canal must not be confused with the one or two minute canals, venous channels to the interior of the bone, which are not uncommonly found in the sagittal plane but a little distance in front of the cranio-pharyngeal canal.20 Breschet 38 observed a canal through the body of the sphenoid in a much deformed female fœtus, the subject of ectopia cordis and encephalocele. Fridolin has described one fœtal skull 21 in which a patent cranio-pharyngeal canal was in association with left coronal and right lambdoid synostosis, and a right hare-lip, and another 22 in which a more extensive cranial osseous defect existed. The condition of the soft parts was not known, but of course the existence of the canal would mean persistence of hypophyseal stalk though that might have been reduced even to a fibrous cord. Bitot 23 describes it as patent in a case of complicated superior median hare-lip. The combination of patent cranio-pharyngeal canal with cleft palate and hare-lip calls to mind Lichtenberg's case, where a female child born with that deformity had a bluish-red tumour, "the size of a small fist," dependent from the mouth. It was an autochthonous tumour of hypophyseal tissue. A ligature was passed round the pedicle which attached the tumour to the back of the pharynx, and on cutting through the pedicle reddish cerebro-spinal fluid escaped from the distal portion. The child died of convulsions three days later, and the pedicle was then found to pass through the sphenoid bone to the pituitary fossa where it was attached to an oval tumour of grey matter covered by pia mater. The lateral ventricles were dilated and there was a congenital defect in the heart. A happier result followed Lücke's operation in the case described by Sonnenburg 36 of a 5-days-old child. The epignathus depended from the skull base through the cleft hard and soft palate and protruded from the mouth. It was of a teratomatous nature, and Sonnenburg deprecated its being a spheno-pharyngeal hernia, and doubted if it were connected with the pituitary through a cranio-pharyngeal canal. Windle 25 has described as a variety of epignathus a somewhat similar though larger tumour associated with absence of the septum nasi. The tumour attached by a fibrous stalk which passed through the cranio-pharyngeal canal overflowed through the mouth and nasal apertures. Such examination as its decomposed state admitted proved it to be heterochthonous, and it may have been a teratoma. The further pursuit of these congenital defects leads to the varieties of anterior craniochisis. which are often but exaggerated examples of patent craniopharyngeal canal incompatible with life, and though developmentally are not clinically interesting. In normal skulls there is considerable variation in the cribriform laminæ, their length, their breadth, the depth at which they lie, and the proportion the crista galli bears to them. It is many years since Sir John Bland-Sutton 26 noted the absence of the crista galli in the chimpanzee, and Duckworth 27 states that the crista galli does not exist in the Simiida as a rule, but complete absence in man is extremely rare. It is generally associated with absence of the cribriform laminæ. Thus Fridolin 28 has described a skull in which absence of the cribriform laminæ and of the crista galli was associated with absence of the premaxillæ, the vomer, and the perpendicular plate of the ethmoid. The corresponding cerebral portion is not described, probably because it was not available. Nevertheless, variations in the cribriform laminæ are generally associated with defects in the rhinencephalon. Schmidt 29 mentions a 29 cm. fœtus which he had examined, in which he found absence of the crista galli and the horizontal plate of the ethmoid. The dura mater simply passed intact over this area, but there was so sign of an anterior perforated spot in the brain. nor of olfactory bulbs or tracts. Morell Mackenzie 30 quotes from Pressat 31 the report of a post-mortem examination on an adult who had congenital anosmia. No trace of olfactory bulbs or roots could be found but the crista galli was present, as was also the horizontal plate of the ethmoid but it was imperforate. Probably a similar condition was present in Levi's case,32 but though the bulbs and tracts were absent from the brain of a female idiot aged 3 years the skull is not described in detail. The crista galli was not absent, though the right cribriform plate was in the case described by Selenkoff 33 The depth at which the cribriform plate lies depends on the size and presence of the frontal air sinuses which, in my case of hypertelorism, had not developed at all. It is obvious that this osseous region develops in relation to the olfactory bulbs, and that the bulbs modify the bones except in such rare circumstances as Schmidt's case,29 where the intracranial connection of a frontal tumour had modified the anterior part of one cribriform lamina and cramped the development of the corresponding olfactory bulb. I have failed to find any reference to so large a horizontal ethmoidal plate as I have described in hypertelorism, and it is plain that this extraordinary develop. ment is in no way due to any anatomical peculiarities of the olfactory bulbs. There is little doubt that in its fully-developed state hypertelorism is a rare deformity, but minor manifestations of it are frequently to be observed. Of hypertelorism, as of so many abnormal or diseased conditions, a better comprehension may be obtained from the careful study of one fully-developed example than from the consideration of many of less degree. Its recognition as a particular defect will withdraw from among other cranial deformities cases which have hitherto but confused their appreciation, and its isolation will facilitate the classification of those which remain. These and other reasons referred to in my paper seem to me to justify the admission of hypertelorism as a definite variety of cranio-facial deformity. REFERENCES. 1 Thomson, J., Trans. Med. Chir. Soc. Edin., 1904, n.s., xxiii., 208. 2 Park, E. A., and Powers, G. F., "Acrocephaly and Scaphocephaly with symmetrically distributed Malformations of the Extremities," Amer. Journ. Dis. Child., Chicago, 1900, xx., 255. 3 Young, F. W., "Acrocephaly," Archiv. Pediat., New York, 1922, xxix., 629. 4 Schultz, A. H., "The Fontanella Metopica and its Remnants in an Adult Skull," Amer. Journ. Anat., Philadelphia, 1918, xxiii., 259. 5 Whitnall, S. E., The Anatomy of the Human Orbit, London, 1921, 9. • Dixon, A. F., "On Certain Markings due to Nerves and Blood-vessels upon the Cranial Vault; their Significance and the relative frequency of their Occurrence in different Races of Mankind," Journ. Anat, and Phys., London, 1904, xxxviii., 377. 7 Whitnall, S. E., op. cit., 47. 8 Macalister, A., "Notes on the Varieties and Morphology of the Human Lacrimal Bone and its Accessory Ossicles," Proc. Roy. Soc., London, 1883-4, xxxvi., 447. 9 Read, E. A., “Olfactory Apparatus in Dog, Cat, and Man,” Amer. Journ. Anat., Philadelphia, 1908, viii., 8. 10 Fawcett, E., "Notes on the Development of the Human Sphenoid," Journ. Anat. and Phys., London, 1910, xliv, 220. 11 Keith, A., Human Embryology and Morphology, London, 1921, 4th ed., 149. 12 Knox, R., "Importance of the Sphenoid Bone and its due Development in Man," The Medical Times, London, 1848, II., xviii., 190. 13 Macklin, C. C., "The Skull of a Human Foetus of 40 mm.," Amer. Journ. Anat., Philadelphia, 1916, xiv., 317. 14 Fridolin, J., "Ueber abnorme Schädel,” Virchow Archiv., Berlin, 1890, Cxxii., 528. *15 Maggi, L., "Il canale cranio-faringeo negli antropoidi," Arch. per l'Antrop. ed. Etnol., 1891, xxi. *16 Waldeyer, W., "Bemerkungen über Gruben, Kanäle und einige andere Besonderheiten am Körper des Grundbeins (Os basilare)," Internationale Monatsschr. f. Anat. u. Physiol., Leipzig, 1904, xxi. 17 Haberfeld, W., "Zur Pathologie des Canalis cranio-pharyngeus," Frankfurter Zeitschr. f. Pathologie, Wiesbaden, 1910, iv., 96. #18 Landzert, "Ueber den Canalis cranio-pharyngeus am Schädel Neugeborenen," Petersburg med. Zeitschr., 1868, xiv., 133. 19 Le Double, A. F., "Le canal cranio-pharyngien, hypophysaire ou pituitaire de l'homme," Bull. et Mém. de la Soc. d'Anthropol. de Paris, 1903, 5o sér., iv., 82. Lawrence, T. W. P., "The Position of the Optic Commissure," Journ. Anat. and Phys., London, 1894, xxviii. (Proc. Anat. Soc., xviii.). 21 Fridolin, J., "Studien über frühzeitige Schädel difformitäten," Virchow Archiv., Berlin, 1885, c., 270. 22 Fridolin, J., "Schädelskizzen," Virchow Archiv., Berlin, 1888, cxii., 535. "Nouveau cas de bec de lièvre median de la lèvre supérieure," Gaz. Méd. de Paris, 1852, 3o sér., vii., p. 346. 23 Bitot, 24 Lichtenberg, G., "Congenital Tumour of the Mouth," Trans. Path. Soc., London, 1867, xviii., 250. 25 Windle, B. C. A., "On the Condition known as 'Epignathus,'" Journ. Anat. and Phys., London, 1899, xxxiii., 277. 26 Bland-Sutton, J., "On some Points in the Anatomy of the Chimpanzee," Journ. Anat. and Phys., London, 1884, xviii., 69. Duckworth, W. L. H., Morphology and Anthropology," Cambridge, 1904, 113. 28 Fridolin, J., "Ueber zwei difforme Schädel," Virchow Archiv., Berlin, 1886, civ., 156. Schmidt, M. B., "Ueber seltene Spaltbildungen im Bereiche des mittleren Stirnfortsatzes," Virchow Archiv., Berlin, 1900, clxii., 340. 30 Mackenzie, M., Diseases of the Throat and Nose, London, 1884, ii., 469. *31 Pressat, "Observation d'un cas d'absence du nerf olfactif," Thèse de Paris, 1837. 32 Levi, Ch., "Idiotie due à un arrêt de développement du cerveau," Bull. Soc. Anat. de Paris, 1896, 5° sér., x., 810. 33 Selenkoff, A., "Ein Fall von Arhinencephalia unilateralis bei einem erwachsenen Manne," Virchow Archiv., Berlin, 1884, xcv., 95. 34 Sokolow, P., "Der Canalis cranio-pharyngeus," Archiv. f. Anat. u. Physiol., Leipzig, 1904, 71. 35 Hutchison, R., "Three Cases of Oxycephaly," Proc. Roy. Soc. Med., London, 1910, iii. (Sect. Dis. Child.), 125. 36 Sonnenburg, -,"Ein Fall von Epignathus. Operation. Heilung," Deutsch. Zeitschr. f. Chirurg., Leipzig, 1875, v., 99. 37 Le Double, A. F., Traité des variations des os du crâne de l'homme, Paris, 1903, 233. Breschet, G., "Sur l'ectopie du cœur," Rép. Gén. d'Anat. et de Physiol. Pathologiques et de Clin. Chirurg., Paris, 1826, ii., 25. Regnault, F., "La femme à deux nez et le polyzöisme teratologique," Bull. et Mém. de la Soc. d'Anthropol. de Paris, 1901, 5o sér., ii., 333. Frangenheim, P., "Zur Kenntnis der seitlichen Nasenspalten," Beit. zur Klin. Chir., Tübingen, 1909, lxv., 54. References marked * have not been verified. Forfarshire Medical Association EXHIBITION OF PATIENTS.* Dr J. D. Gilruth showed (1) a case of acromegaly, the same as shown at Dundee in October last. The exophthalmos was more marked, the headache more frequent, but there was no change in the hemianopia. X-ray photographs taken by Dr Laing showed (a) prominent exostoses of the hand phalanges; (b) mushroomed tips of the terminal phalanges; (c) dumb-bellshaped phalanges of the feet. Professor Patrick had tested sugar tolerance, with 50 grams. of glucose after a night's fast. The amount of blood sugar was as follows: before glucose, 0.172 per cent., after half an hour, 0.18 per cent., after one hour, 0.176 per cent., after one and a half hours, 0.137 per cent. Urine specimens taken at the end of each half-hour were all sugar-free. The renal threshold was not lowered. All the readings are higher than normal although the blood sugar concentration is normal, (2) A case of prostatectomy with preliminary suprapubic drainage. This was done on a patient of 83, using Pezzar's trocar, cannula, and large self-retaining catheter. Owing to the bladder being empty, and the low position of the supra-vesical fold, the peritoneum was incised while the catheter opening was being enlarged to admit a finger. The peritoneum was sutured and the prostate enucleated in the usual way, without complications. Urine was passed normally on the twenty-first day and the wound was quite healed by the thirty-fifth. Good health has followed and urine is passed three times during the night. (3) Cases of Graves' disease treated by X-rays in Dundee Royal Infirmary. (a) A. M., female, aged 24, was given eleven treatments each of thirty milliampère minutes' exposure from a Coolidge tube of equivalent spark gap of 6 in., the target being about 12 in. from the skin. An exposure was made on each side of the neck, the rays being filtered through * Ordinary Meeting held in Arbroath on 14th May 1924. |