Case 7.-Head Pain-Diplopia-Occurrence of Right Hemiplegia of short duration-Probable existence of Tumour in Brain. R. W., aged forty six, painter, admitted May 24, 1872. Ill eight weeks; was quite well before. Had a fall on his head from a height of forty feet when a baby: injured the left side of his head near the vertex, but does not seem ever to have suffered from the accident. Is apt to have rheumatic pains in the limbs, which have often been cured by medicine. Has had gonorrhoea, but no syphilis; no sore or secondaries ever. Married twenty years. Slight traces of blue line on lower gums. Heart- and lung-sounds healthy; pulse 66, regular, weak; tongue coated; bowels costive. He got ill gradually, with loss of appetite and debility; became unable to work; got giddiness and headache four or five weeks ago; about same time noticed that he saw things double. The head pain has kept him awake at night; his head feels sore at the posterior left part when he lays it on a pillow. Has double vision at present, especially of objects at some distance-a pen held about two feet from his face is seen single, but at a greater distance it soon becomes double, and the farther it is removed the more widely the images are separated. If he closes either eye he sees then only one object. The movements of the globes appear to be harmonious. Pupils of medium size, tolerably active. Has good use of all his limbs. Ordered milk Oj., pot. iod. gr. iij., ammon. carb. gr. iv., dec. cinch. 3j., ter die.

28th.-Double vision continues; four windows in the ward appear as eight. He can read a newspaper, but only by closing one eye. Discs not well defined; the large veins appear full.

June 4.-The pot. iod. has been increased to eight grains ter die since 30th ult. There is no improvement; much giddiness. Ordered strychniæ gr. th, acidi nitrici Mj., aq. 3j., ter die.

11th.-Yesterday patient was as well as usual, walking about. He said his double vision was decidedly less; he could see objects single and distinct a good way off-half the length of the ward; more distant objects appeared double. Soon after going to bed he found he could not turn to the right side, and his speech was a good deal impaired, more than it is now, though even now it is not distinct. He did not lose consciousness. Right arm and leg are paralysed, the leg most completely. Sensory power not impaired. No reflex movement on tickling sole of foot. No facial paralysis. Vision not any worse. Pulse 84, of fair force; bowels open. The strychnia was left off, a blister was applied to the left side of head, and he was ordered to have acidi sulph. dil. mx., magnes. sulph. 3 ss., aq. cass. 3j., ter die. S. diet and fish. On the 13th his temperature was 99.8°; pulse 90. 20th.-Has regained much more power in leg; complains of loss of appetite, and of sick headache.

24th. Hemiplegia disappearing; has much less diplopia; can see objects single at the whole length of the ward. 27th.-Repeat blister to left side of head.

July 4.-Can move the arm quite freely, the leg not so well, but is able to walk a little without a stick.

8th.-Left pupil oval; right lid shows slight ptosis. Face is a little drawn to right; tongue put out straight. Hydr. bichlor. gr. th, spt. chlorof. mx., tinct. opii Miij., aq. 3j.,

ter die.

15th.-Feels much better; has good use of his limbs; marked ptosis of right lid. A few days ago had no double vision when looking to right, but had when looking to left.

22nd.-Pain in head quite gone; sight very greatly improved; has quite regained the use of his limbs, but has some ptosis still. Is not able to work yet. He became an outpatient.

He was last seen September 2, when he experienced some giddiness when walking, or, on a scaffold at work, did not feel safe. There was scarcely any ptosis, but he could not see well when using both eyes.

Remarks.-The history of this patient went to negative syphilis, except the frequent recurrence of rheumatoid pains in the limbs, and the pain and soreness of the head, which were suspicious. The fall in infancy can hardly be incriminated as a cause of the disorder occurring forty-four years later. The diplopia and the ptosis are evidence of some interference with the action of the orbital nerves. As the former was present when he looked to the left, but not when he looked to the right, it seems probable that the left external rectus was more or less paralysed, the right remaining sound; yet the ptosis affected the right third nerve. The hemiplegic seizure

can scarcely have been the result of grave organic lesion of the corpus striatum, as it scarcely lasted more than a month; but the retention of consciousness makes against its being the result of an epileptic attack. In the absence of an autopsy, no satisfactory explanation can be given; but that which seems to me most probable is that a tumour (non-syphilitic) existed in the posterior part of the left cerebral hemisphere, which, acting as an irritant, produced inhibitory paralysis of the ocular nerves and of the right limbs, and giddiness. The bichloride probably lessened the quasi-inflammatory morbid action taking place around the tumour, and therewith diminished the inhibitory effect.

Case 8.-Frequent Epileptic Fits-Sequel of Rigid Extension of Fingers and Hands after one or two attacks, of Paralysis after some others.

A. Y., female, aged eighteen, seen November 7, 1872. Has had epileptic fits for two years and a quarter; has had no fits for three months now. She used to have them usually once a week-three or four in a day; the interval was never longer than three weeks. Never injured her head or hurt herself in falling. For about one hour before the attacks came on was sick and giddy, and could not hold herself up. Used to bite her tongue and foam at the mouth. Always fainted away after she recovered consciousness. On November 2, while cleaning, her right fingers and arm began to tingle; she lost her speech and the sight of her right eye for half an hour; her lips swelled, and a shock seemed to go across the top of her head, but she did not become unconscious. Ever since then her fingers and hand have been rigidly extended; her elbow and shoulder were rigid also, but recovered after a few hours. Cannot sleep at night; seems unable to close her eyes. Is otherwise well. No pain in back or head; no epilepsy in family. K. Br. gr. xxv., M.C. 3j., ter die.

November 18.-One fit occurred on the 9th, which did not affect her hands.

On the 13th she had a fit lasting one hour and a quarter, after which both hands were rigid and useless for thirty minutes, but she then regained the use of her hands.

On the 14th another fit occurred, but the hands were unaffected, and she continues to have good use of them.

25th.-Is very ill; has had five fits lately. K. Br. 3 ss., M.C. 3j., 4tis horis.

December 2.-No fits last week. The week before they occurred daily until the last two days. Hands are all right. 16th.-Lost the use of right hand on the 3rd, and did not regain it till the 13th. On the 10th she had a fit, and lost the use of arm as well as hand; both recovered on the 13th. Both discs are small, and of dull whity colour, like mortar; their surface appears slightly rough; there are no vessels on them except the large trunks. Sight perfectly good with both eyes. K. Br. 3j., M.C. 3j., ter die.; ol. morrh. 3 ij., semel die.

Remarks. This patient was an extern, and was seen only a few times by me. The epilepsy appeared to be essential. The loss of speech and of vision during what was evidently the equivalent of a paroxysm, though unattended with loss of consciousness, are interesting phenomena. Is it to be supposed that the vessels of the optic lobes and of the hypoglossal nuclei were spasmodically contracted, while those of the hemispheres were open? That would be a hardy assumption. The chief point, however, for notice is the sequela of rigid spasm of the extensor arm-muscles succeeding two of the seizures, while the previous ones had no such effect, and those of December 3 and 10 were followed by the more ordinary event of paralysis. This fact shows forcibly the affinity existing between spasm and paralysis, inasmuch as both seem to originate in the same morbid state, and throws doubt on the view that hemiplegia is the result of mere exhaustion of corpus striatum cells from the excessive discharges of nerveforce taking place in the paroxysm. I doubt very much whether there will generally be found any direct relation between the convulsive severity of the epileptic fits and the occurrence of paralysis as a sequel. My own experience is to the effect that mild paroxysms may be followed by hemiplegia, while those of greater severity have no such effect. What determines the occurrence of spasm rather then paralysis is altogether beyond our ken. The optic discs appeared to be in an atrophic condition, perhaps from previous neuritis. Case 9.-Rapid Supervention of Cerebral Disorder, probably from Hæmorrhage into Arachnoid-Hemiplegia chiefly of LegRecovery Urine altered.

J. D., aged forty-five, has been thirteen years in the police;

admitted April 6, 1872. Has never had any serious injury to head, but his legs have been hurt. Has been ill about ten days; was suddenly taken at 1.30 a.m., while walking, with a sudden sensation at the top of head, extending downwards, as if his brain was being compressed. He had very violent pains in his head all that day; the pain "took away all power of speech, and thought, and locomotion." His wife saw him two hours after he was taken ill, and says he seemed to comprehend what was said to him, but to be unable to reply, and appeared as if lost." About the following noon he recovered to some extent; was able to speak and give some account of what had happened. He was also very sick and vomited much bilious matter. He says he was sick also before he came home. Never experienced anything of the kind before. An elder brother confirmed subsequently his statement that he was not subject to fits. He never knew any of their family to have any. He had neither eaten nor drank anything that could have disagreed with him. Since his attack he has had violent pains in his head and all over him, relieved somewhat by a sinapism. He can't walk or sit up in bed without aid. Says he seems partly paralysed in the lower extremities; more in left leg than in right. Left hand and forearm for a little way up feel numb and dead. Right hand grasps a little stronger than left. Left leg is very notably paralysed; he can flex the knee a little, but is quite unable to extend the limb again when I hold the foot. The right leg he can extend powerfully against all my efforts. Face not distorted. Tongue put out straight; coated. Has difficulty in passing urine. Bowels act fairly; the sphincter does not seem paralysed. Some pain across forehead, chiefly towards right. He is apt to have pain over the right eye when he gets a bad cold. Dry bronchial râles in both backs and both upper fronts. Pulse 60, of good force. Sounds and action of heart normal. No traces of syphilis. Ext. ergotæ liquidi 3j., aq. 3j., ter die. Broth diet. Blister two inches square to right side of head.

8th. Urine highly alkaline; deposits granular and prismatic, besides oval globules; is not albuminous; effervesces strongly with nitric acid.

10th.-Has much more use of leg; can flex and extend it well, and can push against my hand, resisting it with pretty good force. He tried to walk the other day, but found his leg dragged much. Pulse 69, quiet, steady, of medium size. Right radial compressed by 360 grammes. Urine strongly alkaline; offensive; deposits phosphates. Pupils (as on the 6th) of medium size.

13th. Both optic discs appear obscured and overlaid, as it were, by some semi-opaque substance; the veins are large and dark. He walks about now fairly well with a stick. Says the left foot feels numb. Urine clear, not alkaline.

17th.-Walks now almost perfectly well; has only a little numbness and weakness in the left limbs. Discs to-day appear normal. Went out next day. The urine then was clear, acid, specific gravity 1020, not albuminous.

Remarks. The main features of this case were cerebral disorder, supervening suddenly, though not arriving, I think, at its maximum instantaneously, severe pain in the head, bilious vomiting, alkaline urine, and paralysis of the left leg of some ten days' duration. What causation can be suggested for these phenomena? The mode of onset and the symptoms are so unlike those of epilepsy that I suppose no one will consider the attack to have been of that nature. Besides, it seems certain that there was no epileptic tendency, either in the patient or in his family. Had things been otherwise, a convenient explanation of the paralysis would have been at hand, but as they stand the view of epileptic hemiplegia seems inadmissible. But that the paralysis depended on the cerebral disorder seems to me unquestionable; so that the one point to determine is in what way the encephalon was affected. The symptoms are not those of ordinary hemiplegia from clot in the substance of the brain; they can hardly be attributed to embolism, or softening, or tumour, or syphilitic deposit. Putting these aside, a moderate hæmorrhage into the cavity of the arachnoid at the convexity seems to me the most probable lesion. Such hæmorrhages are not very rare, and may be spontaneous or of traumatic origin. The history makes in favour of the former rather than of the latter. A gradual effusion of blood on the convex surface of the brain might well cause the violent pain in the head and all over him, the sense of compression of the brain, the temporary loss of the intellectual faculties and of speech, and the bilious vomiting. The latter would be produced just as in migraine. The state of the urine must also,

I conceive, be attributed to the intracranial lesion; it concurred with pretty extensive nerve paresis, and passed away together with it. It was, however, a very remarkable instance of the power of brain-shocks to induce an alteration in a nutrient (secretion) process. Not only was the reaction of the fluid rendered strongly alkaline, but the urea itself, the chief constituent, must have been decomposed,. or rendered unusually prone to decompose by this influ ence, for there was nothing to account for it in the condition of the urinary passages. It is of course a trite fact that alkalinity of the urine is often, though not always, present. in states of depressed nerve-power; but breaking up of urea is not produced by mere alkalinity, and betokens a still greater interference with the vital chemistry. The paralysis, I have little doubt, was hemiplegic, and of corpus striatum locality, although the arm was so much less affected than the leg. It depended, I believe, on the inhibitory influence of the effused blood on the nerve-centres, and not on squeezing of the brain.. In fact, this is evident, as otherwise coma must have been coexistent with the paralysis. Why the arm was so little affected it seems impossible to say. The treatment was appropriate to the view of hæmorrhage, and, whether it be held to have accelerated recovery or not, may claim to have been rational.

Case 10.-Paralysis (Hemiplegie) of Obscure Origin, probably Epileptic from Syphilis (?)-Recovery.

J. B., aged thirty-two, groom, admitted June 29, 1874. Had small-pox five years ago. Right forefinger removed two years ago on account of mischief set up by its being poisoned with verdigris. He also got erysipelas in the head, which lasted three weeks. On June 25 he was at work till 8.30 p.m., when he felt a numbing pain in the left shoulder, and in the morning was unable to move his arm. It has remained in the same condition since. He now feels a prickling sensation at timesin the front of the left forearm like pins and needles. Has nopain in the shoulder, except when he lies on it. The arm is totally powerless-falls as an inert mass when raised. The left shoulder is lowered. The line of the shoulder slopes down notably. Sensibility of left arm not at all impaired. No. tenderness in any part of spine. His mouth is slightly drawn to the right. Temperature 37.6° (99.7° Fahr.); pulse 66.

On June 28 his speech was very much impaired, and the day before he fell down, having been left awhile in a room by himself. His head is very tender and aching. Lung- and heart-sounds normal. Potass. iod. gr. x., inf. cascaril. 3j., ter die. Blister to neck.

July 1.-Right fundus hazy; veins dark and full; outline of disc perceptible, but its surface seems overlaid by some semi-opaque matter. Can walk well.

3rd.-Grasping power of left hand weak, but he can raise his arm up vertically above his head, and can flex his elbow well. His speech is normal. Chop.

On the 6th the power of the left hand was nearly, on the 9th quite, equal to that of right; he was quite well except a little giddiness when he moved about. He went out soon after.

Remarks. If it be allowed to assume the existence of syphilis in this case, of which I admit I saw no trace, the phenomena are easily explicable. The tenderness and aching of the head may be taken to signify the existence of endosteitis, or gummatous intracranial deposit, which gave rise to a nocturnal unnoticed epileptoid attack, which caused hemiplegia, which subsided in a few days, its departure being perhaps accelerated by the good effect of the iodide of potassium on the osteitis. Without the above assumption the case is very obscure, unless, indeed, some other agency (say the cause of rheumatism) can cause a train of effects like those of syphilis. I am not sure the possibility of this can be denied.

SOMETHING NEW (OR BELIEVED TO BE SO), IN DENTAL SURGERY.(a)

By WILLIAM DONALD NAPIER, M.R.C.S.E.

BESIDES many other advantages enjoyed by the Fellows of this Society, too obvious as well as too numerous to recount, it is, I cannot help thinking, especially in their favour that the rules by which their proceedings are controlled are sufficiently broad and elastic to admit of the consideration of any one of the (a) A paper read before the Medical Society of London, Nov. 16, 1874.

almost countless branches of the subject to which it owes its name. But for this latitude, on which I have especial reason to congratulate myself this evening, I should have hesitated to tender for your consideration, at any rate without a prefatory apology, a paper connected with the practice of dental surgery. The rapid advance in the practice of medicine and surgery that has been steadily and unceasingly exhibited even within the short period of our personal recollection is doubtless in some measure due to its subdivision into the component parts that are now made severally the subjects of individual study and special application, and it is a considerable encouragement to those whose immediate sphere of action is comparatively limited to one branch of the wide-spreading system that their successes are recognised and esteemed, not as isolated instances of disconnected interest, but as tending to augment the aggregate importance of medical science.

The particular case of which my paper treats I believe to be rare, but not sufficiently so to justify my bringing it under your notice on the ground of singularity. I would rather beg your patient attention to a brief narrative of the means adopted for its treatment, which I have reason to think are devised and practised for the first time; and I shall be especially gratified if it proves to be of sufficient interest to provoke the discussion that is invaluable in the elicitation of relative truth, and the elucidation of the subject on which it is brought to bear in the spirit that animates the Fellows of this Society.

In May, 1873, I was consulted by an Indian officer in the prime of life, and in the enjoyment of good general health, impaired only by a condition of teeth that gave rise to a great amount of painful nervous irritation, interfered with his power of distinct articulation, and, in addition, considerably marred his personal appearance. Extremes of heat and cold, and the -contact of sweets and acids, served to increase his discomfort, and to interfere in more than a slight degree with his enjoyment of life.

The casts which I have on the table will aid me in explaining the appearance of the mouth as it was when first presented to me, and will also be of assistance in illustrating the means I adopted for the relief of the patient; but before submitting them to your inspection, I should like to describe as accurately as I am able, in a few words, the impression produced on my mind by the abnormal condition of both the upper and lower jaw that I was called on to treat.

The teeth in both, and more markedly the six front ones, bore striking indications of deterioration by attrition, but as they failed to attain contact when the jaws were pressed together, it was plain that the loss of substance could not be attributed to their mutual action on each other. Now, although one of my objects in publishing this case is to elicit the opinions of others as to the primary cause of the condition alluded to, I may mention in passing that I am myself inclined to trace its existence to the effects of salivation by mercury, which this gentleman remembered having been subjected to, although so long ago that my inquiries did not at first recall the circumstance to his mind. Previous experience had led me to be especially careful to regard the antecedents of the malady, for I am of opinion that there are other phases of the subsequent action of mercury than those that it -ordinarily presents and that are generally recognised.

John Hunter, in his work entitled "The Natural History of the Human Teeth," published in 1788, bears testimony to the existence of the disease, which he defines as "the decay of 'the teeth by denudation," but he at the same time distinctly states it to be his opinion that it is (I am quoting his own words) “an original disease in the teeth themselves, and not dependent upon accident, way of life, constitution, or any particular management." Joseph Fox, likewise, makes mention of it, and is disposed to think that it may be induced by some solvent quality in the saliva; whilst Thomas Bell, at the same time that he confesses his own inability to assign the -effect to its true cause, condemns Fox's theory as "wholly at variance with the fact that certain teeth are more liable to it than others, as well as with the situation of its commencement, and the regularity of the direction in which its ravages :are carried on." In later works upon the treatment of the teeth, such as Mr. Tomes's, I have failed to discover any mention of this particular form of disease.

But to return to the narrative, from the direct course of which I have a little digressed, and with the purpose I have named.

In addition to the suffering consequent upon the morbid sensitiveness of the teeth, or rather what remained of them,

to which I have already made allusion, an incalculable amount of chronic discomfort was inflicted by the peculiar form which they had assumed, causing them to resemble nothing to which I can compare them but a row of upright spikes so sharp and jagged that it was useless to try even to hope that the mouth could ever accommodate itself to them as occupants; whilst, at the same time, the express stipulation made by their owner in the very first stage of my acquaintance with him-that he should under no circumstances be subjected either to the most trifling measure of pain, or to the influence of any anesthetic whatever-rendered his chance of obtaining relief extremely hazardous.

He, indeed, went so far as candidly to assure me that he would prefer to endure his present distress rather than submit to any treatment that I could not first assure him would be absolutely painless; whilst, as I have already said, his prejudice against nitrous oxide gas and chloroform was far too vivid for me to attempt to overcome it by argument.

Under ordinary conditions the case presented no remarkable complications, and the course of procedure would be simple enough. The teeth would be filed down level with the gum, and each nerve withdrawn singly, either during a state of unconsciousness artificially induced, or, if the patient's courage and endurance were equal to the demand upon it, without deprivation of the sense of touch, preparatory to their being replaced by artificial substitutes. But, fettered as I was by the compact between us that I should desist from manipulation directly my patient was conscious of a sensation of pain, I must allow that I did not anticipate the first operation with the confidence that is so valuable an auxiliary in the attainment of success, being well aware that the withdrawal of the nerve of a tooth is capable of causing-and, indeed, so long as there is vitality, never fails to cause-the most exquisite pain to the subject.

In this instance I indulged a hope that the employment of the ether-spray might render me valuable assistance, and the result did not fall short of my anticipations; but I did not resort to it until I had, on the first occasion of operating, filed the tooth that I selected for experimental treatment as deeply as I was able to do in the ordinary manner, ceasing only when my patient betrayed a sense of discomfort. The application of the spray, judiciously handled by my friend Dr. R. Lee, of whose proffered assistance I had gladly availed myself, and on subsequent occasions, when I was unable to secure his services, the employment of a piece of cotton-wool dipped in ether, and laid first on the tooth and then on the instrument, enabled me to continue the process until the nerve of the tooth, with artery, vein, etc., was exposed.

And it was at this moment that I put to the test of practice the theory that had suggested itself to my mind, as not only a possible solution of the difficulties by which I was somewhat hardly pressed, but as an enduring means of escape from the performance of an operation that has always appeared to me to be at variance with the first principles of surgical art. I mean the demolition of the nerve, which is, as you are doubtless aware, a practice of everyday occurrence, not always, I take it, justified by the circumstances of the case. Here I had cogent reasons for refraining from the attempt, but it was no new thing for me to seek for a method of evading what I believed to be false in principle and defective in use.

If a nerve with the vessels that accompany it is qualified by its nature and position to convey vitality and afford nourishment to so dense a structure as the tooth, I hold it to be a fatal mistake to remove it so long as it is performing functions that you are entirely incapable of causing to be fulfilled without its assistance. And the result never fails to make silent protest against the unmerited treatment; for the tooth, deprived of so important an adjunct as its internal supply of nutriment, eventually perishes-affording another proof, if an additional one were required, of the fact that nothing has been created in vain.

My object was to attain a safe and efficient method of preservation in lieu of the destructive system which I so cordially deprecate, and it is for the success accomplished in this particular alone that I lay claim to the title of originality.

The process I pursued was as follows:-With a delicately cut pencil of hard hickory wood dipped in nitric acid, I very gently and very deliberately cauterised the exposed portion of the nerve in each tooth successively, which, rendering the surface insensate, enabled me to perfect my task of reducing the teeth to the level of the gums with a file, without inflicting on the patient any of the pain he so much dreaded.

It then remained only to replace the ejected members with artificial substitutes, in the use of which he enjoys a complete immunity from the various inconveniences that he had suffered from when in the state I first described to you, and of which the models afford ocular evidence. I think, therefore, that I may fairly assert that in the treatment of the foregoing case, which I have described to you as accurately as I am able, I may count on having at least perfected the subjugation of two formidable obstacles that lay between me and what alone I should care to call complete success. In the first instance I overcame the difficulty- -no mean one, as it appeared to me at first sight of painless manipulation; and in the second, I was able to do what was even more gratifying to myself: to prove the possibility of evading a practice which, though universally recognised as legitimate, I have long held to be in direct opposition to the spirit of the laws that guide us, and by so doing to bring myself a step nearer to the attainment of what we all strive for in doctrine as in practice—the art to retain what is sound and to reject only what is unprofitable.

Before concluding my paper, I should like to advert for a brief moment to the topic with which I opened it-one which has been with me the subject of grave and earnest consideration. I mean the recognition of the various sections into which the great system of medicine is rightly enough divided as "parts of a whole"-branches owing their vitality to the main stem, from which they derive nutrition and support.

I have been perhaps insensibly led to the study of the subject by my experience of the impediments that are occasioned in the paths of both by the line of demarcation that is supposed, and in many cases permitted, to exist between those practising the speciality in which I am myself engaged and those who follow simple medicine or simple surgery. I do not allude to any want of harmony between the men, but to what I am not, I hope, over-bold in defining as a want of mutual professional appreciation sanctioned by the system. I myself estimate daily at greater value every minute atom of the general knowledge that furthers my utility in my special vocation, and in like degree I am tempted at times to regret the deficiency of men infinitely my superiors in mental capacity and attainments in that which would, I know, be of inestimable value to themselves.

Specialism must exist. It has been a spontaneous and, I believe, a healthy growth, consequent upon the expansion of science, the increase of population, the advancement of civilisation. All that I would argue is, not that the specialist should cease to be a specialist, but that his preliminary knowledge should be as diffuse as though a clear and distinct perception might at any moment be demanded of him of other subjects than that which he may make his prevailing study. And, as it is necessarily in his education and training that the balance must be adjusted, I hold it to be extremely advantageous that they should be conducted on as comprehensive a system as possible. I have for this reason-whether rightly or wrongly, certainly conscientiously, discountenanced what are termed "special hospitals," and I hope and believe that the day is not far distant when one roof will shelter all the various schools in which it is advisable that a young man should gain the knowledge that is to be the secret of his strength in days to come.

If each of our metropolitan hospitals were provided with a dental department, duly and fitly organised, and not, as at present, devoted principally to the study and practice of extraction only, the benefit would be incalculable, not only to the rising body of medical practitioners, but to the public. Caries of the teeth is of all diseases the most common to humanity, and all who practise the healing art should surely be capable of its treatment by remedial measures rather than by what ought to be the last resort, extraction. Among the crowd of students who throng the general hospital there are few who know with any approach to certainty where their lot in life will be cast, and it is for them to acquire, as far as possible, the instruction that will render them independent of the facilities that are afforded to the occupants of cities only.

To those gentlemen who may be summoned to practise their calling in remote counties a more thorough acquaintance with this subject would, I believe, be of greater importance than they are aware of; whilst to the many who are placed in charge of the men of the army and navy on foreign service it would be a means of increasing their income to no despicable extent, for to them alone have the civil population in many instances the opportunity of applying for assistance.

In my earnest desire to plead the cause of a science that has hardly, I think, received its due meed of attention, I have,

I fear, sir, trespassed full long on your time, but as my motives have not been wholly interested, I hope that I may be forgiven; and I would only remind those who may be induced to devote more of their time and thoughts to it, that they need hardly account that to be a wholly inglorious field for labour in which they may avow themselves to be fellow-workers with John Hunter.

ON

ALOPECIA AREATA AND TINEA TONSURANS. By TILBURY FOX, M.D., F.R.C.P.,

Physician to the Department for Skin Diseases in University College Hospital.

THE note from the pen of my excellent confrère Dr. Liveing, which appeared in your columns last week, relative to the recent discussion at the Pathological Society concerning the nature of alopecia areata, scarcely conveys a correct idea of the views which were put forth at the Society by myself and others. I therefore seek this opportunity of restating in definite terms what my opinions are regarding the nature and cause of alopecia areata and similar conditions.

Dr. Liveing remarks "that this latter disease (alopecia areata) is not directly produced by any form of parasite, I take to be as nearly as possible proved." But I go farther than this, and affirm that it is certain that alopecia areata is never so produced. At the same time I am bound to state my belief that (omitting syphilitic cases), as far as clinical evidence goes at present, all cases of circumscribed baldness are not instances of alopecia areata. It would appear from the positive statements of dermatologists that very occasional cases are met with in which circumscribed baldness results from the attack of a fungus; in fact, that there is a parasitic and a non-parasitic form of alopecia, as there is a non-parasitic and a parasitic form of sycosis. To the former, very rare in its occurrence, I apply the term "tinea decalvans," to the latter or commoner form that of "alopecia areata." The two things differ clinically, as I have elsewhere pointed out. The real question at issue is surely this: Is there only one cause of circumscribed baldness; and must it always arise from atrophy, and never from the attack of a parasite or from any other cause?

Sir William Jenner, at the Pathological Society, remarked that if the fungus was only occasionally found in alopecia areata it could not be the cause; and Dr. Liveing uses an identical argument for the same purpose. No one disputes its conclusiveness; but is not its use rather like setting up a man of straw only to knock him down again ?-since all admit that no fungus is found, or only occasionally in such minute amount as not to possess any claim to be regarded as a cause, in alopecia areata. These gentlemen quite unintentionally misrepresent such views as those which I hold, from using the terms circumscribed baldness, tinea decalvans, and alopecia areata as synonymous, and from not recognising the fact that others do not. Whilst, therefore, fully admitting that circumscribed baldness in almost all instances is non-parasitie and properly termed alopecia areata, I hold that in rare cases it may arise from a parasitic cause, and should then be termed tinea decalvans. In the latter case the signs of atrophy in the texture generally are not marked. I will not bring forward my own facts in illustration of the existence of tinea decalvans, but I will quote from a paper published two years ago by Dr. White, the Professor of Dermatology at the Harvard University, the following extract. He says, "They [the deniers of the existence of parasitic tinea decalvans] base their opinions upon their failure to find in cases recently examined any such plant as Gruby described or as Bazin and other dermatologists have figured; but inasmuch as their testimony is wholly of a negative character, how is it that they offer it as an offset to the positive observations of other and equally competent investigators? To the list of those who have been fortunate enough to see the fungus in cases of alopecia areata [he means tinea decalvans], I may add myself. In two young gentlemen, aged seventeen and twenty-four, companions, and presenting all the striking and unmistakable characteristics of the disease, all the parasitic elements were found to be abundantly present." (a) With such and similar positive evidence I cannot but hold to the opinion that there is apparently a

(a) "Vegetable Parasites, and the Diseases Caused by their Growth upon Man," by J. C. White, M.D. Boston, 1872.

circumscribed form of baldness which is parasitic in origin. All that Dr. Liveing (and those who think with him) can say is, that tinea decalvans (parasitic) has never occurred in his experience. From pushing negative evidence too far, many mistakes have before now been made, as by Hebra in regard to parasitic sycosis and eczema marginatum, and by others in reference to other diseases.

There is a second matter in Dr. Liveing's communication upon which I desire to offer a few remarks. It relates to the part played by the fungus in the production of tinea tonsurans. Sir William Jenner is reported to have said that the fungus "is probably not the essence of the disease, even though it may be always present." To this Dr. Liveing gives his entire assent. It is quite true that the bodies of patients with tinea tonsurans offer a favourable nidus for the growth of the fungus, and no one could have laid more stress on this point than myself, but it is equally clear that nothing but the growth within and about them can produce the altered, dry, lustreless, swollen, opaque, brittle hairs of tinea tonsurans. These diseased hairs never occur without the fungus. I agree that "the development of the fungus is not always in proportion to changes present in the skin and hair, showing that other causes are at work," but these changes relate to the accidentals and not the essentials of the disease, and are other than the peculiar alteration in the hairs, and are dependent upon the -degree of irritation set up or the state of the health. The special hair-changes in tinea tonsurans are in direct proportion to the degree of luxuriance and amount of fungus.

The statement is made, in disproof of any active part played by the fungus in the production of the disease, "that in many cases of tinea tonsurans the comparatively healthy hair of the whole scalp loses its lustre, becomes harsh, dry, and brittle, and more opaque than in health, without the growth of fungi beyond the ringworm patches, and the same condition of hair remains for months after all parasitic growths have disappeared." If by this is meant that the changes above indicated are identical with those in the parts attacked by the parasitic growth, then I give it a distinct denial. The hair, when eczema occurs on the scalp as a complication to ringworm, or when it is frequently washed with such things as soft or strong soap, and under some other conditions, may lose its colour and lustre, and become dry and coarse, but it never alters in texture, becoming brittle, disorganised, broken off close to the scalp, and fatty, as over the ringworm patch. The microscopic characters are quite different. Hence this argument falls to the ground.

Lastly, Dr. Liveing says-"If the fungus were the essence of the disease, we should expect the malady to be less capricious in its nature," referring to the very varying degree of obstinacy which it exhibits. But this variation in duration is to be explained by the fact of the varying favourability of nidus which the fungus finds in different subjects. The fungus is always the producer of the hair disease, but in some cases is more potent in its action and more difficult to destroy, because of the more favourable conditions which exist for its development and growth.

The proof that the fungus is the essential cause of the ringworm-viz., the diseased hairs and epithelium-is to be found in the fact that these diseased hairs, etc., are never found -except in connexion with a luxuriant fungus, and the disease is then increased pari passu with the development of the fungus.

14, Harley-street, W.

CASE ILLUSTRATIVE OF THE DIFFICULTIES WHICH MAY ATTEND THE DIAGNOSIS OF TYPHUS FEVER.

By JOHN LEWTAS, M.B. Lond.,
Honorary Medical Officer, Liverpool North Dispensary.

A. H., a young man, aged twenty-two, was taken on August 13 of this year with pains in his back and chest, and with headache. During that day he followed his vocation of housepainter. On the 15th he took to bed, and when I saw him he presented no symptoms other than those of general pyrexia. On the 16th he felt so much better that he sat up for an hour. The day following, however-being the fifth of his illness, his condition was described thus: Pulse 92; temperature 104.4"; tongue coated with a thick white fur, and not quite

dry. On the front of the abdomen are six or seven pale rosecoloured semi-papular spots. Some pain felt on pressing over the right iliac fossa. Abdomen not swollen. Bowels regular. 18th. The sixth day of the disease. Pulse 96; temperature 104°. Delirious in the night. A much larger number of roseolæ visible on the abdomen and on the chest as high as the clavicles; none to be found on the flanks, back, face, or arms. Tongue dry. Bowels opened once in twenty-four hours. Temperature at eleven p.m. on this and the preceding night was 104'. Face not flushed. No abdominal gurgling or tympanites.

19th.-Seventh day of disease. Pulse 96; temperature 103-8°. Eruption to all appearance the same as yesterday. Tongue red and glazed. Complains of frontal headache. Temperature at 1 a.m. was 102.4°.

20th.-Eighth day. The trunk and arms are covered with well-marked typhus eruption, both macula and mottling being abundant. At 10 a.m. he was attacked with epistaxis, which was checked with difficulty, and not before he had lost about fourteen ounces of blood. Pulse 104. Temperature at 12 p.m. 103-8°.

21st.-Ninth day. Pulse 102; temperature 103-8°. Evening temperature the same.

22nd. Tenth day. Pulse 120; temperature 102.4° (at noon). Is "shouting deaf." Evening: Delirious and violent. 23rd.-Eleventh day. Pulse 124; temperature 104°. Seems exhausted. Maculæ and mottling of a livid purple colour, and quite unaffected by pressure.

24th.-Twelfth day. Pulse 140; temperature 104.5°. He refuses all food. Subsultus tendinum is a marked symptom. His pulse is with difficulty counted, being tremulous and feeble. About noon he was prevailed on to take some wine, and seemed to rally. However, about 5 p.m. his nurse said he seemed to "go off in a faint," and he died.

Remarks. This case is of interest as exemplifying the difficulties which may attend the diagnosis between typhus and typhoid fevers. In the above instance no clue was given to the particular nature of the disease until the fifth day, when some six or seven roseolar spots appearing on the abdomen led one to expect the development of typhoid. This, it is true, was earlier by a day or two than the usual period at which the eruption of enteric fever appears; but we can rarely in either of these fevers obtain precise dates. A pulse of 92 and a temperature of 104-4° at this (the fifth) day would be as suggestive of typhoid as of typhus. Add to which that the patient experienced pain when pressure was made over the right iliac region, and I think it will be admitted that the idea that enteric fever was imminent had the support of probability. Diarrhoea, it must be owned, had not been a symptom. Consider further the report of the following day: more of these semi-papular spots had come out, and were confined to the front of the trunk. In this connexion I quote from Dr. Buchanan, who says-" But the most essential distinction between the two eruptions is, that that of typhus comes out in one single crop, while in typhoid fresh sets of spots appear day after day.' Further, "the presence or absence of diarrhoea is not much to be relied on for distinguishing the two fevers" (Reynolds's "System of Medicine," vol. i., p. 444.) On the seventh day, also, things remained much in the same position; but on the day after the aspect of affairs was totally changed by the development of the eruption distinctive of typhus. From this point onwards to the fatal termination the case presented no features calling for remark. I may here add that there had not, so far as I could learn, been a single case of typhus fever in the neighbourhood. The man's occupation as a house-painter would, however, take him into all sorts of localities. The epistaxis occurred when all doubt as to the form of the disease had been laid aside; otherwise it again would have thrown its weight into the scale of typhoid. This is not the only doubtful case of this kind that I have seen. When resident in the Seamen's Hospital, where a considerable number of cases of typhoid and a few of typhus come under treatment, one or two of a somewhat similar kind occurred-cases which presented such a medley of symptoms that their precise diagnosis remained dubious throughout; and of these Dr. Ralfe used to say that it would be impossible to assert definitively whether they should be called typhoid or typhus fever. No post-mortem was made in this case, nor would I presume to suggest that typhoid and typhus fevers might occur together in the same individual. Analogous instances might, however, be cited of the co-existence of measles with scarlatina, of the latter with small-pox, of typhoid with cerebro-spinal meningitis, and— most pregnant fact of all-of typhus with dysentery.