . . . 8-07
1873 . . . . 7 '62
per 1,000 recruits.
1876 . . . . 7'07
1877 . . . . 893
1878 . 9'60
In passing the recruits the medical ofﬁcers have to examine the condition of the
teeth ; and, certainly, there cannot be required any argument to substantiate the state-
ment that such an examination would be better eifected if the examiner had the beneﬁt
of special dental instruction and experience.
To meet the requirement of a better administration of dental surgery in the army
than has hitherto existed, the most feasible means would be to impart to the army
medical candidates special instruction. This might be done by a systematic course of
lectures, and of operative work, to be included in the subjects of study at Netley ; and,
ﬁnally, let the pass examination include questions, and, above all, practical work in
dental surgery.
_—
Ame/um 0f Hzg/mzore—Dz'seases and Treatment
Dr. TAFT, Cincinnati.
DISEASES.
The most simple form of affection to which the antrum is subject, is engorgement by
watery or muco-serous effusion. This will take place when the canal leading from the
cavity is closed.
The presence of an excess of the secretion doubtless stimulates the membrane to
a more than normal activity. This state of things may exist, and still a deﬁnitely
diseased condition may not occur. The only indications of this aﬁ’ection, in the
earlier stages at least, will be ﬁrst a slight increase in weight in the part; and after the
cavity is completely occupied, a sense of fulness and pressure; this will be modiﬁed by
the activity of the secreting process within, together with the irritability of the parts
pressed upon.
This engorgement often produces expansion of the cavity by pressing outward one or
more of the walls; the weakest or thinnest being susceptible of course to the greatest
displacement. In some cases the anterior, or facial, wall is so much thinner and less
resistent than any of the others, that it, only, is pressed outward, so that marked pro-
trusion of the check is presented.
The contents of the antrum, during this affection, will vary in different cases. In
some it will remain for a long time in apparently an unchanged condition, without
offensive odour, change of colour, consistence, or vitiation of any kind. But in other cases,
and perhaps far more frequently, a more or less marked change takes place, resulting in
a vitiated, acrid and oifensive state of the contents.
This may occur from the presence of local vitiating inﬂuences, sueli as diseased gums,
574 DISEASES OF THE TEETH.
s
alveolar abscess, or the diseased roots of teeth, that may be in near: proximity to, or
perforate the ﬂoor of, the antrum.
But more frequently the vitiated condition of the accumulation is occasioned by, and
is dependent upon, a'systematie cachexia, or low tone, defective nutrition, or a tendency
to degeneration.
If the membrane is much diseased the secretion will be correspondingly affected,
and, on the other hand, as this product becomes vitiated, it increases the disease of the
membrane. '
TREATMENT.
In all cases of engorgement the natural outlet is closed, but this may be only incidental,
and disappear at once upon the evacuation of the chamber. In some cases it is other-
wise, however, and the engorgement will be found to have originated from closure of this
canal in one of the ways already referred to.
In such a case, if the teeth are all present and free from disease, the attention should
be directed to opening the canal, by the removal of any accumulation upon or within
its oriﬁce, and by bringing to a normal condition the lining membrane of the nose.
If by this means the opening is not effected, a properly formed instrument may be
passed through the canal, and in this way break up any adhesion, or remove any obstacles
that might exist. The instrument for this purpose should be of such size, form, and
elasticity, as not to lacerate or injure the part. This operation has been declared by some
to be impracticable, but the facility with which it has been performed, and the good
results obtained, fully warrant the statement that it is of much value.
The removal of a sound healthy tooth in order to effect an entrance to the antrum
should only be resorted to when no other expedient is practicable.
The canal, ‘from the antrum to the nose, may be opened, in some cases at least, by
injecting ﬂuid through the socket of a teeth, but the latter should be kept free so long
as drainage is required; when occasion for this ceases, closure of the opening should be
effected.
When there is a strongly-vitiated discharge, attention in diagnosis should be directed
to the condition of the general system and, locally, to the lining membrane of the cavity,
and again to the condition of the bone, especially of that part contiguous to the roots of
the teeth 5 and, lastly, to any affected teeth that might exercise a deleterious inﬂuence.
If embarrassment in any of these particulars is found, it must be removed or neutralized.
Nitrate of silver, chloride of zinc, sulphate of copper or iron, chromic acid, and
Sulphuric acid may be mentioned as available local applications.
Over-treatment, with this class of agents, is a too common fault, which must be avoided
if the best results are to be attained. It is important, in any case, to determine to what
extent the discharge serves as an irritant to the tissue from which it proceeds or with
which it comes in contact. This will determine to what extent disinfectants and anti-
septics are indicated; there is much less danger from over-treatment with these than
with escharotics.
In the regions posterior to the antrum there are many delicate structures whose
functions are interrupted or destroyed by disease occurring in the antrum. Among
these are the contents of the spheno-maxillary fossa; in this space lies the spheno-
palatine, or Meckel’s ganglion. Sometimes disease occurs in this structure which
requires operative interference. Important nerves pass to and from this ganglion.
The superior maxillary nerve, as it emerges from the foramen rotundum, crosses
this space at its upper part. These structures, delicate and sensitive, can hardly remain
free from disturbance and functional derangement, with disease in such close proximity
as the antral cavity affords.
DISEASES OF THE TEETH. 5 75
Cerebral disease has originated in disease of the antrum with the most serious, even
fatal, results.
0% the Premaz‘ur/e Loss of Teal/z 6y Dash/action 0f Meir
A Zz/eolz'.
The discussion was opened by Dr. J. WALKER, London, who exhibited a number of sec-
tions : amongst others were some taken from the jaws of an aged dog, whose teeth were
loosening; the conclusion arrived at being that, in the present state of pathological
knowledge, no distinction could be traced between the loss of a tooth-socket prematurely
by disease, its absorption after an extraction, or its wasting in old age, the microscopic
characters being identical. In support of this view, reference was made to diagrams
and specimens enumerated below.
No. 1.-~Avertical section of a temporary tooth, taken immediately after extraction,
with adherent membrane showing multi-nucleated cells, these forming excavating cavities
in the cementum of the fangs. Nos. 2, 3, 41, 2nd series—Vertical sections of the lower
maxillary bone, showing the normal repair and absorption of the walls of the socket,
after the extraction of a sound, healthy tooth. Nos. 3, 4, section made after a longer lapse
of time after extraction.
No. 5. A socket healing after extraction showed :—
(i.)—Tissue stretching from side to side, at the apex of the socket; a simple cell-
growth of adhesive inﬂammation.
(ii.)—On the sides and at the base of the socket,bonela1d down from the osteo-genetic
layer of the periosteum. .
(iii.)—1\/Iulti-nucleated cells, generated by the osteo-genetic layer of the periosteum of
the outer and superior walls of the socket—excavating cavities in the upper walls of the
socket just like cavities excavated on the fang of a temporary tooth.
(iv.)—-The vascular and nerve element in the base of the socket.
No. 6.-—Sections of canine tooth, and vertical sections of lower maxillary bone,
showing the pathological changes in the muco-periosteal membrane and alveolar process
from congested, inﬂamed, and receded gum. The conspicuous points were—
(i.)—The loss of vascularity ; the increase of white ﬁbrous tissue.
(ii.)—Subacute inﬂammation passing into depths of the alveolar processes adjacent
to the inﬂamed gum.
N o. 7.——-Section of diseased bone of tibia ; subacute inﬂammation passing from bone
to cartilage in irregular inﬂammatory areas.
The points suggested are these: Have the niulti-nucleated cells, in normal repair of
bone, the power of secreting acid, and so acting on the tissue of the bone, and, as they
increase in size, excavating large cavities? Is the ﬁbroid condition of the receded gum a
development of the ﬁbrous layer of the periosteum; and, by inanition from the loss of the
vascularity of the membrane, docs death to the alveolar walls ensue '1’
Dr. J. AnKovY, Buda-Pesth; The subject which is now under discussion has been
my subject of inquiry for more than four years; and, lately, I have come to a certain
conclusion. I am going to publish my inquiries, and now I wish to draw your attention
only to one single point of the pathology of the disease. I have found—by examining
the pus of that so-called Riggs’s disease, or pyorrhoea alveolaris, &c.—-that there con-
stantly occurs a certain fungoid formation, which I found to be in close connection with
the wasting of the alveoli and the gingival margin, as well as the subsequent loosening of
‘576 DISEASES on THE TEETH.
the teeth; it is quite different from leptothrix buccalis, although it is in a developmental
relation with it. Such pus, when made free by treatment—which I do not refer to now—-
from any other fungoid formation, except spherobacteria (Cohn) imbedded in glue, was
placed in a watchglass full of water, with sugar and a small quantity of meat, and pro-
duced, after 48 hours, at atemp. 37-38o C.,'leptothrix, and, in 7 days, the same mycelium-
like formation which was originally in the pus, giving an evidence that spherobacteria,
under favourable circumstances—and perhaps only in the mouth—produces leptothrix,
and under still better circumstances, as afforded by the gingival margin and the alveolar
wall—lead to the production of a more complicated form of fungi, the species of which
I hope to be able soon to classify. As to the rest of the etiological question, there
would be yet much to say; but the limited time does not permit me to dwell upon the
subject any longer.
Dr. JosErH ISZLAI, Buda-Pesth: I have also investigated pus of alveoli affected
with the so-called Riggs’s disease, and found very similar forms to those drawn by Dr.
Arkovy. As far as a judgment can be formed of Dr. Arkovy’s present ﬁgures, with-
out the original microscopical preparations, I think they can be explained as a species
of “Sehimmelpilz,” for instance, partly of mucor mucedo, partly of penicillium, and
other mixed spores and threads of leptothrix buccalis, which can often be found in
the mouth. The exact species could only be determined on inspecting the original
preparations. Ifound still other forms than those of ~Arkovy’s, but on a strict examination
they always have been found to be a part or form of well-known mycetes. I am
therefore of opinion that also the forms drawn here by Dr. Arkovy might be parts,
forms, or species of known mycetes. Without a very exact study of mycology it
- is not possible to decide on a causal connection with Riggs’s disease.
Mr. WALTER CorErN, London, explained that his father’s successful treatment of
this disease had been, in his opinion, the supplementing of a removal of mechanical
irritation and conditions retaining disease, by a very thorough antiseptic treatment with
phenylic hydrate (strongest liquid carbolic acid), applied locally only, and very exactly,
to the positions of purulent discharge between the tooth and its sockets and the gum.
He believed that Riggs’s surgical treatment bore to this about the relation that the
cleanly treatment of wounds bore to real antiseptic surgery. The peculiar chemical
reaction of phenylic alcohol with the tissues, saturated by the particular discharge of
this disease, fully conﬁrmed, in his opinion, the septic theory of its origin, whether
associated or not with the predisposing or aggravating inﬂuences of necrosis, calculus,
or other causes.
Mr. OAKLEY CoLEs, London, drew attention to the fact that the early stages of so-
called Riggs’s disease, is due to separation of the margin of the gum from the neck of
the tooth, the result of local inﬂammation, thus forming a pouch for the lodgment of
foreign bodies.
Dr. ATKINSON, New York : That there must be constitutional dehility to promote the
establishment of “ pyorrhoea-alveolaris” in any case he held to be sound, and that there was
a mode of degeneration of that attachment or connective portion of the gum to the neck
of the tooth which is not worthy of the name “ligamentum dentium” he was very certain
was true. That there was atrophy of this, allowing a recession of the margin
of the soft parts surrounding the edge of the alveolar processes, was a matter
of observation to every careful dentist. He attributed that entirely to constitutional,
DISEASES OF THE TEETH.
aggravated by local, instigation—stiﬂ’ brushes foolishly used in a manner to tear the gum
from the tooth. Brushing the lower teeth longitudinally downwards, and the upper-
teeth longitudinally upward, had a tendency to tear away the connection so vital to the
safety of the tooth. Wherever a reproduction of any of these structures was desirable,
it was important to have a pocket to hold the pabulum in the place where the structure
is desired to bereformed; and in every case he would advise the use of at least no
weaker a solution of chloride of zinc, than twenty grains to the ounce of water.
Mr. C. S. ToMEs, London, related a case of a patient, aged 25, in which all re-
maining teeth were extracted at the patient’s urgent desire; on many of the teeth
distinctly affected there was not a trace of tartar.
Dr. SNOW, Hartford, Connecticut: Sixteen years of constant observation at the
chair of Dr. Riggs, warrants me in making the statement that Riggs’ treatment of the
disease is a sure cure; will completely eradicate the disease and restore health. “ Riggs’
disease should be called Riggs’ treatment, not Riggs’ disease.” To a great extent the
disease is the result of neglect and the lodgment of foreign substances on the teeth,
causing the absorption of the alveolar process and ﬁnal loss of the whole denture. It
requires ﬁne manipulation and years of practice to be able to treat the cases successfully.
Dr. FEIEnEIcHs, New Orleans: As the treatment of this disease has been given, I
purpose to give the prophylaxis, but before proceeding, I will state that I differ from
the statement made by a previous speaker that it requires an incipient degree of inﬂam-
matory separation before tartar would be deposited. Now it is well-known and patent
to every dental surgeon, that on examination of any patient’s mouth, who masticates
but on one side, that he will ﬁnd tartar deposited on some of the teeth on the opposite
side, and the mouth being in a healthy condition. The prophylaxis is cleanliness. I con-
tend that, where the teeth are kept perfectly clean, no tartar will be deposited and no
Riggs’ disease will be developed.
PART III. P r
MENTAL DISEASES.
___*-_-
President.
Dr. C. LocxHAET RoEEETsoN.
Vice-Presidents.
Dr. CRIcHToN BROWNE, LL.D., F.R.S.E. | Dr. HENRY MAUESLEY.
Council.
Dr. I. ASHE, Dundrum, Dublin. Dr. Mo'rE'r, Paris.
Prof. BENEDIKT, Vienna. Dr. 0. MI'I'LLEE, Blankenburg.
Dr. G. F. BLANEEOEE, London. Dr. W. ORANGE, Broadmoor.
Dr. T. S. CLoUsToN, Edinburgh. Dr. H. RAYNER, Hanwell.
Dr. J. A. EAMES, Cork. Dr. T. CLAYE SHAW, Banstead.
Dr. A. FovILLE, Paris. Dr. J. SIBEALE, Edinburgh.
Prof. LASEGUE, Paris. Prof. TAHEUEINI, Reggio Emilia.
Dr. A. E. MACDONALD, New York. Dr. HAcx TUKE, London.
Dr. ARTHUR MITCHELL, Edinburgh. Dr. S. W. D. WILLIAMS, Hayward’s Heath.
Dr. H. Monno, London.
Secretaries.
Dr. J. R. GASQUET. I Dr. G. H. SAVAGE.
__+-——
INAUGURAL ADDRESS,
BY THE PRESIDENT,
Dr. C. LO CKHART R0 BERT SON,
Lord Chancellor’s Visitor in Lunacy.
GENTLEMEN,-—In now opening the eighth Section of this great International Medical
Congress, and in offering to the alienists of Europe and America our cordial welcome to
London, I must ask leave to explain to you that it is only by the accident of oiﬁcial
position as senior physician to the Lord Chancellor, who, under the Royal prerogative
and by statute, has in England the guardianship of all lunatics and persons of unsound
mind, that I occupy to-day this presidential chair. But for the desire of the Executive
Committee thus to recognize the paramount authority of the Lord Chancellor in our
department of medicine, I cannot doubt that the place I now ﬁll would have been allotted
to our most distinguished English writer on lunacy, Dr. J. C. Bucknill, one of the vice-
presidents of this Congress‘, whose writings and whose name are a household word in all
the asylums where the English tongue is spoken. Called from my oiﬁcial position, rather
than from personal ﬁtness, to preside in this Section, I may the more venture to ask at your
hands a generous interpretation of my eﬂ'orts, so to guide your deliberations here, that
they may advance the science and practice of this department of medicine in which we
are all enrolled.
r r 2
580 MENTAL DISEASES.
I think I shall best use this occasion by laying before you a brief statement of the
present condition of the insane in England, and of the manner and method of their care
and treatment. In the German tongue the word Irren-Wesen exactly expresses the
subject of this address.
The number of the insane in England of whom we have oﬂicial cognisance is about
71,000, being in the ratio of 979 per 10,000, or 1 in 350, of the population. Of these
no less than 63,500 are paupers chargeable to the rates and maintained at the cost of the
community. The remaining 7,600 are private patients, whose means vary from £50 to
£50,000 a year, much the larger number being nearer £50, for insanity necessarily tends,
by arresting the power of production, to the impoverishment of its subjects. Thus, of
the total of the insane in England, 90 per cent. are paupers maintained at the public cost,
and 10 per cent. only are kept by their own resources.
There has, since the passing of the Lunacy Act of 1845, been a great yearly increase
in the registered numbers of the insane, an increase chieﬂy, if not solely, among the pauper
class, which admits of satisfactory explanation, as I have elsewhere* endeavoured to show,
without accepting the popular fallacy of an increase of insanity; a theory which, if
carried to its logical conclusion, leads us to the result that as the registered lunatics in
1845 were as 1 to 800 of the population, while in 1880 they stand, as I have just stated,
as l'to 350, therefore lunacy in England has more than doubled during the last thirty
years, which is a manifest fallacy. I only regret that my present limits preclude farther
reference to this interesting problemrl‘
My first table exhibits the number of the insane in England, with their place of resi-
dence and their proportion to the population in the decenniums 1860, 1870, and 1880.‘
This table shows that the total registered number of the insane has risen from 38,000 in
1860, to 71,000 in 1880, and the ratio to the population from 191 per 10,000 to 279.
It is evident from my ﬁgures that this increase is mainly in the pauper class. The
private patients in 1860 numbered 5,065, in 1880 they were 7,620, and their ratio to the
population 2'5 and 2'9 respectively, an increase of 'éh only, as compared with the increase
of 841: among the pauper lunatics, on each 10,000 of the population.
TABLE I.——Showinq the number of Lunatics in England and Wales in the several Decenniwns
1860, 1870, 1880, with their Place of Residence and their Proportion to the Population.

,__——
1860 1870 1880
Where detained
(Place of Residence)

Private Pauper Total Private Pauper Total Private Pauper Total

In Public Asyhms , 2,000 17,442 19,442 2,790 23,229 31,009 3,754 39,986 43,730
In Private Asylums 2,948 1,352 4,300 3,144, 1,760 41,904, 3,398 1,141 47,549
In workhouses , , None 8,219 8,219 None 11,358 11,358 None 16,462: 16,464;
In Private Dwellings 117 5,980 6,097 356 7,086 7,442 4168 5,980 6,448

Totals _ _ , 5,065 32,993 '39,053 6,280 48,433 54,713 7,620 53,571 71,191


395° P9110000 of 2-54 1658 19-12 279 21-52 24-31 2-99 24-95 2794
the population
7': The Alleged Increase of Lunacy: Journal of Mental Science, April, 1869. A Further
Note on the Alleged Increase of Lunacy: Journal of .Mental Science, January, 1871.
*t In the Report of the Scotch Commissioners in Lunacy for 1880, this question of the
apparent increase of insanity is ably discussed and dealt with in a careful statistica
inquiry. I pan only here give their conclusion. “We have frequently pointed out that-
MENTAL DISEASES. 58 I
Table II. gives the distribution per cent. of the 71,000 registered lunatics in England
and'Wales, and I have here contrasted the same with that of the 10,000 lunatics registered
in Scotland.
TABLE II.—Showing the Distribution per cent. of all Lunatics in England and
Wales and in Scotland in 1880 (January let).

DISTRIBUTION PER CENT.
A
’-i ‘
W11mm MAINTAINED’ In England and Wales In Scgﬂand

Private Pauper Total Private Pauper Total

In Public Asylums* . 5'0 56'5 61'5 146 610 756
In Private Asylums+ . 5'0 1'5 6 '5 1'6 None 1'6
In Workhousesi . . None 23'0 23'0 None 7'0 7'0
In Private Dwellings§ '5 8'5 9'0 1'1 14'7 158

Total . . . -- -- 100 — -— 100
4-
TABLE IIL—Showing the Distribution per cent. on their several Numbers, of the Private
and Pauper Lunatics respectively in England and Wales anal in Scotland in 1880.

Drsrnmnrzon PBB CENT. l

‘
WHERE MAINTAINED. In Enilllzilldg and i In Scotland
i

|
Private Pauper l Private Pauper

In Public Asylums . . . . . . . 49'0 630 840 73'7

In Private Asylums . . . . . . . 43'0 1'6 I 9'5 N one
In Workhouses . . . . . . . . None 26 '0 I None 8-5
In Private Dwellings . . . . . . . 8'0 9'4 ' 6'5 178


Total 100 1001100 100
I


Table II. is interesting as contrasting the total distribution of lunacy In England with
that of Scotland. In England 61'5 per cent. of the lunacy of the country is maintained

the diﬁ’erence in these rates of increase is not necessarily due to an increasing amount of
mental disease, but is probably due in a. large measure to what is only an increasing
readiness to place persons as lunatics in establishments.” '
'l'r Including county and district asylums and Scotch parochial asylums, lunatic
hospitals, and Scotch chartered asylums, naval, military, and East India asylums,
idiot asylums, Broadmoor Criminal Asylum, and Perth Prison wards.
1' Including provincial and metropolitan licensed houses.
1 Including the metropolitan district asylums.
' § Including 208 Chancery lunatics residing in the private houses of “ the committee
of the person.” -
5 8 2 MENTAL DISEASES.
in the public asylums. In Scotland it reaches 75'6 per cent., while, on the other hand,
the proportion of patients in private asylums is 6'5 per cent. in England as against 1'6 in
Scotland. In England 9 per cent. only of all lunatics are placed for care in private
dwellings; in Scotland the proportion rises to 15'8. In England we have 23 per cent.
in workhouses; in Scotland there are only 7 per cent.
Table III. gives the relative distribution per cent. of private and pauper lunatics
respectively in England and l/Vales, and in Scotland.
Table III. brings strikingly before us the existing difference in the method of care and
treatment of the insane in the two kingdoms. In England 43 per cent. of the private
patients are in private asylums, while in Scotland the proportion is 9'5 only. The public
asylums, on the other hand, have 841 per cent. of the Scotch private patients under treat-
ment as against 49 in England. In England, owing to the traditional preference of the
Court of Chancery for private dwellings for the care of its wards, we ﬁnd the proportion
of patients so placed stands as 8 to 6'5 in Scotland, while with pauper lunatics these
ﬁgures are reversed, the proportion in England being 9'4: as contrasted with 17 '8 in
Scotland.
I. PUBLIc ASYLUMS.
There are 43,7 00 patients in the public asylums of England, or 61'5 per cent. of the
whole lunacy of the country. Of these 40,000 are pauper lunatics, and 3,700 are private
patients. The former are maintained in the county and borough asylums, the latter are
divided between these and the registered lunatic hospitals.
(a) County and Borough AsyZuma—The sixty county and borough asylums of Eng-
land* contain 40,000 beds, the number in each varying from 2,000 to 250. They have
been built and are administered under the provisions of the Lunacy Act of 1845. The
average cost per bed has been under £200; the weekly maintenance of each patient is
10.9., to which must be added the interest on the cost of construction and the yearly
repairs of the asylum, which are borne by the county rate, bringing the yearly cost
for each pauper lunatic maintained in the county asylums to nearly £40.
The government of the English county asylums is entrusted, by the Lunacy Act,
1845, to a committee of the justices of the peace, under the control of the Secretary of
State for the Home Department. The administration is in the hands of the resident
medical superintendent. A yearly inspection of the asylum is made by the Commis-
sioners in Lunacy, and a yearly medical and ﬁnancial report is presented by the com-
mittee and medical superintendent to the quarter sessions, and published.
The proportion of cures (discharged recovered) in the county and borough asylums in
the last decennium, 1870-80, was 4028 per cent. on the admissions, and the mortality
1059 on the mean population. In Scotland, during the same period, the recoveries
were 4:1'6, and the deaths 8'0. The only private patients admissible under the statute
are those bordering on pauperism, and whom the law requires, as to classiﬁcation, diet,

7"? A return Was ordered by the House of Commons to be printed, Aug. 14th, 1878, of
the cost of construction of each of the county asylums, the number of beds, the annual
and weekly maintenance rate, the percentage of recoveries, deaths, 8110. Unfortunately it
has been, as regards England, carelessly prepared, and no abstract or summary of its
contents or averages are given. It is impossible to make out clearly in which asylum
the yearly repairs are included in the total cost of construction and in which they are
omitted. The quarter sessions of Warwiekshire have made no return at all ! In contrast,
in the same Parliamentary paper, stand the clear tables and summary relating to the
public asylums of Scotland. From the English return We can only gather an approximate
estimate of the cost of construction, amount of land, salaries, cures, &e., no averages being
given.
MENTAL DISEASES. 5 8 3
clothing, &c., to be treated as the paupers. Herein the English county asylums differ
from those on the continent of Europe and in America, where alike, and I think most
wisely, special and often excellent provision exists for the care and treatment of private
patients. At the public asylums near Rouen, at Rome, at Munich, and at Utica, in the
States, I have seen extremely good accommodation provided for private patients.
In Mr. Dillwyn’s Lunacy Law Amendment Bill, 1881, which was 'read a second time
on May .‘25, but has since been withdrawn for this session, there was a clause (section 4.)
enabling the visitors of county asylums to provide there suitable accommodation, by
additional buildings or otherwise, for private patients. I regard this proposal as one of
the most important reforms, since the Lunacy Act of 184.5, in the treatment of the
insane of the middle class, providing as it would for the small ratepayers, at a cost
within their means, such care and treatment as they cannot obtain in the cheaper
private asylums, where the accommodation and comfort are absolutely below that of
the county asylums, not to refer to the superior acquirements of the medical superinten-
dents of the latter.
I do not feel called upon from this chair (nor does time admit) to enforce and illus-
trate the now incontestable superiority of public asylums, even in a ﬁnancial point, for
the curative treatment of the insane poor as contrasted with the private licensed houses,
to which, before the Act of 1845, they were farmed out by their respective parishes.
“ Our present business is to aﬂirm that poor lunatics ought to be maintained at the
public charge. I entertain myself a very decided opinion that none of any class should
be received for proﬁt ; but all, I hope, will agree that paupers, at any rate, should not be
the object of ﬁnancial speculation.” These words, spoken by Lord Shaftesbury in the
House of Commons, when he introduced the Lunacy Act of 1845 (the Magna Charta of
the insane poor), settled this question once for all. Whose voice will speak similar
words of comfort and healing to the insane of the upper and middle classes, and declare
with authority which shall no longer be questioned, “that all insane captives whose free-
dom would not be dangerous should be liberated, and those who remain be surrounded
with every safeguard of disinterestedness, humanity, and public responsibility”?
In here recording the success which has attended the Act of 1845—a success that
led my friend Dr. Paget, in his Harveian Oration, to call the site of one of our English
county asylums “ the most blessed manifestation of true civilization that the world can
present ”——I cannot refrain from adding a word of tribute to the memory of my revered
friend John Conolly, whose work of freeing the insane from mechanical restraint, and of
thereby founding our English school of psychological medicine, preceded the legislation
promoted by the Earl of Shaftesbury, and ensured the success of these enactmentsi=

‘Yr “ In June, 1839, Dr. Conolly was appointed resident physician at Hanwell. In
September he had abolished all mechanical restraints. The experiment was a trying one,
for this great asylum contained 800 patients. But the experiment was successful; and
continued experience proved incontestably that in a well-ordered asylum the use even of
the strait-waistcoat might be entirely discarded. Dr. Conolly went further than this,
He maintained that such restraints are in all cases positively injurious, that their use is
utterly inconsistent with a good system of treatment; and that, on the contrary, the
absence of all such restraints is naturally and necessarily associated with treatment such
as that of lunatics ought to be, one which substitutes mental for bodily control, and is
governed in all its details by the purpose of preventing mental excitement, or of soothing
it before it bursts into violence. He urged this with feeling and persuasive eloquence,
and gave in proof of it the results of his own experiment at Hanwell. For, from the time
that all mechanical restraints were abolished, the occurrence of frantic behaviour among
the lunatics became less and less frequent. Thus did the experiments of Charlesworth
584 MENTAL DISEASES.
Dr. Conolly’s four annual reports of the County Lunatic Asylum at Hanwell for
1839, ’40, ﬁll, "12, still form the groundwork of our treatment of the insane poor in the
English county asylums, while these asylums themselves—whose fame, I may be per-
mitted to say, based as it is on the successful application of the English non-restraint
system, has gone forth into the whole civilized world, and brought rescue to the most
suffering and degraded of our race—stand throughout this fair land imperishable monu-
ments of the statesman to whom they owe their origin, and of the physician who asserted
the great principle on which the treatment within their walls is founded. “ The system
as now established,” writes Dr. Conolly, “will form no unimportant chapter in the
history of medicine in relation to disorders of the mind. It has been carried into prac-
tical effect in an intellectual and practical age, unostentatiously, gradually, and carefully,
and is, I trust, destined to endure as long as science continues to be pursued with a love
of truth and a regard for the welfare of man.”*
We have made arrangements whereby you will have the opportunity of visiting and
inspecting two of the best of the English county asylums, that for Sussex at Hayward’s
Heath, and for Surrey at Brookwood; the State asylum for criminal lunatics at Broad-
moor, as also the four great metropolitan asylums, with ajoint population of 6,600
lunatics, at Hanwell, Colney Hatch, Banstead, and Wandsworth. There has, since the
Lunacy Act of 1845, been a steady increase in the number of pauper lunatics placed in
the county asylums. In 1860 the proportion was 50 per cent., in 1870 it rose to 61 per
cent., and in 1880 it was nearly 65 per cent. of their number. I think this continued
increase is most injurious alike to the insane poor and to the due administration of the
county asylums. The accumulation in such large numbers of harmless and incurable
lunatics in these costly asylums is, moreover, a needless burden on the rates.
We may now, with an experience of thirty-ﬁve years, assert that the utmost limits
within which the county asylum can beneﬁt or is needed for the treatment of the insane
poor is 50 per cent. of their numberj‘ and that a further accumulation of lunatics there
serves no practical purpose, and hence is an unjustifiable waste of public money. The

and Conolly conﬁrm the principles of treatment inaugurated by Daquin and Pinel, and
prove that the best guide to the treatment of lunatics is to be found in the dictates of an
enlightened and reﬁned benevolence. And so the progress of science, by Way of experi-
ment, has led men to rules of practice nearer and nearer to the teachings of Christianity.
To my eyes a pauper lunatic asylum, such as may now be seen in our English counties,
with its pleasant grounds, its airy and cleanly wards, its many comforts, and Wise and
kindly superintendence, provided for those Whose lot it is to bear the double burden of
poverty and mental derangement—I say this sight is to me the most blessed manifestation
of true civilization that the world can present.”——T he Haroeian Oration, 1866. By George
E. Paget, M.D. Cantab, Regius Professor of Medicine in the University of Cambridge.
"-t “ The Treatment of the Insane without Mechanical Restraint,” by John Conolly,
M.D. Edin., D. C.L. London: Smith, Elder 82: Co. 1856.
'|~ There is a unanimous concurrence of opinion on the part of the lunacy oﬂicials and
the visiting justices, that the grant from the Consolidated Fund of 4s. a week made by
Lord Beaconsﬁeld’s Government in 1874, for every pauper lunatic detained in the county
asylums, has led to a needless increase in the admission there of aged lunatics and idiot
children, who were and can with equal facility be kept in the workhouses. This grant
has risen year by year, and in the estimates of 1881-2 is placed at .8425, 000. Instead of
relieving the landed interest, as this ill-considered attempt to shift part of their burden
on the fun d-holders was intended, it has actually increased the county rate by the forced
enlargements and extension of the county asylums. The editor of the Times, in 1874
and 1878, allowed me at some length to direct attention to this yearly increasing
misdirection of the public funds. It is to be hoped that, when the heavy local taxation of
England is readjusted, this outlet of wasteful expenditure may not be overlooked.
MENTAL DISEASES. 5 8 5
workhouses contain 16,500 pauper lunatics, or 26 per cent. of their number. A recent
statute facilitates the adaptation of wards in the county workhouses* for the reception
of lunatics ; and if these arrangements were properly carried out, I think another 14
per cent., or 40 per cent. of the incurable and harmless pauper lunatics and idiots might
be provided for in the workbouses. That this is no fancy estimate I may quote the
parish of Brighton, long distinguished for its wise and liberal administration of the Poor--
law, which has already 36 per cent. of its insane poor in the workhouse wards, and 55
per cent. only in the county asylum. The transfer of twenty chronic cases—no impos-
sible feat—from Hayward’s Heath to the Brighton workhouse wards would at once bring
the Brighton statistics up to my ideal standard for the distribution of pauper lunatics——
viz., in county asylums, 50 per cent.; in workhouse wards, 40 per cent; leaving 10 per
cent. for care in private dwellings.
(6) Lunatic Hospitals (Middle-class Public Asylums).——Besides the county asylums
for the insane poor, we have in England ﬁfteen lunatic hospitals, including the idiot
asylums at Earlswood and Lancaster, where the principle of hospital treatment followed
in the county asylums is applied to the insane of the upper and middle class with the
most satisfactory results.
The following table gives a list of these asylums, with the date of their foundation,
their present accommodation (number of beds), and their average weekly cost of main-
tenance :—
TABLE lV.--The Registered I/anatz'o Hospitals (Middle-class Asylams) in England, with
the Date of their Foundation, the Number of Beds, and the Average Weekly Cost of
Maintenance in 1880.


Name and Site of Asylum Ipdiigdzi Nutdlfger ‘giggle
(Registered Hospital) tion ' Beds Costty
£ 3. cl.
Bethlem Royal Hospital , 1400 I 300 1 11 7
St. Luke’s Hospital 1751 l 200 0 19 3
York Lunatic Hospital 1777 160 1 1 1
Friends’ Retreat, York 1792 150 1 12 6
Wonford House, Exeter .. 1801 100 1 11 0
Lincoln Lunatic Hospital 1820 60 1 8 2
Bethel Hospital, Norwich 1825 70 0 15 2
Warneford Asylum, Oxford 1826 70 1 2 7
St. Andrew’s Hospital, Northampton 1836 300 1 10 1
Oheadle Asylum, Manchester 1849 180 2 2 O
The Coppice, Nottingham 1859 70 1 10 4
Goton Hill, Staﬁ'ord 1854 150 1 12 10
Barnwood House, Gloucester... .. 1860 110 1 14 3
Earlswood Idiot Asylum 1847 | 570 0 18 2
Albert Idiot Asylum, Lancaster 1864 i 350 0 14 0


Those asylums have nearly 3,000 beds, and the average weekly cost of maintenance is
:61 10s., or, including the fabric account, :61 15s.

‘Yr The success of the metropolitan district asylums at Leavesden, Caterham, and
Darenth, which contain 4,470 chronic lunatics, maintained at the rate of 7s. a week, shows
how, even in so diﬁicult a place as London, the treatment of chronic and harmless pauper
lunatics in workhouse wards is to be accomplished, with a large saving to the ratepayers
and a relief to the crowded wards of the county asylums, which are thus made available
for the curative treatment of acute and recent cases.
1* The fabric charges are not included in these ﬁgures. Another 53. a week must be
added to complete this estimated Weekly cost of maintainance.
586 MENTAL DISEASES.
There are 7,828 private lunatics registered in England, who are thus distributed :—
In registered hospitals 2702 or 36 per cent. In public
In county asylums 484 or 6 ,, asylums
In State asylums a 558 or '7 ,, 49 p. e.
In private asylums 3408 or 43 ,,
In private dwellings 676 or 8 ,,
The existing lunatic hospitals, or middle-class public asylums, thus already receive 36
per cent. of all the private patients. The advocates of this method of treatment of the
insane, as opposed to the private asylum system, may now fairly say that by thus pro-
viding for the care and treat-ment of 36 per cent. of the private lunatics they have
demonstrated the practicability of this method as applicable to the other 43 per cent.
now in private asylums.
They can also appeal to the official statistics to show their superiority as regards
results over the private asylums. In the last decennium, 1870-80, the average recoveries
per cent. on the admissions in the registered hospitals was 4684 ; in the metropolitan
private asylums it was 305; and in the provincial private asylums 34'7. The mean
annual mortality during the same period was in the registered hospitals 8'12 ; in the
metropolitan private asylums it rose to 1101; and in the provincial private asylums it
was 881. They may, moreover, point to Scotland and say that while in England 49 per
cent, of the private patients only are provided for in public asylums, 84 per cent. are so
cared for in Scotland. What has been accomplished in Scotland may surely be done in
England. And, certainly, as their strong and ﬁnal argument, they may challenge a com-
parison of these asylums, conducted at half the cost, with the best of the private asylums
in England. We have made arrangements for your visiting Bethlemit and St. Luke’s in
London, and also the middle-class asylum, St. Andrew’s Hospital, Northampton. I
should very much like you to see St. Andrew’s Hospital, which now contains 300 private
patients of the upper and middle classes, from whose payments it derives a revenue of
£40,000 a year, of which £10,000 was saved last year for further extensions. It would
be difficult to over-praise the power of organization which has enabled Mr. Bayley, the
medical superintendent, to achieve this great result in the last ten years only. I can
from frequent visitation speak of the order and comfort which reign throughout this
asylum.
Mr. Dillwyn’s Select Committee, in their Report (March 28, 1878), suggested “that
legislative facilities should be afforded, by enlargement of the powers of the magistrates or
otherwise, for the extension of the public asylum system for private patients,” and in his
Lunacy Law Amendment Bill, 1881, read a second time in May,‘ Section 1 enables the
justices to provide asylums for the separate use of private lunatics in like manner as the
county pauper asylums were built. There can be no doubt, after the experience have
just related of St. Andrew’s Hospital, Northampton, that, especially in the populous Home
Counties, where no public provision for private lunatics exists, several such asylums, with
300 beds, might be built on the credit of the rates, and would in 30 years repay
the capital and interest sunk out of the proﬁts, and without, therefore, costing the rate-
payers one penny. This clause alone would have made of Mr. Dillwyn’s Bill a great gift
to the insane of the upper and middle classest I cannot but regret that so valuable a
measure had to be withdrawn for want of time. It is already a well-worn complaint

"k In the Journal of Mental Science for July, 1876, there is a very interesting sketch of
the History of Bethlem Hospital since 1400, by Dr. Hack Tuke.
’l‘ I brought this whole subject before the Brighton Medical Society in 1862, in a paper
on The Want of a. Middle-class Asylum in Sussex, subsequently inserted in the Jou/rnal of
Illental Science for January, 1863.
MENTAL DISEASES. 5 8 7
that home legislation is in England sadly impeded by the weary Irish agitation and
debates.
Another method of providing public accommodation for private patients was laid by
me before Mr. Dillwyn’s Select Committee, in a Memorandum on the Establishment of
three State Asylums for Chancery Lunatics, signed by Dr. Bucknill, Dr. Crichton Browne,
and myself. The insane wards of the Court of Chancery pay upwards of £100,000 a
year for care and treatment in private asylums. Certainly no loss could be incurred by
the Treasury in advancing sums to build these asylums, where the yearly proﬁts would, as
at St. Andrew’s Hospital, ensure the regular repayment of capital and interest. As the
Court of Chancery controls in every detail the expenditure of the income of its insane wards,
it is not an unreasonable demand to require that Court to provide ﬁt public asylum
accommodation, and such as the Visitors deem necessary, for the Chancery patients now
placed in private asylums, in the selection of which their ofﬁcial Visitors have no voice
and over the conduct and management of which they exercise no control.
II. PRIVATE AsYLuMs.
There are 3,1100, or 483 per eent., of the private patients'in England conﬁned in private
asylums, of whom 1,850, or 54: per eent., are in the thirty-ﬁve metropolitan licensed
houses which are under the sole control and direction of the Commissioners in Lunacy,
who diligently visit them six times a year. The remaining 1,550, or 46 per eent., are in
the sixty-one provincial licensed houses which are under the jurisdiction of the justices
in quarter sessions, but are inspected twice a year by the Lunacy Commissioners. I can-
not—even did I so desire—avoid, in an address like the present, stating to you my opinion
of this method of treatment of the insane. The tenor of my remarks, when referring to
the extension of the lunatic hospitals (middle-class asylums), has already shown the
direction towards which my opinions and feelings tend. John Stuart Mill, the strenuous
advocate of freedom of contract, nevertheless in his “ Political Economy,” in treating of this
subject, observes that “insane persons should everywhere be regarded as proper objects
of the care of the State,” and, in quoting this authority, I must add, from long personal
observation, my opinion that it would be for the interest of the insane of the upper and
middle class to be treated as are the paupers in public asylums, where no questions of
self~interest can arise, and where the physician’s remuneration is a ﬁxed salary, and not
the difference between the payments made by his patients for board andlodging and the
sums he may expend on their maintenance. “Is there not," writes Dr. Maudsley,
“ suﬁcient reason to believe that proper medical supervision and proper medical treat-
ment might be equally well, if not better, secured, by dissociating the medical element
entirely from all questions of proﬁt and loss, and allowing it the unfettered exercise
of its healing function? Eminent and accomplished physicians would then engage in
this branch of practice who now avoid it because it involves so many disagreeable
necessities.” '
Probably all not directly interested in this system, and many who, to their own
regret, are so, will concur that, if the work had to be begun anew, the idea of licensed
private asylums for the treatment of the insane of the upper and middle class would be,
by every authority in the State, as deﬁnitely condemned as was in 18% the practice of
farming out the insane poor to lay speculators in lunacy. It is, however, a different
matter dealing with an established system, and I am not of those who call for the sup-
pression of all private asylums. The friends of many patients in England distinctly
prefer them to public asylums, and some patients, who have had experience of both,
contrast the personal consideration and study of their little wants which they receive in
private asylums with the discipline and drill of the public institutions. I see no reason
5 8 8 MENTAL DISEASES.
why private asylums should not continue to exist side by side with the public middle-class
asylums. Time and competition will show which system shall ultimately gain the approval
of the public. I am glad to ﬁnd this opinion supported by Dr. Arthur Mitchell, Com-
missioner in Lunacy for Scotland, in his evidence before the Parliamentary Committee of
1877. “ I think,” he said, “there should be no legislation tending to the suppression
of private asylums. I would let the principles of free trade settle the matter. If the
public have conﬁdence in private asylums, and encourage them, I would let private
asylums exist. I would give them no privileges, and would simplyr take care that the
inspection and control over them are sufficient.”
The verdict of public opinion in Scotland has been deﬁnitely against the private asylum
system. While in England 43 per cent. of the private patients are conﬁned in private
asylums, the proportion in Scotland falls to 9'5.
If private asylums are to continue, there should be entire freedom of trade in the
business. The Lunacy Commissioners have for many years placed endless impediments
in the way of licensing new and small asylums in the metropolitan district. I entirely
differ from this policy, and I think that small asylums for four or six patients, licensed to
medical men, would tend to lessen the existing evils of the larger private asylums.
The monopoly which the Commissioners have established in the metropolitan district has
certainly not raised the asylums there to a higher standard than those of the provinces,
where free trade in lunacy prevails. I am tempted to say that it has had the contrary
effect. '
III. THE INSANE IN PRIVATE DWELLINGS.
Further reform in the treatment of the insane is not merely a question of whether and
how they shall be detained in public or private asylums, but rather whether and when
they should be placed in asylums at all, and when and how they shall be liberated from
their imprisonment and restored to the freedom of private life. This is the reform in
lunacy treatment which is beginning at last to take hold on the public mind in England,
and has received a new impulse by the recent publication of an essay by Dr. Bucknill,
“ On the Cure of the Insane and their Legal Control.” *
It is more than twenty years ago since the question of the needless sequestration of
the insane was ﬁrst raised in England by my friend Baron Jaromir Mundy, of Moravia.
He spoke then to dull and heedless ears. I remember well I thought him an amiable
enthusiast, and I said there was no ﬁt or proper treatment for the insane to be found out
of the walls of an asylum. I have since learnt a wiser experience. Well did he say, on
leaving us, ardores serz't diligens agricola guarumfruclus mmguam aspicz'ct. I am very
glad to have this opportunity of doing honour to the zeal and far-seeing wisdom of the
ﬁrst preacher of this new crusade ; would he were here with us to-day to accept my
formal adherence to his cause.
There is, I believe, for a large number of the incurable insane, a better lot in store
than to drag on their weary days in asylum conﬁnement :—
The staring eye glazed o’er with Sapless days,
The slow mechanic pacings to and fro,
The Set grey life and apathetic end.
In my evidence before Mr. Dillwyn’s Select Committee in 1877 I was examined at
some length on this question, and I stated that, but for my experience as Lord Chan-
cellor’s Visitor, and if I had not personally watched their cases, I could never have
believed that patients who were such conﬁrmed lunatics could be treated in private

* Macmillan & Co. London, 1880. Second edition.
MENTAL DISEASES. 589
families in the way that Chancery lunatics are. I also said that one-third of the Chancery
patients were already so treated out of asylums, and I added that I was of opinion that
one-third of the present inmates of the private asylums might be placed in family treat-
ment with safety. In support of this opinion I put in this table :—
TABLE V.--Showing the Proportion per cent. in Asylums and in Private Dwellings of the
Chancery Mnatics and of the Private Patients (Lunatics not Paupers) under the Com-
missioners in I/nnacy in England and Wales and in Scotland.

Pnoronrroiv PER CENT.
A
,— a
_ Under Home
In Lunatlc Treatment in

Asilums Private Dwellings
Chancery Lunatics . . . . . . . . 65 '4 3413
English Private Lunatics . . . . . . 94'1 5'9
Scotch Private Lunatics . . . . . . 938 6'1

This table deserves your attention. If 346 per cent. of the Chancery lunatics are
successfully treated in private dwellings, while only 654 per cent. are in asylums, it is
evident that of the private patients under the Lunacy Commissioners, of whom 94 per
cent. are in asylums, some 30 per cent. are there needlessly, and hence wrongly, conﬁned.
I see instances of such cases every visit I pay to the private asylums.
Another convert to his cause, made by Baron Mundy, is one of the distinguished
vice-presidents of this Section, Dr. Henry Maudsley, who, in 1867, in the ﬁrst edition of
his work on the “ Physiology and Pathology of the Mind,” strenuously condemns the indis-
criminate sequestration of the insane in asylums, observing;—-“ The principle which
guides the present practice is, that an insane person, by the simple warrant of his
insanity, should be shut up in an asylum, the exceptions being made of particular cases.
This I hold to be an erroneous principle. The true principle to guide our practice should
be this: that no one, sane or insane, should ever be entirely deprived of his liberty, unless
for his own protection, or for the protection of society.”
Dr. Maudsley (to strengthen his argument) pointed to the condition of the numerous
Chancery patients in England who are living in private houses. “I have,” he writes, “the
best authority for saying that their condition is eminently satisfactory, and such as it is
impossible it could be in the best asylum,” and he concluded an elaborate defence of this
method of cure with this remark :——“I cannot but think that future progress in the im-
provement of the treatment of the insane lies in the direction of lessening the sequestra-
tion, and increasing the liberty of them. Many chronic insane, incurable and harmless,
will be allowed to spend the remaining days of their sorrowful pilgrimage in private
families, having the comforts of family life, and the priceless blessing of the utmost
freedom that is compatible with their proper care.”
In his recent essay on “ The Cure of the Insane,” Dr. Bucknill has a chapter entitled
Household Harmony :—
After many moody thoughts,
At last, by notes of household harmony,
They quite forgot their loss of liberty.
I give you therefrom his ﬁnal and weighty conclusions in his own words ;--“ It is not
merely the happy change which takes place in conﬁrmed lunatics when they are judiciously
5 90 MENTAL DISEASES.
removed from the dreary detention of the asylum into domestic life; it is the efficiency of
the domestic treatment of lunacy during the whole course of the disease which con-
stitutes its greatest value, and of this the author’s fullest and latest experience has con-
vinced' him that the curative inﬂuences of asylums have been vastly overrated, and that
those of isolated treatment in domestic care have been greatly undervalued.”
What I have hitherto said under this section applies to the home treatment of private
patients. The treatment of pauper lunatics in private dwellings is another part of this
question, and in which important ﬁnancial results are involved. The system takes its
origin from Gheel, and has been adopted in Scotland with great success. No less than
147 per cent. of the insane poor in Scotland are placed in private dwellings, under the
oﬁicial inspection of the Lunacy Board. Dr. Arthur Mitchell’s evidence before Mr.
Dillwyn’s Select Committee and the several annual reports of the Scotch Commissioners
give details of this method of treatment, which my limits only allow me now to refer you
to. Financially the cost of this treatment does not reach ls. a day; in the county
asylums (including the cost of the fabric) it is not less than 2.9., a difference of 100 per
cent. in expenditure.
With regard to England, 6,000 pauper lunatics, or 85 per cent. of their number, are
registered as living with their relatives, or boarded in private dwellings, under the
authority of the boards of guardians, whose medical officers visit the patients every
quarter, and make returns to the Visitors of the county asylums, to the Lunacy Com—
missioners, and to the Local Government Board. None of these authorities, however,
take much notice of the returns, and little or nothing is known of the condition, care, or
treatment of these 6,000 pauper lunatics. Any further amendment of the Lunacy Law
should certainly, in sbme way, bring them within the cognisance and inspection of the
Lunacy Commissioners, as is done in Scotland.
A successful effort further to extend this system in England is related by Dr. S. W.
D. Williams, the Medical Superintendent of the Sussex County Asylum, Hayward’s
Heath, in his evidence before Mr. Dillwyn’s Select Committee, and also in a paper, “ Our
Overcrowdecl Lunatic Asylums,” published by him in the Journal of Mental Science for
January, 1872. My limits compel me to be satisﬁed with this brief'reference to the im-
portant questions included in this third section of my address, “ The Insane in Private
Dwellings.”
IV. THE ENGLISH LUNAcr ACT.
Lastly, I would say a few words on the Lunacy Law of England, which, setting aside
the special statutes, dating from King Edward II., regulating the proceedings in Chancery,
are the result of the legislation of 1845, and consist chieﬂy of Acts amending other Acts.
They form a large volume, which has been carefully edited by Mr Fry?“< A Bill for the
general consolidation and amendment of these several statutes is an urgent need. The
Government of Lord Beaconsﬁeld announced, in Her Majesty’s speech from the throne on
the opening of Parliament in February, 1880, that such a measure was in preparation;
and although the political necessities of the Irish question have this year unfortunately
absorbed all the energies and time of the Government, we have assurance, in the extreme
solicitude which the Lord Chancellor on all occasions so markedly shows for the welfare
of the insane, that the Government will be prepared to give the question of Lunacy Law
Reform their early and careful attention. I’am disposed to think that, previous to such

it‘ “The Lunacy Acts: containing the Statutes relating to Private Lunatics, Pauper
Lunatics, Criminal Lunatics, Commissioners of Lunacy, Public and Private Asylums, and
the Commissioners in Lunacy; with an Introductory Commentary,” the. By Danby
P. Fry, of Lincoln’s Inn, Barrister-at-law. Second edition, London, 1877.
MENTAL DISEASES. ‘ S 9 I
legislation, a Royal Commission should be issued to investigate and report on the working
in detail of the Lunacy Law, and to make suggestions for its consolidation and amend-
ment.
It is exactly twenty-one years since a Parliamentary Committee reported to the
House “On the Operation of the Acts of Parliament and Regulations for the Cure and
Treatment of Lunatics and their Property.” Many changes have passed over this
department of medicine since the date of that report, and the temporary amendments
of the Lunacy Law of 1845, which resulted therefrom, have almost served their purpose.
The chief of these enactments, the Lunacy Acts Amendment Act, 1862, passed the follow-
ing year, and embodied the various suggestions of the Lunacy Commissioners, based on
their experience of the working of the Act of 1845, and from an oﬁicial point of view
was a valuable contribution to the Lunacy Law, but it failed to give effect to many of the
recommendations of the Select Committee of 1860. In the same year passed the
Lunacy Regulation Act, 1862, which led to considerable amendment of the proceedings
in Chancery. The important requisite, however, of a cheap and speedy method of placing
the property of lunatics under the guardianship of the Lord Chancellor has yet to be
attained. One of the most experienced officials in Chancery, Master Barlow, in his
evidence before Mr. Dillwyn’s Committee in 1877, said :—“ I am a great advocate for a
great reform in Lunacy (Chancery) proceedings; I would facilitate the business of the
procedure in the oﬂice, and shorten it in such a way as to reduce the costs.”
After the evidence given by Dr. Arthur Mitchell before Mr. Dillwyn’s Select Com-
mittee of 1877, it is evident that in the consolidation and amendment of the English
Lunacy Laws the Scottish Lunacy Law and practice must be carefully considered. It
is in Scotland alone that the whole lunacy of the kingdom is under the control and
cognisance of the Lunacy Board?‘
Again, the relation of the Lunacy Commissioners to the county asylums under the
County Financial Boards (whose advent is nigh at hand) is a diﬂicult question, the ﬁnal
solution of which will inﬂuence for good or evil the future of these asylums. Herein
also falls the question I have before referred to, of the annual Parliamentary grant for
pauper lunatics maintained in asylums, and reaching now to half a million a year. Is
the Central Government to check, through the distribution of this grant, the county
boards; or are they to retain the same authority over the county asylums as is now
exercised by the justices in quarter sessionsiJ The whole future eﬂiciency of the
English county asylums depends upon the right adjustment of the relative control
given to the local authorities through the new county boards, and to the Central Govern-
ment through the Commissioners in Lunacy.
There is also for consideration, as in contrast with the Lunacy Laws of Scotland,
the divided jurisdiction of the Local Government Board and the Commissioners in
Lunacy over pauper lunatics in workhouses, of whom 17,000, or 26 per cent of their
number, are there and in the metropolitan district asylums under the control of the
Local Government Board with the merest shadow of inspection by the Lunacy Commis-
sioners. Again, to what extent is the credit of the ratepayers to be used in the estab-
lishment of public asylums for private patients? I have already said how much I desire
to see the public asylum system, as now existing in the registered lunatic hospitals,
extended, more particularly in the Home Counties, by this method. Then the wide question

* I may be pardoned, if I venture here to refer to the annual reports of the Commie.
sioners in Lunacy for Scotland, as containing an amount of well-digested statistical
information regarding the lunacy of the kingdom which we Search for in vain elsewhere.
5 9 2 MENTAL DISEASES.
\
of official asylum inspection. Is the present amount of it enough, and the method of it
sufficient for the needs and protection of the insane, or does the Lunacy Commission
require both extension and remodelling?
These are but a few examples of the diﬁiculties besetting the question before us of
the consolidation and amendment of the English Lunacy Law, and which leads me to
the opinion that the whole subject, now ripe for solution, requires skilful and scientiﬁc
sifting by a Royal Commission, previous to any consolidating and amending Act being
laid before Parliament. I am glad to have this occasion to express my personal conﬁ-
dence in the ability, industry and integrity with which the existing Lunacy Law is
administered by the Commissioners. If I were disposed to criticise their policy, I
might say that they trust too much to their one remedial agent, the extension of the
county asylums, for meeting all the requirements and exigencies ‘of the insane poor,
while as regards the private asylums, with 5d per cent. of the private asylum population
under their sole control in the metropolitan district, that they have from the ﬁrst, since
1845, been content to enforce the remedying of immediate shortcomings, rather than
endeavoured to place before the proprietors any standard of excellence to which they
shall attain.
In concluding my remarks on the last section of my subject—the Lunacy Law of
England—I would say that no mere amending Act like that of 1862, embodying simply
the further suggestions of the Lunacy Commissioners, will satisfy the requirements of
the medical profession or of the public. In the evidence taken before Mr. Dillwyn’s
Select Committee in 1877 will be found many suggestions for the further amendment
of the Lunacy Law of an important character, one or two of which Mr. Dillwyn
embodied in his Liuiacy Law Amendment Bill of this year, which, as l have already said,
has been withdrawn. It is impossible for any private member of Parliament, actuated
though he be by an earnest desire to remedy grave evils, to deal with so wide and
complicated a question as the consolidation and amendment of the English Lunacy Law.
No one is more fully aware of this impossibility than is Mr. Dillwyn, and no member
of the House is prepared more heartily to support the Government in passing a wide and
comprehensive measure of Lunacy Law Reform.
I fear, gentlemen, that I have exceeded the limits of an opening address. Yet the
wide subject which I selected—Lunacy in England (Englamls Im'en-Wesen)-—did not
admit of shorter treatment or of further compression. It is, after all, but a bare out-
line that I have to-day been able to sketch, of the present condition of the insane in
England, and the manner and method of their care and treatment. I may claim to have
endeavoured to give you a truthful picture of our present state, and I certainly have not
desired to hide our many shortcomings from you. Indeed, my object in selecting this
subject for my address is the hope that the position I ﬁll to-day in this great Inter-
national Medical Congress, may gain for my ideas on lunacy reform, which I have thus
brought before this Section, a practical recognition such as I could not, under other
circumstances, expect my humble opinions to command. If such a result should follow,
I truly believe that the use I have made of this great opportunity may be the means of
extending to the insane of all classes in England that further measure of protection
and liberty which the experience of the past working in the county asylums of the
Lunacy Act of 1845, on the lines of the non-restraint system, has now shown to be alike
practicable and safe.
MENTAL DISEASES. 593
Sur [a Me’galomaizg'e.
Dr. ACHILLE FOVILLE, Paris.
Je m’acquitte d’un devoir agréable en rappelant que la première description du délire
orgueilleux est due à. un médecin anglais, Arnold, en 1728. Mais elle paraît avoir peu
frappé l’attention jusqu’à l’époque de la découverte de la paralysie générale de 1820 à,
1825. Bayle alors regarda le délire des grandeurs comme un caractère nécessaire et
sufﬁsant de la paralysie générale; mais cette opinion fut combattue par Georget et Cal-
meil, et n’a jamais été complètement admise. Tous s’accordent à. déclarer, qu’il y a des
cas nombreux de paralysie générale sans délire ambitieux, et, d’autre part, que ce délire
existe dans des cas de folie.» étrangers à. la paralysie générale. C’est sur un point limité
de cette question que je reviens aujourd'hui.
On constate très-facilement que les cas de folie ambitieuse constituent deux groupes;
l’un appartenant à. la paralysie générale, l’autre à. ce que l’on appelait autrefois les mono-
manies. La distinction est ordinairement assez facile; dans la paralysie générale, le
délire ambitieux est diﬁ'us, mobile, incohérent, généralisé, absurde; tandis que dans le
délire partiel, il est ﬁxe, systématisé d’une manière logique et progressive. C'est sur-
tout à. cette dernière espèce que M. Dagonet a donné le nom de Mégalomanie.
Ici, l’on pourrait, au premier abord, croire que ces aliénés doivent se sentir très-heureux
et jouir de leurs avantages imaginaires. Rien ne serait moins conforme à. l’observation
qui montre que les idées ambitieuses sont constamment associées à. des idées mélan-
choliques. Si l’on interroge avec assez de patience les mégalomanes, on manquera bien
rarement de constater chez eux, à. côté de leurs idées d’ambition et d’orgueil, un véritable
délire de persécutions, accompagné d’hallucinations de l’ouie.
Voici le travail mental dont cette coexistence résulte le plus souvent. Pour certains
hallucinés persécutés ce n’est pas assez de s’être convaincus qu’ils sont traqués par des
ennemis acharnés, ils veulent pénétrer la cause de cette persécution. Quel motif peuvent
avoir des personnes puissantes de s’acharner sur eux, gens inconnus, d’une situation
modeste? Ils ﬁnissent enﬁn par entrevoir une solution à. cet étrange problème; ils ne
sont pas des personnages si peu importants, et l’on tient ainsi à les tenir dans l’obscurité
\
ou de faire ignorer leur véritable origine. Ils appartiennent donc a une famille prin-
‘cière, royale, et sont les victimes d’une conspiration infâme, d’une substitution
criminelle.
Dans toutes les histoires de mégalomanes qu’il m’a été donné d’étudier en détail à, une
époque assez éloignée du début pour que la maladie fût arrivée à sa période d’état, j’ai
trouvé la même combinaison d’hallucinations chroniques, d’idées de persécution et de
délire ambitieux systématisé. Il faut, je crois, considérer comme une cause prédispo-
sante morale, le fait d’être enfant naturel; ainsi, sur les douze observations relatées dans
mon premier travail, cinq appartenaient à. des enfants naturels.
Si je me permets de produire de nouveau, après un délai de douze ans, devant le
Congrès International de Londres, cette théorie de la Mégalomanie, c’est que jela con-
sidère maintenant déﬁnitivement demontrée, et devant entrer dans la science médioc-
psychologique.
DISC USSION.
Dr. MAUDSLEY, London: laid particular stress upon the frequency of this form of
insanity in natural children, cf which he remembered to have himself seen an example;
PART 111. Q Q
594 MENTAL DISEASES.
and Dr. SAVAGE, London: referred to its frequency (in his experience) among governesses
and others whose position in life was not in accordance with their cultivation and
accomplishments.
Physiologie Paz‘ﬁologlgzæ des Hallucinations.
Dr. EDOUARD FOURNIÉ, Paris.
Après avoir dit que l’hallucination se distingue de l’illusion pathologique en ce que la
première n’a. pas besoin pour se produire de l'occasion d’une cause impressionnante
extérieure, intérieure, ou psychique, et qu’elle est immédiatement le produit du cerveau
malade, M. Fournié ajoute que l’hallueination est un phénomène de mémoire morbide.
Partant de là, il établit les conditions anatomiques et physiologiques de la mémoire.
Les premières sont les couches optiques, les cellules de la périphérie corticale du cerveau
et les ﬁbres unissantes du noyau blanc de l’eneéphale. Les couches optiques transfor-
ment les causes impressionnantes en choses senties, soit que l’exeitation provienne de la.
périphérie par les nerfs sensitifs, soit qu’elle provienne de la couche corticale du cerveau;
les cellules de la couche corticale, après avoir reçu l’ébranlement qui correspond à. une
impression perçue dans les couches optiques, gardent en puissance ce mode de vivre et
quand plus tard celui-ci vient à. se produire, spontanément, ou sous l’inﬂuenee d’une
excitation de voisinage, l’excitation se transmet à. travers les ﬁbres du noyau blanc
jusqu’à. la cellule correspondante des couches optiques. Le réveil de celles-ci sous
l’inﬂuenee d’une excitation provenant de la couche corticale donne naissance à. une sensa-
tion de souvenir.
Cette sensation n’est qu’une partie de la mémoire. Pour se souvenir tout-à-fait, il
faut avoir le sentiment de son activité passée ; et ce sentiment consiste, pour l’intelligenee,
à se reconnaître dans ses propres actes. Elle seule a le pouvoir de connaître, et du‘moment
qu’elle connaît, elle a conscience du travail qu’elle a effectué pour acquérir la connais-
sance. La sensation de souvenir et le sentiment de l'activité passée telles sont les
conditions fondamentales de la mémoire.
La mémoire est toujours identique à elle-même, mais les conditions de son développe-
ment varient selon la nature des sensations de souvenir.
M. Fournié divise par ce motif les mémoires ainsi qu’il suit :
1.-—Mémoire des sensations de la vie fonctionnelle de nutrition.
2.——Mémoire des sensations de la. vie fonctionnelle de reproduction.
3.—-—Mémoire des sensations des organes des sens.
4.—Mémoire des sensations qui résultent de l’aetivité volontaire de nos organes.
Après avoir signalé les particularités que présentent ces divers groupes, M. Fournié
s’applique surtout à faire connaître le dernier qui est le plus important, car il renferme la
mémoire du langage. C’est à. l’aide de cette mémoire que l’homme pense, imagine, et
raisonne, c’est elle par conséquent qui constitue les hallucinations de la pensée, de
l’imagination et de la raison.
Passant à l’applieation de la physiologie à la pathologie, M. Fournié déﬁnit l’hallu-
eination: Un acte de mémoire involontaire et inconscient, dans lequel la représentation
subjective est exagérée au point de donner à. l’halluciné le sentiment d’une représenta—
tion objective.
Cette déﬁnition repose: 1. Sur ce que l’hallucination s’impose au malade comme un
fait à la participation duquel sa volonté et sa conscience restent complètement étrangères.
2. Sur ce que dans l’hallucination la représentation subjective dépasse les limites
MENTAL DISEASES. S 9 S
normales a ce point que les sons, les images de souvenir, deviennent pour l’halluciné une
réalité objective.
Le mécanisme de l’hallucination est absolument le même que celui de la mémoire
physiologique: L’halluciné trouve dans les cellules de la périphérie corticale du cerveau
les conditions du souvenir de tout ce qui l’a impressionné. Ces cellules venant à entrer
en activité d’une manière maladive, elles réveillent dans les couches optiques l’apparition
de l’impression qu’elles représentent, et ce réveil s’étendant jusqu’aux nerfs de la péri-
phérie, donne à l’halluciné le sentiment d’une cause impressionnante réelle.
Après avoir caractérisé, déﬁni et montré le mécanisme de l’hallucination, M. Fournié
a adopté le classement suivant:
1.—-Hallucinations des sensations de la vie fonctionnelle de nutrition.
2.-Hallucinations des sensations de la. vie fonctionnelle de reproduction.
3.——Hallucinations des sensations des organes des sens.
4.-Hallucinations des sensations qui résultent de l’activité volontaire de nos
organes.
Cette classiﬁcation, il est aisé de le voir, repose sur les données physiologiques et a
permis à. l’auteur de montrer sous leur véritable jour des hallucinations dont le caractère
était mal déterminé jusqu’ici. C’est ainsi qu’il a exactement déﬁni ce qu’on appelle
hallucinations psychiques, en disant qu’elles ne sont autre chose que l’hallucination de
la fonction-langage ; c’est ainsi encore qu’il a montré le tort que l’on a de classer les
paroles entendues par l’halluciné parmi les hallucinations sensorielles. Ces paroles con-
stituent l’hallucination de la fonction-langage.
DISCUSSION.
In the discussion that followed, Dr. Fournié’s views were generally dissented from,
their hypothetical nature being particularly insisted on by Dr. ASHE, Dublin: and the
fundamental difference between hallucination and memory urged by Professor LASÈGUE:
Paris—Professor DE Jone, Amsterdam : pointed out that there need be no activity of
the peripheral organs of sense in hallucinations: he believed these to be due rather to
stimulation of the sensory centres in the cortex. cerebri, which transmit their impressions
to the optic thalami.
Dr. SAVAGE then exhibited some Brain Sections made by Dr. Holler, and. explained
the method employed. In Dr. Holler’s absence his paper was taken as read; but the
following is an abstract :—
Prizpamz‘z‘ommez‘hode zur Anlegung grower Dum/zsc/mz'z‘z‘s-
pmpemze des menschlichen Gehirns.
Dr. ANTON HOLLER, Vienna.
Allgemeines über die Methode; ihre Unterschiede und Vorzüge gegenüber andern
Härtung des Gehirns in doppeltohromsaurem Kali oder in Miiller’scher Flüssigkeit
ohne Alcohol.
Anlegung von grossen Hirndurehschnitten, nöthige Instrumente und Vorrichtungen.
Färbung dieser Schnitte in oarminsaurem Ammoniak.
Einlegen derselben in Canadabalsam.
Präparation der auf dem Objectträger ﬁxirten Schnittpräparate zur mikroskopischen
QQ2
596 MENTAL DISEASES.
Untersuchung: anfangs kann mit groberen Messer'n geschnitten werden, spatcr wird mit
feinen, tenotomformigen Messerchen gesckabt.
Einschliessen der Praparate nach Aufhellung mit Nelkenol, 8:0.
Schwierigkeiten dieser Methode.
Beschreibung der ausgestellten und auf diese Art angefertigten Pr'aiparate.
DISCUSSION.
This was particularly discussed by Professor BENEDIKT, Vienna: who pointed out
that this method was much easier than the use of Gudden’s microtome, and might there-
fore be employed with advantage by beginners, but was less accurate, owing to the dis-
placement (particularly of pathological changes) which must inevitably be eaused.--Dr.
DE JONG, Amsterdam: considered Holler’s method most suitable for macroscopic sections,
where alcohol is not injurious; but for microscopic purposes gave the preference to
Gudden’s sections.
Cenz‘ain Moi/din’ Appearances produced 6y Jllez‘nods of
Handening N 67/7/0748 T issnes.
Dr. SAVAGE, London.
Dr. SAVAGE read a paper on “ Certain Morbid Appearances produced by Methods of
Hardening Nervous Tissues,” of which the following is an abstract :—
Various pathologists have from time to time shown that changes which seem to be
due to disease are owing to the preservative agents used; but the subject has attracted
too little attention, considering its importance. About eight years ago I was much
struck with the fact that I always found certain bodies in all brains and spinal cords
sent to me from a distance for examination. By examining healthy human brains, and
also those of rats, squirrels, monkeys and parrots, I found bodies which were not
due to disease, but to the mode of preservation. They occur particularly in nervous
tissue which has been kept long in spirit before being placed in the chromates; the time
required for their formation varies. My opinion is that these bodies are due to some
decomposition which goes on in the spirit, and not to be distinguished from miliary
degeneration. There are several kinds of bodies found; but none of them seem to be
soluble in ether, alcohol, or chloroform, or to present the reaction of amyloid matter.
Dr. Savage exhibited some specimens, obtained from healthy brains, human and
of the lower animals.
DISCUSSION.
Dr. BENEDIKT, Vienna: endorsed the importance of the subject, and fully agreed
with the author that the appearances are due to some kind of decomposition, but
believed that they occurred more readily in diseased tissue than in healthy.
T he T eacning qf Psyeniaz‘nic Medieine.
Dr. T. S. CLoUsToN, Edinburgh.
I propose in this paper to say very little about the advantages to medical men of
some knowledge of mental disease, or of the necessity which I believe exists that
psychiatric medicine should be taught in our Medical Schools. If the arguments,
that already there are 500 members of our profession who have to treat the insane in
MENTAL DISEASES. 597
Asylums, that the law throws most responsible medico-legal duties on most members
of our profession in relation to insanity, that the home treatment of the disease in
its early stages falls in ordinary course on the general practitioner, and that one in
every 300 of our population is insane and needs treatment of some sort, if those
arguments are not sufficient to show that our medical students should be taught
something of insanity before they begin to practise medicine, then assuredly the
pleadings of a teacher of psychiatric medicine will not avail much. It is surprising,
however, how unanimous is the opinion that all medical men ought to know something
about mental diseases, and that all students ought to be taught something of them.
It is a general principle on which doctors do not differ, and lawyers are in complete
accord, while those of the general public, who are in the way of having insane people
about them requiring treatment, assert the principle very strongly indeed.
Two excuses are commonly assigned why the knowledge has been imperfect, and
the teaching not attended to. The one is that there had been no convenient oppor-
tunity of the student studying the disease, and the other the already “ Overloaded
Curriculum.” A third argument was brought forward last year by the President
of the Psychological section of the British Medical Association, at Cambridge—viz.,
that “ the teachings of psychological medicine are still so ambiguous and unsystematic,
that they can scarcely pretend to supply either much useful instruction, or a valuable
discipline to the mind,” and he accordingly strongly discourages students from having
anything to do with it. The “ no chance,” “ no time,” “ no good,” excuses will have
to be met, not by argument and talk, but by a practical demonstration, that many
students have actually taken the time, that they have opportunities, and that they
have got some good from the instruction received, If Dr. Browne’s present opinion
that psychological teaching does not pretend to supply much useful information, is to be
taken seriously, it would be very discouraging to the present teachers of the subject,
as coming from one who himself taught it for many years, extolled it highly, and two
or three years ago, after having said that his professional brethren “ generally” know
very little about lunacy, told a Select Committee of the House of Commons, that “it
would be a great improvement if it were made compulsory upon medical men to obtain
some training in lunacy during their medical education, if a course of instruction
in mental disease was a part of a medical education.” Of course circumstances alter
cases, and it would be hard on any of us, if we were tied down to express the same
opinions always. Dr. Browne told his Cambridge audience that, this psychological
food which was so useless to the student, was very good indeed for them when
properly administered through the British Medical- Association, and it was a right and
proper thing for them to take their ﬁll of it.
My present remarks will be addressed to the following questions :—
(1) What is the best mode of teaching psychiatric medicine to the studentiJ
(2) Can the student with four or ﬁve years of study at his disposal, devote as
much time as is requisite to be taught as much about mental diseases, as will be
really useful to him in practice P
(3) If the subject is not to be one of those on which a student’s knowledge is to
be tested, even to a minimum extent, when passing his examination for his ordinary
license, should it not at least be one of the subjects of examination for honours in the
medical degrees, for all the higher qualiﬁcations such as the M.D. when the M.B.,
has been taken already, Memberships and Fellowships of Colleges, &c., and should it
not be required for such public appointments as those in Public Health, to Gaols,
under the Local Government Board, and in the Indian, Army, and Navy Services P
The ﬁrst question, “ What is the best mode of teaching Psychiatric Medicine to
the Student P” can only be answered satisfactorily by an appeal to experience. I am
well aware too that in referring to my own experience I am appealing to a limited
range of facts. Another man’s experience may be totally different from mine. Other
men may teach far more successfully in other ways than those I am about to describe.
5 9 8 MENTAL DISEASES.
My own experience as a pupil was derived from my predecessor at Morningside,
Dr. Skae, who taught insanity in the Medical School at Edinburgh. His method
was to deliver a set course of two lectures a week during the summer session, and
have his students out once a week to the asylum. They were taken round the wards
by himself or one of his assistants, and the cases talked about as they were met with.
No systematic attempt was made to collect together cases of the same disease the same
day, and the histories of the cases were not read from the case books, or minutely
gone into. Dr. Skae had classes of over thirty students, and charged a fee of three
guineas for his course. The subject was required for the Army Medical Service at
the time. In common with very many of Dr. Skae’s old students, my experience is
that very much and most useful and practical knowledge of insanity was derived from
his course. We were made to recognize its chief types, it passed deﬁnitely into our
consciousness and experience as a disease to be studied and treated like any other
disease, and we were all intensely interested in the whole course.
Dr. Laycock for twenty years taught and professed to teach, not psychiatric
medicine in its restricted and practical sense, but medical psychology in its large sense,
as understood by Feuchtersleben. Indeed Dr. Laycock’s conception of his subject
was best understood by the title of his book, “ Mind and Brain.” He delivered four
systematic lectures a week during the summer session in the university, with a
clinical demonstration in an asylum about once a week, with practice in signing
certiﬁcates of lunacy. Dr. Laycock’s course was most suggestive, original, and
instructive. His class sometimes amounted to forty students; his fee being latterly
four guineas for the course.
I have now had eight years’ experience as a teacher of mental diseases in
Edinburgh. I have tried various methods of instruction, and have tested theinresults
by general observation, as well as by severe class competitions, and I shall describe the
method I at present adopt, which, I think, has yielded the best results so far.
My course is a summer course of three months, and by far the majority of the
students are in their fourth year. I must say also that as a general rule the students
who attend my class are rather above the average in ability and application, and I
always have a few men who are all round the the best of their year. I give twelve
systematic lectures in the University, one a week; the students come out to the
asylum twice a week for clinical instruction, and towards the end of the course I give
four systematic demonstrations from specimens and diagrams, two being macroscopic,
and two microscopic, on the pathology of insanity. I always begin the course by a
lecture on the general functions and structure of the brain, as far as they relate to its
mental functions or to mental disease. I shall not say anything regarding the
systematic lectures, for every teacher will take his own classiﬁcations, divisions, and
methods. But one thing I have been strongly impressed with in the delivery of
those lectures to the students : the more one sticks to the concrete facts of Nature, the
better one is attended to. The narration of an illustrative case will rouse the attention
of every student in the sultriest day, when it was ﬂagging in the effort to listen to
general descriptions. And another thing I have been impressed with: the interest of
the students always seemed to heighten if the condition of mental disease being
described could be traced to physiological psychical states—6.9., if the morbid exaltation
of simple mania can be clearly connected and related in its symptoms and evolution
with the physiological exaltation of a sanguine temperament and a nervous diathesis,
or with the normal exaltation seen in a sane brain from extraordinary stimuli and
causes of joy, or with the normal psychical exaltation of a young child. I devote one
lecture towards the end of the course to the medico-legal and medico-social duties of
our profession, and the last to general facts about the numbers of the insane, the
curability and mortality of the insane, the prevalence of the different forms of insanity
at different ages and places, &c. I supply a printed syllabus of each systematic lecture
to each student as he enters the class-room.
MENTAL DISEASES. 599
It is regarding the clinical teaching of insanity that I wish specially to speak.
All my experience has been that this is the backbone of the teaching. For real use
to the student, for interest to him at the time, for the permanent impressions left on
his mind, we must look to this. Here he gets the facts of Nature at ﬁrst-hand seen
by himself. Here he is brought as a physician face to face with a new disease affecting
the supreme part of man, and it never fails to interest him. Here he gets the ﬁrst
real glimpse and realization of these great medico-psychological and medico-social
questions relating to the connection of mind and morals with organization and brain.
If any teacher could impart to the student clinical instruction in a case of mental
disease commensurate with its real interest, every student would ﬂock to his class.
I never feel myself so helpless as when I have before me an interesting case of
mental disease and a class of students to whom I have to explain its features
and import. It is then that our present imperfect knowledge of the mental functions
of the brain is most fully realized. The problems of heredity, causation, subtile
inception, and co-relation with the nutrition and dynamics of brain cells are so pressing
and yet so undeﬁned scientiﬁcally in such circumstances, that he would be a very self.-
conﬁdent man who did not feel the load of his ignorance more oppressive than the sum
of his knowledge. Student and teacher feel instinctively that here the facts are most
important and most interesting, whether we can interpret them rightly or not,
medico-psychological teaching may be valueless, but the medico~psychological facts
to be seen in any actual case of mental disease must be of value to a physician who
has to practise his profession. N o rational man can doubt that every advanced student
must be the better for having had an opportunity of seeing such facts in a patient, and
few people can doubt that every student would be the better for seeing a well-assorted
typical series of such cases before he is licensed to practise. Now how can a case of
mental disease be best seen and studied, and its main features brought out to a class
of students in what is ordinarily understood by a clinical lecture or demonstration?
And how can a typical series of cases be best brought before them? Of one thing I
am quite sure from my experience. Much system and order must be adopted in such
a short course as mine. Going through asylum wards too much does not admit of
this. The student’s attention is distracted, and you do not ﬁnd together cases that
illustrate properly all the facts of one type of insanity. I devote the ﬁrst three
cliniques to the illustration of disorders and alterations of each of the great brain and
mental functions seriatim. I take cases each one showing typically, impairments and
changes in the following mental and brain functions—viz., the reasoning powers, the
affective faculties, the inhibitory power, memory, the animal and organic appetites and
instincts, the special sense functions, the sexual and generative functions, the power of
rest in sleep, the motor, sensory, and trophic functions of the brain. The students sit
in a room, and the cases are brought in singly while I try to direct and concentrate
their attention on the one point to be illustrated by each case. My object is to create
in each student’s mind a vivid sense of the direct connection of brain derangement
with abrogation and alteration of each of what he has been taught to regard as a
faculty of the mind, in insanity. Nothing so enables a student to realize that maternal
affection is a brain quality, as to see a puerperal case where the woman has forgotten
her sucking child, or has had her aifection for it so completely perverted, that she has
tried to murder it. N 0 amount of talking will make such an impression on him, that
the instinct of the love of life is directly connected with soundness of brain function as
to see a case of suicidal melancholia where the patient desires to die with as great
intensity as any man ever wished to live. This I look on as introductory to the real
clinical course. I don’t go into the history of those cases or into any other features
than those illustrating the point I wish to bring out.
In the next ten cliniques I endeavour to illustrate the chief symptomatological
varieties of mental disease by taking two or three typical examples of each, ﬁrst
reading the history of each case to the class, then having the patient in, and bringing
6oo MENTAL DISEASES.
out the features as best I can, and then making some remarks as to prognosis, &c.,
after the patient has left the room. Some varieties of insanity admit of a full com-
mentary in the presence of the patient. In most cases, however, this cannot be done.
I don’t ﬁnd the patients often object to being made the subjects of a lecture. In many
cases they are proud of it. I have never known it do a patient any harm. It is
unquestionably diﬂicult in very many cases to bring out the mental symptoms clearly
and in a reasonable time before a class of students, but in one’s endeavour to do this
students have a valuable lesson as to how to speak to insane patients and treat them.
In this way I go over the great conditions of morbid mental depression, exaltation,
delusion, enfeeblement, and loss of inhibition.
I then begin to tell off one or two students each day to see patients alone, to
diagnose the disease present, and to sign a medical certiﬁcate of lunacy. These cer-
tiﬁcates are each day read aloud and commented on before the end of the clinique.
In that way I get plenty of opportunities of saying all I have to say as to this im-
portant matter. Each student has in turn to sign a certiﬁcate, and have it criticised.
By this time the students know as much about the disease as to make an occa-
sional visit to the wards proﬁtable, especially to the admission and sick wards. They
now look on the patients, not from the point of view of mere curiosity and amusement
at their peculiarities, but as examples of disease, from the physician’s point of view.
The bulk of the real and exact clinical teaching, I believe, is done by the study of
individual cases brought in before the students.
The remainder of the session is taken up with the illustration of the clinical
varieties of insanity, the epileptic, puerperal, climacteric, senile, &c., forms. When
any interesting case is admitted, it is often the subject of a special clinique, such as
cases illustrating the suicidal or homicidal tendencies, the complications of insanity
with hysteria, aphasia, or special motor, sensory, or trophic symptoms. One clinique
is devoted to idiocy and congenital imbecility. All the post-mortem examinations that
occur during the session are done after the cliniques.
My experience goes to Show beyond all doubt that most students are much inte-
rested in cases of mental disease. With the immense disadvantage of the asylum
being a mile and a half from the university, and their having therefore to spend two
hours to each clinique, they come out with most commendable regularity, and they take
up the points of the cases with keen intelligence. It is a real pleasure to have a few
good cases to bring out before them. They look on it as a new ﬁeld with certain
features quite new to them.
I ought to have mentioned that on the Saturdays during the months of March
and April, I give preliminary informal cliniques for the beneﬁt of those who propose
to take out the class in May, so that it may not be quite a term» incognita to them,
when the summer session begins.
2.——The next question is this—“ Can the student with four years of study
at his disposal devote as much time as is requisite to be taught enough about mental
diseases to be really useful to him in practice?” ,
This is the real point at issue between those who do not think that the student
should be examined as to his knowledge of mental diseases, and those who do. I
have most carefully inquired into this matter, seeing how the time and attention
required seemed to affect their other studies and preparations for the examinations, and
talking with many students on the subject. Last year I had a class of forty-ﬁve.
There were about 120 fourth or ﬁfth year’s students who went up for the examination
for the M.D. degree, about ninety of whom passed, and to my knowledge only two of
my class were among the plucked men. N ow this of course may be read in different
lights. It may be said that it was the best men, those who were well up, that took
out such an optional class as mine. Here I may say that they have no pressure or
inducement whatever to take out the class of mental diseases, except a desire to know
something of the subject. No question is ever put on the subject for the degree, the
MENTAL DISEASES. 60 I
class is not needed for anything, the university authorities do not recommend them
to take it out, I am not an examiner in any subject, they never see me till they come
to the class, and they have to pay me a fee of three guineas for the course. No
doubt the best men take out this as well as the other extra classes, but considering
that they are passing their degree examinations during the summer they have out the
class, and that it depends on how they answer the questions in the ordinary subjects
whether they take honours or not, the fact that they should have devoted any time at
all to such a subject shows that they do not think it withdraws their attention unduly
from their examination subjects. As a matter of fact, the “Ettles Scholar” of the
year at the graduation—that is, the man who has attained the most marks all through
the various examinations—has taken out the class of mental diseases three years out of
four both in Professor Laycock’s time and in mine. Such facts prove conclusively
that the best men can study mental diseases before taking their degree, without
affecting injuriously their other and necessary studies. I must say they do not read
up the subject from books. They all say they have no time for that. But at my
class competition for the prize, as well as in my intercourse with the students, I have
proofs that they acquire a most practical knowledge of the subject. In the former I
give six questions over the whole of the subject, and after answering these each
student gets a. patient whose case he has to write out, giving the diagnosis, prognosis,
and treatment, and then he signs a medical certiﬁcate of lunacy. I often have the
answers, the cases, and the certiﬁcate about as well done as I could do myself. Can
anyone doubt that a man with this special knowledge goes into practice better
prepared for all emergencies that may arise, than the man who has never seen a case
of mental disease?
But then comes the question as to the student who is under the average or just up
to it? Can he afford to have any distraction of his mental energy at all, just when
passing his ﬁnal examinations? Should he be encouraged to undertake anything that
may lessen his chances of passing, or withdraw his mind from what is essential? The
opinion of many of the members of our Edinburgh Medical Faculty, I believe, is, that
such students should not take out more classes than those in the curriculum except
they study for ﬁve years. I have some such students in my class, and I never
heard of one who was plucked in consequence, but I am willing to admit that for
many such men such a course as I have described in their last summer session would
be distracting, and might imperil their chances of attaining the degree. But when
such men go into practice, they, like their fellows, will have to treat cases of insanity.
to sign certiﬁcates of lunacy, and give evidence as to mental disease in the courts of
law. And this without having seen a case of the disease previously, or been told any-
thing about it. It is all very well to say they should read it up after passing. These
are just the men who don’t read much then but trade on the capital they have acquired
in their medical course. Is there no way of meeting the dilﬁculty? I think like all
other diﬂiculties it should be faced. I think a sort of minimum course of instruction
could be instituted within the reach of every man who is ﬁt to enter our profession at
all. It should be intensely practical, and therefore purely clinical and short. I
think much could be done in twelve clinical demonstrations, say on Saturdays
during the last winter session. You must have patients to see to do any good. All
students can be interested in the facts of nature and disease. I am often much
impressed and amused in reading the answers to my questions at the class examina-
tions. Men are apt not to stick to the descriptions I have given in my systematic
lectures, but will rather take the features of the cases they have seen and describe them.
‘We had an epileptic who tried to tear away another’s testicles, one year. In that year’s
answers tearing away testicles was put down as characteristic of epileptic insanity
by almost every student of the class! The twelve cliniques would therefore require to
be given on most carefully selected cases with vivid and typical features. The whole
thing would need to be most practical. Each student would require to sign a lunacy
602 MENTAL DISEASES.
certiﬁcate, and to be brought personally in contact, face to face, with a lunatic, to get
the physician’s mode of looking at him, instead of the sensational and popular mode
which is natural to all men, who have not come practically in contact with the insane.
Such a course to be well done would need far more thought and care than a complete
course. Were it without care and slovenly, it would fail : well done, I believe, it
would be of inestimable advantage to our profession, and to the insane. It is an insult
to the intelligence of our medical students to say that such a compulsory course would
interfere with their other studies. N o mere lectures in a medical jurisprudence course
could possibly take the place of seeing cases and hearing them commented on clinically
by a competent teacher.
3.—The third question—via, whether aknowledge of mental diseases should not
be required for all higher degrees or qualiﬁcations, and for most of the public services
and appointments—is one which few would care to deny in toto. The mental functions
of the brain are the highest region of which our profession takes cognizance. Their
derangement forms a diﬁicult and important study. A complete knowledge of those
derangements, their causes and prevention or cure, would necessarily be the very highest
department of medicine. If it is not so regarded now, this is because our knowledge
is as yet very imperfect, as compared with some other departments of the profession.
Therefore increased study and attention are much needed by the best minds in our
profession. All these reasons point strongly to the advantages of making the study
one of those required for the higher qualiﬁcations in medicine.
The argument for some knowledge of mental diseases being neccessary for appoint-
ments in the public services is simply that men in these services have to do acts,
which, to be done properly, require such a knowledge. It is unfair to the doctor and
the patient to make a man determine the question of the sanity or insanity of a
patient, the question of the abrogation of his personal liberty and his civil capacity, to
lay on him the duty of signing medical certiﬁcates of insanity, when he has never had
the opportunity of seeing a case of the disease, or receiving any instruction in regard
to it. The very nature of his appointment gives him no choice as to doing these
duties, and gives the patient no choice as to the man who shall decide for him these
momentous questions. All the lunacy statutes clearly imply some knowledge of
lunacy on the part of the medical men who carry them out. Is there such a know-
ledge? If not, then is our profession placing itself in a proper position with regard
to those laws? Apart from the interests of individual patients, the interests of i
the State demand such a knowledge. There is looming up very near us a great
question of State lunacy policy. Through the operation of previous Acts such
numbers of persons, technically of unsound mind, have been sent by our profession to
the asylums for the insane, that they are all nearly full, and every increase made to
their accommodation is ﬁlled at once. The quiet imbecile, the harmlessly crazy, the
restless paralytic, and the helpless dotard, occupy the wards intended for the curable
and the actively insane. The public who has the bill to pay, is showing signs of
restiveness and inquiry. No one can doubt that we shall soon need receptacles for
the incurable apart from the asylums for the curable. That will imply the expression
of an opinion, in some legal document, by a member of our profession, not only as to
whether the case is of unsound mind, but whether it be curable or incurable.
Such are the considerations that, to me, seem very cogent in giving an aﬂirmative
reply to the question as to whether public medical officers, who have to do statutory
duties in connection with lunacy, should be called on to prove that they know some-
thing about it before they undertake those duties.
I
DISCUSSION.
Dr. I'IACK TUKE, London : opened the discussion on Dr. Clouston’s Paper. He con-
tended that some knowledge of mental diseases should be required of every candidate for
a degree, and he believed the difficulties alleged to be in the way of clinical instruction
MENTAL DISEASES. 60 3
would soon disappcar.—Dr. MACDONALD, in New York, and Professor BALL, in Paris,
have found no want of interest on the part of the students, who acquired a satisfactory
knowledge of the subject; they have never seen the patients suffer from their examina-
tion before the students.
Dr. MAUDSLEY, London : considered that it is not at present possible to provide clinical
instruction in London, with its scattered medical schools, and few asylums accessible;
for this reason the subject has not been made compulsory by the University of London.
Mr. MoULD, Cheadle : on the other hand, has found no difficulty in getting students
to come out nine miles from Owens’ College, to his asylum, for instruction.

0a Moral Deaaagemeat aaa’ [mam'z‘y in cases of Paralysis
Agz'z‘aas.
Professor BALL, Paris.
From the earliest dawn of medical science, the frequent occurrence of mental
derangement, in convulsive diseases, has been considered as an ascertained fact. Epilepsy
both in its milder and in its more severe forms—--chorea, and especially hysteria, have
always been closely connected not only with a peculiar turn of mind, but also with
certain deﬁnite forms of insanity. Of late, the limits of this peculiar province of morbid
psychology, have been greatly enlarged; and other nervous affections, among which
exophthalmic goitre stands prominent, have been joined to the list of the causes which
produce insanity.
That painful and distressing malady, generally known under the various names of
shaking palsy, Parkinson’s disease, or paralysis agitaazs, although nearly similar in
appearance to certain organic disorders of the nervous centres, whose symptoms closely
resemble its own, still remains a member of that class of diseases in which no distinct
and permanent lesions are found to account for symptoms observed during life; and,
although my excellent and eminent friend, Dr. Luys, has, in some of these cases,
discovered hypertrophy of the motor—cells in the medulla oblongata, it still remains to
be proved that Parkinson's disease is constantly associated with this state of things.
Paralysis agitans may therefore be considered, in the present state of our knowledge,
as a convulsive neurosis; and, as such, it seems natural to anticipate that, like
epilepsy and chorea, it will sometimes be associated in some cases with certain peculiar
forms of mental derangement.
In classical descriptions it is stated, in general terms, that, towards the latter end
of the disease, the patient often falls into a state of despondency, which may, sometimes,
amount to lypemania, and is occasionally attended with sensorial delusions, or with a
marked diminution of intellectual power. But, as far as I have been able to ascertain,
the record of cases positively amounting to insanity, in patients suffering from shaking
palsy, is short and poor indeed.
In 1870, Dr. Althaus published a case of paralysis agitans, in which the patient,
while under treatment by bromide of potassium, exhibited various symptoms of mental
derangement—viz., agitation, delirium, and visual hallucinations. The question, of
course, arises, how far the mental troubles were due to the treatment employed, and how
far they might be attributed to the disease itself.
In the second volume of the “ West Riding Lunatic Asylum Reports,” Dr. Patrick
Nicol inserts an elaborate Paper on the mental symptoms of ordinary disease, in which
he draws attention to the mental and moral changes observed in two cases of
Parkinson’s ' disease. In the ﬁrst, an extreme irritability of temper, which had not

604 MENTAL DISEASES.
previously existed, was the leading character; in the second, a general depression of
the intellectual faculties was, in a psychological sense, the most important feature.
The late lamented Professor Lorain, in 1875, in a Paper on nervous diseases rising
from strong moral emotions, mentions a case in which a sudden fright produced not
only the motor troubles of shaking palsy, but also a general suppression of mental
capacities, which fell barely short of complete fatuity.
Lastly, my friend and master, Professor Lasegue, records the interesting history
of a lady who, after Suffering for two years from partial dementia, became a victim of
paralysis agitans. In this case, the usual process would seem to have been reversed,
and the mental symptoms to have preceded the locomotor troubles, instead of following
as usual in their train.
That other facts, which have not been brought to my knowledge, may point to the
same conclusion, I have not the slightest doubt; but, from a rapid glance at the
literature of the subject, it would seem that but little attention has been paid to this
point. Struck with the leading features of Parkinson’s disease, most observers have
not inquired how the background of the picture was ﬁlled up; and, from existing data,
it might naturally be inferred that psychological troubles in shaking palsy are a
merely accidental occurrence.
Now, it so happens, that, within a limited space of time, a considerable number of
such cases have been forced upon my attention. As, however, the mental symptoms
were, in general, too moderate to bear analysis, I will select three of the more strongly
marked cases, in which a sharp outline allows us to seize the more prominent points,
which give this peculiar state of mind a distinct and characteristic appearance.
It may be Said that the psychological symptoms in shaking palsy naturally arrange
themselves under one of these headings.
In the ﬁrst class of cases the symptoms are those of intense lypemania, amounting,
in fact, to positive insanity. In the second, moral and intellectual depression, with
loss of memory, and general weakness of mind, are the most prominent features.
In the third, the mental disease assumes an intermittent form.
Each instance which I have selected corresponds to one of the three classes which,
I repeat it, are not artiﬁcial, but natural and necessary divisions.
CASE I.-—Paralysis agitans with intense lypemania, hallucinations of sight and
hearing, mania of persecution, and suicidal impulsions.
Charles B , an accountant, aged ﬁfty-three, has been suffering, for the last
ﬁve years, from shaking palsy.
The ﬁrst symptoms of the disease were pains in the ﬁnger-joints of the left hand,
and a slight tremulation in that part. The intensity of these morbid phenomena
rapidly increased; and, after a space of eight or ten months, the whole of the left arm
was affected with tremor. The progress of the disorder, from this time, was slow, but
regular; and, eighteen months later, the lower limbs also were involved; in short, two
years after the beginning of the disease, the patient was totally incapacitated from labour.
On the 11th of February, 1881, he was admitted into my service at the “ Hopital
Laennec.” '
The stiffness of his attitudes, the perfect immobility of his features, and the
continual tremor affecting the upper and lower limbs on both sides, as well as
the head, made the patient a perfect type of paralysis agitans. The man is able to
walk, but with a strong tendency to run forwards. He enjoys the use of his hands,
but both arms are semi-ﬂexed at the elbow-joints, and the ﬁngers are stiff: their atti-
tude may be compared to that which they naturally assume in the act of writing, or in
holding a pencil. The voice has a nasal twang: the patient speaks slowly, and with
some difficulty, and the tongue is affected with a slight tremulous motion.
All these symptoms are manifestly increased by the slightest emotion ; the mere fact
of seeing the doctor approach his bed, and exchange a few words with him, sets the
whole machine in motion.

MENTAL DISEASES. 60 5
The patient is, in fact, of amorbidly sensitive disposition ; tears start to his eyes on
the slightest provocation, and the general bent of his character is deep despondency.
But the most prominent and characteristic feature of his mental condition is a
rooted belief that he is persecuted by imagining enemies, who, as he expresses it, are
constantly “ at him.”
On examining the grounds of this obstinate delusion, we discover that, for the last
ﬁve or six months, he has, every night, been tormented by visual and auditive halluci-
nations. Night after night he hears voices at a distance, which threaten, upbraid, and
insult him. At the same time he sees and even feels his enemies: they stand round
his bed, they approach him, they even touch him, and he struggles violently to save his
life, which he believes to be in imminent danger.
The scene changes when the day breaks: his imaginary tormentors have disappeared,
and he only remembers the terrifying visions of the night. During the earlier period
of his delusions he was able to remember what the voices had said, and was able to
repeat it the next morning; at present, however, his memory simply retraces the fact
that such voices were distinctly to be heard; but he can no longer repeat their very
words, as he formerly used to do.
Under the inﬂuence of his delusions, the patient has more than once evinced a
strong tendency to commit suicide, but the most attentive supervision has, up to the
present moment, kept him out of harm.
In other respects his judgment appears to be sound, and his conversation is
rational: he exhibits, however, a considerable failure of memory, and never speaks of
his own case without taking the most unfavourable view of the future.
I have considerably abridged the history of the case, omitting some important par-
ticulars, in order to draw attention to the psychological features of the case. A man,
upwards of ﬁfty, having never exhibited signs of mental derangement, and free from all
hereditary taint, is affected, ﬁve years before entering our hospital wards, with shaking
palsy ; the progress of the malady reduces him to absolute impotence; and, without any
other known cause, he falls a victim to nocturnal hallucinations, under their inﬂuences,
becomes affected with the mania of persecution, the whole process culminating in a
violent tendency to suicide.
We ﬁnd here a strongly marked case of unmistakable insanity, in which the
predominating neurosis seems exclusively responsible for the mental phenomena;
neither the treatment adopted, nor the patient’s personal or hereditary disposition,
can, in any degree, be called to account.
It may be noticed, in connection with the auditive hallucinations, that, for some
years past, the subject had been gradually growing deaf.
Our second case exhibits mental derangement of an entirely different type.
CASE II.-—D , aged thirty-four, a hairdresser by trade, was born in Sardinia,
and came to live in Paris in 1867.
During the war of ‘1870-71, he served in the French army, and took a part in the
defence of Paris. Having considerably suffered from cold and damp, he attributes to
these causes the disease from which he suffers now; yet the premonitory symptoms
only made their appearance three years ago. He ﬁrst began to feel a burning
sensation in the lower limbs, whenever he stood up, or attempted to walk; after which
it seemed as if cold water was trickling slowly down his legs; from time to time
this painful sensation disappears, but only to return again, after a short interval.
About eight months ago the patient began to experience a slight tremulation in
the left arm, which rapidly increased after the slightest exertion, so far as to compel
him almost entirely to relinquish his employment as a hairdresser, in which, if we are
to believe his own statement, he was singularly proﬁcient.
Shortly afterwards, that is to say, about six months ago, the mental phenomena
to which we desire to call attention, ﬁrst made their appearance.
Like many of his countrymen, he formerly enjoyed great vivacity of sp'n'its; his

606 MENTAL DISEASES.
temper was cheerful, his movements quick, his habits active. Gradually, however, he
grew cold, lazy, and indifferent to everything around him; his heart was no longer in
his work, nor did he take any pleasure in the amusements for which he formerly had
a considerable relish; and, after having been an active, busy and intelligent man, he
seemed to lapse into the condition of an idle, apathetic and half demented fool. His
memory failed him ; his movements became slow and clumsy, and, three months before
entering our wards, he was literally ﬁt for nothing.
From that time, the disease made continual progress; and, on the 18th of
January of the present year, that being the date of his admission, he exhibited marked
symptoms of paralysis agitans.
The face is pale, rigid, and without the slightest expression: not a muscle quivers
in his countenance; he is able to walk and to use his hands, but moves with slowness
and diﬁiculty. The tremor is entirely limited to the left side; and, while hardly per-
ceptible when the patient is at rest, it increases considerably when he attempts to move.
But the most striking feature in the patient’s {outward appearance, is a state of
local asphyxia affecting both hands and feet; a bluish purple colour spreads over their
surface, whenever the patient stands or walks, and their temperature grows icy cold.
These singular phenomena partially disappear when the subject reclines in bed.
There exists great difficulty or, at least, great slowness in speech, without any
tremulation or paralysis of the lips or tongue; at times, D seems almost to be
affected with aphasia, and can scarcely ﬁnd words to express himself; he enjoys,
however, greater ﬂuency of speech in his native language than in French.
The general impression which results from a ﬁrst glance at the patient, is that of
an impediment in all the functions of the brain. Motion and sensation, thought and
speech appear to meet with some permanent obstruction ; and, although the subject is
not positively delirious, he stands in close proximity to a state of apathetic dementia.
The absolute indifference which he exhibits to all things—the seemingly total absence
of ideas, and the evident failure of memory—suggest the notion that sluggish circulation
and local asphyxia exist in the brain as well as in the hands and feet.
The man left our ward on February 14:, and has since returned to his native
country.
While the above-mentioned case exhibits, in a marked degree, the depressive form
of mental disturbance connected with Parkinson’s disease, the third and last patient,
whose history I will briefly record, is a type of intermittent, or transitory excitement.
CASE IIL—A lady in an advanced period of life was taken, ten years ago, with
shaking palsy, limited at ﬁrst to the right hand, then to both limbs on the right side;
and extending, at a later stage of disease, to the left side of the body.
From the very outset the patient exhibited signs of evident mental derangement.
Her conversation, which had never been conspicuous for wit or brilliancy, but which
used to be sensible and rational, became, all at once, rambling and disconnected: she
would talk and mutter to herself for hours together, and always evinced great irrita-
bility when interrupted or disturbed. But the even tenor of her ramblings was
occasionally interrupted by ﬁts of considerable excitement. On these occasions she
would start from her bed, declare that she was going to leave the house, and threaten
to commit suicide. After being quieted, with considerable difficulty, she would
suddenly break forth again; and this state of perpetual excitement would last for two
or three days together, after which she subsided into her usual state, and was com-

, parativel y calm.
The progress of the disease extended over three years; and the patient died in a
state of insensibility, after an unusually long period of excitement. No post-mortem
was allowed to take place.
From the preceding facts, I would beg to deduce the following conclusions :—
1.-—-That mental derangement is more frequent in cases of paralysis agitans than
has generally been supposed;
MENTAL DISEASES. 60 7
2.-—That, in its slighter forms, the psychological change is limited to irritability
and restlessness ; but that, in the more severe cases, it amounts to positive insanity.
3.—-That three forms, at least, of mental disturbance may be observed in such
cases: the ﬁrst corresponding to what is generally called lypemania, the second
closely bordering on dementia, the third exhibiting an intermittent or periodical cha-
racter.
Lastly, that there is in cases of shaking palsy no distinct connection between the
loss of intellectual power, and the severity of physical symptoms.
DISCUSSION.
Dr. SAVAGE, London : remarked that intellectual disorders were connected with disease
of the sensory rather than of the motor tract; and that the cases of paralysis agitans
related might, therefore, be said to occupy an exceptional position.
Dr. C. MERCIER, London: thought that there was mental defect in every case of
paralysis agitans, but that this, being usually negative, was overlooked, because of the
greater prominence of the motor symptoms.
Dr. HUGGARD, London: related a case of insanity associated with paralysis agitans at
present under his observation; the symptoms were those of folie circulaire, with
exalted delusions during the excited periods.
Questions Mambo-légales : a’e [Explosion Soua’az'rze d’acce‘s
d’AZaooZz'sme Aigu ou Suéazlgu par C/zoc Moral.
. Dr. MOTET, Paris.
\
Les questions médico-légales relatives a l’aliénation mentale soulèvent les plus
graves problèmes: j’ai l’honneur de vous soumettre l’une d’elles, qui, pour n’être
pas des plus compliquées, n’en présente pas moins, dans la pratique, des difﬁcultés de
recherches assez grandes. Parlant devant des hommes qui sont l’honneur de la médecine
mentale en Angleterre, je suis certain d’être approuvé par eux quand je dirai que plus
le rôle du médecin qui tient dans ses mains la liberté, l’honneur, la vie quelquefois d’un
citoyen, est considérable, plus grands aussi doit être sa préoccupation d’arriver a la
vérité scientiﬁque, et à, la juste appréciation de la responsabilité de l’auteur d'un crime
ou d’un délit.
Dans le monde, et dans le monde médical aussi souvent que chez les personnes
étrangères ànotre art, il semble que rien ne soit plus facile que de reconnaître si un
homme est ou n’est pas un aliéné. Je ne vous apprendrai rien, Messieurs, en disant
combien cette affirmation suppose parfois de recherches délicates; dans un livre accueilli
en France avec une faveur méritée, l’un des vôtres, M. le Professeur Maudsley a déterminé
avec une grande netteté, avec une grande élévation d’idées, la mission et le devoir du
’ médecin expert, et montré qu’à côté des cas évidents pour tout le monde, il y en avait
d’autres d’une interprétation diﬁicile, où la limite exacte entre la raison et la folie était
presque impossible à. ﬁxer, et dans lesquels il fallait tenir compte des conditions
défectueuses de l’organisation mentale de certains individus.
Le sujet que j’ai choisi est plus circonscrit. J e veux traiter devant vous une question
de médecine légale que je prendrai surtout par son côté clinique.
608 MENTAL DISEASES.
Vous savez, Messieurs, que chez tout individu qui se livre aux excès alcooliques se
développent des aptitudes à un délire spécial qui peut bien ne pas éclater tant que
l’équilibre de la santé ne sera pas compromis, mais qui fera explosion aussitôt que la
maladie surviendra. Un alcoolisé est pris d’une pneumonie, au cours de cette affection
aiguë fébrile, il est pris d’un accès de delirium tremens, c’est la de l'observation
journalière. Un autre fait une chute, reçoit une blessure grave, il est pris de la même
manière après deux ou trois jours. Eh bien, Messieurs, sans qu’il soit possible d’établir
une parité entre des maladies aiguës fébriles, un traumatisme physique et le traumatisme
moral, ce dernier produit les mêmes effets, aboutit aux mêmes résultats. Je vous en
présenterai seulement deux cas qui seront des types, et que je choisis entre un grand
nombre qu’il m’a été permis d’observer.
Un homme ayant depuis longtemps des habitudes d’intempérance, commet dans des
conditions tout-àfait simples, ordinaires, un délit ou un crime. Il est arrêté : interrogé
par le magistrat, il reconnaît sa faute, il a agi avec une entière connaissance de cause, il a
prémédité, voulu l’acte, qu’il savait être un acte délictueux ou criminel.
Mais, au cours de l’instruction, pendant qu’il est en prison, soumis à la détention
préventive, il est seul, en face de lui-même: les conséquences de ses actes au point de
vue pénal lui apparaissent. Préoccupé, inquiet de sa situation, souffrant de sa captivité,
sa santé se trouble, il perd le sommeil, l’appétit, et après quelques jours d’emprisonne-
ment, il entre dans un accès d’alcoolisme aigu ou subaigu. Il a l’agitation, les visions
terriﬁantes, les tremblements ﬁbrillaires des muscles, les symptômes caractéristiques de
l’intoxication alcoolique. Cette explosion soudaine, eût pu être indéﬁniment ajournée
si cet homme avait. continué a vivre au dehors, s’il avait conservé l’intégrité, l’équilibre
de sa santé. Elle a éclaté du jour où cet équilibre a été rompu par l’action de causes
morales dépressives qui ont aboli sa résistance à l’inﬂuence de l’agent toxique. En
présence du trouble survenu le magistrat se demande s’il n’a pas affaire à. un aliéné : le
médecin consulté répondra que l’accès est transitoire, que d’ici à quelques jours il aura
complétement pris ﬁn; et, sachant sous quelles conditions il s’est développé, il pourra
dire qu’au moment du crime ou du délit, la responsabilité était entière. La connaissance
exacte de semblables états est nécessaire. Il faut savoir qu’un homme peut avoir eu des
accès de delirium tremens, et rester, avant comme après, responsable de ses actes, Si toute
la période remplie par le délire est couverte par l’irresponsabilité, il n’en saurait être de
même pour ce qui est en dehors d’elle. Il est bien entendu que je laisse de côté l’alcool-
isme chronique, où des altérations cérébrales permanentes, durables, créent une situation
toute différente.
J ’ai eu à. examiner un jour un homme qui représentait a Paris une grande maison de
commerce de l’étranger: il avait falsiﬁé ses écritures et commis une série nombreuse de
vols au préjudice de son patron; son médecin déclarait, de très-bonne foi, que cet
homme avait été fou à plusieurs reprises, et il décrivait les accès de délire pour lesquels
il lui avait donné des soins. Il pensait que cet homme n’était pas responsable de ses
actes. Nous avons dû rechercher à. quelle époque avaient eu lieu ces accès, et si les
falsiﬁcations, ou les erreurs dans les écritures étaient contemporaines de ces accès.
L’examen des livres de commerce nous démontra que les erreurs étaient volontaires,
qu’elles avaient été commises a une époque où l'inculpé était en pleine possession de
lui-même, que c’étaient bien moins des erreurs que des abus de conﬁance prémedités,
exécutés avec habileté; nous avons démontré que le désordre dans les idées et dans les
actes n’eûtjamais permis une série de faits régulièrement accomplis; qu’aux périodes de
délire correspondait une suspension complète des opérations commerciales, et nous avons
conclu qu’il fallait considérer cet homme comme responsable de ses actes.
Pour revenir à. la thèse que je soutiens devant vous, Messieurs, voici un fait très-
MENTAL DISEASES. 609
intéressant qui la conﬁrme. Un homme de soixante ans, gardien depuis plus de vingt
ans de l’un des passages de Paris, concourt à l’arrestation d’une dame dans des circon-
stances particulières. Ccttc arrestation fait beaucoup de bruit, la dame est mise en liberté,
et cet homme craint d’être poursuivi pour arrestation illégale, et de perdre sa place.
C'était un buveur d’habitude; il ne s’énivrait pas, mais tous les jours, il prenait en
assez grande quantité du vin blanc le matin, à. jeun, de l’cau de vie, 850. Sous l’inﬂuence
de ses inquiétudes, de ses préoccupations, il perd le sommeil et l’appétit, il prend de la
ﬁèvre avec de l’embarras gastrique, et est obligé de garder la chambre. Alors, éclate un
accès d’alcoolisme subaigu. Il entend des voix menaçantes, il voit, dans sa chambre, des
personnages à, ﬁgures grimaçantes, il essaie en vain de les éloigner, il assiste à des scènes
de violence qui le troublent profondément. Pendant cinq jours il reste dans cet état,
puis, il se rétablit en apparence et reprend son service. Il n’était pas guéri, des idées
délirantes de persécutions le tourmentent, il croit qu’on le regarde de travers, que les
personnes avec lesquelles il est en relations habituelles, s’éloignent de lui avec mépris.
Alors, il cherche d’où peut venir ce changement, et il demeure convaincu que son collègue
a indisposé tout le monde contre lui. Un matin, il arrive chez lui, et lui dit r “ Tu m’as
trahi,” et au même moment, il dirige sur lui le canon d’un revolver; on put lui saisir le
bras, et l’empêchcr de commettre un meurtre. La conviction délirante avait tout fait,
et bien différent du délirant persécuté qui reste pendant des mois, des années, passif, et
ne devient persécuteur a son tour que par suite d’une évolution lente de son délire, cet
homme dans l’espace d’une dizaine de jours était sorti de la santé pour entrer brusquement
dans la maladie par suite d’une préoccupation morale vive, d’un véritable traumatisme
moral. Nous avons fait ressortir toutes ces considérations, et déclaré qu’il était irre-
sponsable. C’était en effet du délire alcoolique et rien de plus.
Je pourrais, Messieurs, multiplier ces exemples, ils sont, ou peut dire, d’observation
journalière. Ceux que je viens d’avoir l’honneur de vous citer, suffisent pour établir
qu’un choc moral, tout aussi bien qu’une maladie aiguë, une chute, une blessure, préparent
chez un homme qui se livre habituellement a des excès alcooliques, l’explosion du délire
qui eût pu être indéﬁniment ajourné si l’équilibre de la santé n’avait pas été rompu.
DISCUSSION.
In the discussion that followed, Dr. ASHE, Dublin: remarked that he had seen
symptoms of the same kind produced by moral shock alone, without any history of
alcoholism; and Dr. BUCKNILL, London : insisted on the novelty and importance of the
subject.——Drs. CLOUSTON, Edinburgh; and C. MERCIER, London : spoke of the violent
mania often produced by alcoholism; and Dr. .MAUDSLEY, London: inquired if there
was any history of hereditary insanity or epilepsy in these cases, to which Dr. MOTET,
Paris: replied in the negative.
——-|_
Some 0f {/26 C mm‘a! C ﬁamcz‘erz'sz'z'cs 0f fa’z'ocy.
Dr. SHUTTLEWORTH, Lancaster.
The remark is not uncommon, even on the part of medical visitors to idiot
asylums, that the heads of the patients do not, when casually surveyed, appear so
abnormal in size and form as they had expected to ﬁnd them. A study of the leading
varieties of cranial abnormalities existing among idiots, especially such as are
characteristic of typical varieties, may therefore not be devoid of interest.
Employing the word idiocy in its comprehensive sense, as including cases of
infantile arrest of mental development as well as those which are congenital, it may be
said that the general average of the measurement of heads of a large number of
PART III.‘ a R
6 I o MENTAL DISEASES.
idiotic children, and of a large number of normal children of corresponding age, will
not differ very materially from each other. Thus, taking a series of 300 idiots and
imbeciles at the Royal Albert Asylum, Lancaster, and of 100 normal children of the
same social class at a neighbouring charitable institution, it was found that the
average maximum head—measurements (circumferential) of groups of children of
corresponding ages differed comparatively little in the two institutions, as sliown in
following table :— “

Circumferential Head- Ages. Ages. Ages.
measurements, given in 5 to 10 10 to 15 15 to 20 Average.
Inches. years. years. years.

I
RO’JC‘ZAH’MAMJZM l 20-10 ,18'83 20-20 20-19 20-83 2018 20-5 19-9
Imbeciles
Orphan Institution ) 0 _ ‘ _ ‘ ' ’ .
Normal Children g 20 89 19 '73 20 70 20 60 2125 21 25 2087 20 33


Thus the general head-circumference at the Royal Albert Asylum was 205 inches
(521 c.) and 199 inches (505 c.) for males and females respectively, as against 208'?’
inches (53 c.) and 2033 inches (51'7 c.) at the Orphan Institution. Examining the
matter more closely, however, it would be soon apparent that the comparatively respect-
able average obtained for the head-measurements of the idiots was due to the abnormally
large heads, which more than compensated for the abnormally small heads in the series.
We see then that mere size of head, save in extreme cases, is but of little help in
the diagnosis and classiﬁcation of idiocy. We may, however, often derive valuable aid
from observing the varieties of cranial form. We shall, of course, ﬁnd the most striking
deviations from normal form amongst congenital cases. Perhaps the most remarkable
of these is the microcephalic variety, which we will consider ﬁrst. In different
microcephals there are many differences of conformation, but there are, generally speak—
ing, certain prevailing characters in the conﬁguration of head and face. In the majority
of cases which have fallen under my observation the skull has been oxycephalic, and
the occiput imperfectly developed; the facial features have been well-formed, the orbit
large, the eyes prominent, and. the nose often of the Roman type. Sometimes there is
a tendency to prognathism. The tapering forehead and prominent nose give to the
physiognomy, in some cases, a bird-like aspect, Whilst, in others, the expression has been
compared to that of a beaver or a mouse. The so-called “Aztecs” are idiots of this
type ; and the portraitsit and head-contours of the boy Freddy (a patient at the Royal
Albert Asylum) show most of the characters alluded to. This boy, seventeen years of
age, and 41 ft. 6 in. high, has a head, the greatest circumference of which is under
15 in. (38 c.). This boy is still living. In the case of another whose head-
measurements were even Smaller, and who died at ten years of age, the weight of the
brain was but 13-;. oz. (383 grammes). In another case of microcephaly, in which
the head measured 17-;- in. (4,415 c.) in circumference, the brain weighed 27% oz.
(780 gr.) ; and, in a third, with a circumference of 16% in. (426 c.) the cerebral weight
was 21% oz. (610 grammes).
The authority of the illustrious Virchow has often been quoted in support of the
view that the cause of microcephaly is premature cranial synostosis. I am not sure that

* Exhibited at Meeting; engraved in “Ireland on Idiocy,” p. 93.
1‘ For Head-contours of Microeephal (A. A., aet. ten) see Fig. 21, p. 612. Measure-
ments—Oircumference, 141,; in. = 358 c. From nasal notch to occipital protuberance over
vertex, 9;‘; in. = 24 c. ; Oallipers, 4.5 in. = 115 c. From ear to car over vertex, 10in. =
255 c. 5 Oallipers, 3 in. = 7'6 0.
, MENTAL DISEASES. » 6 I I
this opinion is held by him without qualiﬁcation, but so far as my humble experience
goes I am inclined to think that the premature synostosis is, as a rule, the consequence
rather than the cause of the imperfect brain development. Such, at least seemed to be
the case in an instance of microcephaly which I had the opportunity of pretty
thoroughly investigating. As this case was fully described in the Journal of‘ Mental
Science for October, 187 8, I will only now allude to it to say that the microcephaly
depended upon some arresting inﬂuence having been brought into play to check the
growth of the cerebral hemispheres backward and downward at about the sixth month
of gestation, the development of the frontal convolutions having proceeded normally so
far as the formative processes were complete. In this case the coronal suture was but
imperfectly ossiﬁed though the girl was ﬁfteen years of age. In another case (A. A.),
a boy of ten, the anterior fontanelle seemed but imperfectly ossiﬁed and there was
adhesion of the dura mater to that locality, and all along the inter-parietal suture.
Microcephalic idiots present many varieties as regards their mental condition,
their intelligence varying to a considerable extent with the size of the head ; but
speaking generally it may be said that this class possess, as compared with other idiots,
quick observation, expressive gesture, but deﬁcient speech.
To pass to another well-deﬁned type of idiocy, that known as the Mongol or Kalmuck
type, we shall again ﬁnd certain characteristic cranial and facial conformations. The
‘skull is obtusely rounded, the longitudinal not much exceeding the transverse diameter,
and the plane of the face and forehead, and that of the back of the head tend ( as has
been pointed out by Dr. Arthur Mitchell) to form parallel lines. There is, moreover, an
obliquity of the superciliary margins of the orbits and an outward turning of the
zygomatic arches together with a ﬂat-bridged squat nose, which tend to impress on the
patient the Mongolian aspect whence the name of the type is derived. Combined with
these osseous abnormalities coexists a coarse papillated condition of the skin and
tongue, the latter being transversely ﬁssured, and there is a clubbed appearance of the
ﬁngers and toes. Dr. Langdon Down has spoken of ethnic degeneration in connection
with this type; but, however this may be, the etiology is generally pretty clear. In
these cases there is no hereditary mental taint, no consanguinity of parents to be
traced, but in almost all it is found that there has been some lowering of the maternal
vigour, either through ill health, advancing years, or, it may be, some depressing
emotion during gestation. Idiots of this type are for the most part very imitative, they
have a good ear for tune and time, and are capable of a fair degree of scholastic educa-
tion. But their temperament is sluggish, and their vital powers feeble, and soon
after puberty, if not before, they may be expected to die of some phthisical degeneration.
The following are the measurements taken from the head of an imbecile of this type,
thirteen years of age z—Circumference 19313- in. = 49'5 0. Transverse, 13 in. = 33 c.
Callipers, 5% in. : 14:5 0. Longitudinal, 12 in. : 30'5 c. Callipers, 6%,- in. : 16'5 c.
Contours are exhibited in Fig. 2.
In cretinoid idiots, the large irregularly-expanded head, the distant orbits, and the
depressed root of nose, co-exist with general heaviness, dulness of eyes, and wide and
coarse nose and mouth, and a corresponding stupidity and slowness of comprehension.
A special and peculiar class of these cretinoid idiots has been described by Curling,
Hilton Fagge, and others under the name of “ sporadic cretinism,” and in these there
is a more pronounced dwarﬁshness of body with a curious bagginess of skin, as if the
bony skeleton were made on a smaller scale than that of the integument. The mental
stature as well as the bodily is dwarfed, and there is a remarkable deliberateness about
all their actions, and in their speech, which in many cases is moderately well developed.
The physical resemblance to each other borne by idiots of this type is very striking.
I have not had an opportunity of examining post-mortem any example of the
latter type; but Dr. Beach and others have described the existence of fatty tumours
above the clavicle and the absence of thyroid enlargement as characteristic of these
cases. I have indeed only had one autopsy of a cretinous patient, a lad twenty
R R 2
6 I 2 ' “ Comparative Oram'aZ Uontours 0]" Idiots.
Fig. 21.
VERTEX.
VERTEX.


ANTERO-POSTERIOR. CIRCUMFERENCE. ‘ TRANSVERSE.
Fig. 22.


A
‘ I
|
l
|
I
|
|
I
I
|
r
|
:
P
F' . 2 .M' oce halic Oontours.-'—-Fig. 22. “ Mongol” Type ditto.--Fig._ 23. Hydrocephalic
1g 1 lgigatof—Fig. 24. Scapho-cephalic ditto. —-A11 one—fourth real dmmeters.
MENTAL DISEASES. 6 1 3
years of age, 4 ft. 72- in. high, who had enlarged thyroid, and presented the ordinary
characters of cretinism, though born in N orthamptonshire, in a district where
crétinism is not endemic. In this case the sutures were all closed, nothing remarkable
was noticed about the spheno-basilar bone—[the head measured 20,1- in. (51'5 c.) in
circumference, 13% in. (35 c.) transversely, and 13% in. (348 c.) antero-posteriorly]—
though a horizontal position of the basilar process—21a, an absence of the occipito-
basilar angle—has been noted by Lombroso, Fodéré, Ackermann and Niépce as one of
the characteristics of cretinism. In the other variety alluded to (that somewhat con-
fusingly called sporadic cretinism) a remarkable steepness of the clivus has been noticed
by Virchow and other observers.
The cranial characteristics of hydrocephaly consist of a general obovate appearance of
the crown looked at from above, the contour from back to front and side to side being
more or less globular, and the greatest circumference being found at the temples, where
there is sometimes a perceptible bulging. The back of the head is somewhat ﬂattened.
Imbeciles of this type, if not suﬁ‘ering from active disease, usually improve very con-
siderably under training, and at last approach very nearly the standard of ordinary
intelligence. This is exempliﬁed in one of the cases whose head contours are exhi-
bited, a lad of twenty-one, who, with the exception of a certain amount of childish
curiosity and moral imbecility, may be described as cured.*
Resembling the hydrocephalic cases in size, though not in form of head, are
those comparatively rare cases of hypertrophy of brain, which, when complicated with
encephalitis, usually issue in a form of idiocy tending to pass into a variety of mania.
Dr. Fletcher Beach, who has paid much attention to the subject of hypertrophic
idiocy, gives the following as the points of cranial distinction between hypertrophy
and hydrocephalus :—
“ In hypertrophy of the brain the head does not attain so large a size as in chronic
hydrocephalus. The head of my ﬁrst case measured 23 inches in circumference, that
of the second 22 inches. I have three cases of chronic hydrocephalus now in the
asylum, and their heads measure 23%;, 25,12 and 25% inches respectively.
“In hydrocephalus the increase in the size of the head is most marked at the
temples ; in hypertrophy above the superciliary ridges.
“ In hypertrophy the head approaches the square in shape; in hydrocephalus it is
rounded (see outlines). In hydrocephalus there is often an elasticity over the late
closed fontanelle; in hypertrophy there is none, and there is often a depression in
that situation.
“ In hydrocephalus the distance between the eyes is increased from the ﬂuid
inserting itself between and distending the sutures formed by the frontal and ethmoid
bones; in hypertrophy this is not the case.”~l'
Dr. West says this disease is usually associated with rickets. In the only case
which I can bring forward—that of a girl of twelve—there are no signs of rickets. In
this case there is frequent complaint of headache, and the progress at school is slow.
In some cases of paralytic idiocy, atrophy of the brain on the opposite side
produces marked asymmetry of cranial contour. Dr. Ireland mentions an instance in
which a very irregular outline of the left side of the head corresponded with want of
power of the right arm and leg. That such asymmetry does not always obtain, is
shown by the head contour of E. C., a girl twenty years of age, whose right hand and
arm are atrophied and partially paralyzed, the right hand being barely two-thirds the size
of the left, but in whom the skull is fairly symmetrical. It must indeed ever be borne
in mind that cranial asymmetry is by no means necessarily a sign of deﬁcient brain

"‘ Head mcasumements: Hydroccphalic Imbccz'lc (R. .51., (ct. twelve).—Circumference, 23.‘,
in. = 595 0. Transverse, 15.‘; in. = 395 c. Oallipers, g in. = 124 0. Longitudinal,
145iL in. = 37 '5 c. Callipers, % in. = 194 c. Contours are exhibited in Fig. 23.
1' Journal of McntaZSc'icnce, April, 1881.
614 MENTAL DISEASES.
development; indeed I have heard, on the authority of a noted hatter, that men
distinguished for intellectual power (Lord Chancellors and others), are the men who
have the most uneven heads ! (In proof of this assertion a number of “ Hatter’s Shapes,”
taken from the heads of ordinary customers, by the Conformateur, were produced and
compared with outlines supposed to be characteristic of abnormalities).
Paralytic idiots, in whom there is no advancing disease, improve under training
very considerably in intelligence, and those in whom athetotic movements exist, often
possess a considerable degree of intelligence which is masked by their involuntary and
ungainly contortions.
Scapho-cephalic heads, in which there is compression of the cranium from side to
side with dolicho-cephaly, and a prominent ridge in the inter-parietal line and in the
middle line of the forehead. are sometimes found amongst idiots. Pressure in
parturition has been stated (I think erroneously), to be a cause of this distortion; but
it is a condition normally found amongst the natives of New Caledonia, New Hebrides
and the Caroline Islands. In the sporadic cases of scapho-cephaly, which have been
examined in this country, a total absence of the sagittal suture has been observed,
and Dr. Minchin ascribed the condition to the abnormal occurrence of only one central
and vertical centre of ossiﬁcation for the two parietal bones. Fig.241 shows contours of
a case of scapho-cephaly in a child one year old.
Traumatic cases vary so much in cranial characteristics and also in mental
characters, that no general rule concerning them can be laid down. In one curious
case I had under care, there was a large depression of the left occipital region, deep
enough to admit the tips of two ﬁngers, and at the autopsy the posterior part of the left
hemisphere, which was thinned and elongated, overlapped the right.
The question of the inﬂuence of the use of the forceps on cranial deformity and
resulting idiocy, can only be very brieﬂy alluded to. Speaking generally, I concur in the
conclusions arrived at by Dr. Langdon Down in his paper, read before the Obstetrical
Society, that the forceps has but little to answer for in the production of idiocy.
Protracted labour, unassisted by forceps and producing asphyxia neonatorum, is
probably a much more potent factor of idiocy. Dr. Down remarked, that of 2,000
cases examined by him, only 3 per cent were delivered by forceps, though as many as
20 per cent were born with well-marked symptoms of suspended animation. In
the ﬁrst 600 cases in the books of the Albert Asylum, not more than 2 per cent are
recorded as having been forceps deliveries, though I ought to add that of the last 250
cases (I know not from what cause), a much larger ratio of cases is attributed to the
use of forceps—viz., about 4: per cent. In less than a quarter of the cases, however,
are there any marks left by forceps.
The subject of artiﬁcial cranial deformations is one full of interest, but the only
variety met with in this country is that produced by unilateral suckling, of which I
have seen several examples, though the cranial asymmetry, which consisted of
ﬂattening of the parieto-occipital region on one side, was unaccompanied by any
mental deﬁciency. It would appear that very considerable artiﬁcial deformation may
be produced by prolonged, but comparatively gentle, pressure in one region of the skull,
compensatory enlargement going on elsewhere, and no detriment to the intelligence
resulting. The Flat-head Indians (Chinooks), are modern examples of this statement,
which however was observed so long ago as the days of Hippocrates, with regard to
the Caucasian Macro-cephali.
MENTAL DISEASES. 6 1 5
The Morphological and Hz'sz‘clogz'cal Aspects of Mz'crccep/znlz'c
and Crez‘z'noz'd [diary/F"
Dr. FLETCHER BEACH, Darenth Asylum.
This paper is intended specially as a contribution to the subject of microcephalic
and cretinoid idiocy. I had intended to add to it an account of atrophy of the brain in
imbeciles, and brieﬂy refer to some other cases, illustrating them by microscopical sec-
tions, but want of time has prevented me from carrying out this part of my subject.
It appears to me, that by connecting the mental symptoms occurring during life with
the appearances, both naked eye and microscopic, found in the brain after death, some
advance may be made in our knowledge of the relation which the one bears to the
other, and as usually the symptoms in idiocy are less complex than those of insanity, so
we may hope for some success in the inquiry, and possibly aid in elucidating the more
obscure relations between mental symptoms and brain states in the latter disease. Just
as Broca has connected aphasia with disease, usually of the posterior part of the third
left frontal convolution, or as some think of the operculum which is included between
the ascending and horizontal limbs of the ﬁssure of Sylvius, which immediately overlaps
the island of Reil, and as motor paralyses of the limbs have been connected with disease
of certain convolutions, by the labours of Hughlings Jackson, Ferrier, and others, and
some light has been thrown upon the parts of the brain implicated in disease, involving
loss of the sense of hearing, sight, 810., so we may hope in time by the same method to
explain the mental symptoms occurring during life in cases of idiocy. Observation and
experiment, the latter made for us by disease, have always been the means of elucidating
the truth, and it assuredly will do so for us in medico-psychology, as well as in
other branches of science. I am aware that it is held by some that disease affecting
the mind cannot, and never will be explained by appearances found in the brain, and
assuredly the attempt to do so will involve some labour and hard work, but I hold that
it is better to make the attempt than to fold our arms and do nothing in that direction.
The admirable researches of Bevan Lewis and Professor Betz, the latter of whom has
made 5,000 sections of different parts of the brain in different individuals, show that
the layers of nerve cells are differently arranged, not only in different convolutions, but
in different parts of the same convolution, and mark a considerable advance in our
knowledge of the subject. The study of the histology of the convolutions of the brain
in health and disease is yet in its infancy; but, as time goes on, other facts will no
doubt be made out.
To illustrate my subject, I have related in this paper two cases of microcephalic
idiocy, and exhibit and describe the condition of the brain in both, adding to the latter
case a short description of the microscopical appearances. The brain of the ﬁrst case
which weighed seven ounces when removed from the body is one of the smallest on
record, and I have therefore given a full account of its ﬁssures and convolutions.
With respect to cretinoid idiocy, I propose to exhibit the brain of one case, the fatty
tumours of another, and microscopical sections from a third.
E. R., aged eleven years, was admitted into Clapton Asylum, May 8, 1875, with
the following historyz—The parents were of temperate habits, sound mentally and
physically, and not connected by consanguinity. There was no history of hereditary
disease in the family. The child had a small head when born, and had at no time

The term Idiocy is used in this paper in deference to the opinions of those who made
use of it when drawing up the list of subjects for discussion in this section, but the author
believes the word Imbecility to be a far preferable one, as it includes all cases, both
“congenital and acquired, of mental defect, and avoids all difficulty in their classiﬁcation,
such as sometimes occurs when the words Idiot and Imbecile are used, for it is sometimes
difficult to say under which heading a patient should be placed.
6 I 6 MENTAL DISEASES.
shewed much intellect. The mother assigns the patient’s condition to the father
playfully striking her across the forehead with a cod’s head and shoulders when she was
four months advanced in pregnancy. There are nine other children who are healthy
and well-formed.- Two of these are married, and their children present no defect.
Two children have died, and of these one, the youngest in the family, was microcephalic,
and died in Oaterham Asylum, aged six years. The present is the eighth child.
On admission, she was a fairly nourished child of dark complexion. Her head was
very small. Her forehead sloped backwards at an obtuse angle, and there was
prognathism of the lower part of the face. From the size of her head and her facial
aspect, she was called by the nurses “ the ﬁsh.” Her hair which came low down on
her forehead was light brown and erectile. Eyes blue, arch of palate high, tongue of
normal size, teeth good, protruding beyond lips. Ears 2% inches in length, 131,» inches
in breadth. Her arms and legs presented many soft and downy hairs of a light brown
colour. She was 3 feet 6-}— inches in height, and weighed 2 stone 6 lbs. N 0 sign of
rickets.
.. \

E. R, microcephalic idiot, from a photograph taken after death.
She could not stand or walk, though she could move her arms and legs about. There
was no Sign of paralysis, and she Was not epileptic. Her sight was normal. She was
quiet in disposition, obedient, and spent most of her time sitting in a chair in her ward.
She passed her urine and faeces under her, and made so sign to have these wants
attended to. She could not speak. She was fed with a spoon, and was entirely
dependent on others for existence. After about six months’ residence in the asylum,
she became rather more intelligent, made an attempt to speak, and mumbled something
indistinctly. She would put out her hand when told to shake hands, and would
recognize, by a smile, the nurse and myself when we spoke to her. After about
four months more she was noticed to "grind her teeth when pleased, and when
spoken to pretended to be shy, and put her hands before her eyes. Her habits became
slightly improved. She was fond of her nurse. Observation, attention, memory,
affection, and some power of voluntary movement were therefore present. On the day
before her death she became suddenly collapsed, but recovered slightly. In the
evening she became restless, and her breathing, quick, and on January 24th, 1876, she
died. She was twelve years old at the time of her death. The following are some
measurements taken during life.
MENTAL DIsEAsEs. 6 I 7
HEAD.
Circumference of head . . . . . . . . . . . . . 12 inches.
Transverse diameter (between tips of cars) . . . . . . 4% 9,
Root of nose to occipital protuberance 7
Tip of nose to auditory meatus . . 4
Occipital protuberance to auditory meatus . . 4
Root of nose to chin . . . . . 4
Auditory meatus to chin . . . . . . . . . . . . - 5
Auditory meatus to alveolar margin . . . . . . . . . . a’
Height of forehead . . . . . . . . . . . 2
Width of forehead _ , . . , ' . . . 3%
BODY.
Tip of shoulder to elbow . . . . . . . . . . . . 8 inches.
Elbow t0 wrist . . . . . . . . . . . . . . . . 6 :5
Wrist to tip of middle ﬁnger . . . . . . . . . . . . 4:12- a;
Anterior inferior spine of ileum to knee . . . . . . . . 11 ,,
Knee to external malleolus . . . . . . . . . 9 2:
Sole of foot (from heel to end of big toe). . . . . . . . . 9 ,-
Circumference of chest (one inch below nipples) . . . . . . 22 ,,
Circumference of abdomen . . . . . . . . . . . . 17 a:
The autopsy was made forty-eight hours after death. Body thin, but not
emaciated. There was a cyst over the left part of the forehead, the size of a large
cob nut, and the thyroid gland was enlarged. The pubic hair was fairly developed.
On examining the head, the vault of the skull was found to be arched, the occipital
region ﬂattened, and the forehead sloping. After the scalp had been removed, the
sutures were examined. They were united, but the coronal was found to be much
farther back than normal. On removing the calvaria and brain the base of the skull
was inspected, and some measurements taken.
Anterior border of cranium to anterior clinoid process I}; in.
Between clinoid processes . . . . . . . . . . . . . . g: in.
From posterior border of Sella turcica to posterior margin of cranium . 2-2-1,— in.
Transverse measurement of anterior fossae ‘2% in.
Middle fossae in length 1% in.
Middle fosee in breadth . _ _ _ _ 1% in,
Transverse measurement of cerebellar fossae . . . . . . 2% in.
Transverse measurement of interior of cranium . . . 3% in.
The form of the base of the skull was generally normal, but the ﬂoor of the
anterior fossae was more prominent than usual. The cerebellar fossae were large and
deep. The anterior and posterior clinoid processes were on the same level, and the
descent from the latter was sharp and perpendicular. The suture between the
sphenoid and occipital bones was soft, and could be cut with a knife. The palate was
2-;— inches in length, and was much narrowed perpendicularly. The incisor teeth were
placed obliquely.
The brain weighed seven ounces. After preservation in spirit for six years, it
weighs two ounces, and might be the brain of a good sized doll, rather than that of a
child twelve years old. The different portions have not been weighed separately, as I
have been anxious that members of the Congress should see it as nearly as possible in
the entire condition?“ It must be understood that the following description refers to
the preserved brain and not to its fresh state.
The cerebrum when viewed from above is seen to approach the isosceles triangle in
shape, being narrow and pointed in front, and of a somewhat square shape behind.
There is an absence of the roundness seen in the normal brain, and the borders are

* This was afterwards found impossible.
6 I 8 MENTAL DISEASES.
narrow and angular. The upper surface is flattened. The two hemispheres are
markedly asymmetrical. The left is appreciably larger and longer than the right,
and is pear-shaped, while the right is more triangular. Of the lobes, the frontal and
temporo-sphenoidal are well developed, the parietal fairly so, while the. occipital are
small, and chieﬂy developed on the under surface of the brain. As regards mass, on the
left side, the temporo-sphenoidal are the largest, and next come the frontal, parietal and
occipital, in the order mentioned. On the right side the frontal and temporo-sphenoidal
are about the same size. The cerebellum, a large portion of which’ is uncovered,
projects half an inch behind the cerebrum, and forms nearly a fourth of the entire
mass, and gives a short ovoid appearance to the whole encephalon. Viewed from the
base, the size of the cerebellum is again a marked feature. The temporal and frontal
regions are well marked, the latter being triangular and pointed, while the former
approach the oblong in shape. The orbital surfaces are only slightly excavated. The
base as well as the upper surface is ﬂattened.
Fissm'ca—Tlre ﬁssures of Sylvius (horizontal portions) are well marked and are
very deep; that on the left side being 1%- in. in depth, and on the right i in. They

Brain of E.K., a microcephalic idiot—natural size—the sutures are not clearly
shown as the membranes have unfortunately not been removed.
both have an oblique position from without inwards, but the left is more oblique than
the right. The upper end of the left bifurcates to receive the posterior end of the
supra-marginal lobule. The ascending portions of these ﬁssures are not visible.
Tire ﬁssures qf Rolando are not so well marked as the ﬁssures of Sylvius. The
right is better marked than the left, and commences a little above the middle of the
ﬁssure of Sylvius; curves slightly round a projection of the middle part of the ascend-
ing parietal convolution, and terminates nearly 31, in. from the longitudinal ﬁssure.
On the left side it is less perfect. Its commencement is faintly seen to commence
J, in. from the upper end of the Sylvian ﬁssure. After passing upwards % in. it ceases,
but ui‘lr in. further on recommences, being still faintly marked, and runs for g in. to-
wards the longitudinal ﬁssure, the upper %in. being well marked. It can then be
faintly seen to curve for i in. round the posterior part of the parietal lobule, then
MENTAL DISEASES. 6 19
runs backwards for ~1— in. (this part being well marked) and ends ﬁnally on the inner
surface of the hemisphere.
\ Of the external perpendicular ﬁssures the left is the better marked. It com-
mences by a deep sulcus on the inner surface of the corresponding hemisphere, which
a little in front has commenced to diverge from the right, and runs backwards and
outwards for % in., where it is interrupted by the ﬁrst external connecting convolution.
The right commences by a curve on the inner surface of the right hemisphere and
runs almost transversely outwards for -‘§- in., being joined at the outer extremity by
a sulcus running at right angles to it, which separates the parietal lobule from the
ﬁrst external connecting convolution.
0f the great parallelﬁssares the left is deep, simple and well marked, and runs in
aslightly curved line backwards for one inch. On the right side it is not so well
marked and is slightly tortuous.
The callosal-marginal ﬁssures are very different on the two sides. That on the
left side is very simple. It passes backwards in a continuous curved line and reaches
the surface of the hemisphere some distance behind the binder end of the corpus
callosum. On the right side it is interrupted by a convolutional bridge above the
middle of the corpus callosum. It reaches the upper surface of the hemisphere on a
level with the hinder border of that body.
The internal perpendicular ﬁssures are also different. That on the left side
descends obliquely, but is interrupted by a small convolutional bridge in the middle.
On the right side it descends and takes two curves forwards (the curves being caused
by projections of the quadrilateral lobule) and ends just above the posterior extremity of
the corpus callosum. Neither of these ﬁssures joins those of the hippocampi below.
The ﬁssures of the hippocampi are not horizontal. On the left side the ﬁssure is
represented by two parallel ones running obliquely downwards, and separated by a thin
ridge of convolutional substance. One, the longer, commences at the tip of the occipital
lobe, the other, the shorter, commences gin. below. Both join inferiorly a deep sulcus
which represents the posterior part of the collateral ﬁssure. n the right side it
approaches the perpendicular in direction and commences with a slight curve a little
below the tip of the occipital and then runs straight downwards.
The collateral ﬁssure on the right side is marked by a very slight irregular
depression. On the left side anteriorly there is a curved depression which is separated
from the deep sulcus before mentioned by a layer of convolutional substance, i in. in
width.
With respect to these ﬁssures, the Sylvian are shorter than in man (normal) or the
ape. They are more vertical than in man, less vertical than the ape. Neither has an
ascending branch. The ﬁssure of Rolando on the right side is much in advance of
that on the left in consequence of the smaller size of the latter hemisphere. On this
side it is a simple, oblique, slightly curved sulcus more perpendicular than in man. On
the left side it is interrupted in its course and less distinct. The external perpendicular
ﬁssures are interrupted by the ﬁrst external connecting convolutions as in man.
Assuming the total length of the cerebrum to be 100, the relative length of the
three regions—in front of the ﬁssure of Rolando, between it and the perpendicular
ﬁssure, and behind that ﬁssure—are in the preserved brain on the left side 61, 14,, 25,
and on the right 60, 20, 20. In the healthy brain the lengths are 541, 23, 23, and in
the chimpanzee 419, 28, 23. The frontal part then of this brain is relatively the largest
in both hemispheres and slightly exceeds the healthy ratio, while the parietal part is
largest in the right brain, where it nearly reaches that ratio. It is only about two-thirds
the proper size in the left hemisphere. The occipital region is slightly larger in the left
hemisphere, which slightly exceeds the healthy ratio, but on the right side it is a little
below it. Both frontal regions considerably exceed the corresponding ones in the
chimpanzee; the left parietal region is only half the size of the region in that animal,
and the right about two-thirds the size. The left occipital is a little above, and the right a
620 MENTAL DISEAsES.
little below the occipital region in the chimpanzee. The parallel ﬁssures are shorter
than normal, but preserve the oblique direction. Of the internal perpendicular ﬁssures,
the right is the more tortuous, and oblique, and consequently marks a greater contrast
with the vertical directibn in the ape. The left is also oblique, but not to so great an
extent as the right. Neither of the ﬁssures of the hippocampi are horizontal, and that
on the right side is nearly vertical and so approaches the quadrumanous form. On the
left side it is anomalous in consequence of its division and its junction with the col-
lateral ﬁssure. There is marked asymmetry of all the ﬁssures on the two sides of
the brain. /
Con'voliztiona—T/ie orbital connotations are very simple. The sulcus which
lodges the right olfactory nerve is represented simply by an oval depression the size of
a pin’s head, and a small linear depression lg in. long, separated from the oval one by a
small line of brain substance. The sulcus on the left side is absent. Instead of the
triradiate sulci there is on the right side externally a short, deep, slightly angular
depression in. in length, and internally a shallow, straight one iin. in length. On
the left side there is internally a deep straight depression nearly w‘gin. in length and
externally a shallow one a little more than %in. long. There is therefore asymmetry.
The three frontal conoolutions can be distinguished on both sides, but are asym-
metrical. The superior frontal on the left side extends backwards 2 inches in a longi-
tudinal direction and is a simple broad band of brain matter, marked only by three depres-
sions %-in. long in the anterior half. This convolution forms nearly half the frontal
lobe. Its lower border in the anterior third of its course joins the upper border of the
second frontal, which lies immediately below it. This (second) convolution is not so
well deﬁned in its posterior part. It- is bounded above and in front by the ﬁrst frontal,
and posteriorly is separated by a shallow straight depression from the ascending frontal.
Below it bifurcates and joins the anterior and posterior parts of the third frontal con-
volution which runs horizontally below the second and the ﬁrst convolution. On the
right side the ﬁrst frontal extends backwards for 1741; in. only and is absolutely with-
out any depression o'n its surface. The second is placed perpendicularly below the ﬁrst,
which it joins by a thin convolution posteriorly. It also joins the upper surface of the
third by its anterior inferior border. This second convolution is simply a broad band
of brain matter with a curved depression gin. long in its centre. The third runs
horizontally below the other two, and is joined to both.
Of tlze two ascending frontal convolutions, the right is the better marked, but
both are simple. It commences a little in front of the middle of the upper border of the
Sylvian ﬁssure, and in its upper third curves slightly backwards, becomes wider, and
ends by joining the upper part of the ascending parietal. The outline of the left is not
well marked below and in front. It joins the posterior part of the ﬁrst frontal above.
The ascending parietal are much better marked, and of the two the right is the
larger. Both are very simple, being straight convolutions, ascending on the right
side from the middle, on the left side from the posterior part of the upper border of
the ﬁssure of Sylvius. There is a simple square parietal lobule on the right side, and
a curved oblong one 011 the left.
The supra-marginal convolution, its lobule, anal the angular con/volution on the
left side, are exceedingly small and form one single convolution. The lobule joins
in front the ascending parietal and behind a branch from the ﬁrst external connecting
convolution, which forms the second external connecting convolution. Below, the angular
convolution joins the upper part of the ﬁrst temporal about its middle, in. posterior
to the upper end of the ﬁssure of Sylvius. On the right side they still form one con-
volution, but it is much larger. In front it is seen to join the lower third of the
ascending parietal, while by its posterior surface it is connected with the second and third
connecting convolutions. The angular portion joins the middle of the upper part of
the ﬁrst temporal, curving round the lower end of the Sylvian ﬁssure. Posteriorly it
is connected with the third external connecting convolution.
MENTAL DISEASES. 62 I
The central lobe, or island of’ Reil, is not distinctly recognizable on either side.
On the left side there is a slight projection of brain substance, which may represent it,
continuous with the lower part of the ascending frontal and the posterior part of the
third frontal at the entrance to the Sylvian ﬁssure. On the right side the projection
is a little more prominent in the same position, having the same relation to the
neighbouring convolutions. The tenqooral convolutions are much larger on the left
side than the right, but are very simple on each side. The ﬁrst is ‘continuous in
front and below with the upper part of the second,above, about its middle, with the
second connecting convolution, and behind with the occipital by means of the third
connecting convolution. It is separated from the third temporal below by the parallel
ﬁssure. The second is very small, measuring only one inch in length. It is continuous
above in its anterior part with the ﬁrst, andbelow, both anteriorly and posteriorly,
with the third. The latter is the largest of tlie three, and is somewhat pear-shaped.
Its upper part is situated at the lower and outer border of the hemisphere, being
bounded above and in its posterior half by the parallel ﬁssure. The greater portion of
this convolution, is situated on the base of the hemisphere, where anteriorly it forms
the body of the pear, so to speak, and is separated from the uncinate convolution by
the collateral ﬁssure which in this part is very shallow. A curved sulcus @- inches in
length, is situated in the centre of this convolution. Posteriorly and inferiorly it joins
the occipital. On the left side, the temporal convolutions are altogether smaller and
not so well marked. The ﬁrst is continuous, superiorly, and posteriorly, with the
occipital by the fourth connecting convolution. The second is placed at the lower and
outer border of the hemisphere, the greater part of it being situated on the base, and,
owing to the contracted state of the brain here, is situated above the uncinate
convolution. The third is continuous with the lower part of the second, by a fairly
broad convolution, and then describes a simple semicircle around a large irregular
opening % in. long, and 7}: in. broad, which is the posterior part of the lateral
ventricle. The posterior half of this convolution is placed below the occipital portion
of the brain.
The occipital convolutions on the left side are represented on the convex surface
by a narrow ridge of brain substance, connected in front with the parietal lobule and
ﬁrst and third temporal convolutions by the ﬁrst, third, and fourth external connecting
ones. The greater portion, owing to the narrow posterior border of the hemisphere, is
situated on the base, where a triangular convolution having in its centre a small
triradiate sulcus is present. N o distinction of three layers of convolutions can be seen.
On the right side, on the convex surface, a larger portion of brain substance representing
them is present and a smaller portion on the base, but as on the left- side, no
distribution of three layers can be clearly made out. The portion on the convex
surface is connected with the parts in front by means of the four connecting
convolutions. Of the external connecting convolutions, the upper are the largest and
completely bridge over the perpendicular ﬁssure. The left is the larger of the two,
and is relatively to the size of the brain a broad massive band. It gives off from its
lower border a branch forming the second connecting convolution which joins the
supra-marginal lobule in front, and the ﬁrst temporal by means of a convolution below.
The third joins the ﬁrst temporal, and the fourth the third temporal. All are quite
superﬁcial. On the right side, the convolution is still large, and takes a sinuous course
downwards and forwards to join the posterior part of the ascending parietal. Although
its course is superﬁcial, its junction is not, for a deep sulcus intervenes. The second
is placed low down and joins the supra-marginal lobule; the third is blended with
the fourth behind, but in front it joins the angular convolution, while the fourth
joins the ﬁrst temporal. The third and fourth are not so well marked as those on the
left side. ' They are quite asymmetrical on the two sides.
The marginal convolutions on both sides are very simple, much more so than in
th'e'ape, being simple bands of brain substance, uninterrupted by transverse sulci,
which run backwards and terminate on the left side, inch posterior to, and on the
62 2 MENTAL DISEASES.
right opposite to the hinder end of the corpus callosum. On both sides, owing to the
large size of the frontal, and small size of the parietal, convolutions, they terminate in
front of the ascending parietal convolutions—in fact, opposite the junction of the upper
part of the ascending frontal with the ascending parietal. Above the corpus callosum
the marginal convolution is joined, as usual, to the convolution of that body, on the
right side, but the connecting band is absent on the left side.
The convolution of the COTZD’MS callosum on each side commences in the usual way
beneath the genu of that body, and on the left side passes backwards and becomes
wider, but its connection with the uncinate convolution cannot be made out. Instead,
the smooth lower border of the convolution of the corpus callosum is continuous with
the smooth lower borders of the quadrilateral and occipital lobules, and indeed there is
a deep sulcus % in. wide, between the lower border of the occipital lobule, and the
posterior end of the uncinate convolution. The lower border of the convolution of
the corpus callosum and of the quadrilateral lobule is bounded below by a thin ridge
of brain substance % in. long and scarcely the thickness of a wafer, which connects the
posterior extremity of the corpus callosum with the posterior extremity of the
uncinate \convolution. On the right side the convolution becomes thinner as it passes
backwards, and ends, a little posterior to. the corpus callosum, by joining a thin band of
brain substance, which is continuous with the anterior extremity of the occipital lobe.
On this side, as before mentioned, there is a connecting bridge of convolutional
substance passing from this to the marginal convolution. Both convolutions of the
corpus callosum are absolutely simple, and without transverse sulci.
The quadrilateral lobule, the prolongation upwards and backwards of the
convolution of the corpus callosum, is well developed on both sides. On the left it is
continuous with the posterior and lower border of the convolution of the corpus
callosum by a small convolution nearly :1- in. wide. On the right side it sends forward
a wedge-shaped ridge of convolutional substance to join the lower border of the
marginal convolution at its posterior extremity. The lower border of this lobule is
bifurcated by an intervening sulcus. The left lobule is not quite so oblique as it _
normally should be, but the right is nearly vertical, as in the ape.
The occipital lobule on the left side approaches the square in shape, and is divided
below by a'deep perpendicular sulcus, before referred to. It is otherwise perfectly
simple. On the right side it is a long simple convolution, wide above, but becoming
thinner below, which curves downwards and forwards, running beneath the quadrilateral
lobule to join, by a thin band of brain substance, the convolution of the corpus callosum,
Owing to the contraction of this part of the right hemisphere, both the quadrilateral
and occipital lobules are placed much further forward than normal.
Of ‘the internal temporal convolutions, the ﬁrst on the left‘side cannot be seen.
On the right side, in the open space before referred to, at the posterior part of the
lateral ventricle, is a convolution the thickness of a wafer, and marked by a linear
depression, which may represent it. It is connected posteriorly with the middle
internal temporal. This latter convolution is much better marked on the left side
than the right, but on neither side can the crotchet be seen. The lower internal
temporal, which is the same as the lower external one, is well marked .on both sides ;
but on the right side it is placed much further back than normal, owing to the con-
traction of the brain in this region. All these convolutions are simple.
Since the ﬁssure of the hippocampi does not join the internal perpendicular ﬁssure
in either hemisphere, the lower internal connecting convolution is necessarily absent.
With respect to other parts of the brain, the pons, medulla, corpus callosum, crura
cerebri, &c., are all present and well developed, considering the size of the brain. The
corpora striata and optic thalami were not examined, in order that the surfaces of the-
brain might not be disturbed. As before mentioned, the cerebellum is much in excess
of the healthy ratio. -
Some measurements of the preserved brain were taken:
MENTAL DISEASES. 62 3
Left lobe-length (from tip of frontal to tip of occipital convolution). 3 inches
2’ ,, breadth (from upper end of parietal lobule to middle of
third temporo-sphenoidal at widest part) . . . . . 1% ,,
,, ,, height . . . . . . . . . . . . . . . . ~13— ,,
Right lobe-length (as above) . . . . . . . . . . . . é ,,
,, ,, breadth ,, . . . . . . . . . . . . 1% ,,
,, ,, height . . %
so that the left lobe is % inch longer than the right, while the breadth and height of
each lobe are equal.
Frontal lobe, depth . . . . . . . . . . . . . . . 1 inches
,, ,, width .
Length of each orbital surface . . . . . . . . .
From point of middle lobe to hinder end of brain, each side .
Projection of cerebellum beyond cerebrum
Cerebellum, breadth . . . . .
H
w NIH mim H 0.16:
,, length (in middle line where two lobes of hemisphere
diverge) . n
,, depth . . . . .
ml]?! col-q mlq
Greatest transverse diameter of brain . . . . . . . . . ,,
Remarka—With the exception of the lower internal connecting convolutions and
the internal temporal, all are represented, though they are exceedingly simple, many
being smooth elevations of cerebral substance, without any evident convolutional
folding. The left external temporal show this folding the best, then the right
external temporal, both frontal and the left occipital on the base, in the order
mentioned.
Some parts are better deﬁned than others; thus, the ascending frontal, and
ascending parietal are best seen on the right side, but the occipital convolutions on the
left. Both parietal lobules are Well marked. The supra-marginal lobule and angular
convolution are best seen on the right side, though they are simple on both sides.
The island of Reil can scarcely be distinguished. The ﬁrst external connecting
convolution is well marked in both hemispheres: the second is best seen on the right,
and the third and fourth on the left. The marginal convolution of the corpus callosum,
especially the left, quadrilateral and occipital lobules, are well deﬁned. The frontal and
temporo-sphenoidal have the best deﬁnition, and then the parietal and occipital.
Many convolutions are not so highly developed as those in the foetus at the sixth
month in Gratiolet’s plates, but they are more advanced than the one of 5% months.
The cerebellum apparently has been developed after that of the cerebrum had ceased,
so that there has not been arrest of development at a certain time, but irregularity of
evolution.
The chief differences between this and the ape’s brain are the marked asymmetry
of the two hemispheres, the superﬁcial condition of the four external connecting con-
volutions, and the absence of the upper internal connecting one seen in this brain.
On the other hand, the deﬁcient development of the supra-marginal lobule is important,
as it is regarded by Gratiolet as peculiarly characteristic of man.
As to the relation between the state of the brain and the mental and bodily con-
dition, it has been shown that although the brain is so small, the convolutions so
simple, certain qualities of the mind, observation, attention, memory, and affection
(the latter belonging to the emotional part), were present, corresponding with the
relatively large size of the frontal lobes. The absence of speech is interesting, as the
posterior part of the third left frontal convolution, the island of Reil, and the operculum,
are very small. Her sight and hearing were good, and the centres governing those
parts were well developed. Her power of movement was limited, corresponding with
the small size of the ascending frontal and parietal convolutions.
It should be mentioned that in the description of the ﬁssures and convolutions
624 MENTAL DISEASES.
of both of this and the other brains, Marshall’s classiﬁcation has been chieﬂy followed,
and that no microscopical examinations of this brain were made, as the topographical
anatomy was considered very important. ‘'
E. H., aged six years, was admitted into the Darenth Asylum on January 9,
1879, and died July 29, 1879. She was an illegitimate and the only child. No-
thing was known of the father or his side of the family. The mother was a tem-
perate woman, and up to the time of her trouble enjoyed good health; but she be-
came very delicate and died eight months after the birth of the patient. The grand-
mother of the child was in a lunatic asylum, suffering from “ softening of the brain.”
The mother was in great trouble during the time she was pregnant, and the labour
was tedious and diﬂicult. The child had had one slight convulsion before admission.
When admitted she was found to be a fairly nourished, dark-complexioned child, two
feet 521,- inches in height. Her head was small, measuring 15% inches in circum- -
ference, 9-;- inches transversely between each auditory meatus, and 11 inches
antero-posteriorly from the root of the nose to the occipital protuberance. Her hair
came low down on her forehead, which was 395- inches in width. She could walk
about the ward, had perfect use of her limbs, and during her residence in the Asylum
had no epileptic ﬁts. She was of a happy disposition, easily pleased, and was very
much attached to her nurse. She noticed what went on around her, was very sociable
with the other children, but could not utter a word, though her hearing was good.
Her habits were faulty. Though she could pick up and play with objects, she had no
idea of feeding herself. She had a fair amount of observation and attention, as well
as memory, the latter being shown by the fact that she remembered persons, par-
ticularly the nurse and myself. She was kept in the Inﬁrmary during her residence
in the Asylum, and did not attend school. Her health continued good up to a few
days before death, when pneumonia of the right lung came on, of which she died.
At the autopsy, made forty-eight hours after death, her body was fairly nourished
and her legs and arms hairy. The cranium was symmetrical, the sutures well united,
but there was flattening of the occipital bone. The dura mater was very adherent,
so that the portion covering the convex surface of the brain had to be removed with
the calvaria. The brain weighed 20%,- oz. The convolutions were simple, but by no
means so much so as in many brains of microcephalic idiots. There was no congestion
of brain or membranes, and no excess of ﬂuid in the ventricles. After preservation
in spirit for one year, the brain weighs 14% ounces. It is, compared with the pre-
ceding brain, very highly organized, although the convolutions are much simpler
than in the adult human cerebrum. It is as simple, if not simpler, than the infant’s
brain, and in shape is a short, rather than the long ovoid usually present. It is in
convolutional arrangement very far in advance of the ape’s brain, whose shape it does
not resemble, for there is no narrowness and want of depth of the frontal region.
The cerebellum is not only covered, but slightly overlapped by the hemispheres. The
greatest length of the brain, measured from the tip of the frontal to the tip of the
occipital lobe, is six inches, and its greatest breadth, situated about the centre, be-
tween the Sylvian ﬁssures is 4% inches. The brain is very small as a whole, but the
occipital lobes are very slightly developed. The frontal, parietal, and temporo-
sphenoidal are well developed. Supposing the total length of the hemispheres, as
seen vertically, to be represented by 100, the part in front of the ﬁssure of Rolando
will equal 66, that between the ﬁssure of Rolando and the external perpendicular ﬁssure
will equal 27, while the occipital portion 'will be represented by only 7.
In the human brain the proportions are 541, 23, 23. The frontal part is therefore
larger than usual, the parietal about the normal, while the occipital is only a third
of the proper size. This occipital shortening probably accounts for the shortness of
the brain from before backwards.
The ﬁssures are all present and well-developed. The right Sylvian, however, in the
posterior third of its course, takes a sharp turn upwards in an oblique direction. The
MENTAL DIsEAsEs. 62 5
external and internal perpendicular ﬁssures on the right hemisphere are half an inch poste-
rior to those on the left, and the occipital lobe on the right side is correspondingly smaller.
On this side, too, the calcarine ﬁssure is separated from the dentate ﬁssure by a much
thinner ridge of brain substance (that connecting the convolution of the corpus callosum
with the uncinate convolution) than on the left side. The calcarine joins the internal
perpendicular ﬁssure at a very acute angle, especially on the right side, so that the
occipital lobule is very small, and the convolutions rudimentary. As to the convolutions,
though simple, they are much in advance of some other idiots’ brains which I have
dissected. The three tiers of frontal convolutions are easily made out, but are diffe-
rently arranged on the two sides. Thus, on the left side the ﬁrst frontal consists of one
long convolution joining behind the ascending frontal; in front the second frontal and
below—about its middle—the same convolution. The second frontal is also a compa-
ratively straight convolution placed immediately below the ﬁrst, and joining, about its
middle, the third, which approaches the triangular in shape, below. On the right side
the ﬁrst frontal is triangular, and joins the ascending frontal in its lower third. The
second is placed below, and anteriorly is in front of the ﬁrst, and is also of a triangular
shape; while the third is circular, and is joined below and in front to the second. A
deep sulcus, dividing the lower part in two, ascends in the centre of this convolution,
and then bifurcates at an obtuse angle. The ascending frontal on the left side is
simple, but on the right takes a curious course. About an inch from its commence-
ment it divides into two broad convolutions; the anterior one ascends, and is joined
to the posterior part of the ﬁrst frontal, of which it may be said to form the posterior
portion, while the posterior branch passes on in the usual direction of the ascending
frontal, and joins the ascending parietal behind. This ascending frontal convolution
looks, in fact, like a tree with two branches. The ascending parietal on the left side
is very irregular. It is broad below, then becomes contracted, and receives on its
posterior concave border the anterior convex border of the supra-marginal lobule, after
which it again widens and passes on to be connected with its lobule, which on this side
is nearly two inches long. On the right side it is in its whole length rather thin, and
its lobule is not so long as the left. On the left side the supra-marginal lobule is very
small, but the angular gyrus is of fair size. On the right the lobule is larger, and
owing to the ascent of the posterior part of the Sylvian ﬁssure on this side, it curves
round its upper end. The angular gyrus is larger, and is posterior to that on the left
side. The island of Reil is completely shut in by the sides of the Sylvian ﬁssure on
both sides. It is apparently very simple, but, as the brain in its neighbourhood is very
soft, it is difficult to make out its outlines. The external temporal convolutions —with
the exception of the ﬁrst—are situated on the base of the brain, and the third is placed
further back than usual. The connecting convolutions on the left side are well marked.
The third and fourth, in consequence of the situation of the temporal, are lower down
than usual. On the right side the ﬁrst is not superﬁcial in its whole course, but the
second is so. The third and fourth cannot be made out in consequence of the injury
to the brain, caused in taking it out of the skull where they are situated. '1 he occipital
lobes, as before mentioned, are small. The marginal convolutions are well marked.
On the left side an intervening convolution joins it to the convolution of the corpus
callosum about its posterior third. This is not present on the right side, and the posterior
part of the marginal convolution is not so broad as usual. The corpus callosum is
well formed. The convolution of this body on the right side has a larger crest than
normal. The quadrilateral and cuneate lobes are well seen, but that on the right side,
as before mentioned, is very small. The crotchets of the unciform convolutions are well
marked. The left is the larger of the two.
The orbital convolutions are fairly developed. The cerebellum, pons and medulla
are of normal size relatively to that of the cerebrum.
Some excellent microscopical sections of a portion of the frontal convolutions
adjoining the orbital ones, were made for me by my friend Mr. Marsh, of the
PART III. s s
626 MENTAL DISEASES.
Lincoln County Asylum, and the appearances found were as follows :—In the sections
stained with logwood, a large number of leucocytes were seen, both in the grey and
White matter, so that under a low power, with which they were best distinguished, only
ﬁve layers could be made out. In the sections stained with aniline black, the ﬁrst
second and third layers were most clearly distinguished. The cells were generally
round, sometimes pear-shaped, and the nucleus which was round or oval in shape,
usually situated in the centre with a space around. Occasionally the nucleus was placed
at the base. The space was sometimes clear, but more often nearly ﬁlled with faintly
stained protoplasm. Only a few cells had processes, and these were small and stunted.
This patient was considerably in advance of the preceding one in intellect, so corre-
sponding with the better developed brain. As before mentioned, observation, attention,
Fig. 27.


Cells from third layer of cortex of frontal convolution of E. H., microcephalic
idiot. a. nucleus. 1). retracted protoplasm. c. granular matter. The retracted
protoplasm and granular matter are represented too dark in the wood-cut.
Hartnack obj-, No. 8, eyepiece, No. 4, tube drawn out. Fletcher Beach, (lelt.
memory and affection were present, and the frontal convolutions it will be remembered
were well developed. This child however had perfect use of her limbs, as would be
expected from the larger size of the ascending frontal and parietal convolutions in this
case. Sight and hearing were good, and the angular and ﬁrst external temporal
convolutions were well marked. As to speech, the third frontal convolutions on both
sides were comparatively small, and the island of Reil simple. We must remember in
addition, however, that speech depends upon a perfect combination of ﬁne muscular
movements, so that not only must the centre from which they proceed be present, but
its structure as well as the rest of the brain must be of good quality. In this case the
part concerned was deﬁcient in quantity as well as in quality, as shown by the
microscopical appearances. The scarcity of processes, and the rounded shape of the
cells particularly noticed in this and many other cases of idiocy, may ultimately be
found to account in some manner for the deﬁciency not only of speech, but of ideas, in
cases of low type, for ‘if thought and ideas originate in nerve cells, an obstruction to
their development would, of course, be caused by imperfect development of the cells, and
want of deﬁciency of communication between them, in consequence of the scarcity or
complete absence of cell processes.
CRETINOID IDIOCY.——F. It, aged ﬁve years, admitted into the Clapton Asylum,
October 1, 1875, and died, January 10, 1876, of bronchitis. The parents were
healthy, but the father was very intemperate, being so even at times of coition. The
maternal grandmother suffered from melancholia for six weeks at the change of life,
and the mother was subject to neuralgia. The parents were not connected by con-
sanguinity. The mother ascribes the child’s condition to fright and trouble during
pregnancy. She was born in London, has always been well fed, and the situation of
the house is said to be airy. This is the eldest child. Two others have been born,
one of whom has died, but they present no malformation. The mother had one
miscarriage previously to the birth of this one. On admission the child was seen to
MENTAL DISEASES. 6 2 7
be a well-marked case of sporadic cretinism, the name given to these cases by Dr.
Hilton Fagge. She was well nourished, of fair complexion, with brown hair, 2 feet
612 inches in height, and weighed 20 lbs. Her head was of an average size,
ﬂattened at the top, and spread out at the sides. It measured 20% inches in circum-
ference, ll tranversely, and 11i- inches, antero-posteriorly. A depression could be felt
in the position of the anterior fontanelle. Her face was, as usual in cretins, broad.
Her forehead measured 4 inches transversely, and there was a distance between the
tip of the forehead and the chin of 5;}:- inches. Complexion sallow. Nose pug-shaped;
scarcely any bridge could be felt. Mouth usually open, and tongue protruding.
Lips thick. Arch of palate ﬂattened. Teeth regular. N o goitre present, and
apparently no thyroid gland, but fatty swellings in the posterior triangles of the neck.
The arms and legs were short and curved. There was some fulness of the wrists, but
‘no bending of the ribs. Her skin was much smoother than usual, and could be easily
separated from the subjacent tissue. Her countenance was usually vacant. but she
would often smile when spoken to, though she could not speak. She was of a placid
and quiet disposition. She could not stand nor walk, but spent most of her time in a
chair. She noticed what went on in the ward, and generally seemed of higher

Gretinoid Idiot.
intelligence than another cretin who lived in the same ward with her. At the
autopsy, the anterior fontanelle was found to be widely open, and there was a.
depression in front of it. The sutures were fairly united, their line of union being
evident by congestion. When the calvaria and brain were removed and the base of
the skull examined, it was found not to present the changes seen in the case of
E. R. S., reported by myself, in the Pathological Transactions of London. 1876. in
which the foramen magnum was seen to be smaller than usual and surrounded by an
elevated ridge, the basilar process horizontal and narrowed laterally, and the cerebellar
fossae ﬂattened. In this case the foramen magnum was of normal size. and there were
very slight ridges around it. The clivus, or inclined plane, formed by the union of
the basilar process of the occipital with the sphenoid bone. was very steep. thus
corresponding with the case reported by myself, in the Journal of Mental Science,
July, 1876. '
The brain weighed 38 ounces. The convolutions were of normal size, differing
from the two cases just alluded to, in which they were coarse (in one case in., in the
other from in. to in. in width). The posterior lobes slightly overlapped the
cerebellum. The ventricles were of normal size and contained no excess of ﬂuid.
Septum lucidum perfect. The brain was not at all reduced in size, and, to the
naked eye, appeared healthy. The trachea showed no sign of a thyroid gland, but
on the outer sides of the neck were two fatty tumours, small in size, pinkish
in colour, and lobulated, without any investing envelope, sending processes upwards
ss2
6 2 8 MENTAL DIsEAsEs.
and backwards, beneath the sterno-mastoid muscles, and downwards beneath the
clavicles.

In the centre is seen the trachea with the sterno-hyoid and thyroid muscles turned
aside. Outside these are the sterno-mastoid muscles and still externally are the fatty
tumours.
P. (1., aged 15 years, admitted into Clapton Asylum, May 14,, 1875, and died
January 31,1878. His father was a delicate man, who is said never to have been
very sharp, and who worried himself a good deal about trivial matters. His mother,
a Dutch woman, was generally healthy, but suffered from bad headache at times.
There is a history of phthisis in the family of the parents, who were temperate, and not
connected by consanguinity. No family history of neuroses. The conformation of the
boy’s body is said to have existed, as now seen, at birth. The mother did not suffer
from trouble during pregnancy. The patient fell on his head when six months old, but
did not become insensible. He is the second son; there are seven others, all healthy,
presenting nothing remarkable about them. ~ On admission he was seen to be an idiot
of the cretinoid type, but not of so marked a character as the preceding or succeeding
case. His complexion was muddy. He was 4 feet 5% inches in height, with a square
head, measuring 21% in. in circumference, 13 in. in the transverse direction, and 15 in.
antero-posteriorly. There was no sign of paralysis, but he was very slow in his
movements. He did not suffer from epilepsy. He was able to speak, but did not say
much. He was very pugnacious, continually ﬁghting with the other boys. On both
sides of the neck were fatty tumours, and correspondingly there was an absence of the
MENTAL DIsEASEs. 629
thyroid gland. He went to school in the asylum, but was very lazy and dull. An
attempt was also made to teach him the trade of a shoemaker. At the end of 12
months he could spell “ cat,” “go,” “to,” could count to 7, and from 9 to 15. He
knew the names of, and sometimes would distinguish, a colour. He had made no
improvement in the shop. After another year’s training, that is, at the end of 2 years, he
' could spell one or two more words and add 1 and 1, count to 12, and distinguish the blue
and red colours. He had made, therefore, very little progress in school, as was
also the case in the shop. He continued in the same state, and died of pneumonia,
January 31, 1878.
At the post-mortem the body was found to be very fat. The cranium was thicker
than normal, and the interior of the skull—cap, which was eburnated, was closely attached
to the dura mater. The brain weighed 2 lbs. 15 oz., and was, therefore, of average weight.
The convolutions, though more highly developed than in the second case of microcephalic
idiocy, and the other two cases of cretinoid idiocy, were yet simpler than normal. The
sulci were well marked. On further examination the ﬁssures were found to be all
present, and the convolutions of some ‘degree of complexity. It is presented for
inspection by the Members of the Congress.
On examining the trachea, some fat was found at the lower and front part of it,
communicating on each side with lumps of fat, not encapsuled, in the posterior tri-
angles of the neck. ' i
F. ,T., aged nine years, was admitted into the Darenth Asylum, February 12,
1880, ‘and died June 8, 1880, of pneumonia. The father died of inﬂammation of the
lungs six months before the patient’s admission. He had been a temperate man
before the birth of this child, but three years ago took to drink. The mother was a
temperate, healthy woman. There was a history of phthisis on both the father’s and
mother’s side; a paternal aunt had died of epilepsy, and the mother had ﬁts as a
child. The paternal grandfather was paralyzed. Hereditary predisposition, therefore,
not certainly to cretinislm, but to an unstable brain, was markedly present. No history
of consanguinity. The child is said to have had nice features up to two years of age,
and, when ﬁfteen months old, could walk round a chair, and was able to say a few
words. As the result of whooping-cough when one year and eight months old, she
lost the power of talking and walking. She was noticed to get fat when two and a half
years old, and has been getting fatter ever since. She seemed to stop growing when
seven years old, and has not grown an inch since. The cause of the child’s condition
is assigned by the mother to a fright by an insane gentleman during her pregnancy.
'It must, however, be stated that the mother lived, and the child was born, in a valley
which was foggy and marshy, and the soil very chalky. On admission, the child
presented the usual signs of a sporadic cretin as related in the case of F. R. The
circumference of her head measured 19-2 in., transverse diameter 12;}- in., antero-
posterior 13 in., width of forehead 41 in. She was 2 feet 6%— in. high, and unable to
stand, though she could move her legs. She could hold things, but not move herself
about. Her hearing was dull, and she ‘could not utter a word. Disposition placid and
quiet. She was unable to swallow solids. She noticed. me when I paid her my
morning visit, but otherwise did not take much notice of what went on in the ward.
At the autopsy, the cranium was found to be square in shape, and the sutures well
united. There was a steep descent of the clivus, as in the case of F. R. The brain
weighed 36 ounces. The convolutions were rather simple. Some admirable sections
of this brain were also made for me by my friend Mr. Marsh. In the logwood stained
sections, a large number of leucocytes were noticed, as in the microcephalic idiot, and
ﬁve layers of nerve cells were made out both in these and the sections stained with
aniline black. The cells were larger than in the case referred to, and the spaces also.
In shape, they (the cells) were round or pyramidal. A few were without spaces, and
these had an irregular, angular appearance. More of the spaces were clear than in the
case of E. H ., and those not clear presented faintly stained protoplasm. The nuclei were
6 3 o MENTAL DISEASES.
round, oval, or irregularly angular. Many of the cells had no processes, some only'one,
and a few had three or four, but the processes in each case were stunted. Owing to
the number of cells, with large spaces, a curious honeycomb appearance was produced.
Fig. 30.


Cells from third layer of cortex of frontal convolution of F. T., cretinoid idiot.
a. nucleus Z). retracted protoplasm. c. granular matter. The retracted pro-
toplasm and granular matter arerepresented too dark in the woodcut.
Hartnack, obj. N o. 8, eyepiece No. 4, tube drawn out. Fletcher Beach, clclt.
Cases of cretinoid idiocy are known by the peculiarity of their features, their stunted
growth, usually the absence of thyroid gland, and generally the presence ' of fatty
tumours in the posterior triangles of the neck. They are usually of a placid and quiet-
disposition, and although the boy P. C. was pugnacious, yet he was noticed when in
school to be dull and lazy.
DISCUSSION.
The discussion on the two papers on Idiocy-was opened by Dr. HUGGARD, London ; who
pointed out that extreme distortion of the skull (such as existed in some from Malikolo,
recently exhibited by Professor Flower) had no tendency to produce idiocy, provided that
the pressure is not sudden. He considered that this supported Dr. Shuttleworth in his
belief that microcephalism is not due to premature synostosis, as Virchow supposed.
Dr. IRELAND, Stirling: conﬁrmed this last statement, pointing out that in some micro-
ccphalic heads the fontanelles are open and the sutures not united. He believed that
idiocy is rarely due to the use of‘ the forceps, and that harm is more frequently done by
prolonged labour.
Dr. DALLY, Paris : objected to the terms “ \llongol ” and “ Kalmuck ” as applied to
‘idiots, for although there might be some superﬁcial resemblance, idiots of this type had
not the large, open orbit and heavy jaw of the Mongolian races.
Dr. CnoeHLEY CLAPHAM, Sydenham: laid special stress on the deﬁciency of‘ occipital
v development in idiots.
Dr. SnurcrLnwontrm-Lancaster: in his reply, stated that at the Royal Albert Asylum
from a to 5 per cent. of the patients had heads measuring not more than 19 in.; and
about the same proportion were of the Mongol type; cretinoid idiocy being very rare.
He explained that he had used the term “ Mongol,” to designate a type of idiocy, not
because he accepted the theory of “ethnic degeneration,” but because having been
MENTAL DISEASES. 6 3 r
employed by Drs. Down, Mitchell, Ireland, and others, it conveniently distinguished the
class referred to.
Dr. FLETCHER BEACH, Darenth: said that he had made measurements in reference to
the development of the frontal portion of the brain. The frontal convolutions were well
developed in idiots. In one case the proportions were 61 frontal, 14 parietal, and 25
occipital. In the healthy brain the proportions were respectively, 541, 23, and 23 ; and
in the chimpanzee 4:9, 28,'and 23. In another case reported by him the proportions
were 66 frontal, 27 parietal, and 7 occipital. The question which Dr. Hack Tuke had
brought under their notice as to the high palate was important. The true position was
this : if they had an idiot brought before them with a vaulted palate, they could say the
case was a congenital and not an acquired one, and in practice this would be found an
important point.
C67667/dl Lacalizaz‘iori mm’ Hallucinai‘ioizs.
Professor TAMBURINI, Reggio Emilia.
Professor TAMBURINI read a short paper on “ Cerebral Localization and Hallucina
tions,” of which the following is a sketch :—
He began by pointing out that the ﬁrst discovery of a sensory centre (that of sight)
in the cerebral cortex was due to Panizzi, in 1856, but the full development of the dis-
covery is due to Professor Ferrier. He reviewed the various theories which would ascribe
hallucinations to disorder of the peripheral organs, of the optic thalamus, and of the
sensory cortical centres, concluding that the latter is the only view consistent with the
present state of. physiology. He proceeded to support this by relating three cases in
which there had been persistent auditory hallucinations during life, and after death
Ferrier’s auditory centres were found diseased. He brought the subject forward in order
to support Professor Ferrier’s teaching, and to urge others to further inquiry.
DISCUSSION.
Dr. FERRIER, London: referred to experiments already shown in the Physiological
Section, as proving to demonstration the existence of an auditory centre; and he was almost
equally certain that there were similar centres for the other senses. He believed that
hallucinations were due to morbid excitement of these sensory centres, in the same way
as convulsions are produced by excitement of the motor centres.
.—_-—-n
7716 Brains of Criminals.
Dr. BENEDIKT, Vienna.
Dr. BENEDIKT read a paper on “The Brains of Criminals,” of which the following
is an abstract :—
With the view of supplying a new element in the science of physiological psychology,
I have collected more than 40 brains of criminals, and have brought here 48 hemispheres,
from 37' brains. These brains are not selected, but are those of all the persons who died
in a certain prison during a certain time. It will be seen that they differ from the
normal (typical) brain chieﬂy in this, that the ﬁssures tend to run together, instead of
6 3 2 MENTAL DISEASES.
being separated from each other (“the type of conﬂuent ﬁssures”). These conﬂuences
cause the human brain to resemble that of monkeys ; in particular it will be noticed that
in nineteen cases the scissura hippocampi (sulcus dentatus) is connected with the united
parieto-occipital and calcarine ﬁssure ; and in two cases the calcarine ﬁssure is separated
from the parieto-occipital :—both of these being characteristics of the simian brain. The
calloso-marginal ﬁssure, again, frequently enters the quadrate lobe, and may extend as far
as the scissura hippocampi. ' '
Another interesting peculiarity is the formation of another ﬁssure, which proceeds
from the Sylvian ﬁssure, dividing the external portion of the frontal lobe from its basal
or orbital part. This I have named the “external orbital ﬁssure ;” traces of it are to
be found in healthy human brains, but in animals it is important, having been supposed
by Boza to be represented by the central ﬁssure in man.
The type of four gyri has attracted more notice from French and Italian authors:
this is sometimes produced (as I formerly supposed to be always the case) by division of
the ﬁrst frontal gyrus, sometimes (as Mr. Hanot believed) by division of the second:
sometimes both are divided, producing a type of ﬁve gyri. It is also interesting to
remark that in these criminal brains the cerebellum is often either wholly or partially
uncovered by the cerebrum.
These examples will prove that there exists another type of human brain, divergent from
the normal one, and that most of my criminal brains belong to that type; they are also of
use in assisting us to identify the several ﬁssures in man with those in the lower animals.
DISCUSSION.
Dr. CRICHTON BROWNE, London: considered that the brains demonstrated by Dr.
Benedikt were merely brains of a simple type, differing in no respect from ordinary brains
which were imperfectly developed. He expressed his belief that the author would be
unable to pick out twenty brains of criminals which had been mixed with a hundred
brains of ordinary people.
Dr. DALLY, Paris: urged that in examining the causes producing habitual criminality,
it is unreasonable to concentrate the attention upon the cerebral characteristics of the
individual, disregarding his social relations, which were more z'mportmzt factors.
0% Um'laz‘eml Hallucz'naz‘z'om and M62? Relation 2‘0
Career/a! Lacalz'zaz‘z'on.
Dr. ALEXANDER ROBERTSON, Glasgow.
Dr. ALEXANDER ROBERTSON read a paper on “ Unilateral Hallucinations and their
Relation to Cerebral Localization,” of which the following is an abstract :—
It has long been known that hallucinations may be one-sided, and this is shown by
reference more particularly to the writings of French and German authorities. It
appears from their statements that such cases are considered to be very rare; but it is
maintained in the paper that their rarity is more apparent than real, and is due to the
point having been seldom investigated, at least in the form and stage of insanity when
one-sided hallucinations are most frequently present. A short abstract of the con-
clusions of a former paper by the writer on the subject, read at the annual meeting of
the British Medical Association, in 1875, is then submitted, and is followed by brief
MENTAL DISEASES. 6 3 3
details of cases since then observed by him. These yield a basis for general considera-
tions respecting the pathology and relations of this class of phenomena. Care is taken
to include only such cases as are of cerebral origin ; those in which there was disease of
the sense-organ, or where there was ground for believing that peripheral disease had
crept up along the nerves to the cerebral centres are excluded. It is stated that one-
sided hallucinations are most common in the forms of insanity due to alcohol, particularly
when they are the result of recent excesses. The degree of frequency of unilateral, as
compared with bilateral hallucinations, is considered, also the comparative liability of the
respective senses, and the reason why the unilateral forms should preponderate so greatly
as they do in the auditory sense. The fact that they are much more common in the left
than the right ear is also noted.
The question, How does it happen that the centre for one side is implicated, while
the other is free? is discussed. Much light is thrown on this and other points in
cerebro-mental disorders by a study of Sir James Paget’s philosophical views on general
pathology. A part that is congenitally weaker, or has been enfeebled by disease, is apt
to be aﬁ’ected ﬁrst, and to suffer most, when a general morbid action arises in the system.
This is illustrated from the writcr-’s practice. In unilateral hallucinations the special
centre involved is held to be weaker on the one side than the other, through some cause,
either congenital or acquired, and such an agent as alcohol in the blood acts with special
virulence on this part. From this point morbid action spreads, generally involving the
mind as a whole.
The psycho-sensorial centres in the convolutions are held to be affected rather than the
centres of special sense in the sensorium. It is urged that the general mental disturb-
ance which in a greater or less degree almost always accompanies the hallucinations, or at
least quickly supcrvenes on them, points very distinctively to the supreme centres as the
seat of the disorder. In this connection the fact is alluded to that not infrequently
auditory hallucinations, both unilateral and bilateral, persist for a day or two after
positive insanity has disappeared, and is considered to show that healthy action has
been everywhere restored, save in the solitary supreme centre, or centres for hearing.
Attention is directed to the analogy presented by certain motor disorders, particularly
jumpings of the legs and body generally, which are occasionally marked symptoms in the
initial stage of mania. In relation to the mental disorder, these seem to point to the
motor convolutions as the centre of morbid action. The psycho—sensorial phenomena
under consideration are probably associated with some other portion of the cerebral
surface. But though we know the position of the motor centres, we are still in
ignorance of the localization of the special senses. Ferrier, no doubt, indicates with
great precision their probable site, and cases are recorded which seem to bear out his
conclusions; but the number of these cases is small, and the results of other observa-
tions are not in harmony with Ferrier’s views, &c.
6 3 4 MENTAL DISEASES.
Mental Stupor’.
Dr. HACK TUKE, London.
I wish to bring under your notice to-day several cases of mental stupor for the
purpose of raising the question of their true nature, and the nosology of mental stupor
in general. These cases presented marked cataleptic symptoms.
I here use the term “ mental stupor,” as synonymous with the French “ stupidite,”
which, as you are aware, comprises all that we understand as acute dementia and
melancholia attonita or cum stupore, whether with or without catalepsy.
These cases were admitted into Bethlem Hospital, 'two under Dr. Williams’ and
one under Dr. Savage’s care, to whom I am indebted for permission to use them. They
were frequently examined by myself.
One was a young woman between nineteen and twenty, a school-teacher, who
suffered severe disappointment from failing in an examination. Mental symptoms
developed themselves not 1 long afterwards, and in two months she was admitted into
Bethlem. There was no family history of insanity- She herself had never had ﬁts of
any kind, epileptic or hysterical. ' ' '
The early symptoms were marked by what was regarded as sullen behaviour.
Then she had distinct hallucinations that she saw the devil and that she heard some
one whispering to her not to pray; and laboured under the delusion that her soul was
lost. She then became silent, obstinate, and refused her food. To one of the medical
men who signed her certiﬁcate, she whispered that she heard the clanking of chains and
that she wanted to do penance for her sins. To her father she said she was in great
misery and in dread of eternal punishment.
Up to the time of admission into Bethlem Hospital, menstruation was regular, but
during the previous catamenial period she had caught cold, and after admission the
catamenia ceased. Amenorrhoea therefore did not stand in the relation of cause to her
attack.
Her condition after admission was as follows :—
She did not respond by word or gesture to questions, but it was inferred from
increased tremor of the eyelids and slight suffusion of the face that she was conscious to
some extent at least, of what was said to her.
She ~sat or stood motionless, perfectly passive. Her eyes were shut, and there was
generally a quivering of the lids. On raising the latter the globes were found to be
strongly directed upwards and inwards, and the pupils moderately dilated. From
their position it was difficult to determine their reaction to light. Her mouth was
partly open, the saliva constantly dribbling down upon her dress. The facial expression
as a whole was a blank.
The hands were somewhat cold and blue, but not to ‘the degree so often observed;
and there were no chilblains. The clinical thermometer did not indicate anything
' abnormal, the pulse was 72, feeble; the sphygmographic tracing, taken by Dr. Savage,
normal.
Faradic reaction was found to be only about two cells below normal.
Tickling the soles of the feet produced some, but diminished, reaction.
\Vith regard to general sensation there was well~marked loss of sensibility in the
upper extremities; not so pronounced in the lower. Blood was slow in following the
prick of a pin, which could be introduced into any part of the arm or neck without the
slightest indication of feeling. -
The ﬁnger could be passed over the conjunctivae without any resistance or
flinching.
No tender spots on the chest, ribs, or back were made out, and there did not appear
to be ovarian tenderness.
MENTAL nIsEAsEs. 6 3‘5.
Passing to the motor system, it was found, on raising her arms, that they remained
in the position in which they were placed for a very considerable time. There was no
more rigidity than served to support them in their position. The hand or ﬁngers
could be moulded in any direction desired, so as to present a fair example of ﬁexibilitas
cerea. Although the arms thus preserved their position and for so long a time, it was
easy to bring them down again, with gentle pressure. The lower extremities were
much less cataleptic.
If the patient was made to stand, she remained in that position an indeﬁnite length
of time; never walking unless pushed forward.
She had to be dressed and undressed, being as passive and powerless as a doll, and
required to be fed with a spoon.
She did not attend to the calls of Nature.
This description will, I hope, convey a tolerably clear notion of the case, but you.
will see better by this photograph the appearance she presented when her arms were
raised and her mouth was open. (Photograph exhibited.)
The two other cases to which I have referred were young men, but I will not
occupy your time in describing their symptoms, because their close resemblance to that
which I have given renders it unnecessary. I may observe, however, that one of these
cases stood like a sign-post with extended arms, inanimate, regardless of all that passed
around him, a pitiful object, with only the whites of his eyes visible. Slavering like an
idiot, and wholly careless of personal cleanliness, it seemed as if the mind was an utter
blank. It was not, however, the blank of dementia, and the term “acute dementia ”
is on this account misleading in such cases. Moreover, dying of phthisis, he conversed
rationally with his relatives‘ during some weeks prior to his death. In this case
M. Roussel tried the effect of transfusion of blood, but without decided beneﬁt.
The other patient was removed to Hanwell and remains there under Dr. Rayner’s
care, but not in his former cataleptic condition. (Photographs of both exhibited).
Taking the classiﬁcation of the French, who comprise under the generic term
stupidité, three varieties, one arising out of melancholia in which painful delusions
more or less persist and dominate the physical signs; another in which it results from
moral shock, depression of the vital powers, epileptic attacks, or as secondary to acute
mania; and the third, catalepz‘g'form stupidite', we have no diﬂiculty in assigning these
cases to the last-mentioned class; but as cataleptic symptoms are not peculiar to either
of the other species—divisions which correspond to the terms melancholia cum stupore
and acute dementia—we have still to inquire what is the mental condition of patients
presenting the appearance which was present in these cases.
As a matter of fact different mental physicians do arrive at different conclusions on
this point, and employ different designations. Amongst ourselves, some would call
these patients excellent examples of acute dementia, others of melancholia attonita (or
cum stupore); and this, in fact, occurred in these particular instances. I offer no apology,
therefore, for bringing the subject under the notice of this Section of the Congress, and
I do so in order to learn myself from others, with scant hope of adding to your knowledge.
I ask you, therefore, to regard the részmie' as affording points for discussion rather than
dogmatic statements. As every one knows, M. Baillarger disputed the distinction
between these states, and no doubt he succeeded in proving that careful inquiry of
the patient after recovery will generally reveal the presence of painful delusions even
when they were not suspected, thus reducing materially the number of cases of so-called
acute dementia—a condition Esquirol says he rarely met with.
However, it will be generally admitted that there may be two different mental states
by whatever name we call them, in one of which there is, for a time, a suspension of
the mental powers generally; as from starvation, exhausting diseases, &c., while in the
other, the patient is in the state of mind described by Sauvages, as long ago as 17 4.5,
as characterising melancholia attonita or cum stupore. “ The patient,” he says,“ does
not move from his place, and retains the same attitude. If he is seated, he does not
6 3 6 MENTAL DISEASES.
rise from his seat; if standing, he does not sit down ; if lying down, he hardly ever
sits up, or walks, unless he is moved by those who are standing by and is driven from
the place. He does not flee from company. Asked a question, he replies not;
although he seems to direct his attention to what is spoken. He regards not advice, as
if he were deaf; he does not attend to objects of sight or touch. He alternately sleeps
and watches; and eats and drinks What is put into his mouth as if musing and
distracted by cogt'tation on other matters.”
Such a condition as this ought not to be confounded so long as it remains at this
stage with the following, although both may be called states of mental stupor.
A woman, whom I have often examined at St. Luke’s, used to stand with her
head awry, her hands by her side, her eyes open without expression, and did not
reply to questions. The saliva ran from her mouth, and the mucus from her nose,
unheeded; she had to be fed and dressed, and altogether treated as a child. There
was no indication of pain on being pricked, and no opposition to the ﬁnger being
placed on the conjunctiva. No attention was paid to the calls of Nature, she was
greatly emaciated, the skin of the hands cold and blue. The mental condition was
apparently a blank, although there was not any evidence of incurable dementia.
These are typical illustrations or descriptions of melancholia cum stupore, on the
one hand, and acute dementia as it is called, on the other, but with little reason, as I
venture to think.
Exception may indeed be also taken to the former term, as applied to the
description by Sauvages, for it seems at ﬁrst sight a contradiction in terms, to speak
of Stupor in a casein which the patient directs his attention to what is spoken to him,
and is “musing, and is distracted by cogitation;” and no doubt the expression is
used here in a sense somewhat different from that in which it is frequently employed.
But it has the support of classic usage, for Ovid employs it to describe a state of
violent grief, which does not allow of tears (“ ﬁne carent lachrymae, nisi cum stupor
obstitit illis.”—-P0nt. I. ii. 26), and it was employed by the Romans to indicate the
condition of one lost in admiration, which is certainly inconsistent with stupor under-
stood in a literal sense.
There may be the absorption of the whole being in a dreadful idea, the arrest of
all action of the mind by one impassable impediment; the stoppage of mental traffic
by reason of a Waggon-load of care standing in the way, and blocking up the
thoroughfare; or, to change the metaphor, out of the clouds in which the unhappy
melancholiac is enveloped, a thunderstorm breaks over his head, which, instead of
clearing his mental atmosphere, is followed by a lightning stroke, which leaves him
ﬁxed in one position of mind and body, for such was doubtless the idea of those who
invented the term “ thunderstruck melancholy”-—melancholia attonita.
Absorption, even painful absorption, in woe, or a terriﬁc delusion, may make a
person oblivious to the outer world, and I take mental stupor to be a condition in
which the re action to external impressions is more or less suspended and blunted for
a time, the patient responding little if at all to questions, generally motionless, some-
times cataleptic, and frequently anaesthesic. When established, it is a form of
mental disorder having its own special character, and is distinguished from acute
melancholia by silence and immobility, and from true dementia by there being no
certain evidence of permanent mental weakness.
Such a case is, or rather was, that of the woman at Bethlem, whose symptoms I
have described, as also the other two cases in the same hospital. I believe that they
had passed into a condition closely resembling, if not constituting, one form of
somnambulism—chronic somnambulism as it proved—and that when we see persons in
this state, it is utterly impossible to say whether the foundation of the case was laid in
melancholia, or in simple mental exhaustion. At an earlier stage, the differential
signs usually stated in textbooks, no doubt apply, and I cannot add to those given in
the last edition of the “ Manual of Psychological Medicine,” but no test symptom can
MENTAL DISEASES. 6 3 7
be laid down at the later stage of which I speak, for the simple reason that the two states
may then be identical. It will be said, perhaps, that there were in the Bethlem case
all the signs of (so-called) acute dementia—a vacant physiognomy, dribbling saliva,
inattention to the calls of Nature, and so forth ; but all these might equally well occur
in the stupor induced by melancholy, or in a prolonged cataleptic form of somnambulism.
Moreover, I do not doubt that if this condition persists for long, it may pass into a
state of actual mental weakness. How far the degree of Faradic reaction may assist
in deciding between these states I am not prepared to say.
In this woman the cataleptic condition lasted about ﬁve months, then she slowly
emerged from it, and recovery seemed probable; but unfortunately she relapsed, not
into the cataleptic condition, but into one of childishness; to he succeeded by a return,
to some extent, of the former cataleptic state. Anaesthesia is still well-marked, and
there is a slight tendency for the arms when raised to retain their position.
It is in its relation to the prior melancholy ﬁxed idea or morbid sensation, that I
believe We have not suﬁ‘iciently regarded the catalepsy which occurs among the insane.
My belief is that dwelling upon a painful delusion may, in certain constitutions, or in
certain states of the constitution, produce a cerebral condition in which the patient passes
beyond an active or painful phase of thought, and is in very vague relationship to the
outer world; a higher restraining and guiding centre becoming, so to Speak, itself
inhibited by a dominant idea or morbid sensation. The patient’s actions are conse-
quently at the mercy of others, or of his own inferior centres.
Thus, as I submit, the Bethlem girl being absorbed in the ﬁrst instance in her
own sombre reverie, glided into a self-induced hypnotic condition of the cataleptic
variety. In some cases the course of events is as follows: uterine or sexual excitement;
irritation transmitted through the sensory nerves to the brain and cord, affecting the
mental functions, and by reﬂex action, disturbing the normal action of the muscles, and
causing vaso-motor paralysis.
I may here say that, hearing in mind the case of catalepsy reported by Pau de St.
Martin which recovered under hypnotic treatment, I repeatedly tried hypnotic mani-
pulations upon her, with Dr. Savage’s permission, but without any inﬂuence on the
course of the disorder. The only point of interest was this : that her eyes being, as always
since admission, shut, and the eyelids turned upwards, the manipulations which I
employed were followed in the ﬁrst experiment, by relaxation of the spasm of the eyes,
and their opening Widely, for about two minutes; the ordinarily blank face becoming
for the time normally intelligent. Then the eyeballs resumed their usual position, the
lids closed, and the face became again expressionless. Slight and ﬂeeting, however, as
was this success, the circumstance conﬁrmed my opinion that in this, and similar cases,
the patient is, pathologically, in a state allied to somnambulism, and that whatever
explanation is ultimately found to be true of the state of the brain in the latter, as
regards partial vascular changes or inhibition, will be found true also of the cases in
question. I
No doubt, in not a few cases of mental stupor, the muscles have a tendency to
assume a cataleptic position, although such well-marked cases as those I have mentioned,
in which other signs of catalepsy are present, are not in my experience very common,
and I observe M. Dagonet speaks of cataleptic stupidité as rather rare.
On analysing ﬁfty cases of mental stupor examined by myself or competent alienists,
and which I have tabulated in respect to their mental, motor, and sensory state, I ﬁnd
that there were twenty-one, or forty-two per cent. in which the muscles assumed, in a
more or less decided degree, a cataleptic form. =-
Of these, eight were cases in which the demented rather than the melancholic form
of stupor presented itself at an early period of the attack.
One point to which I have specially turned my attention is the statement of the
patient himself when he recovers, as to his mental condition during the time of his
stupor.
»6 3 8 ' MENTAL DISEASES.
Out of the ﬁfty, there were twenty-one who gave more or less clear descriptions
of their feelings during the time—these feelings being generally associated with some
terrible delusion. The question of course arises, in relation to diagnosis, were there
in any of these instances the outward signs usually attributed to acute dementia?
Undoubtedly there were. Take one case, as illustrating the class, which ‘I saw at
\Vakefield under Dr. Major. The expression of the patient was apathetic and indifferent.
He stared vacantly at the questioner. The saliva dribbled from his mouth. The ﬁies
crawled over his nostril, or lighted upon his eyes, but he was perfectly indiﬁ‘erent. He
never cared to change his position, however uncomfortable. He did not speak.
Was not this a case of acute dementia? The event proved that it was not. He
said before his death that he had been perfectly well aware of all that had gone on
around him, and that he had been labouring under the idea that the angels would not
allow him to speak, and that he believed his food was poisoned. This explained both
his silence and his refusal to eat.
I hold then that in some, if not many, instances it is impossible to tell whether we
have before us what is called acute dementia or melancholia with stupor, notwithstanding
the differential signs usually given to distinguish them, and I am not surprised to ﬁnd
that Dr. Mickle has for some time ceased to employ the term acute dementia. I
certainly think it would be desirable to relinquish the use of the term, and to employ
those of mental stupor and mental stupor with melancholia, respectively.
In one of his cases which I examined a few months ago, the patient, a man, had
been admitted without any history, having been picked up as a wandering lunatic. His
expression was vacant. He was silent. With these and others symptoms he might
well have been entered as a case of acute dementia. But when he improved and was
willing to speak, he said to Dr. Mickle that his idea was that he should be killed; and
to me, he said, “ I was afeared.” Thebasis of the mental state then was a delusion
of a melancholy character, although it had passed on to the stage which, as I have said,
it is impossible to distinguish from that of acute dementia without that knowledge of
the subjective life of the patient which he alone can give us after his recovery.
I would add, that of the patients whom I have collected in my list who described
their condition during their stupor, several said that they had felt as if in a dream,
others had felt as if spell-bound and so unable to speak, they knew not why: and some
thought that they had got into the lower regions and were afraid to utter a word.
In regard to sex, twenty-four were males, twenty-six females.
The average age was twenty-seven. '
As respects sensation, in twenty-four (forty-eight per cent.) it was certainly lost; pro-
bably the proportion was larger, the sensibility not having been always recorded at the
time of examination.
The recoveries were nineteen in number (thirty-eight per cent.), and Six died insane
(only one of these being cataleptic). Of the remaining twenty-ﬁve, very few were
hopeful cases. The large majority (eleven) presented the delusional form.
Of the six deaths, there were in four, post-mortem examinations, the appearances
not being striking or uniform. In one there was marked oedema of the brain,
which, as you are aware, has been frequently observed when cases have run a long
course. If—being an effect—it does not throw light on their primary pathology,
it is consistent with the stagnation or partial vascular changes in the brain already men-
tioned, and to which I have, as regards somnambulism, referred in the Journal of
Mental Science as vaso-motor ; the sympathetic being irregularly inﬂuenced by
sensory and emotional impressions; different areas and their functions being thus in
different states of functional activity.
It seems to me, that in trying to ﬁx upon one case as acute dementia, and
.another as melancholia cum stupore, we are apt to forget that the same case may
present these and even other forms of mental disorder. An examination of these
\lifty cases, from this point of view, shows that in quite a number of instances the
7
MENTAL nIsEAsEs. 6 3 9
patient had passed through a stage of excitement, melancholia, stupidité, and dementia,
thus bearing out to a considerable extent the circular character of the mental disorders
with which motor trouble other than paralysis is often associated, as insisted upon by
Kahlbaun in his memoir on Katatonia. By approaching the disease from the physical
side, Dr. Kahlbaun has made the disorders of motility, and not the form of mental
derangement, the essential part of the malady, and has studied rigidity, spasm, choreic
movements, and catalepsy, as they occur in the insane, as affections analogous to the
occurrence of general paralysis. In fact he does not trouble himself with the distinc-
tion between the different forms of mental stupor—does not pretend to diagnose between
melancholia attonita and acute dementia—but takes the most prominent symptoms
at the time as constituting the stage of what he regards as circular insanity. But I
think he carries his views too far, and that as the morbid mental state conditions the
motor trouble, it is right to take the former and not the latter as the basis of classi-
ﬁcation; at the same time, it is very important that in view of the psycho-motor
centres, these motor and psychical (as also the sensory) troubles should be brought into
relation.
In conclusion I would sum up by saying that I think the cataleptic variety of
mental stupor (and probably other varieties also) is a condition to be regarded as
caused by the exclusive direction of the mind upon a melancholy delusion, or if this
is absent, from brain exhaustion due to various causes, calculated to paralyse voli-
tion, and allow of involuntary action, and that this state, when completely estab-
lished, is no longer one of either melancholia or dementia, as regards the patient’s
actual mental condition at that time, although it may terminate in the latter.
Further, I believe that the more. cases of so-called acute dementia are investi-
gated, the more shall we be driven to conclude that in a much larger proportion of
instances than is often supposed, they are examples of melancholia with stupor, the
melancholiac having passed into either a state of hebetude which is identical patho-
logically with acute dementia, or of indifference to everything around him, accom-
panied by delusions; the physiognomy of indifference masking the painful feelings,
and the discovery of the patient’s melancholy delusions and hallucinations only being
made by his physician on the recovery of the case. \
Lastly, as to nomenclature, while I recognize the different mental states marked
by an intensive and melancholic absorption of mind on the one hand, and by an utter
blank on the other, the former blends so imperceptibly into the latter, and they so
frequently cannot be distinguished until after the patient’s recovery, that it appears to
me more convenient to employ the term Mental Stupor as comprising both, qualiﬁed by
the words “with melancholia ” when we have certain proofs of this condition being
present, thus getting rid of the term “ acute dementia ” altogether, which confounds
the curable state in question with a form of mental disorder with which it has not
necessarily any pathological relation. '
DISCUSSION.
Dr. FOVILLE, Paris : agreed with Dr. Tuke, that the term “ acute dementia" was
a misnomer; and, in fact, although introduced by the French, it was no longer used
in France—Dr. CnIcHToN BROWN, London: and Dr. CLonsToN, Edinburgh: believed
there was an essential difference between the two mental states in question, and the
latter hesitated to admit the analogy between somnambulism and any form of mental
stupor.
640 MENTAL DISEASES.
An Expem'mem‘al Sz‘ua'y 0f Hypnaz‘z'sm.
Professor TAMBURINI, Reggio Emilia.
Professor TAMBURINI read a paper on “ An Experimental Study of Hypnotism,” of
which the following is an abstract :— '
Ces recherches, que j’ai faites avec la collaboration de M. Seppilli, ont eu le double
but, d’éclaircir quelques points de l’hypnotisme et d’établir des faits objectifs qui pour-
raient écarter la simulation, dans l’intérêt de la médecine légale.
La première série de recherches portait sur une ﬁlle de 28 ans, hystérique: en voici
les résultats les plus saillants. Tous les phénomènes d’hyperesthésie musculaire (contrac-
tures, &c.), se sont montrés plus marqués du côté droit que du côté gauche. En même
temps que les contractures, une analgésie de tout le même côté du corps se produisait.
Avec une ﬂexion forcée plantaire, cette analgésie disparaissait et était suivie par une con-
tracture diffuse des muscles latéraux de la poitrine, avec respiration stertoreuse et
cyanose de la ﬁgure; et cet ensemble de phénomènes durait quelques moments.
Pour l’examen des phénomènes respiratoires et circulatoires pendant l’hypnose, nous
avons employé le pneumographe de Marey et l’hydrosphygmographe de Mosso. Il est
facile de voir, dans les tracés graphiques que je vous soumets, que pendant le passage
de la veille au sommeil hypnotique, la respiration devient plus profonde, fréquente et ir—
régulière; la fréquence est d’abord doublée, la pause inspiratoire supprimée: en même
temps le cœur bat plus vite et plus fort. L’application de l’aimant à une distance de 3 à.
4: centimètres du thorax ou de l’épigastre produit presque toujours de profondes modiﬁ-
cations. Le plus souvent, immédiatement après l’application, on constate un arrêt des
mouvements respiratoires; une vraie apnée qui se prolonge plusieurs secondes z quelque-
fois cette pause est précédée d’une forte inspiration. D’autres fois, nous avons observé
un accroissement notable dans l’amplitude des excursions thoraciques, ou bien un ralen-
tissement sensible.
L’enlèvement de l’aimant s’accompagne presque toujours d’un mouvement inspiratoire
profond, suivi d’amples excursions thoraciques. Les simple’s pauses ont suﬁî pour
modiﬁer la respiration dont les mouvements sont devenus plus faibles et plus fréquents.
L’application de l’aimant à, la région cardiaque excite les mouvements du cœur.
On verra que des observations vont à l’appui de la théorie qui rapproche l’hypnotisme
l’hystèrie et la métalloscopie, et qui les fait consister en modiﬁcations moléculaires du
système nerveux.
Gouz‘y Jmam'z‘y.
Dr. RAYNER, Hanwell.
Dr. RAYNER read a paper on “ Gouty Insanity,” of which the following is an
abstract 2-—
It is remarkable how few cases of insanity are ascribed to gout ; and in the absence of
any statistics of the frequency of gout in the population at large, it is impossible to do
more than assert my belief that gout is as frequent a cause of insanity as of any other
disease.
Dr. Berthier, in 1869, seems to have been the ﬁrst to collect the recorded cases of
insanity from gout, which proved (What I had previously concluded) that every form of
MENTAL DISEASES. 64 I
insanity may be thus produced. My object will be to support Dr. Berthier’s views, and
to Show the ways in which gout seems to produce insanity. The retrocession of gout has
been frequently observed to produce insanity ; the commonest condition being mania, very
sudden in its inset, and rarely lasting long, recovery being ushered in by an attack of
gout. A case is related of this kind. ‘
Two cases are related where the gout had taken the “ atonic ” form—that is, the
joints having ceased to be affected owing to general debility. Here the symptoms were
hallucinations of sight and hearing, producing great suspicion and distrust; the patients
recovering after an attack of gout.
There is yet another condition where gout may produce insanity; where the joints,
having been extensively affected, are incapable of giving the relief which formerly
followed their inﬂammation; this may be termed “ restrained,” or “ inpent,” gout. In
such a case as related the delusions were at ﬁrst exalted; these were soon followed by a
state of melancholy, which disappeared after an acute attack of gout consequent upon
great improvement in health.
In these, and two other cases, where gout played a part in the causation of insanity
secondary to plumbism and alcoholism, I have noticed two remarkable physical symp-
toms. The ﬁrst is a remarkable prominence of the eyes, especially marked in the atonic
and restrained forms : the second is an extreme darkness of complexion, more particularly
in melancholic cases. Both of these symptoms diminish as the health improves; they may
be seen in other cases of insanity, but only when we have reason to suspect the blood is
insufﬁciently depurated.
I am led, on the whole, to the following general conclusions :—
1.—Protracted gouty toxaemia, when not very intense, usually results in sensory hallu-
cinations or melancholia :--
2.-—-Sudden and intense toxaemia results in mania or epilepsy.
3.—-Intense and protracted toxaemia usually results in general paralysis.
4a—If there is a tendency to vascular degeneration, from plumbism, alcoholism, 820.,
varying degrees of dementia are produced.
DISCUSSION.
In the discussion which followed, Dr. SAVAGE, London: expressed himself as a convert
to the belief in gout as a cause of insanity; and Dr. ORICHTON BROWNE, London : stated
that he believed or insanity only occurred in gouty patients who were hereditarily predis-
posed to insanity or epilepsy, when the nervous disturbance produced may pass on into
actual insanity. He connected many cases of melancholia attonita in young girls of
feeble circulation with inherited gout.
Epileptic.
Prof. LASEGUE, Paris.
En vous parlant de l’épilepsie je ferai moins une communication qu’une demonstra-
tion; toute étudc d’une maladie est confuse si on n’a d’abord ﬁxé sa nosologie. On
doit admettre nosologiquement et cliniquement deux grandes classes d’épilepsie: les
vraies et les fausses.
La premiere comprend: l’épilepsie par malformation du crane, c’est la vraie, la
solennelle, celle qu’en empruntant un mot a la langue anglaise, on doit appeler genuine.
PART III. T T
6 42 MENTAL DISEASES.
Au-dessous, l’épilepsie par déformation du crâne, déjà moins franche, consécutive à.
un traumatisme de la voûte crânienne et a laquelle la trépanation est applicable.
Dans la seconde classe plus confuse sont comprises les épilepsies fausses (epz‘lepsz‘a
spzm‘a) qui se divisent en:
l.—Epilepsie traumatique par le fait d’une lésion cérébrale sans déformation du
crâne, commotion, &c.
2.——Epilepsie symptomatique d’une maladie inﬂammatoire ou organique du cerveau.
3.——Epilepsie toxique, saturnine, alcoolique, &c.
4:.—-Epilepsie hystérique se divisant en deux espèces suivant que l’un des deux
éléments prédomine.
Toutes ces variétés s’éloignent de plus en plus du type, à ce point qu’on ait pu se
demander si l’hystéro-épilepsie avait une affinité quelconque avec l’épilepsie.
Je veux dans cette étude détacher le premier groupe et l’envisager seul, c’est le vrai,
le pur ; tous les autres peuvent lui emprunter plus ou moins de ses caractères, ils ne se
confondent jamais avec lui. Ce sont, si vous me permettez cette comparaison, les
actionnaires d’une maison de banque, ils ne sont jamais la maison de banque elle-même.
Traduisant ma pensée par un thème, l’épilepsie sera représentée par une circonférence
centrale, autour de laquelle gravitent les états épileptiques.
Chacune de ces formes prend a l’épilepsie vraie plus ou moins de ses caractères, elle
lui emprunte plus au moins, jamais elle n’arrive a se confondre avec elle.
Dire d’une maladie qu’elle dépend d’une malformation crânienne, c’est énoncer un
fait dont on ne doit pas attendre la démonstration “ post mortem,” il faut déterminer le
fait du vivant même du malade.
Cette malformation n’appartient pas à l’enfance, mais àla période de consolida—
tion des os du crâne, elle tient à, l’évolution de l’appareil osseux de l’individu.
Dans l’enfance où la soudure n’est pas faite encore, il y ades compensations qui
s’établissent et écartent les causes de compression.
Entre la 12e et la 20e année la consolidation se fait, se complète, c’est Page auquel
l’épilepsie vraie apparaît. Rappelez-vous, Messieurs, les faits d’épilepsie que vous avez
observés, les vraies, ils sont certainement de cet âge. A 40 ans, vous ne la rencontrerez
plus jamais; l’épilepsie de cette période de la vie est due a une blessure, à une aﬁection
cérébrale, elle se traduit par des crises épileptoïdes; son évolution n’est pas celle de
l’épilepsie. _
Pas plus que le vieillard ou l'adulte, l’enfant du premier âge n’est un épileptique vrai;
il sera sujet à, des crises terribles d’éclampsie, de convulsions, il deviendra un imbécile,
un idiot, il subira toute sa vie les pires aventures cérébrales: il n’est pas et ne sera
jamais un épileptique.
De 12 a 20 ans la tête se consolide, l’intclligence s’assied; l’épilepsie survenant à. cet
âge, il faut constater si la tête est symétrique.
Les déviations limitées au crâne sont indifférentes et se compensent; les déviations
constatées aux os de la face ont la principale importance: elles indiquent l’asymétrie de
la base du crâne; or les compressions irrégulières exercées sur la base du cerveau
expliquent l’épilepsie.
Tout homme asymétrique de la face n’est pas un épileptique; mais tout épileptique
frappé d’asymétrie appartient a la grande espèce. Les lois de son évolution sont les
suivantes :
D’abord, elle n’est pas héréditaire tout au moins elle ne l’est pas plus que les autres
malformations, le bec de lièvre, le pied bot, &c., et elle obéit aux mêmes lois de trans-
mission. Dans une famille nombreuse, chez les‘ consanguins, par exemple, un enfant,
d’eux au plus, naissent malformés, les autres sont indemnes; il en est ainsi de l’épilepsie.
MENTAL DISEASES. 64 3
Le père et la mère n’ont jamais été épileptiques, l’enfant aura été conçu dans des
conditions défectueuses, ce n’est plus de l’hérédité vraie.
Le second caractère de la grande épilepsie avec malformation éclatant entre la 12e
et la 20e année, c’est que le premier “ insultus ” égale le dernier. Les accès peuvent se
multiplier, mais ils restent identiques. Aussi l’attention du médecin ne doit-elle pas
‘porter sur l’intensité insigniﬁante des attaques, mais sur l’état de santé des malades dans
les intervalles. Les autres étaient devenus épileptoïdes a la suite d’une maladie du
cerveau, ceux-ci deviennent malades du cerveau à la suite de l’épilepsie.
Troisièmement l’épileptique n’engendre pas d’épileptique: c’est l’exception rare. J’ai
été souvent consulté sur les conséquences du mariage avec un épileptique; j’ai toujours
résisté à ces unions, mais, consulté sur la question de savoir si les enfants à naître
étaient fatalement condamnés a l’épilepsie, j’ai répondu non, et pas une fois ces unions
'n’ont donné naissance à. un enfant épileptique.
Quatrièmement, l’épilepsie vraie, par malformation, n’admet pas d’aura prémonitoire .
L’attaque est instantanée, foudroyante, la perte de conscience immédiate. Tout malade
averti de l’attaque imminente est un épileptoïde.
Cinquièmement, aucune inﬂuence quelle qu’elle soit, morale ou physique, ne peut
provoquer l’attaque, elle survient à son heure et n’a a compter ni avec la. santé générale,
ni avec les indispositions accidentelles. Une seule condition semble provoquerle retour
des accès: c’est le sommeil ; encore n’agit-il qu’aux dernières heures de la nuit ou aux
premières heures du matin, dans le passage du sommeil a la veille. Tout homme, pris
d’une attaque dans le passage de la veille au sommeil, est éclamptique, mais non
épileptique.
Ce fait clinique n’est pas sans importance. J’ai dû me borner à. ces courts aphorismes
devant un auditoire si compétent et auquel les occasions ne manquent pas pour en
vériﬁer l’exactitude, et je vous remercie de votre bienveillante attention.
Testamem‘m/y fmapacz'z‘y.
Dr. BUCKNILL, London.
As our colleagues from the Continent may not be aware of the diﬁerences
which exist between our laws and theirs on the subject of wills, testaments, or
bequests, Iwill premise my observations by mentioning : First, that with us a sane
man may will or bequeath the whole of his possessions to go after his death
to whomsoever he thinks ﬁt. Secondly, that he may do this without the
assistance or intervention of any notary or other oﬁîcial person. And thirdly, that
the rules by which the validity of the will is determined are ﬁxed not by any
system or code but by precedents afforded by the decisions of the Courts themselves.
In this manner the same authorities both make and administer the law, and it so
happens that in this subject of testamentary capacity the law has been remade
and as I venture to think upon fallacious arguments and upon deceptive grounds.
The old law of England was that an insane man cannot make a will. Then
necessarily came the question, lVho is an insane man in this regard? and much
thought and learning were devoted by the principal minds of our most eminent
legal authorities to the proper answer. Omitting on this occasion any reference to
incapacity for want of: mental power, I shall restrict myself to the consideration of
the point in which the law has been altered by a comparatively recent decision—
namely, in the point of the inﬂuence of insane delusion.
T T 2
644 MENTAL DISEASES.
Unfortunately I cannot get at the subject without reference to the metaphy—
sical arguments which have been employed by our great lawyers. It had been
argued by Lord Chancellor Brougham, presiding over the ultimate Court of Appeal
in our House of Lords, that because the mind is one and indivisible therefore an
insane delusion aﬁ'ected the mind as a whole, and consequently that every act of
a person suffering from an insane delusion was an insane act.
any testament made by a person suffering from any insane delusion had been
considered invalid so long as the case of Waring v. Waring, was looked to as de—
ciding the law on the subject. However in 1871 the Lord Chief Justice of England
presiding over his own Court of Queen’s Bench as a Court of Appeal changed all
that.
It is to the facts and the arguments contained in this leading case of Banks 0.
Croodfellow that I particularly desire ,to draw your attention. I will, in the
ﬁrst place, read the description of the testator, as given by the Lord Chief Justice :—
“ It is a fact beyond dispute that the testator, John Banks, had at former times
been of unsound mind. He had been conﬁned, as far back as the year 1841, in
the county lunatic asylum; discharged after a time from the asylum, he remained
subject to certain ﬁxed delusions. He had conceived a violent aversion towards a
man named Featherstone Alexander, and notwithstanding the death of the latter
some years ago, he continued to believe that this man still pursued and molested
him; and the mere mention of Featherstone Alexander’s name was suﬁicient to
throw him into a state of violent excitement. He frequently believed that he was
pursued and molested by devils or evil spirits, whom he believed to be visibly
present. Besides these delusions, which were spoken to by two witnesses whose
evidence was above suspicion, the one a medical man who attended him from 1856
to the end of 1862, the other the clergyman of the parish in which the testator
resided, there was a body of evidence, which, if believed, was strong to establish a
case of general insanity. The jury, however, found in favour of the will, and
therefore must have believed this evidence to have been greatly exaggerated, or
must have come to the conclusion that the will was made during a lucid interval.
From September 1873, he had a succession of epileptic ﬁts, and a blister was
applied to his head, and the. medical man who attended him throughout this
period, deposed that his mental power, such as it was, suffered from the ﬁts, and
that he considered him insane, and incapable of transacting business during the
whole time.” rI‘he will was made in December, 1863.
The Lord Chief Justice goes on to describe the manner in which the will was
prepared and executed, from which it is apparent that the testator knows what
he was doing, so far as a knowledge of his possessions went, but which throws no
light upon the motives which inﬂuenced him in disposing of them.
rI‘he will itself contained no intrinsic marks of insanity; neither is it a docu-
ment demanding for its production such an exercise of sound judgment as to
constitute evidence of mental power and capacity.
Now, in considering the above descriptions I think you will agree with me that
the mental condition of the testator was erroneously considered in the Courts as
one of partial insanity or monomania. It seems to me clear that it was one of
‘Lhe mania of persecution, and, therefore, that the judgment of the Court of
Queen’s Bench, which is the existing operative of the law relating to testamentary
incapacity, has been founded upon arguments relating to monomania upon a case
which was not monomania but the mania of persecution.
I do not think that any of my learned, experienced, and interested audience will
On this principle ,
\
MENTAL DISEASES. 645
concur in the opinion of the Court of Queen’s Bench that John Banks as describe
by the Lord Chief Justice was capable of making a valid will, but putting aside the
question of false diagnosis in the particular instance, let us assume that the case
was that which the Court of Queen’s Bench believed it to be, and briefly examine
the reasonings applied to it in that supposition and the conclusions to which they
led.
The Judicial Committee of the House of Lords in that judgment in Waring c.
Waring, which was the leading precedent up to the time of the judgment in Banks
'0. Goodfellow had declared that the mind being one and indivisible it was im-
proper to speak of the delusions of monomania as affecting part of the mind. The
Court of Queen’s Bench on the contrary declared that the mind like the body being
composed of a number of separate and distinct organs and faculties, any one of
which might be and often was affected Separately and exclusively, it was correct
to Speak of some cases of insanity as affections of part of the mind. And here I
must observe that all these great authorities speak of the mind as if it were some
distinct entity, whereas the only exact and correct way, is to speak of a man’s
mind as the whole mental quality of each individual man. Now I venture to assert
that a man’s mind, my mind for instance or your President’s mind, is not a bundle
of distinct faculties, but that it is the whole mental activity of each man, his whole
Sensory and cerebral activity inherited and acquired, and that if we examine any
mental activity which may on slight consideration seem distinct, we shall ﬁnd it
really involves the activity of a man’s whole mind. Let us not despise these
metaphysical or more strictly speaking psychological questions, for in medico-
legal questions relating to insanity they cannot be easily evaded, for the lawyers’
inquiries are always how a man thinks and desires to act, and not how it happens
that bodily conditions inﬂuence his thoughts. It is our experience as bearing upon
beliefs as they inﬂuence action, and not our physiology as bearing upon mental
activities that is So useful in the great administration of the law.
But what is a delusion? The Court of Queen’s Bench either used language very
carelessly or it considered a delusion to be a faculty of the mind, seeing that it
spoke in this judgment of “ delusions and other faculties of the mint .” Without
stopping to refute this curious notion we may remark that a delusion being a false
belief caused by mental disease implies the activity of a man’s whole mind as much
as any true belief implies such activity. If I were to believe that this room was
full of skeletons I should have to construct almost as complex an idea as I have
to construct in believing it to be ﬁlled with living men. Therefore a deluded man
is not insane in part of his mind, and the French law which permits the Courts in
that country to invalidate part of a man’s will because it may Seem to be made by
the insane part of his mind, and to establish the remaining part of the will as if
it were dictated by the sane portion of mind is only carrying out to the extreme
the principle of our own Courts. This at length is the root of the whole question
or rather the tap root for there are many divergent ﬁbres. For my own part I
cannot believe that a lunatic with active and operative insane delusions can perform
any acts as a reasonable man. He may no doubt do many things which have all -
the characteristics of reasonable actions. But the quality of the actions does not
convert a lunatic who leaves a reasonable will into a reasonable testator, any more
than the success of that painter who throwing his brush at the canvas produced a
sublime effect thereby proved him to be a great artist. The more tenable theory of
the law would be that partial insanity, is the insanity of a man’s whole mind on a
particular Subject or subjects, leaving the man’s whole mind free to form reasonable
646 MENTAL DISEASES.
judgments and to be guided by healthy and right feelings and motives in other
subjects. Our experience would in exceptional instances conﬁrm this theory, but I
do not think it .would conﬁrm it to the extent it has been stretched to by our existing
law either in its application to criminal irresponsibility or to testamentary incapa-
city, for in one case to satisfy the lawyers the delusion must have been upon the sub-
ject of the crime and in the other case it must have been upon the matter of the will.
Our experience would I think lead us to declare that in the great majority of cases
active delusion upon one subject or class of subjects is sufficient proof that the man
is incapable of exercising his judgment, controlling his feelings, and directing his
conduct rightly and reasonably upon any subject, or at least that he cannot be
trusted so to do.
This view was not unknown to the Lord Chief Justice who remarked in this
judgment—“ It is said, indeed by those who insist that any degree of unsoundness
should suﬁice to take away testamentary capacity, that where insane delusion has
shown itself it is always possible, and indeed may be assumed to be probable that
a greater degree of mental unsoundness exists than has actually become manifest.
But this view, which is by no means universally admitted, is unsupported by proof,
and must be looked upon as matter of speculative opinion” (p. 570). I do not,
however think that I have derived my belief in the extension of the influence of
delusion beyond the range whence it is generally manifest from speculative opinion.
I believe that I have obtained it from the observation of facts, however, that are not
capable of such proof as the Lord Chief Justice would have demanded, facts like
weather facts which he as a seafaring man would have observed and believed, but
which he could not easily prove. But having sufficiently criticized the mistaken and
misleading arguments which constitute the grounds of the precedent upon which the
law of testamentary capacity is administered in this country, may we not be asked
whether our knowledge of the phenomena of insanity, will enable us to aﬁord any
sure guidance for those engaged in the actual practical duty of determining what
wills ought to be established and what others ought to be invalidated on account
of insane delusion? It is not for us to decide upon the amount of mental health
power or completeness which shall enable a man to make a will, for the community
might if it so thought ﬁt decide that it should be law that any and every will made
by a lunatic should be valid. l/Vhat we have to do as witnesses of special expe-
rience is to assist the Courts in determining how the facts of nature come within
the principles of reason which are, or are supposed to be the laws on this as
on other subjects.
lVe cannot do better than quote the clear principles laid down in this
judgment as to the mental power or completeness needful to testamentary capacity.
“It is essential,” says the Lord Chief Justice, “to the exercise of such a power that
the testator shall understand the nature of the act and its effects; shall understand
the nature of the property of which he is disposing; shall be able to comprehend
and appreciate the clauses to which he ought to give effect; and with a view to the
latter object that no disorder of the mind, shall poison his affections, pervert his
sense of right, or prevent the exercise of his natural faculties—that no insane
delusion shall inﬂuence his will in disposing of his property and bring about a
disposal of it, which if the mind had been sound, would not have been made” (p. 565‘).
It is clear that under this ruling if an insane delusion has any effect whatever
upon a man’s mind at the time he makes his will the testament will be invalid.
But if I understand the judgment aright it was ruled that in order to invalidate
a will by proof of delusions, it was needful to Show that the delusion was likely to
MENTAL DISEASES. 64 7
have an effect upon the will, and it was certainly argued that very pronounced
delusions might and frequently did exist without such inﬂuence.
I venture to suggest that the rule ought to have been put the other way, namely
that the proof of an insane delusion should necessarily invalidate a will unless it
were shown that the delusion was of such an exceptional and peculiar nature that
it did not and was not likely to have effected the will. This is the relation of
delusion to action which Mr. Justice Stephen has contended for, in its bearing upon
the criminal law. He mentions that in the trial of offenders a delusion having been
proved, the burden of proof should be shifted to the accuser to shew that the
delusion was not inﬂuential in the causation of the offence. And so also it should
be in the Probate Court—that if an insane delusion be proved, it should be
incumbent upon the party propounding the will to establish the fact that the
delusion could not in any way have inﬂuenced the disposition of the property,
either by_its effect upon the testator’s affections, or upon his sense of right, or by
affecting in any way the natural and healthy exercise of his mental faculties.
But are there any delusions so uninﬂuential upon conduct or rather upon the
particular conduct of will making? I think there are, and that it is our duty to
discriminate them. Hypochondriacal notions are an obvious example of delusions
which rarely aﬁect the conduct of the suﬁerers towards others, so that it might
be well maintained, that a man could make a will notwithstanding that he had
refused food, because of a delusion that he had no passage through his intestines ;
while another man who had refused food under the delusion that he was ruined
and could not pay for it, could not make a will.
Great care and caution ought to be exercised with regard to all kinds of delusions
on establishing the fact that at the time of making the will there existed such
an active state as to inﬂuence conduct. I do not intend by this to endorse what
appears to me to be somewhat of a quibble of the courts about active and latent
delusions upon which much legal ingenuity has been expended. By a latent
delusion the lawyers mean a delusion upon any subject upon which the man is
not thinking about at the moment. For instance John Banks was not always
thinking about Featherstone, and then his delusion was latent; but the mention of‘
Featherstone’s name made the delusion active and threw John Banks into violent
excitement. This is not at all the kind of latency to which I attach importance.
That mental state of which I wish to speak as the result of my observation is, that in
a certain number of cases, delusions which at one time, would clearly invalidate a will
because they would inevitably inﬂuence its provisions, become after a time so
.sluggish and imperative that they do not in any way inﬂuence conduct. So
much so is this the case in some instances that I have had to raise the question
in consultation as to cure and treatment—Is all this we have heard an existing
delusion or the mere memory of a delusion? And sometimes I am convinced
that a patient will talk from mere memory in the most deceptive way about old
delusions which have really passed. If one man can deceive by hiding delusions
which exist, another will sometimes describe delusions which are only remembered
as delusions which are existent. But the more important cases in reference to our
‘subject, are those in which old delusions have faded butinot disappeared; their
continued existence being so weakly that they are quite inoperative uponconduct.
I do not know how often a man’s mind becomes as clear and strong after an
‘attack of delusional insanity as it was before, but I am sure that there is very
often a cicatrix which it is one’s duty to distinguish from an open wound.
The Genesis of Delusions has been especially studied with accuracy and philosophic
648 MENTAL DISEASES.
insight by our French colleagues, but the Exodus of Delusions is a ﬁeld of
research which has not yet received a thorough investigation. Although in regard
to our present subject, and also in regard to other questions affecting the insane,
it is a matter of the highest importance. When however, the Exodus of Delusions
comes to be written, a fact most important in its bearing upon our subject will
have to be stated; that although the intellectual delusion may have faded, the
perverted feelings excited by the delusion, or which were concomitant with the
delusion in its active state, may remain as intense as ever. And testamentary
injustice is more likely to arise from personal antipathies founded in delusions which
have passed, than from weak and faded intellectual delusions which may still exist.
But I must conclude with the feeling that I have only opened the ﬁrst parallel
against this stronghold of error and injustice, for the probate of Wills in this
country has been transferred from learned and thoughtful judges to the decision
of juries, who are certainly not always able to appreciate the questions before
them; and the more that under bad law the Court needs the assistance of expe~
rienced and competent witnesses, the less is their aid invoked. Under the old law
when the probate of a will depended upon the simple fact of insanity, a well-in-
structed judge might not ﬁnd the satisfactory discharge of his more simple duty
too diﬁicult. But now that the probate or the rejection of a will, depends upon the
degree of insanity and the inﬂuence of delusion, so that the question before the
Court is rendered vastly more complicated, and the administration of justice
greatly more difficult, decisions as to the ownership of commons, and accounts of
property are habitually arrived at, under a precedent of laws which seems wrong
in almost every respect—wrong in fact, in argument, and in principle ; and by pro-
cedure which the constant occurrence of compromise and settlement out of Court
indicates as precarious and untrusted. Instead of being settled by judges, such
as Sir John Nichol who brought great learning, philosophical habits of thought
and intimate acquaintance with the subject to bear upon his decisions, the probate of’
wills is now left to what is called the common sense of juries which in recondite ques-
tions too often means common ignorance; and these juries are led by a bar of extra»
ordinary technical skill and power—skill and power, that is, in the art of leading such
juries. One cannot read any of the great judgments in lunacy without perceiving
how recondite the questions and matters involved must be. One cannot witness an
actual lunacy trial before a jury without perceiving the low level to which all argu-
ments are purposelybrought, and a low traj ectory—a great merit in a rifle—is scarcely
such in an argument. It would be social treason to doubt the competency of our own
jury system to the decision of any question which can be litigated, but Lord Chief
Justice Cockburn seems to have perceived that such a doubt might arise, since he
gave himself the trouble of answering it. “ Such an inquiry, [whether delusion
has not affected the general faculties of the mind], may involve, it is true, con-
siderable difficulty, and require much nicety of discrimination, but we see no reason
to think that it is beyond the power of judicial investigation and decision, or may
not be disposed of by a jury directed and guided by a judge.” The Judge of the
Probate Court enjoys the very highest reputation for all the qualities which make
a judge illustrious, but he administers a different law to that which was admini~
stercd by his immediate predecessor, Lord Penzance, and he was himself one of the-
legislators who made that law by the judgment in Banks '0. Goodfellow. More:
over from time to time he must feel that juries will not allow themselves to be
directed and guided by a judge, in the application of a precedent, which opens the‘
door to various considerations which the stricter rule of the superseded law did not
MENTAL DISEASES. 649
admit. I think the ﬁrst thing which drew my attention to those matters was hearing
the President charge a jury against a will, which was certainly made by a lunatic,
which the jury well established against the evidence, and notwithstandingthe charge.
Perhaps there is no Court in which the aid of science and experience is more
needed than in the Probate Court, probably there is no Court in which they are
less invoked. Compromises and the rule of thumb prevail.
DISCUSSION.
Dr. MACDONALD, New York: stated that much diﬂiculty of the same kind had
arisen in the United States : he related an interesting case, where a Frenchman, under
the inﬂuence of a belief in metempsychosis made a will in favour of animals, which was
sustained, on the ground that metempsychosis was a religious system, and not a delusion.
Dr. MAUDSLEY, London: expressed his surprise at hearing Dr. Bucknill maintain that
a person suffering from monomania should be debarred from making a valid will. The Lord
Chief Justice, in his ruling, only followed in the lines of certain decisions given by one or
two of the leading American judges; and it had always seemed to himself that a genuine
advance had been made in that case. If the will were such an one as a perfectly sane
man would have made, surely it should not be upset because of some delusion.
Dr. WOOD, London: agreed with Dr. Maudsley, remarking that there were many persons
in private asylums who were perfectly capable of making wills.
Dr. ORANGE, Broadmoor: believed that the main advantage of the Lord Chief Justice’s
decision was that it took the question out of a groove, would cause each case to be dealt
with on its own merits, and would necessitate the advice of skilled experts.
Dr. BUCKNILL, in reply, said, that, as to whether a will was a proof of insanity, Lord
Penzance had declared that a will could scarcely be conceived which would carry in itself
the proof that it was not written by a lunatic. The dispostions of a will might be so
reasonable as to afford evidence that it was a reasonable will, but as in cases reported
this might be unreliable. The particular will in question clearly carried in itself no
proof of reason. It was an unnecessary will. It left the property to the heir. With
respect to what had been commented on as to the capacity of patients in asylums to
make‘ wills, he for one was not at all disposed to dispute it. Not long ago he was called
to see a patient in a private asylum for the purpose of making an aﬁidavit for an
inquisition. He found the patient quite well. The patient said he wished to make a will,
and be, Dr. Bucknill, saw no reason why he should not do so, and he expressed that
opinion. He understood that, not long afterwards, the patient was taken out of the
asylum to the oﬁice of the family solicitor; that every precaution was taken to ascertain
his sanity at the time, and the patient made a will that same day. He believed there
‘were many patients in asylums who were competent to make wills. On the other hand
he thought there were many persons outside of asylums who were not competent to
make wills. He had little more to say except that he much regretted that no notice had
been taken of that which he had considered as a most important point in his paper—via,
the part wherein he fully expressed his opinion, which he was afraid was not quite under-
stood, that in certain cases of restricted delusions wills might be made, only it ought to
be shown that those delusions had no inﬂuence upon the will, and the burden of proof
ought to be thrown upon the persons who wished to establish the will. He also wished
that a discussion had arisen upon the point that a delusion which might, in an active
state, have very likely caused such a condition of mind as to render the deluded person.
incompetent to make a will, might become, after a time, so mitigated that the delusion
would be quite inoperative, not affecting his conduct in any way.
6 50 MENTAL DISEASES.
Tneatrnent 0f t/ze Pnoa’ronzat Stages of Insanity.
Dr. OTTO MI'JLLER, Blankenburg am Harz.
Dr. O'r'ro MULLER delivered ,an address upon the “Treatment of the Prodroinal
Stages of Insanity,” of which the following are the heads :—
1.—Die Psychiatric hat die klinische Behandlung der Prodromalstadien der Psycho-
pathien als das Object ihrer Thatigkeit anzustreben, und darf nicht, wie bisher, nur die
entwickelten Psychosen in Austalten behandeln.
2.-—Sowohl wissenschaftlich als practisch ist die innige Vercinigung der Psychiatric
und Neuropathologic anzustrebcn, der Isolirung der Psychiatric dadurch entgegen zu
arbeiten, und ihr ihre voile segensreiche Thatigkeit zu sicheren.
3.-—Es ist die psychiatrische Bildung des praetischen Arztes und die Begriindung
oifener Curanstalten fiir die Prodromalstadien ein dringendes Bediirfniss der Gegenwart
The following papers and abstracts, owing either to want of time or the absence
of their authors, had to be taken as read. They are placed in the alphabetical order
of the writers’ names.
On t/ze Rate-Retatz'onsnafs of Gena/at Paralysis.
Dr. ASHE, Dublin.
If one of the medical staff of an English asylum were to visit an asylum in Ireland
there is probably no feature which would strike him as being in more marked contrast
with those familiar to him in England than the absence of general paralysis among the
inmates. -
Accustomed to see from 3 to 12 per cent. of his inmates suffering from this
disease, and to recognize its presence in perhaps 10 per cent. of his admissions, or
sometimes even more, while of his deaths, '20, 30, 4.0 per eent., or even more, are due
to this cause, he may absolutely examine one asylum after another in Ireland without
ﬁnding a single case of it.
The late Dr. Robert Stewart, for forty years physician-superintendent of the Belfast
asylum, for that town and the county of Antrim, informed me that during that period
he had not seen a single case of the disease. His successor, Dr. Merrick, has a similar
experience. In 1875 in answer to some inquiries of mine on this subject, he wrote,
“ We have no case of general paralysis in the Belfast asylum at present.” In answer
to the questions now proposed by the committee of this section, and referring to the
answer he then gave, he writes, “I have had no case since.” This asylum has an
average of 440 inmates drawn alike from the agricultural population of the county
Antrim, and the largely manufacturing population of the towns of Belfast, Lisburn, &c.,
the former having a population of about ‘200,000. "
The Cork asylum contains about 800 inmates, drawn like that of Belfast from a
large agricultural population, and a town population of about 100,000. In 1875, Dr.
Atkins then assistant-physician writes, “ one spurious case at present in the asylum.” At
the same date, Dr. McCabe, then physician-superintendent of the central criminal asylum
at D'undrum, near Dublin, writes, “ I regret that there are no materials here; I have
not had“ a case of general paralysis since I took charge, three years ago." This
asylum, containing on the average 180 inmates, has now been for over ﬁve years under
my charge, and in all that time I have had but one case of the disease, a very well
MENTAL DISEASES. 6 5 it
marked case occurring in a male; there is, however, another case in a female which I
regard as one of arrested general paralysis, exhibiting the optimism, the fat condition of
body, heavy face, occasional outbursts of violence, and, now and then, a slight tripping
of the tongue, not perhaps to be recognized by an ordinary observer; but for ﬁve years
this case has made no progress.
During three years that I was superintendent of the Londonderry asylum with 250
inmates, I had but two cases, both well marked and typical, and both males.
It has even been hinted that in Ireland we do not know the disease when we see it.
That this charitable view is not correct, may be shewn by the extract from a letter
from Dr. Petit, superintendent of the Donegal county asylum at Letterkenny, con-
taining about 300 inmates, drawn from an agricultural and sea-board population; he
writes in reply to the queries of this section. “ Since I took charge of this asylum, I
have not had a case of general paralysis, that takes in a period of six years; while
assistant in Richmond asylum, Dublin, I was quite familiar with the symptoms of the
disease.”
The Richmond is the largest asylum in Ireland, containing over 1,000 inmates,
drawn from Dublin and its suburbs, and the towns of Dundalk and Drogheda, giving a
town population of about 320,000, and from the otherwise almost pure agricultural
counties of Dublin, Wicklow, and Louth. Dr. Lalor’s annual returns shew also that
this asylum presents the disease in a proportion quite exceptional for Ireland, the
number of cases treated for it during each year averaging from 2 to 3 per cent. of the
number of male inmates, usually between 4:00 and 500. The cases occurring among
the female inmates, however, are often nil, and do not appear ever to reach so high as
'2 per cent. on an average of over 500 females.
It will also sometimes happen that an Irish asylum will exhibit a number of cases
much in excess of what will at other times be found in it. Thus the Cork asylum of
800 inmates, reported free from the disease by Dr. Atkins in 1875, is now reported by
Dr. Eames as having ﬁve cases, all males, or about 1% per cent. on the male,
inmates. In Omagh, out of 300 male patients there are two general paralytics.
In Clonmel, out of 200 males, Dr. Garner reports one case only. In Killarney
Dr. Woods, who, as having been assistant in an English asylum, must be fully
acquainted with the disease, reports one doubtful case out of 186 male patients.
In Limerick, with 235 male inmates, Dr. Courtenay, who is similarly qualiﬁed by
English experience, reports no cases. Nor has Dr. Daxon any at Ennis, out of 135
males, but he says one died in J annary last. Thus the disease is known, indeed, and
its recognition unquestionable on its being seen, but its occurrence is rare to an extreme
degree as contrasted with what is known in asylums in England, \Vales, or Scotland, at
least in its large town populations. The question whether it is to the predominance of
Celtic blood that Ireland owes its immunity is one of much interest, and that not of a
theoretical or speculative character only; for undoubtedly the determination of the
cause of so well marked an immunity as this must approach very nearly to a determi-
nation of the cause of the disease where it is commonly prevalent, and the bearing of
this on preventive measures, and curative treatment, is at once obvious. '
In investigating this question, it is necessary to guard against an error regarding
the inhabitants of Ireland which is only too prevalent in England, that, namely, of
ignoring any community of race and blood between the two countries, and regarding
those who live west of St. George’s Channel as being Celts, pure and simple, and without
any substantial exception. That all who have been born and live in Ireland are pro
z‘cmto Irishmen, is a proposition hardly to be denied. That all Irishmen are Celts, is a
proposition universally maintained in England, but widely at variance with actual fact.
As well might it be asserted that the Irish population of Liverpool have, by virtue of
their residence in that town, become Saxon. The blood of the Saxon invaders of
Henry II’s time, has, indeed, become thoroughly mingled with that of the Celtic
aborigines, so that the race elements can no longer be differentiated; but the settlers of
the reign of Elizabeth, the Ulster plantation colonists of James, the Scotch lowland
6 5 2 MENTAL DISEASES.
occupants of the same province, and the Cromwellian settlers, appear, owing to
the combined antagonisms of race and religion, to have refrained almost entirely from
intermarriage with the Celtic Irish, and are to this day readily distinguishable, not only
by the obvious test of religious denomination, but even by their type of face and-
physiognomy. I am, I think, correct, in regarding the lowland Scotch as being in the
main Saxon. Certainly this is the view taken by Sir Walter Scott, than whom there
could be no higher authority, where he makes the Highland chieftain, Roderick Dhu,
address James V. as a Saxon, and speak of the Lowlanders as his own foemen and of
that race.
“Now, gallant Saxon, hold thine own.”
And again,
“ No, by my faith, while on yon plain
The Saxon rears one shock of grain.”
The English, again, are spoken of by Fitzjames as Normans. Hence, I think it is
to be considered that the Lowland Scotch element so widely distributed over Ulster,
and which is quite recognizable by its adherence to the national creed of Scotland, is a
Saxon element of population, of blood perhaps as pure as the English element
undoubtedly is. Hence I think we must hold that, in the counties of Antrim and
Down, where the population is about one-fourth Catholic, and three-fourths belonging
to some denomination of Protestantism, we have, in fact, a much larger Saxon element
than is to be found in Wales, Cornwall, or the highlands of Scotland: In the other
counties of Ulster the proportion of Saxon and Celt will probably be about equal. In
the province of Leinster the proportions will probably be reversed; while those of
Connaught and Munster may be regarded as being, to all practical interests and
purposes, purely Celtic.
Examining in view of these considerations, the statistics with which we have been
furnished, we ﬁnd, contrary to what might have been expected, that it is actually in
the most thoroughly Saxon districts of Ireland, that the immunity from general
paralysis is most strongly marked; that is to say, in the county of Antrim, for it was ‘
in the Asylum of this district, that of Belfast, namely, that Dr. Stewart, as above ‘
mentioned, found a complete immunity from the disease, during a 410 years’ tenure of
oﬁice, and that his experience has now been conﬁrmed by his successor, Dr. Merrick,
during six years thereafter. And this is the more noticeable in view of the well-known
proclivity to the disease presented by a town population so large as that of Belfast, and
200,000, and one moreover much engaged in manufacturing and marine occupations.
On the other hand it is in the Richmond Asylum, where fully four-ﬁfths of the
inmates are of Celtic blood, that general paralysis has, as regards Ireland, its especial
home. Small as are the numbers affected with this disease in the Richmond as com—
pared with those to be found in an English Asylum, it is yet to be borne in mind
that, as regards Ireland, they exceed the average in‘\ the proportion of about 6 to 1.
This is arrived at by comparing the numbers returned as affected with the disease in
the different asylums; for of the numbers dying from it in any year,.I have no
account, even from the Richmond; nor do the Tables of the Irish Inspectors contain
any head for this disease; neither does their Annual Blue Book refer or allude to it.
As regards my own undoubtedly rather limited number of cases, in Londonderry
Asylum, where the population was about half of Saxon, and half of Celtic blood, I had
one case of each during three years. In my present Asylum, the State Asylum of
Ireland, where the proportion of races, drawn from the whole of Ireland, is about 85
per cent. of Celtic blood, and 15 of Saxon, both my cases have been Celtic.
Let us turn now to the consideration of other parts of the United Kingdom, in.
which Celtic blood is known to predominate. Monmouthshire, though an English
county, is largely inhabited by people of Celtic race, while Brecon and Radnor are
Welsh; the Superintendent of the Joint Counties Asylum at Abergavenny, however,
states that the races are so intermixed that it is impossible to assign the proportion of
each. However, out of 283 male inmates, he returns 18 as affected with general
MENTAL DISEASES. 65 3
paralysis at the present time, and 5 females out of 270. That is to say, about 6'3 per
cent. of the male patients, and about 2 per cent. of the females. The Commissioners’
Report of 1875, gives 21 per cent. of male and female deaths together as due to this
disease. In yiew of this return I think it must be admitted that Celtic blood has not
done much towards protecting the people of these three counties from the disease.
Turning next to Glamorgan, the superintendent, like many others to whom appli-
cation was made, found himself unable, from press of work, to ﬁll up the returns sent
by the Section; but on examination of a couple of the Annual Reports of the Asylum,
we ﬁnd—First, that he regards his population as essentially Celtic. Secondly, that of
new cases admitted in the year 1879, 10 per cent. of the males were suffering from
general paralysis; no females; and in the year 1880, 7 per cent. of the male cases
admitted, and 1 female out of 61 admissions were thus affected. Thirdly, that, in
1880, 9 per cent. of male, and 13 per cent. of female deaths were due to this disease.
In 187 9, 15 and 7 per cent. respectively, and in 187 8, as stated in the Report of the
Commissioners in Lunacy, the deaths from it numbered 13 cases, or 18 per cent. on the
total number of inmates. If, as is usually the case, the greater number of these
deaths occurred on the male side, they will represent a mortality from the disease equal,
perhaps, to the average of English Asylums. Again I think we must conclude that
Celtic blood has not afforded much exemption to Glamorganshire.
The Statistical Tables of the Carmarthen Asylum are very peculiar, and, as in the
ase of Glamorganshire, I have been obliged to depend on them only for information.
I presume we may consider the population to be practically entirely Celtic. From the
Annual Reports of some years back, we gather that of male cases admitted, 4. per cent.
in 1880, 10 per cent. in 1879, 3 per cent. in 1878, and 10 per cent. in 1877, and 12 per
cent. in 1876, were found to be affected with the disease; and of female admissions
there were 3, 5'5, and 3 per cent. similarly affected in the years 187 7, 1878, and
187 9, respectively.
As regards deaths, it appears that 10 per cent. of all deaths in 187 41, 8 per cent. of
male deaths in 1877 , and 10 per cent. in 1880, were due to it. This proportion is
almost exactly that of the State Asylum at Broadmoor, which, as drawing its popula—
tion from the entire of England and Wales, may perhaps be taken as representing the
average percentage of the kingdom.
The Welsh county of Montgomery sends its insane to the Asylum of the English
county of Shropshire, and, as the Statistics are not afterwards kept separate, it is
impossible to make any reference to the condition of this county as regards the subject
of this Report.
There is not, perhaps, in the three kingdoms any Asylum which draws its inmates
from a more purely Celtic population than that of Denbigh, its district comprising the
counties of Denbigh, Carnarvon, Anglesea, Flint and Merioneth. The Commissioners
report, in 1875, the deaths from the disease to have been over 25 per cent. of the total
male deaths, and 11 per cent. of the total female deaths. In view of the statistics
above presented, I think we are forced to the conclusion that, at least as regards the
Cymric division of the Celtic race, there is no exemption whatever from the ravages of
this disease.
In the county of Cornwall there is, as- is well known, a great preponderance of
Celtic blood among the lower orders of the population; the exact proportion I am
unable t9 estimate, no return having been made in reply to the circular sent out by
the section. The reports of the Lunacy Commissioners are, therefore, the sole basis of
information regarding the statistics of general paralysis in this country. We ﬁnd that,
in 1875, 10 per cent. of the total male deaths, and 4! per cent. of the total female, were
due to it.
In 187 6, the ﬁgures were 7 per cent. of the total mortality, that is without
distinguishing the mortality of the sexes.
That is without distinguishing the mortality of the sexes.
In 187 7, 16 per cent. of the total.
654 MENTAL DISEASES.
In 1.87 8, the Commissioners do not specify the numbers.
In 1879, 14. per cent. of the males, and 5 per cent. of the females. There is here
no ground for alleging that Celtic blood in Cornwall affords any exemption, any more
than in Wales. Coming next to Scotland, the statistical tables of the Scotch Commis-
sioners’ Reports afford valuable information, as being based on the aggregate averages of
many years. Their tables, however, refer only to Royal and district asylums, and do
not include the statistics of parochial asylums or workhouses. Assuming that the view
propounded above is correct that the southern counties of Scotland are essentially of
Saxon blood, and the northern essentially of Celtic, it is difficult to come to the conclusion,
from an examination of these Scotch tables, that race or blood, as such, has anything
whatever to say to the prevalence of this disease, though it may, perhaps, in some
degree, be inﬂuenced by differences in the nature of the occupations or general character
ofxthe died of the two races. Beginning with the lowest rate of mortality given in the
tables, and proceeding to the highest, we ﬁnd that the proportion of deaths from
general paralysis on the total mortality was, in—
MALES FEMALES
Inverness 6'4: 0'6
Elgin 6'6 2'9
Perth district 7'6 3.3
Roxburgh 8'6 —
Haddington 8'8 6'6
Perth Royal 11'1 1'7
Dumfries 13'1 ‘3'3
Montrosc 13'1 4K3
Midlothian 14'?) -—
Argyll 16'2 ... 2'0
Fife 16'8 0'9
Stirling 19.8 7'7
Glasgow 20'0 4'8
Banﬁ' 20'0 6'8
Ayr 22'1 —
Aberdeen 25'2 8.7
Edinburgh 25'3 7'0
Dundee 288 7'0
The general average for Scotland being 18'7 and 4'7, here we ﬁnd that Haddington
and Roxburgh, which are southern and Saxon counties, have a mortality from general
paralysis amounting to about half that of Argyll, which is almost purely Celtic, and less
than one—third of that of Aberdeen and Forfarshire, which are doubtless strongly Celtic
also. ‘
The replies furnished by Dr. Cameron, of the Argyll Asylum, to the question
proposed by the Section. show that, though about 80 per cent. of the population are
engaged in agriculture and ﬁshing, and only a very small percentage in manufactures,
yet of 3 cases of general paralysis at present in the Asylum, this small proportlon contri-
butes 2, while only 1 is furnished by the agricultural contingent. Yet Ayrshire, with,
I think, a purely agricultural population, is not far from the head of the list, at least, as
regards male cases, with 22 per cent. of its total mortality due to general paralysis.
The disparity between the large percentage of this county, and the total absence of the
disease just across the channel in Antrim, with a population no less Saxon, and much
more largely engcved in manufactures, and with such a town as Belfast in its midst,
is certainly a very remarkable phenomenon and shows, I think, that we must look
somewhere altogether beyond either race or occupation for the true causation of the
disease, and the true account of its absence in Ireland.
It has recently been suggested, as is well known, that a syphilised constitution is the
MENTAL DISEASES. 6 5 5
true cause of the development of nervous disease into general paralysis; and certainly
the country population of Ireland is remarkably free from this disease; but yet, against
any general acceptance of this fact as accounting for the absence of this type of insanity
in Ireland, the singular town of Belfast would seem to bar the way, for it cannot be
supposed that a town of such a size, largely devoted to manufacturing and marine
occupations, would present any such immunity from syphilis as would be required to
maintain such a view, especially if contrasted with the agricultural population of
Ayrshire just on the opposite coast.
The view has also been upheld that the immoderate use of alcohol, in one shape or
other, is the cause of general paralysis; but it is well known that the Irish are not
an ahstemious people, as this theory would undoubtedly require that we should ﬁnd
them. The inhabitants of Belfast and Antrim drink as much as do those of Ayrshire
and Glasgow, and moreover use the same form of intoxicating liquor. Indeed, the
north-east counties of Ireland are much given to a still more rapid and pernicious mode
of intoxication in the shape of ether-drinking, yet, general paralysis does not make its
appearance, as on this theory it ought to do.
It would appear, therefore, that a careful examination of the statistics at our com-
mand eliminates from the causation of general paralysis the elements of race, syphilis,
or venereal excess, and alcohol. To none of these elements can we point and say, this
is different in Ireland, and therefore the disease is absent. There remains the question
of diet. And here we at once ﬁnd a marked difference of a national character. The
potato in Ireland replaces the cereal food of England and the lowlands of Scotland.
England eats Wheaten bread; Scotland oaten; Ireland eats the potatp. The question
whether this can have anything to say to the exemption of Ireland from general
paralysis is certainly worth experimental investigation.
It is well known that‘m‘e'l’én'iéntof diet has a more potent inﬂuence in the pre—
vention of sea-scurvy than the potato. I have also observed, in the Londonderry
Asylum, that just at the season of the year when the old potatoes can no longer be
used, and the new ones have not yet come in, a sudden and marked fall in the vigour
and vitality of the feebler patients. Those who were maintained in fairly average,
though feeble, health then sank into an utterly prostrate condition and died. Observing
this for two years in succession I afterwards kept potatoes specially for such cases, and,
if at all practicable, never allowed the house to go on a wholly cereal diet, issuing
potatoes three times a week even at their worst period, and since I have done so I
have not observed the peculiar sinking of vitality at the period of the year referred to.
It seems highly probable- that the cereal diet of England and Scotland is a potent
element in the energy and cerebral activity of the Saxon race as compared with the
listlessness and indolence of the Celtic. But it would appear to be well borne out by
the observations of English alienists that it is just the man of most energy and cerebral
activity who is the most exposed to the invasion of general paralysis. It might be
worth while to make experiments on the use of the potato, fresh vegetables, vegetable
acids, with comparative abstinence from cereals, or a too largely nitrogenous diet, in
the treatment of general paralysis in its early stages.
The Section have made inquiries regarding epilepsy in relation to race as well as regar-
ding general paralysis. N 0 reports or tables that I have seen appear to imply that there
is any difference between the two races, or between the dwellers on the two sides of St.
George’s Channel in respect of this disease. The proportion of epileptics to the total
number of inmates varies in Irish asylums from 2 per cent. to 16 per cent. ; and the
average of the whole of Ireland is 6 to 5 per cent. of males, and a fraction less of females.
This is as regards males almost exactly the same as at Broadmoor which perhaps may be
taken as presenting an average of the whole of England and Wales. The Broadmoor
percentage of females is however only 2'6. The English reports and commissioners’
tables give the statistics of epilepsy only as a cause of death, not, in general, as aﬂ'ecting
such or such a number of inmates. In exceptional cases, however, we ﬁnd 12 per cent.
of the total number of inmates spoken of as a very high proportion, and probably the

6 5 6 a - MENTAL DISEASES.
average of England and Wales would be found to be not very different from that o '
Ireland.
m
A Paper on “ The Chemical Investigation of the Urine and Blood of the Insane”
was read by Dr. A. WYNTER BLYTH, London.
Psyeizoplzysz'eal Researches 0% Me Rapz'a’z'z‘y 0f Perception
in Z/ze [meme
Dr. BUCCOLA, Reggio (presented by Professor Tamburini).
Obersteiner parait être le seul qui se soit occupé de ce problème. Voici les ré-
sultats des nombreuses expériences que j’ai faites dans l’asile de Reggie avec le chrono-
scope de Hepp sur des malades de toutes les principales variétés d’aliénation mentale.
Chez les idiots, j’ai pu trouver, avec beaucoup de difficulté, que le temps moyen de
réaction aux excitations acoustiques et tactiles est prolongé ; et que la différence entre
les plus hauts et les plus bas chiffres dépasse de beaucoup celle de l’état physiologique.
Chez les aliénés, il y a aussi un retard dans le temps physiologique; retard qui est
d’autant plus marqué, que les malades sont plus affaiblis 5 et la différence entre les cas
extrêmes est plus grande aussi. \
Dans l’exaltation simple, la période de réaction est assez régulière, et s’approche de
la normale; quelquefois même elle ne s’en écarte point. Mais dans ces cas, si le malade est
très-distrait, on obtient des chiffres bien hauts. '
Dans la lypémanie, la période physiologique moyenne est toujours élevée; et ceci pro-
vient de la préoccupation du malade par les idées tristes, qui l’empêcuent de réagir promp-
tement, car, lorsque l’on parvient à ﬁxer son attention, les temps de réaction s’appro—
chent davantage du normal. Les chiffres les plus élevés m’ont été fournis par un cas
de lypémanie suicide.
Dans l’épilepsie simple, la pèriode de réaction est a peu près normale et régulière;
‘mais, lorsque les attaques durent depuis quelque temps et se répètent fréquemment, les
phénomènes se rapprochent de ceux présentés par la folie. Quelques heures après une
attaque, le temps de réaction moyen est accru, et la différence entre les maximum et
minimum est augmentée.
0% Accz'a’wzz‘ally Induced Hypnoz‘z'sm.
Dr. J. MORTIMER GRANVILLE, London.
The point the author is desirous of bringing forward is the following: The several
centres, or congeries of centres, composing the nervous system, are doubtless liable to be
thrown out of their natural relations, while retaining their respective activities. This is
well known; but I think we do not adequately recognize the facility with which this
breaking of the normal relation may be brought about by means of excitants, acting
continuously on some one special centre when the others are quiescent. I venture to
suggest that, just as light may be polarized, so mind, in certain conditions, is liable to be
“ polarized ”--as light may be disintegrated in the spectrum, mind may be disorganized;
and this is, I think, what occurs in the “hypnotic” state. Any sensory excitant
MENTAL DISEASES. 6 5 7
may suspend the mutual relations of the nerve-centres, causing in ordinary cases nothing
beyond exhaustion, stupor—ending perhaps in sleep. Some persons, from the loose
organization of their nervous system, are specially liable to be thus disorganized; and
such a person is, in the hands of a practised believer in hypnotism, “trained,” inten-
tionally or not, to the performance of certain deﬁnite processes. In particular, when
the lower centres have been detached from their allegiance to the higher, they may fall
under complete subjection to another mind. In the course of a prolonged investigation
into the nature of sleep, I have found that there is a special liability to become hypno-
tized, when employing some of the means recommended to produce sleep. Such cases
are very common among children and the old z—FOI’ instance, when an endeavour is
.made to set children to sleep by singing to them, setting a candle before them, &c., the
state produced is not ‘true sleep, but hypnotism. So, too, I have formerly found that
a large number of insane patients, however violent, may be hypnotized by a sudden noise,
a bright light, or other means of ﬁxing the attention. The process seems to be nearly
_ that by which Rarey trained his horses. I believe there is great peril of mental disor-
ganization in all these cases, and that the peril is greatest when the hypnotic state is
induced accidentally. I believe that religious ecstasy, and, in a lesser degree, religious
“impressions” generally, are commonly accidental hypnotism, produced by ﬁxed gazing
into space, listening to a sermon, or to impressive church music, &c. In other cases I
believe epilepsy to have been thus induced.
Sm’ le Tv/az'femem‘ des Alz'c’zzc’s en V filage.
Dr. PEETERS, Gheel.
Je me propose d’insister surtout sur les rapports qui ont existé entre Gheel et les
établissements fermés; et je montrerai que l’hospitalité accordée par cette colonie aux
aliénés venant des autres asiles a été en grande partie l’origine du discrédit jeté sur elle.
J’espère prouver que le traitement familial, loin de rendre service seulement comme
‘refuge aux incurables, a une action curative remarquable. Pour résumer en quelques
mots les services rendus par Gheel il suﬁira de remarquer:
L-Que la population de Gheel s’est parfois élevée jusqu’au quart de la totalité des
aliénés en Bolgique; quelquefois elle est descendue au sixième; actuellement elle en est
le cinquième;
2.-Que le tarif d’entretien a toujours été moins élevé que celui des établissements
fermés ;
3.——Qu’il n’a jamais coûté au gouvernement que 200,000 francs qui ont été consacrés
à la construction de l’inﬁrmerie ; tous les autres agrandissements ont été payés par la
colonie.
Les établissements fermés ont largement usé de l’hospitalité que leur offrait Gheel
Dans les vingt années de 1860 à. 1880, sur un total de 5,310 admissions, 1,643—un peu
moins du tiers—sont des transferts. Il a done constamment reçu l’excédant des maisons
fermées : et cet excédant se compose presque toujours d’aliénés qui ont passé des années
à. l’asile, pour qui tout espoir est perdu. Voici quelques chiffres pour les dernières an-
nées. En 1877, les malades transférés étaient incurables dans plus de 87 pour cent ; en
187 8 pour 7 8'2 pour cent ; en 1879 le pronostic était fâcheux dans 90 pour cent. des cas.
Enﬁn en 1880 les transferts réputés incurables montaient pour les hommes a 89, et pour
les femmes à. 79 pour cent,
PART 111. U U
6 5 8 MENTAL DISEASES.
Dans ces circonstances, Gheel a donné une proportion de guérisons, qui équivaut à 2 4
pour cent des admissions. Cette proportion est notablement inférieure à celle d’autres
établissements Belges, mais en tenant compte des transferts incurables, il n’existe aucun
doute que le patronage familial ne donne des résultats aussi favorables que les maisons
fermées.
—————————
072 Exop/zZ/zalmz'c Goitre, and z'z‘s Relations Z0 Umoundmss
0f Mina’.
Dr. G. H. SAVAGE, London.
Three cases‘ of completely developed Graves’ (or Basedow’s) disease, have come into
Bethlem Hospital within the last few years. All three of these cases have been young
women, and there was evidence of hereditary insanity (in two of them in the dir e et line)
All the most recent suggestions for treatment have been tried, but without avail; two
of the patients have already died, and I fear there is little doubt the third will soon
follow. One case began, as far as was known, with exalted delusions and excitement;
the other two were originally depressed, and had melancholic delusions ; but in all there
was a tendency to impulsive violence, to refusal of food, and to dirtiness in habits : the
sexual functions seemed little or not at all affected. With these may be connected three
other cases in which some of the symptoms of Graves’ disease have been noted. In one,
an instance of recurrent mania in a lady of twenty-one, most marked exophthalmos
is present with each recurrence of excitement : this patient was most markedly beneﬁted
by hyoscyamine. In a second case, the symptoms are slowly developing ; and in a third
—a male of thirty-nine—the exophthalmos accompanies general paralysis, and his pulse
varies from 100 to 150.
———_—_——_
0% Z/ze Proposed [mZz'm/z Lunacy Law.
Professor TAh/IBURINI, Reggio-Emilia.
Un projet de loi sur les asiles publics, privés et criminels, a été récemment présenté
par le ministre de l’intérieur au parlement italien, et y sera bientôt discuté. J usqu’a
présent l’Italie n’a pas eu de loi générale pour les aliénés; une seule province, la Toscane,
en possédait une qui datait de 1838. Depuis longtemps cette loi a été réclamée par les ‘
aliénistes Italiens; et enﬁn, le ministre Cambelli en 1874, et Nicotera en 1877, ont pré-
senté des projets de loi, qui contenaient (surtout le dernier) de bonnes prévisions, mais
qui ne contenaient aucune disposition pour les aliénés criminels.
Le projet actuel a été préparé à la suite d’une commission nommée pour le préparer
dont j’ai eu l’honneur d’être membre. En voici les principales dispositions :
Asz'les publics et privés.
1.--Obligation pour chaque province d’avoir un asile pour tous les aliénés qui y seraient
présentés;
2.——-Chaque asile doit être autorisé par le ministre de l’intérieur, et placé sous la di-
rection d’un médecin, qui ait déjà, pratiqué dans un asile;
3.-Réclusion dans les asiles toujours autorisée par le pouvoir judiciaire (comme dans
la loi Toscane); en cas d’urgence, l’autorité de sûreté publique pourra, d’après avis mé-
dical, ordonner provisoirement la réclusion;
MENTAL DISEASES. ~ 6 59
{in—La réclusion ne sera considérée déﬁnitive qu’après un rapport constatant la folie,
fait par le directeur de l’asile, rapport qui doit être envoyé à. l’autorité dans la première
quinzaine;
5.—-—Après un an de réclusion et un rapport du directeur, attestant que l'inﬁrmité men-
tale est habituelle, l’im‘erdz‘ctz'on devient obligatoire.
6.—Les mêmes dispositions sont applicables aux aliénés gardés par la famille ;
7.——Pour les malades reconnus incurables et inoﬂ'ensifs, obligation aux communes de
les placer dans un asile de mendicité, ou de les conﬁer à. leurs familles ou à des personnes
qui s’en chargeraient;
8.--La surveillance de tous les asiles sera faite par le ministre, qui nommera des mé-
decins aliénistes inspecteurs, qui feront des rapports particuliers ;
9.—Asz'les pour les aliénés criminels—Ils seront établis aux frais de l’Etat. On y
placera, d’abord les criminels devenus fous pendant la durée de leur punition, sauf
les inoffensifs et tranquilles, qui pourront rester dans les prisons : aussi les accusés qui
sont reconnus dangereux après avoir été absous pour cause de folie, et les accusés qui
sont encore en jugement et qui ont besoin d’être gardés avec soin;
10.-Les criminels chez qui le tribunal (d’après la section 95' du code pénal italien)
reconnaîtra une aliénation mentale qui n’enl‘eve pas toute responsabilité, seront placés
dans des “ Case di custodia ” particulières.
l
072 #26 Comz’z'z‘z'oiz of #26 Blood 2'72 Pellagavous Imam'z‘y.
Dr. SEPPILLI.
The author’s observations were made upon ﬁfty-ﬁve patients suffering from pellagra
thirty of whom were females and twenty-ﬁve males. He conﬁned himself to estimating
the proportion of red and white oorpuscles by means of Hoyem’s apparatus, and the
amount of hæmo-globin by means of the “ chromocytometer ” of Bizzozero.
The red disks were usually diminished in number, the number of white oorpuscles
being generally unaltered. The haemo-globin was almost always deﬁcient, and sometimes
much below the normal. There is no invariable relation between the amount of haemo-
globin present, and the number of red disks.
These observations conﬁrm the belief that, whether from the action of a speciﬁc
poison or from insufficient food, notable changes occur in the blood during the course of
this disease.

Mom! Insanity.
Dr. C. H. HUGHES, St. Louis.
Moral insanity, included in the term affective insanity, exhibits functional derange-
ment in the affective rather than in the reﬂective faculties.
1.——If both are affected, then the intellectual is not primarily so, and no more than
in ordinary passion.
2.--It is to be regretted, so far, the chief objection has been by assertion that it
must be so-and-so; but we have to consider what we actually ﬁnd. It does not follow
that because these functions are united in health that they cannot be disassociated by
disease.
3.—-If the intellect is not diseased in the exercise of the emotions such as passions,
66o MENTAL DISEASES.
love, hate, 820., why may not some excess of these exist without intellectual perversion
in the cases of affective insanity as seen after blows on the head, fevers, &c.
4:.-—-Tl16 aﬁ'ective and the reﬂective functions are not directly related by development
or in decay.
5.—Normal mind is the sum of the aggregate display of cerebro-psychic functions
constituting the natural “ ego ;” abnormal mind consists of such disorder of one or more
of the cerebro-psychic functions, as causes so marked a change in the natural psychical
characteristics of the individual, whether principally involving the emotions and reasoning
powers or will, as to make an inconsistency and inharmony in the person’s character
explicable only by disease.
6.—Generally, intellectual disorders exist with the affective, such as delusions ; but it
does not follow because one symptom is absent that the disease does not exist.
7.—-—Clinically affective insanity—moral insanity—does exist. The author protests
against the metaphysical objections of the inseparable union of functions.
8.—Justiﬁcation of the term, moral insanity.
9.--The non-recognition of the disease may be disastrous to the patients from legal
points of view

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