Q OOP 005 650 v THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES r A SYSTEM OP OEAL SUEGEEY: BEING A CONSIDERATION OF THE DISEASES AND SURGERY OP THE MOUTH, JAWS, AND ASSOCIATE PARTS. BY JAMES E. GARRETSON, M.D., D.D.S., Oral Surgeon to the Medical Department of the University of Pennsylvania; Author of Diseases and Surgery of the Mouth, Jaws, and Associate Parts ; late Lecturer on Anatomy and Surgery in the Philadelphia School of Anatomy ; late Professor of the Principles and Practice of General Surgery in the Philadelphia Dental College; Member of the Philadelphia Pathological Society ; Member of the Odontographic Society of Pennsylvania ; Member of the Delaware County Medical Society, etc. IUu;5itvHtfd mill |tumevo«,g ^Usl glnit^ mt\ n^ooA-mt^, PHILADELPHIA: J. B. LIPPINCOTT & CO. 18 7 3. Entered according to Act of Congress, in the year 1872, hy J. B. LIPPINCOTT & CO., In the Office of the Librarian of Congress at "Washington. Lippincott's Press, Philadelphia. ^^^^ .4J TO THE LEARNED AND DISTINGUISHED GENTLEMEN CONSTITUTING THE CORPS, PROFESSORIAL AND CLINICAL. OP THE UNIVERSITY OF PENNSYLVANIA, WITH WHOM IT IS THE PLEASURE AND PRIVILEGE OF THE AUTHOR TO BE ASSOCIATED, PREFACE TO THE SECOND EDITION. The kind reception accorded to the volume of which the present one — though greatly modified and enlarged, and under a different title — may be considered a second edition, has aroused the warm gratitude of the author, and stimulated him to exertions which he trusts will be found to have rendered the present effort more worthy of the commendations so generously bestowed upon his labors. Since the issue of the previous work — a period of rather more than two years having elapsed — the author has de- voted himself somewhat exclusively to investigation and observation in the • direction of the specialty herein dis- cussed. Favored happily with opportunities not commonly enjoyed both in the direction of hospital and of private practice, he may not but feel satistied of the value and solidity of the experiences and teachings here recorded. The present volume has been entitled a system: a system the author has exerted himself to make it ; step by step, from the elements of the subject — from the first departures from normal life — attempt has been made to follow the various conditions to and through their pro- foundest complications. During the time of writing the book, the author has had continuously in mind the recognition of the important fact that in no department of medical science has there existed a hiatus such as that found to-day between general surgery and dentistry, — a lacking span, trul}^, in the bridge of practice. A patient with an oral disease of any complexity, trusting himself to the average dentist, meets wnth disaster because of the absence of surgical knowledge and skill. Approaching from the side of medicine, he suffers alike from (V) vi PEEFACE TO THE SECOND EDITION. the want here of a special character of information which has hitherto been looked upon as having relation alone with a specialty. To bridge this gap by supplying the lacking span is the highest ambition, as it has been the almost life-long labor, of the author. Any sacrifice that may have been made in the work, and in the preparation of the present volume, will find ample compensation, if the dental practitioner learn from it that an acquaintance with the principles of medicine is necessary to the comprehension of oral surgery ; and, on the other hand, if the general practitioner be led to perceive the necessity for a familiarity with that which hith- erto has been deemed to belong exclusively to the province of the dentist : that both may realize that oral surgery is a specialty to which no man may bring learning and skill which shall not find abundant opportunity for their highest expression. How oral surgery shall be practiced, whether by the general surgeon, or, as in ophthalmic surgery, by a special- ist, the author is not concerned to discuss: what is for the highest good comes through a law of its own to grow into usage. What is to be the manner of the medical practice of the future may safely be left to that future. To his publishers, for a liberality which, as the volume will show, involved a large latitude in expense; to S. S. "White, Esq., for the unstinted use of his valuable collection of cuts, and for numberless favors, — the conferring of which must have cost much trouble ; to Dr. Butler, publisher of the "Medical and Surgical Reporter," for cuts, and also to Messrs. Johnson & Lund and to Mr. Kolbe, for similar favors, the author returns his sincere thanks. To his friends and clinical assistants, Drs. De Forrest Willard and Elliott Richardson, for aid in preparing the index, and to Dr. Vallette, for drawings made of clinical cases, he desires to express his obligations. Philadelphia, 1537 Chestnut Street, :Nov. 1, 1872. PREFACE TO THE FIRST EDITION. In the fulfillment of many promises made from time to time to bis students and other friends, the author has prepared the following pages, as embodying the results of his observations and experiences during a somewhat ex- tended practice in that branch of the profession to which it specially relates. "With the hope that the volume will be a useful text-book in assisting the student to prepare for the responsible duties of the profession, and a reliable guide to the intelligent practitioner, it is herewith oftered to the attention both of those who are about to enter the field of their labors and of those who, though more familiar with the practical duties thereof, may desire to acquaint themselves more fully with the latest methods of practice. That the work may prove a source of benefit to his fellow- beings is the highest hope concerning it of The Author. . CONTENTS. CHAPTEK I. PAGE Surgical Anatomy of the Mouth and Face 29 CHAPTER II. Tlie Mouth 57 CHAPTER III. The Fifth Pair of Nerves 77 CHAPTER IV. Dentition 93 CHAPTER Y. Dentition — Continued 101 CHAPTER VI. Associative Lesions of First Dentition Ill CHAPTER VII. Anomalies of Second Dentition and their Surgical Relations 141 CHAPTER VIII. The Teeth and their Diseases — Alveolar Abscess 170 CHAPTER IX. Anchylosis of the Jaw 182 CHAPTER X. Dental Caries 214 CHAPTER XI. The Local Treatment of Dental Caries 274 (ix) X CONTENTS. CHAPTER XII. PAQE Filling Teeth 281 CHAPTER XIII. Pilling Teeth— Continued 307 CHAPTER XIV. Odontalgia 361 CHAPTER XV. Pilling the Pulp Chamber and Canals 384 CHAPTER XVI. The Extraction of Teeth 395 CHAPTER XVII. General Remarks on Extraction of Teeth, Local Ana3Sthesia, etc 422 CHAPTER XVIII. General Anjesthesia — Ether 431 CHAPTER XIX. General Anaesthesia — Chloroform 441 CHAPTER XX. Artificial Dentures — Pivot and Plate Teeth 456 CHAPTER XXI. Irregularities of the Teeth 478 CHAPTER XXII. Salivary Calculus 495 CHAPTER XXIII. Denudation of Dentine 505 CHAPTER XXIV. Salivary Fistulse 507 CHAPTER XXV. The Tonsil Glands 516 CONTENTS. xi CHAPTER XXVI. PAGE The Gums and their Diseases 532 CHAPTER XXVII. Caries of the Maxillje 5o2 CHAPTER XXVIII. Necrosis of Maxillte 56G CHAPTER XXIX. Wounds of the ilouth and Associate Parts 598 CHAPTER XXX. Fractures of the 31axillary Bones 623 CHAPTER XXXI. Dislocation of the Inferior Maxilla 637 CHAPTER XXXII. Ozaena 644 CHAPTER XXXIII. The Antrum of Highmore, and its Diseases 658 CHAPTER XXXIV. TheAphthaj 674 CHAPTER XXXV. Ranula 695 CHAPTER XXXVI. Neuralgia 709 CHAPTER XXXVII. The Tongue and its Diseases 756 CHAPTER XXXVIII. Tumors, General Consideration of 804 CHAPTER XXXIX. Tumors of the Mouth— the Epulides 819 Xll CONTENTS. CHAPTEK XL. PAGE Tumors of the Mouth— Exostosis 833 / CHAPTEK XLI. Tumors of the Mouth— Cystic Tumors 84G CHAPTEPv XLII. Tumors of the Mouth — Non-explainable Tumors .' 874 CHAPTER XLIII. Tumors of the Mouth— Non-explainable Tumors 895 CHAPTER XLIY. Epithelioma 918 CHAPTER XLY. Tumors of Parts associated with the Moutli 932 CHAPTER XLVI. Operations upon the Lips and Cheek •. 952 CHAPTER XLYII. Operations upon the Li})S and Cheek 973 CHAPTER XLVIII. Rhinoplastic and Rhino-cheiloplastic Operations 999 CHAPTER XLIX. Palatine Defects and their Treatment 1009 CHAPTER L. Obturators 1030 CHAPTER LI. Resections'of the Maxillary Bones 1058 LIST OF ILLUSTRATIONS. Fia. PAGE 1. Front and lateral region of tlie skull 30 2. Superior maxillary bone of the left side — outer view 33 3. Superior maxillary bone of the left side — inner view 33 4. Inferior maxillary bone 38 5. Palate bone of right side — posterior view 41 6. Palate bone of right side — exterior view 41 7. The vomer — view of left side 43 8. Articular relations of vomer 44 9. Position and relations of turbinated bones 45 J,0. Ethmoid bone — general view 46 11. The sphenoid bone — upper view 48 12. The sphenoid bone — front view 49 13. Anterior view of the nasal bone 52 14. The malar bone — outer view 53 15. The lachrymal bone — external view 54 16. The hyoid bone 55 17. Antero-posterior section of cranium 55 18. Ptight half of the base of the skull 56 19. Muscles of the face - 59 20. Arteries of the face 60 21. The common carotid, with its divisions 61 22. Nerves of the face 63 23. Veins of the face 64 24. Sectional view of the nose, mouth, and pharynx 66 25. Side view of the muscles of the tongue 67 26. Upper surface of the tongue 68 27. Papillaj of the tongue — moderately magnified 70 28. Diagram of papillse — highly magnified 70 29. Vertical section of the articulation of the lower jaw 75 30. External view of the temporo-maxillary articulation 75 31. General view of the relations of the fifth pair of nerves 77 32. Trifacial division and ganglia 78 33. Superior maxillary nerve 82 34. Inferior maxillary nerve 84 35. Ophthalmic ganglion — the outer part of the right orbit removed 87 36. View of the spheno-palatine ganglion, the outer wall of the left nasal cavity, and the olfactory nerve 88 37. Deciduous teeth 93 38. Permanent teeth of superior jaw 94 ( xiii ) xiv LIST OF ILLUSTBATIONS. FIG. PAGE 39. Permanent teeth of inferior jaw.. 94 40. Lateral view of the upper and lower permanent teeth 95 41. Vertical section of a molar tooth 96 42. Transverse section of a molar tooth 96 43. Vertical section of a cuspid tooth 97 44. Dental pulp — magnified 98 45. Nerves of dental pulp 98 46. Tubuli of dentine and enamel 98 47. Vertical section of the fang of a canine tooth 98 48. Three enamel columns — highly magnified 99 49. Section of enamel — highly magnified 99 50. Interglobular spaces in dentine 99 51. Diagram of the mode of development of the teeth 107 52. First and second dentitions 109 53. Ringed tooth 153 54. Metal cap used in periodontitis 155 55. Sac of alveolar abscess 170 56. Kolbe's wedge screw 207 57. Wedge of Scultetus 208 58. Modified oral wedge 208 59. Superior dental arch — perfect type of 251 60. Superior dental arch — faulty type 251 61. Structural consolidation of dentine 275 62. Hoe excavators and modifications of 287, 288 63. Hatchet excavators and modifications of 288 64. Rose and spear drill 288, 289 65. Merry's drill 290 66. Bur thimble 290 67. Forms of chisels used in dentistry 291 68. Jack's double-end enamel chisels 292 69. Forbes's gouge, and Jack's paraboloid chisels 293 70. Separating file— Taft's pattern 294 71. File-carrier 294 72. Simple cavities on grinding face of molar teeth 294 73. Cavities on posterior face of incisors 295 74. Neck cavities in incisor teeth 295 75. Cavities of imperfect enamel 295 76. Cavities on buccal face of molar teeth 295 77. Buccal cavities 296 78. Carious denture .' 297 79. Separating files 297 80. Complicated dental cavities 298 81. Complicated dental cavities 299 82. Complicated dental cavities 300 83. Complicated dental cavities 300 84. Excavators, lathe matrices, and bur drills 301 85. Forms of files used in separating molar teeth 303 86. Mouth mirror ' 306 87. Mouth mirror 306 LIST OF ILLUSTRATIONS. xv FIG. PAGE 88. Syrinsre 306 89. Syringe 306 90. Plain-pointed plugging instruments 307 91. Serrated-pointed plugging instruments a 307 92. Flagg's tongue-holder 309 93. Morrison's duct-compressor 309 94. Dibble's saliva-pump 310 95. McQuillen's extension-finger 311 96. Taft's thimble 311 97. Kich's Stenonian-duct-compressor 312 98. Hodson's rubber-dam appliances 315 99. Forbes's fork for fixing rubber dam 320 100. Hot-air syringe 321 101. Foil-carrier 323 102. Kedman's pluggers 324 108. White's head-rest 326 104. Jack's matrix 330 105. Jack's matrix 331 106. Fixing points for Jack's matrix 331 107. Jack's matrix 332 108. Jack's plugger-point 334 109. Outline contour cavities 335 110. Atkinson's pluggers 338 111. Atkinson's burnishers 339 112. Butler's pluggers 339 113. Varney's pluggers 340 114. Abbott's pluggers '. 341 115. Plugging mallets 343 116. Automatic plugger 347 117. Electro-magnetic mallet 348 118. Finishing files 351 119. Bur and wheel files 352 120. Set of burnishers 352 121. Porte polishers 358 122. Filed teeth 357 123. Diminished pulp-chamber 377 124. Diminished pulp-chamber 377 125. Secondary deposit of dentine 378 126. Pulp nodule 379 127. Pulp nodule 379 128. Nerve extractor, with holder 385 129. Nerve extractors 385 130. Nerve-canal pluggers 387 131. Permanent teeth of upper jaw 896 132. Permanent teeth of lower jaw.' 396 133. Upper incisor forceps 397 134. Lateral incisor forceps — upper 398 135. Lower incisor forceps — hawk-bill 398 136. Lower incisor and bicuspid forceps, for either side 398 xvi LIST OF ILLUSTRATIONS. FIG. P-^^E 137. Hawk-bill forceps for lower incisor and crowded teeth 398 188. Upper and lower root forceps— half curved 400 139. Lower root forceps — full curved 400 140. Upper and lower bicuspid forceps 400 141. Upper back root forceps — universal 400 142. Half curved, narrow beak forceps 400 143. Upper bicuspid and canine forceps 401 144. Upper bicuspid and incisor forceps 402 145. Lower Taicuspid and canine forceps 402 146. Lower bicuspid forceps 403 147. Upper bicuspid forceps — safety 403 148. Upper molar forceps — right and left 403 149. Upper molar forcepis 404 150. Upper molar forceps 404 151. Upper molar forceps — for either side 405 152. Cow-horn forceps— right and left 40G 153. Upper molar cow-horn forceps — either side; 407 154. Lower molar forceps — either side 407 155. Lower cow-horn forceps 408 156. Lower cow-horn forceps — right side 408 157. Lower cow-horn forceps — leftside 408 158. Wolverton's forceps 409 159. Hutchinson's forceps 409 160. Upper dentes sapientise forceps 410 161. Physick's forceps 410 162. Forceps for wisdom-teeth — lower side 411 163. Fulcrum forceps 412 164. Fulcrum forceps 412 165. Fulcrum forceps.... 412 166. Fulcrum forceps 413 167. Elevators used in extracting roots of teeth 413 168. Relation of fractured roots to alveolar line 414 169. Stellwagen's incising forceps 415 170. Stellwagen's incising forceps 416 171. Screw for extracting roots of teeth 416 172. Dubs's screw forceps 417 173. HuUihen's screw forceps 417 174. Eoot forceps 418 175. Eoot forceps 418 176. Root forceps 418 177. Root forceps 418 178. Eoot forceps 419 179. Root forceps 419 180. Root forceps 419 181. Anomalous teeth '. 419 182. Anomalous teeth 421 1'83. Anomalous teeth 421 184. Spray apparatus — hand instrument 429 185. Spray apparatus — foot instrument 430 LIST OF ILLUSTRATIONS. xvii FIG. . PAGE 186. Pivoted tooth 456 187. Excising forceps 4-58 188. Excising saw 459 189. Pivot files 459 190. Hand-lathe 4G0 191. Foot-lathe 461 192. Impression tray 468 • 193. Impression tray 468- 194. Impression iv 487 206. Metal cap for front teeth 488 207. Irregular articulation 488 208. Inferior maxilla — showing angle at diiierent ages 489 209. Occipito-mental sling 490 210. Corrected denture 491 211. Ketaining plate 491 212. Wedged denture 492 213. Expanding screw 494 214. Instruments employed in scaling teeth 503 215. Denudation of teeth 505 216. Denudation of teeth 505 217. Salivary fistule 508 218. Operation for fistule 511 219. Tonsil glands 516 220. Hypertrophied tonsil 520 221. Tonsillotome -523 222. View of the air-tubes 527 223. Uvula scissors .530 224. View of gums inflamed by vulcanite plate .543 225. View of case of general hypertrophy of gums 545 226. View of chronic ulitis, with recession 546 227. Sequestrum after measles 582 228. Appearance of patient with phosphor-necrosis 593 229. Crossed and knotted bandage 600 230. Barton's bandage, and jaw-fracture dressing 628 231. Gibson's bandage 629 232. Garretson's bandage 630 233. Gunning's first splint 631 284. Gunning's second splint 631 B xviii LIST OF ILLUSTRATIONS. FIG. PAGE 235. Gunning's third splint 632 236. Gunning's fourth splint 632 237. Complete dislocation of jaw 637 238. Manipulations in dislocation 641 239. Yertico-niontal cap 642 '240. Superficial ranula — showing treatment by seton 699 '241. Deep-seated ranula 700 ;242. Microscopic view of cancer-cells — after Paget 770 243. Amputation of tongue by strangulation ■. 796 :244. Transfixing ligature 797 '245. Chassaignac's ecraseur 798 '.246. Wire ecraseur 798 247. Kegnoli's operation for ablation of tongue 799 248. Syme's operation for ablation of tongue 799 249. Epulic tumor 820 250. Odonto-periosteal tumor 821 251. Ulitic tumor 821 252. Epnlic tumor 827 253. Epulic tumor 827 254. Epulic tumor 827 255. Epulic tumor 827 256. Epulic tumor 827 257. Operations on lower jaw 830 258. Odontoma 835 259. Odontoma 836 260. Microscopic section of 836 261. Hyperostosis 839 262. Osseous tumor 842 263. Hyperostosis of tuberosity of maxilla 843 264. Microscopic section of. 845 265. Odontocele 850 266. Dentigerous tumor 856 267. Microscopic section of 857 268. Dentigerous tumor 859 269. Dentigerous tumor 860 270. Dentigerous tumor 861 271. Microscopic section of 862 272. Antral cyst 870 273. Secondary cj-st of antrum 872 274. Osteo-sarcomatous tumor 894 275. Cysto-sarcoma 894 276. Nodulated tumors 907 277. Hard cancer-cells 910 278. Encephaloid tumor 915 279. Encephaloid tumor 916 280. Microscopic view of cells in soft cancer 916 281. Cells seen in soft cancer 916 282. Dotted nuclei of soft cancer 916 283. Clustered nuclei of soft cancer 917 LIST OF ILLUSTRATIONS. xix FIG. PAGB 284. Caudate cells of firm encephaloma 917 285. Small elongated cells of enoejjhaloma 917 286. Indurated epithelioma 918 287. Ulcerating epithelioma 918 288. Epithelioma of gum 919 289. Sebaceous tumor of face 933 290. Cartilaginous cysts 935 291. Lobulated lipomatous tumor 936 292. Microscopic structure of an adipose tumor 936 293. Fatty tumor from under the tongue 936 294. Venous tumor 939 295. Strangulated tumor on lip 940 296. Transfixed tumor 941 297. Transfixed tumor 941 298. Keloid boa of neck 950 299. Elliptical incision in the operation for hare-lip 957 300. Hainsby's compress 960 301. Hare-lip operation 963 302. Hare-lip operation 964 303. Double hare-lip 965 304. Projection of intermaxillary bone 969 305. Complicated hare-lip 970 306. Complicated hare-lip 970 307. Complicated hare-lip 970 308. Complicated hare-lip 970 309. Complicated hare-lip 971 310. Hare-lip pins and ligatures 972 311. Mouth-stretcher 978 312. Study in lip operations 983 313. Study in lip operations 985 314. Study in lip operations 985 315. Study in lip operations 986 316. Study in lip operations 986 317. Study in lip operations 987 318. Study in lip operations 988 319. Study in lip operations 989 320. Study in lip operations 989 321. Study in lip operations 989 322. Study in lip operations 990 323. Plastic operation on face 992 324. Study in rhinoplasty 1000 325. Study in rhinoplasty 1001 326. Study in rhinoplasty ." 1001 327. Study in rhinoplasty 1001 328. Study in rhinoplasty 1003 329. Study in rhinoplasty 1002 330. Study in rhinoplasty 1006 331. Study in rhinoplasty 1007 332. Mouth gag 1029 XX LIST OF ILLUSTRATIONS. FIG. PAGE 333. Study in obturators 1037 334. Study in obturators 1008 335. Study in obturators 10-iO 336. 'Study in obturators 1041 337. Study in obturators 1042 338. Study in obturators 1043 339. Study in obturators 1044 340. Study in obturators 1045 341. Study in obturators 1046 342. Face without nose 1049 343. Palatine arch with obturator 1050 344. Artificial nose 1052 345. Attachment of artificial nose 1052 346. Artificial nose in place 1053 347. Face without nose and superior lip I'.lv, 348. New-made lip 1056 349. Artificial nose in place 1057 350. Artificial nose, showing springs for retaining 1057 351. Mouth-stretcher applied 1066 352. Mouth-stretcher applied 1066 353. Surgical anatomy of inferior maxillary nerve 1070 854. Incision for exposing coronoid process of lower jaw 1071 PLATES. I. Anomalies in dentition 157, 158 II. Anomalies in dentition 160, 161 III. Anomalies in dentition 163, 164 IV. Dental tumors, with microscopic appearance of 166 V. Anomalies in dentition 1G7, 169 VI. A view of the anatomy of the side of the face and of some of the operations practiced on it 515 VII. A view of operations performed on the trachea 531 VIII. Appearanceandpositionof some of the tumors seen about the neck 931 IX. Hare-lip and atresia oris 972 X. Plastic surgery of lips 972 XII. Operations on the tongue 795 XIII. Operations in rhinoplasty 990 XIV. Khinoplastic and cheiloplastic operations 1003 XV. Khinoplastic operations 1005 XVI. The operation of staphyloraphy 1024 XVII. Kesections of maxilla 1061 STUDENT'S PREFACE. Special surgery, like surgery proper, considers and treats of dis- ease as contradistinctiv^e to ease. Ease implies the normal condition. A body in a state of ease is in harmony, part with part, no source of derangement existing to interfere with its functional life. Dis-ease, in the greatest breadth, as in the narrowest, of its signi- fication, has its meaning in a single word, — ^' irritation. ^^ Irritation is that derangement, of any and every nature, which ensues from the presence of an irritant. An irritant is that which irritates, or which interferes with func- tion. What an irritant may be, — how it deranges, — how it inter- feres with ease, producing disease, — how we are to antagonize it and its results, — this is the province of the science we study. Imprimis : A student will look most simply, yet truthfully and fully, at the subject-matter of our study, thus : Whenever a patient presents himself with his complaint, no matter what may be the character of the lesion, where or how situated, the trouble has its origin in the presence, directly or indirectly, of some agent of irri- tation. This appreciated, a deduction naturally follows, — that the relief and cure of disease should lie in the discovery and removal of a cause inducing it. An irritant is an offense of many aspects. It may be a simple splinter pricking the finger, easy of recognition and treatment, or it may be some adventitious deposit in a viscus, which the nicest refinement of modern diagnosis shall not enable us to discover. The study of medicine comprehends much. If it begins with the splinter, it has its domain bounded alone by the widest investigations of physics. A surgeon is full, in proportion as he comprehends from the central principle outward. To pull a splinter from a wounded finger, to lift a mote from an eye irritated through its presence, — 2 (17) 18 STUDENT'S PREFACE. these ai"e surgical performances, simple, it is true, yet are applica- tions, in such direction, of kaowledge We may pass outward to the inflamed jaw which the carious tooth worries and frets by its pres- ence, and, with the comprehension of an effect from a cause, extract the offending organ, and from his dis-ease the patient is immediately restored to ease. We find a bone necrosed, and are instruments of good to a sufferer so far as our attainments shall direct in the means to his relief. We meet with an arm or a leg fractured, and as we shall comprehend the meaning of such accident in its relation with the laws of the human organism, so we restore the member to useful- ness, or complete its destruction. From evident causes of disease an observer finds himself led to an appreciation and judgment of the occult and complicated. Judg- ment grows an offspring from knowledge, and becomes a power as reliable as that which has emanated it ; thus, through the seen, is the unseen not unfrecjuently to be recognized. When the body is in a state of ease, we say it is in a physiological state ; when in dis-ease, we pronounce the pathological condition. Pathology is a study having its basis in physiology, and physiology is a science having its foundation in anatomy. The animal body is a machine. To comprehend a machine, one must analyze it, — take it apart, look into and recognize piece by piece its construction, know where this and that fit, and what is the harmony of the asso- ciation. This is anatomy. A man may never be a surgeon, gen- eral or special, who begins not with such analysis as his foundation. A knowledge of the construction of a machine enables one to under- stand the principles and nature of the movements pertaining to the construction, let these be what they may. That which is the life — the movement — of a machine, is its physiology : one may scarcely be expected to possess the ability to appreciate the wrong-going of a machine who knows not what is the right-going of it. Physiology, then, is, to the surgeon, a preliminary stud}', succeeding, with him, Anatomy. Pathology is the expression of Irritation ; irritation we recognize as the signification of disease. Having familiarized himself with the anatomy and physiology of a human being, a student is prepared to appreciate collectively, in association, or distinctively, any fact or facts presented to him in surgery. By Irritation, we have understood an effect which follows from the presence of an irritant. The sources and causes of irritation a STUDENTS PREFACE. 19 writer might scarcely attempt to enumerate. Food, which to-day digests and nourishes, to-morrow ferments and poisons ; the glisten- ing stone, wiiich in the morning the child delights to show its play- mates, in^the afternoon kills its owner by falling into his windpipe; water refreshes, or it may scald or drown ; sunshine affords life, or burns and depresses to death ; years grow vigor and breed debility. We may fairly embi'ace this aspect of our subject only by recognizing that there is nothing which is incapable of becoming a source of irritation. As the reflection of part upon part is concerned, we instance the deranged stomach, the congested liver, the parasite- loaded bowel, the stone in the bladder, the calculus in the kidney, the tumor over the nerve. The phenomena, however, which designate and characterize the presence of an irritant, — these we are to comprehend and appre- ciate. The presence of a source of irritation finds primary expression in a disorder of sensation ; such disorder being of an extent and char- acter corresponding with the nature of the offending agent, or the idiosyncrasy of the individual. Disordered sensation may be gen- eral or local : shock, from the reception of sudden tidings, illustrates the first ; the tingling half-frozen fingers are an example of the second. Disordered sensation may be attended or unattended with the feeling of pain ; pain in disordered sensation originates in me- chanical pressure or other source of offense arising from the lesion. Evidences of irritation are, in their relationship, direct or indirect. An aching tooth may express itself by a neuralgia seated in the dura mater, or on any branch of the trigeminus ; a worried liver may speak its complaint in the subscapular Ijranches of the cervical plexus ; a gorged stomach will not unfrequently look its distress from an enlarged and fixed pupil. The effects of an irritant acting upon a part are apt to have a history modified by the temperament, or state of force, of the indi- vidual. A blow received by a delicate woman upon the lower jaw, breaks, perhaps, that bone ; received by the scrofulous child, it in- flames and kills the part; the same force of offense to a vigorous farm-laborer scarcely elicits recognition. Phosphorus, while utterly destructive to the bone of one workman in the match-factory, is fully resisted by his fellow laboring at a neighboring table. A single carious tooth in the jaw of one person may provoke necrosis ; in another, a mouthful similarly affected fails of such an end. The slightest extent of irritation may suSice, in the plethori«,. to excite 20 STUDENTS PREFACE. an inflammation ; in the lymphatic man it takes a very great amount to elicit from the sanguineous system even a response. In the case of the non-cognizable irritants, as the epidemic, endemic, and infec- tious poisons, such modification finds most marked illustration. One individual shall be so susceptible as to succumb without resistance^ a second finds his system offering long-continued battle ; a third seems not at all susceptible. We are to infer, then, that the evi- dences of the presence of an irritant have a much modified expres- sion. We pass here to the observation of the common expressions; and, that we shall possess an illustration recognizable by any student, we consider, first, the simple mechanical irritant. A man, for example, receives a shot in his body. Here, as the primary condition, there is a break of continuity in the tissues, asso- ciated with more or less injury. How will the system endure and treat this offense ? First, recognition is received by the sonsorium through the medium of the injured sensory nerve-filaments ; pain is felt, and functions are interfered with according to the extent and na- ture of the injury. The sensorium, immediately responsive, issues directions for the expulsion of the offending agent ; the means to this end is to be the loosening of the body and the floating of it from its lodgment. This applies to every description of foreign substance, whether it has come from without, or should develop within, as in the case of dead bone or calculi. First, it is perceived that neigh- boring parts increase in redness. This is the result of a superflow of blood to the parts. It is termed, technically, " simple vascular excitement." This flow increases, until at length everv vessel be- comes engorged. This is the state of "congestion." A succeeding stage is the stoppage of this mass of blood, — "stagnation." Nu- trition now ceases, the parts die, and, in a stream of pus " suppura- tion," the agent of the offense and its immediate envelope are floated away. Thus, Nature has relieved herself, and, the process of repair taking the place of the destructive process, the lost part may be quickly restored. The action thus hastily described is, however, a rule with excep- tions. A foreign body may become encysted, — that is. Nature may find her easiest and quickest relief by enveloping the offense in a cyst, and, while affording it lodgment, yet shut it out from all rela- tionship with the life surrounding it. As examples of such relief, cases are on record of balls remaining without discomfort in the human body for years. STUDENTS PBEFACE. 21 The presence of a foreign body may be tolerated through other natural provisions. Thus, a calculus forming in a duct may have such duct enlarge the provisions of its carrying copacity so that the body shall not complete an obstruction. Illustrations of this pro- vision e.xist in the case of gall and salivary obstructions. A stone in the bladder will excite that extent of vascularity which shall overbalance the mechanical attenuation and thinning through a resulting hypertrophy, thus antagonizing the destructive influence. A foreign body may be cast out through the offices of a functional activity excited in the parts invaded: the lachrymal secretion wash- ing a particle from the eye furnishes an illustration. Irritation, when existing as an element in the process of the expulsion of an offending body, is classible as the first of the inflam- matory phenomena. Thus, we study inflammation under six asso- ciated aspects : 1. Irritation. 2. Simple vascular excitement. 3. Active congestion. 4. Stagnation. 5. Suppuration. 6. Repair. The associate characteristics by which we distinguish the existence of inflammation are redness, heat, pain, swelling, and granular activity. The study of inflammation is the completion of the circle of the meaning of irritation. No man may know of surgery but as he knows of inflammation. General irrifaf ion. — Viewed from the medical stand-point, we are to assume the existence within the human system of a force which we term excitability. Of this force we affirm, as of the blood, that there is just so much, and, like unto the blood, that it is harmonious and proportionable in its disposition. This excita- bility, vis vitse, is a correlating essence or thing, and is consequently to be considered as allied with matter. The correlating of this vis vitae differs in no respect, save in manner, from the principle employed in converting beat into steam, and steam into momentum, and mo- mentum back again into heat; and the life itself differs not in kind from that which is the cohesive force of a weed. Physical life is a phenomenon, — this, and nothing more. What, from lack of better understanding, we term the vis vitse, is to have from us no more respect, nor is it, as the physician is to estimate 22 STUDENTS PBEFACE. it, less an anatomieo-physiological thing, than is a bone, a muscle, or a brain-cell. As physicists, we consider it physiologically, and through such consideration we direct and circumvent its vagaries as we do that of the blood in its associative inflammatory perversions.* Excitability we are to accept as the vivifying principle. As this force exists in a correlative fullness, man lives; as it diminishes in him, so he proportionably dies. Ample illustration of such truth exists in the matter proper, as we recognize it, of the body. In what we term the physiological state we find the act of life-renewal a per- fect process ; the organism is maintained in its integrity. In sick- ness, correlation is deranged, the circle is broken, and that matter which is constantly passing from the body is not replaced by that which in the normal life is constantly coming to it; hence the wast- ing, — the decrease. It is the classic legend of the pelican constantly repeating itself, — the bird feeding its offspring with its own body, having in its turn no nourishment. Excitability — i.e. the vis vitse, the vitalizing principle — is not to be confounded with nerve-matter, or with the sanguineous system, or with any special relation. It is Force: a something in itself, — in abstracto. Negatively, we recognize it in its going out from organic tissue. First, its existence in the muscular sense, say of a living bullock ; then its complete absence in flesh which is called putres- cent. In the meat of the shambles we see that extent, relation, and conjunctive quantity of it which is the mean between that which pertains to moving life and disintegrative death. In other words, we see in the meat the relation between force and matter, in that the law of the transformations and transmigrations of the one is the common law of both. The treatment of disturbance of excitability through nervines finds its explanation, I conceive, in a deadening impression made on the instruments of its expression ; as, for example, in the sanguineous system we may, through the application of ether-spray or other means of cold, so contract the capillaries of a part that, in defiance of the most urgent protest of a fever-irritated heart, we utterly abro- gate the office of these vessels, and, so far as the parts are concerned, deny, ipso facto, the power to the organ of expression. Accepting, then, the premises of the existence of excitability. * The author denies a right to criticise this passage except to him who recognizes a distinction assumed between the Ego and the physical man. STUDENT'S PREFACE. 23 without a present consideration or speculation as to what it is, we find our first expression of systemic irritation in the perversion of the equilibrium of this something*. General irritation is super- excitation. It has been maintained that as the body contains just so much excitability, and that this expresses fullness, there cannot be such a thing as general excitation ; but this is certainly a fallacy, for as well might we say that the oceans of water could not be roused from their normal calm and lashed into rolling waves. It does not seem at all necessary to fall back on the premise that, although the system has such limited amount of excitability, the full force of it is not called into play in health, and that general irritability means the provocation into action of the reserve. In fever, the circulation is in a state of general disturbance or irritability, and of this fluid there is in a body just so (proportionable) much; but here we are not at fault in reading the phenomenon ; only, however, are we not so, because we deal with a cognizable thing. That excitability uses primarily the nervous system as the instru- ment of its expression seems fully demonstrated in such metastatic transfers of inflammatory phenomena as are found in tlie relation of parotitis and orchitis; while a negative proof, having the wide signification of exhibiting the comparative separability of the Ego from the common life of a man, is seen in the exemption of the nerves of special sense from the uses of organic life. To make an example: we may so benumb the fingers that incisions can be made without pain, yet during the process find the special sense of touch unim- paired ; or we may make another demonstration in witnessing the painless cutting, lacerating, or burning of a nerve of special sense while beholding the writhings which attend the wounding of a part supplied from the excito-motor system. Recognizing thus the existence of a common life-principle and its subjectiveness to general supei'-excitation, we are prepared to pass, with sounder judgment, to the expressions of irritability as mani- fested in its employment of the resources of the sanguineous system in the perversions known as inflammatory. Fever, the expression of general excitability, seems to partake of the nature of a reactive process ; preceded by depression so great, it may be, as to amount to chill; its division into the three stages of invasion, reaction, and resolution are commonly very marked. Invasion. — This maybe characterized by a distinct chill or shiver- ing fit, or may be confined to general malaise, the pulse being- depressed, the appetite defective, with indifference to food, and, it 24 STUDENTS PREFACE. may be, nausea; the surface of the body marks a diminished tem- perature, and is not unfrequently shriveled, presenting the peculiar roughness known as the cutis anserina. This state of depression may exist from a few hours to several days. Eeaction. — The second condition is marked by increase of pulse, with heat that soon grows into a sense of general flush ; appetite still further diminishes ; the tongue most likely becomes furred ; the bowels are constipated ; thirst grows a prominent symptom ; the tem- perature naturally finds an elevation from the increasing rapidity of circulation and cell-change, the pulse running up not unfrequently as high as 110°. The overexcited brain, unable to perform its functions, deranges more or less all expressions of which it is the instrument; taste is disagreeable, or, it may be, is lost; the seuses of seeing and hearing grow preternaturally sensitive ; in short, up to a certain point — the point of exhaustion — the system at large manifests the condition of super-excitation. It is the quiet of water disturbed by the storm. Declining stage. — In fever, disassociated with organic derange- ment, — tbat is, in the " ferveo" of simple super-excitation of the vis vitce, — the return to the equilibrium is gradual and without the marked phenomenon of a crisis. The sense of heat passes away gradually, thirst diminishes, the skin relaxes, the secretions restore themselves, and in a greater or lesser length of time, depending on the temperament of the individual, the harmony of functional life is restored. It is the disturbed water recovering its calm. General Remarks. Fever is always to be looked on as disturbance of the vitalizing principle. A fevered patient is in a condition analogous to a burn- ing caudle variously disturbed by excess of carbon or oxygen ; boih the one and the other influence aside from the mean. Depres- sion or super-excitation may exist within the limit of non-functional disturbance, thus demonstrating the ability of organic life to endure without ill result a certain extent of trespass. The state of invasion of fever is to be viewed as that condition in which the vis vitse is restrained. Reaction is that stage in which, overflowing or break- ing such restraint, accumulation exhibits itself in consequent super- excitation. Irritation is, or is not, the first of the inflammatory phenomena (locally expressed), according as it is, or is not, followed by perver- sion of the circulatory system. When irritation has excited vascular STUDENT'S PREFACE. 25 derangement, then the term is merged into the varying terms ex- pressive of the stages of inflammatory action. Inflammation is not a general, but a local condition, and its normal history is that which tends to the relief of irritation through the expulsion or destruction of a cause inducing it, as is illustrated in the process of suppuration. Fever and inflammation, as thus exhibited, are not to be esteemed necessarily coexisting phenomena. Fever commonly associates itself with inflammation, being aroused by such condition acting as an irritant, while, in turn, febrile disturbance may readily provoke an inflammation through its excitation of the circulatory system ; but it is frequently enough to be remarked that fever, even of severe grade, may readily run its course without inducing that extent of vascular perversion which yields the phenomenal expression of in- flammation. DISEASES OF THE MOUTH ASSOCIATE PAKTS. CHAPTER I. SURGICAL ANATOMY OP THE MOUTH AND FACE. Beginning with this first chapter, the author assumes a famili- arity on the part of his reader with the principles underlying general medical practice, allusion to which has just been made, — a familiarity which is alone able to render intelligible, useful, or desirable the study of any one of its specialties. In a work on oral diseases and surgery, a source of ready and accurate reference to parts involved would seem to be an essential. With such view we map out, as accurately as the photograph and pencil may represent nature, all such parts as, surgically, we may have to deal with or comprehend. As — unless with the very expe- rienced — it is always desirable to precede an operation on the living with a test performance on the dead, so with the student it is as desirable to found the comprehension of any pathological perversion on an understanding of normal characteristics. In presenting these photographs of the various parts associated with oral surgery, the suggestion may be added, that the bones rep- resented be procured and laid carefully away in the cabinet: the assistance of their silent expressions will be found invaluable. So far as the soft parts are concerned, one may either possess them in alcohol, or, what is even better, where it can conveniently be done, may make it a point to dissect them yearly. Fig. 1 (exhibited on page 30) represents the lateral aspect of the face ; this is seen to form, almost accurately, an. oblong square. A modification on such a square, however, will be found to exist in the case of the child, where the ramus of the inferior maxil- lary bone is at a more obtuse angle with the body; also in the case of an adult with prominent os frontis: in either of these cases this aspect is triangular. Bounded circumferentially by the supra- orbital ridge of the frontaL bone, the nasal process of the superior maxillary, and the malar bones, we find a pyramidal cavity, the (29) 30 ORAL DISEASES AND SURGERY. orbital, for the accommodation of the organ of sight. Looking at the natural bone, no less than seven pieces are observed entering YiQ. 1. — Frokt and Lateral Region of the Skull. The sKCLl sees partly is front and on the bight side. 1, frontal bone; 2, parietal bone- 3, temporiil bone, its squamoiis portion; 4, tlie spbeuoid bone, tomporiil surface of its great win"; 5, etlimoid bone, its orbital surface; 6, superior maxillary bone ; 7, malar bone : 8 lacbrvnial bone ; 9, nasal bone ; 10, inferior maxillary bono. a. orbital plate of the frontal lione ; b, temporal surface ; c, orbital surface of the great wing of the sphenoid bone- d mastoid portion of tha temporal bone; e, orbital surface of the malar bone; f, orbital plate of the superior maxillary bone ; g, infraorbital foramen ; /i, mental fora- men- i symphysis; j, ramus; k, coronoid process; I, neck supporting the condyle ; m, angle ; n, lachrymo-nasal duct. into the composition of this cavity, some of which pieces in their relations closely affect proceedings in oral surgery : for example, it will be seen that a large portion of the floor of this cavity is made up by a process, the orbital, which is a part of the superior maxilla ; glancing at a disarticulated bone, it will be seen that this process constitutes as well the roof of the antral sinus; it will also be found to be a very thin plate, and capable of being easily elevated or depressed, according as any pressure might be brought upon it from below or above ; constituting a source of support to the eye, it will also be seen that, where it is possible, it should be left undis- turbed in operations demanding extensive interference with the bone of which it is a part. At the inner inferior aspect of the cavity a groove will be observed, the lachrymal, being the entrance to a canal, AXATOMY OF THE MOUTH AND FACE. 31 the ductus ad nasum, earning the tears from the orbit to the inferior meatus; the outer wall of this canal, which it is most important to maintain patulous, is made up by the inner face of the nasal process, another portion of the superior maxillary bone. Diseases of the sinus not unfrequently react on the eye, and to such an extent, that blind- ness of several months' standing has been cured by the extraction of a diseased tooth-root which had affected the antrum to its engorge- ment. Closure of the lachrymal canal is almost certain to occur if the nasal process becomes inflamed, and such inflammation I have frequently met with as the result of an odontocele. Immediately below the inferior boundary of the orbit is seen a foramen, the infraorbital, for transmission of the infraorbital branches of the fifth nerve. Passing a bristle through this foramen, it is seen to emerge in the groove marked on the floor of the orbit, — the infra- orbital groove in which the nerve lies in its passage outward. This groove and this canal are both in the maxillary bone, and are, alike with the ductus ad nasum, influenced by its diseases. The canine fossa, seen back of and above the canine tooth, has, as its floor, a thin plate of bone, which is the external face of the antrum, and through which, if it should be found necessary, the cavity may be easih' entered. The tuberosity of the bone, occupied in part by the wisdom tooth, and marked for the attachment of the buccinator muscle, is a point of surgical interest, — it being not at all uncommon to have necrosis of this portion of the bone, the result of an ostitis, induced and kept up by an imprisoned dens sapientiae. Standing, as is seen, at an angle, and tubercle-like, it is plainly evident that neither deformity nor harm would result from its separation as a sequestrum. The alveolar pi'ocesses are remarked to constitute quite a large part of both the superior and inferior maxillary bones. These pro- cesses, vascular and spongy, subjected to all irritations residing in diseased teeth, are, without doubt, more liable to take on patho- logical action than any other portion of the ossa corporae. From the alveolo-dental periosteum spring epulic outgrowths of various signification. Sarcomatous degeneration finds here a favorite seat : simple and compound cysts are very familiar; degenerative ostitis is "not uncommon, while abscess is found in almost every mouth. The mental foramen, seen upon the inferior maxilla, a little anterior to the middle of the body, is the outlet of a canal traversing the centre of the bone, and conducting beneath the teeth the dental artery and nerve. The size, general character, and inlet of this 32 ORAL DISEASES AND SURGERY. canal should be observed, as not unfrequentlj injuries to tbe artery require that the canal should be plugged, either as foramina are concerned which exist beneath each tooth, or as the channel proper is interfered with in operations for tumors or sequestra. Neuralgia of some of the peripheries of the inferior dental nerve makes necessary, occasionally, its section within the canal. To get at this nerve, requires either that we shall extract some tooth, and make the section from the base of the socket, or otherwise that a trephine shall be used from the outside. The easiest mode of per- forming such operations is to be observed, as relation is had to location, and character of the bone. The association of the teeth with their spongy processes is a mat- ter which should receive close attention, the operation for their extraction being a very common one. These processes, if examined in a number of bones, will be found to vary greatly in character: in some being of such loose structure that the teeth are capable of the easiest separation ; in other instances being so firm and un3'ielding that it is quite an impossibility to make such extraction without more or less fracture. The number and shape of the roots of the teeth are to be ex- amined. A knowledge of their curves contributes much to skill in their removal. Indeed, no one but the experienced can appreciate how much easier it is to remove the teeth with than without such knowledge. The nasal bones, forming in their conjunction the nasal arch, should be examined in their relation to each other and to neigh- boring pieces. Articulating with the perpendicular plate of the ethmoid, it has not unfrequently happened that the depression of this arch from a blow has carried the crista galli into the sub- stance of the brain, and thus produced fatal consequences. The nasal bones are frequently the seat of syphilitic degeneration. Their destruction compels the falling in of the nasal arch, thus yielding the flattening of the bridge occasionally observed, — one of the most repulsive of deformities. The incisive fossa, observed between the anterior nasal spine and central incisor teeth, frequently yields its floor to the ravages of necrosis or caries. There would seem to be here less vital resistance than in other parts of the bone, as necrosis of a tooth is almost necessarily associated with disease of the superficial surface of its alveolus. This plate is, however, quite thin, and its loss seldom seems of much consequence. ANATOMY OF THE MOUTH AND FACE. 33 The position of the groove for the passage of the facial artery, seen on the inferior maxilla, is to be noticed, as location and dis- tance from the angle of the jaw are concerned, — the control of hemorrhage about the lips and cheeks being here secured through simple pressure on the artery as it passes over the base. With such general observation of the surgical features of the bones in conjunction, we pass to a closer stud}', by examining the pieces in their separate capacities. Figs. 2 and 3. — Superior Maxillary Bone. w « Superior maxillary boxe of the left side, outer view. 1, liofiy ; 2, tuberosity; 3, alve- olar border; 4, orbital plate ; 5, nasal process ; 6, nasal notch ; 7, nasal spine ; 8, lachrj-nial groove ; 9, entrance of the infraorbital canal ; 10, infraorbital foramen; 11, orifices of the posterior dental canals ; 12, malar process ; 13, articulation for the internal angular pro- cess of the frontal bone; 14, incisor teeth; 15, canine tooth ; 16, premolar teeth ; 17, large molar teeth. Superior maxillary boxe or the left side,. inner view. 1, nasal surface of tlie body; 2, surface for the palate bone ; 3, alveolar bor- der ; 4, orbital plate ; 5, nasal process ; 6, ridge for the articulation of the turbinated, bone ; 7, nasal spine ; 8, groove contributing to form the lachrynio-nasal duct ; 9, maxil-- lary sinus; 10, palate plate, its articulating, border for the right maxillarj' bone; 11, in- cisive foramen continuous with the naso-- palatine canals; 12, tuberosity; 13, articular extremity for the internal angular process of the frontal bone; 14, incisor teeth; 15,. canine tooth ; 16, premolar teeth ; 17, large molar teeth. Glancing hastily at the superior maxillary bone, it seems like a quadrilateral, more or less irregular, solid piece. Looking at it critically, and from the surgical stand-point, we find it to consist of a series of processes, so grouped together as to form, or rather inclose,. a cavity so large that the apparently solid body is found to be simply a shell. This cavity of the shell is called the maxillary sinus, or the antrum of Highmore. It is a very irregular cavity,, differing, indeed, in shape in almost every bone ;. generally, how- 34 ORAL DISEASES AND SURGERY. ever, being found as a single cave, but not unfrequently divided into two or more by septi of bone vertically placed. How far, in the mean of cases, the cave is found to run forward and bow far back- ward ; what, in the mean, is its relation to the roots of the various teeth; which of its boundaries are the thinnest; are matters which, because of their very practical signification, are worthy of being most attentively studied, and which study can only be made by an observa- tion of many bones. Abscesses of the roots of teeth frequently void themselves into this cavity : we are to understand how and why, anatomically, such accidents occur. Engorgements of the cavity, puruloid or dropsical, bulge outward some part or other of the circumferential walls, perhaps throwing the eye upon the cheek, projecting the canine fossa, or making a tumor on the palatine aspect of the mouth: we are to understand why such bulging, from a common cause, is found so variously situated, or why, indeed, such accumulations exist at all. If we make such a section of the superior maxillary bone as to expose the antral cavity, we shall find that in many cases, not in- deed in all, its floor is studded with little hills; break into one of these elevations, and you will find that it is a very thin crust, con- cealing the root of some tooth or teeth. In infrequent cases, a root or roots will be found projecting into the cavity, entirely uncovered, save with the membrane which had existence in the living part. Such a view explains very satisfactorily dental abscess within this sinus. The processes which, in their conjunction, make up the bone, are four in number : the alveolar, the palatine, the nasal, and the malar. The alveolar process, wedged in between the malar and palatine, constitutes perhaps the greatest bulk of the bone. Looked at from below, it is found to l)e excavated into cavities or pits, correspond- ing with the character and number of the roots of the teeth ; these pits are termed alveoli, and, in the recent bone, are found lined with periosteal tissue, which tissue is reflected around the roots of the teeth, forming the immediate bond of connection. lu some bones, the structure making up this process is exceedingly loose and spongy ; in others it is condensed, and cortical-like. After the loss of the teeth, this process is removed through absorption ; hence the approximation, in old people, of the chin and nose. Fractures of this process, the re- sult of falls, blows, or attempts at tooth-extraction, are quite common. The tuberosity of the bone may be esteemed as the posterior ex- tremity of the alveolar process, being, indeed, not unfrequently excavated for the wisdom tooth. This tubercle, as implied in its ANATOMY OF THE MOUTH AND FACE. 35 name, is simply a bulb of bone ; it is quite vascular, however, and its relation to the posterior tooth subjects it to sources of irritation which not unfrequently results in its inflammation and death. The malar process, seen projecting from the middle of the bone, is a rough, serrated facet for articulation with the malar or cheek bone. This process, in front, is somewhat concave ; behind it has similar curvature, and forms part of a fossa known as the zygo- matic. The chief point of interest connected with it, however, lies in the character of the suture which unites the maxillary with the malar bone, this being the place of separation in amputation of the maxillary. The nasal process, well represented in the drawing, but better studied and understood from observation of the bone, is observed standing above the orbital surface. Rising from the anterior facial aspect, it continues upward and somewhat backward, until it ends in a rough facet, which articulates the bone with the frontal and ethmoid, and assists in closing in the anterior ethmoidal cells. Lined in the recent state with the Schneiderian membrane, which membrane is continued into the cells of the ethmoid and frontal bones, a moment's reflection recognizes the meaning of that sense of fullness so common about the anterior base of the cranium, when inflammation and congestion exist in the nasal canals. Ex- ternally, the face of the process is concave, thus assisting in carrying out the natural curve of the lateral aspect of the nose ; numerous foramina are also observed on this face, for the passage of vessels. The teudo oculi has its attachment on this surface, while near, on the same plane, is a line giving origin to the levator labii superior alaeque nasi and orbicularis palpebrarum muscles. Anteriorly, the border of the process is thin, and serrated for articulation with the nasal bone. Posteriorly, it is thick, and hollowed into a groove for the lodgment of the lachrymal sac and duct. When in position, in the articulated skull, this groove is converted into a canal by annex- ation with the lachrymal bone ; the canal, traced downward, is found to have somewhat of an hour-glass shape, being considerably con- tracted in the centre, and finally terminating at the inferior meatus in a bell-shaped opening. A little tubercle, the lachrymal, is seen where the anterior lip of the groove joins the orbital surface ; this is a guide, directing the bistoury of the surgeon into the canal, when operations for its stricture are demanded. The orbital surface of the bone, seen before in its articulative position, is here observed separate ; falling at an almost direct right 36 OBAL DISEASES AND SURGERY. angle from the facial aspect of the bone, it is remarked by such rela- tion to form a large part of the floor of the orbital cavity ; while looked at from the cave of Highmore, it is seen to form as well the roof of this vault. When broken, or held against the light, it is found to be almost a scale in thinness. The infraorbital ridge is simply the rim made by the bending downward of this orbital surface. Running along the free edge are observed three distinct articular faces: the outer, for the palate bone, the two inner for the orbital or plane plate of the ethmoid and lachrymal bones. Below the rim, or infraorbital border, is seen the orbital foramen. Passing a bristle into this opening, we find it directed to the groove on the orbital face, the intraorbital. Passing the bristle now from the groove toward the fornmen, we find it may take some other track, and not appear at the opening. Searching for an explanation, we find the groove, soon after entering beneath the ridge, to divide into two canals, one of which passes to the face, as observed; the other enters the antrum, and transmits across this cavity the nerves and vessels designed for the nutrition of the anterior teeth. The osseous boundary of the nose is seen to advantage in tliis drawing. It is a complete curve, and gives attachment by its continuous crest, or edge, to the cartilaginous wings. The zygomatic surface, seen back of the malar process, enters into the formation of the fossa of that name. It is to a degree convex, and more or less rough. Dotting its surface are observed a number of foramina; these are entrances to canals, the posterior dental, and transmit vessels to the posterior teeth, all situated back of the canines. At the lower part of this surface, to the nasal aspect of the tuberosity, is a groove destined to be converted into a canal through an articulation with the palate bone, the posterior dental groove. This groove or canal transmits vessels to the palatine face of the bone, and is seen to terminate on the under side of the tuberosity. The muscles of expression, to which the outer surface of the bone gives origin, are numerous. From the second bicuspid tooth back to the tuberosity, is a rough line for the trumpeter's, or buccinator (a similar line existing on the inferior maxilla). Above this first line, and below the malar process, certain fibres of the masseter are attached. Above the canine fossa is the origin of the levator anguli oris ; while without this, toward the concavity of the nose, is the line for the compressor naris. In the incisive or myrtiform fossa is seen the origin of the depressor alse nasi. Turning now toward us the inner face of the bone, we see the AI^ATOiMY OF THE MOUTH AND FACE. 37 fourth process, the palatine. This process starts out from the middle of the bone, and divides it into two unequal parts. Like the orbital plate, it is at right angles with the body, and, when the piece is articulated, is seen to divide the nose from the mouth, constituting the floor of the first cavity and the roof of the second. Posteriorly, it is quite thin, and articulates with the palatine process of the palate bone. Running forward, it grows thicker aud heavier, and ends in the anterior nasal spine. Viewed above, its surface is slightly con- cave, to form the floor of the nares. Externally, it becomes merged into the body of the bone; internally or mesially, it rises into a ridge, which is the one side of a groove receiving into articula- tion the vomer. A bristle passed through an opening in the pro- cess shows the position of a canal, the anterior palatine, transmitting vessels of that name, which find entrance into the oral cavity through the incisive foramen seen just back of the centre tooth. A nerve, the naso-palatine, having considerable surgical signification, enters the mouth at the orifice of this canal, but is not transmitted by it, having a canal of its own in the intermaxillary suture. The three marked points of surgical interest in this process are — first, the fact of its forming the boundary between the mouth and nose ; a break in its continuity, and which, unfortunately, is a not infrequent acci- dent, throwing these two cavities into one; second, the nature and relation of suture with the palatine process of the palate bone, this being the line of separation in amputation; third, the position of entrance of the naso-palatine nerve, paralysis of the parts supplied by this nerve being a frequent result of ill-applied pieces of dental apparatus. To these three might be added a fourth, the position of the artery occupying the posterior palatine canal, an artery which is sometimes of considerable size, and which might easily be cut by the slip of a lancet applied to the gum of a wisdom tooth, or in the act of dividing the tendon of the flexor palati where it curves around the hamular process. The other features observable on this aspect of the bone are with- out special surgical interest. Above the inferior meatus, which is the space between the floor of the nares and the inferior turbinated bone, is seen the crest of attachment for this scroll. Still higher, on the nasal process, are the crests for union with the superior and middle scrolls. The middle meatus, into which opens the antrum, is observed to be quite a large space, particularly when compared with the superior meatus, which is the slit lying between the upper and middle crests. The opening of the antrum, seen in the back 38 ORAL DISEASES AND SURGERY. part of the- middle meatus, is here portrayed of a natural size — that is, natural to the disarticulated bone. It will be remembered, how- ever, that it is filled in by other bones, which, in the articulated skull, reduce the opening to an outlet not larger than an ordinary probe; the bones closing in this cavity are the ethmoid, palate, and inferior turbinated. (See descriptions of these bones.) The superior maxillary bone articulates with nine others: by its nasal crest with the frontal, ethmoid, lachrymal, and nasal ; by its malar process with the malar ; at the intermaxillary suture with the opposite maxilla; by its palatine process with the palate and vomer, and at the lower of the lateral crests with the inferior turbinated bone. Nine muscles have their origin from this bone : the orbicularis palpebrarum, the inferior oblique of orbit, the elevator of superior lip and wing of nose, the proper elevator of lip, the angular eleva- tor, the compressor naris, the depressor of the ala, the masseter, and the buccinator. INFEKIOR MAXILLAKY BONE. The inferior maxillar}^ bone, the largest and strongest bone of the face, consists of a body, horseshoe in shape, and of two rami, joined to the body at right angles. The body, which is the anterior portion, is surmounted by a process of more or less spongy bone, excavated for the reception of the teeth ; the basement portion, or Fig. 4. — Inferior Maxillary Bonk. 1, body; 2, ramus; 3, symphysis; 4, base; 5, angle; 6, mental foramen; 7. condyle; 8, coronoid process ; 9, semilunar notch ; 10, inferior dental foramen, the entrance of the corresponding canal; 11, alveolar border; 12, incisor teeth; 13, canine tooth; 14, pre- molars ; 15, large molars. that portion beneath the spongy series of cells, or alveolar process, is made up of very dense structure, and so hard and resisting as to be able to withstand very considerable blows. The rami, curved and angular at the base, terminate above in two processes : the ANATOMY OF THE MOUTH AND FACE. 39 condyloid, for articulation with the glenoid cavity in the temporal bone, and the coronoid, for the attachment of the temporal muscle. The angle of relation of the perpendicular to the horizontal portion of the bone varies with different ages. In early infancy it is very obtuse ; indeed, the two portions are nearly on the same plane. In adult life a right-angled relation is obtained, and this changes again to the obtuse as age advances, and the teeth fall out. Taking advantage of a knowledge of these changes, the surgeon is enabled to correct, in young life, the great deformity of an unduly projecting lower jaw. Looking at the external face of the body, the attention is first at- tracted by a prominent foramen situated beneath the bicuspid teeth. This foramen is called the mental, and from it pass out, to be dis- tributed to the lip and gum, the inferior dental artery and inferior dental nerve; the situation of the foramen represents the line of re- lation between the hard and spongy portions. It is at this opening that section of the nerve is occasionally made for severe and resisting labial neuralgia. A bristle passed into this foramen, inclined back- ward, is directed along a canal at the base of the teeth, and emerges at an opening situated on the inner face of the ramus. Passed for- ward, it enters a smaller canal, which continues under the central teeth, carrying to these organs branches of the nerve and artery. An oblique line — the external oblique line, as it is called — fairly divides the surface of the body into two triangles. This line is for the attachment of muscles, and accommodates the buccinator, in part, the depressor anguli oris, and the depressor labii inferioris In old persons, after the loss of the teeth, and absorption of the alveolar process, it is found to run almost along the upper surface. The centre vertical line, called the symphysis, represents the position or division existing in the young bone, union of the two halves not occurring until about the end of the first year. The levator metiti muscle has its origin from the fossa at the side of this line. The mental process, the tubercle at the base of the symphysis, is only a thickening, for the greater strength of the part. Viewed from above downward, the body of the lower jaw is concave ; from behind forward it is convex. The external face of the ramus or perpendicular portion of the bone exhibits a quadrilateral aspect, broken above by a notch, the sigmoid, which separates the two projecting processes. The anterior of these processes is a thin, flattened, triangular eminence, giving attachment to the masseter and temporal muscles. The posterior 40 ORAL DISEASES AND SURG ERF. eminence, the condyloid process, is an oval projection, convex and smooth, with its face covered with articular cartilage, and having its greatest width from side to side. This process articulates the bone with the temporal, and is occasionally the seat of fracture and luxation. The internal face of the bone presents the same general vievr as the external. A ridge, the mylo-hyoid, divides the body by its oblique line into two parts. To this ridge is attached, or rather from it has origin, a muscle of the same name. This muscle, with its fellow of the oppo- site side, forms the floor of the mouth, so that looking at the line one sees exactly how much of the bone is within and how much without the oral cavity. Just below the line, about midway of the body of the bone, is seen a fossa or depression, the submaxillary, for the accommodation of the gland of that name. The mesial line or sym- physis presents on either side two tubercles, called the genial tubercles, to which are attached the genio-hyoglossi and the genio- hyoideus muscles. Outside of these tubercles; on either side, are two fossae for the lodgment of the sublingual glands ; these fossae are called by the name of the glands. It will be observed that as these fossae lie above the ridge, the lingual glands must be within the mouth, while the submaxillary fossae being below it, these glands are without the cavity. One most important feature to remark is the relation of the anterior border of the vertical portion of the bone to the molar teeth. It not unfrequently happens that this border so nearly approximates the second molar that there is no room for the eruption of the third; the most formidable inflammations sometimes result from such a cause, the crown of the tooth being held down under the ramus. Extraction of the adjoining anterior tooth, it will be seen, would allow the confined one to fall forward. A marked feature of diflFerence between the internal and external face of the ramus is the existence in the former of a large foramen, the inferior dental, for transmission into the canal alluded to, as passing beneath the teeth, of the inferior maxillary vessels and nerve. The position of this foramen is to be appreciated by accu- rate measurement, as just within it is performed the operation of section of the nerve. A groove, the raylo-hyoid, transmits to the muscle of the ridge an artery, which comes from the inferior maxil- lary just as it is about to enter its canal. Attached to the border and internal face of the coronoid process is the tendinous expansion of the temporal muscle, while to the face of the condyloid is attached ANATOMY OF THE MOUTH AND FACE. 41 the pteiygoideus externus, the internal pterygoid being related to the angle. The semilunar depression, separating the two condyles, the sigmoid notch, is crossed by the masseteric artery and nerve, while in its immediate proximity are the internal carotid and internal maxillary arteries. Figs. 5 and 6. — Palate Bone. Posterior view of the right palate boxe. 1, palate plate; 2, nasal plate; 3, pyraiiiiditl process ; 4, articular border for the left palate lione ; 5, palate spine ; 6, ridge for junction with the turbinated bone; 7, spheno-palatine notch, between 8, the orbital, and 9, the sphenoidal process ; 10, groove for the in- ternal pterygoid process of the sphenoid bone ; 11, position of the posterior palatine foramen. Exterior view op the right palate bone. 1, rough surface articulating with the su- perior maxillary bone, and diminishing the aperture of the maxillary sinus; 2, posterior palatine canal, completed by the tuberosity of the superior maxillary bone; 3, spheno- palatine notch ; 4, 5, 6, orbital process ; 4, surface directed toward the pterygo-max- illary fossa; 5, orbital surface; 6, maxillary border; 7, sphenoidal process; 8, pyramidal process. The palate bone in position is seen to form the back part of the hard palate, a portion of the floor and side of the nares, and a part of the orbital cavity. It also enters into the formation of three fossae: the zygomatic, spheno-maxillary, and pterygoid. Like the inferior maxillary, the bone consists of two portions : one horizontal, the other at right angles with it, or vertical. The horizontal portion is irregularly quadrilateral, presenting two surfaces and four borders : the upper of the two surfaces is concave, and forms the back part of the floor of the nares; the lower or under surface is also concave, and forms the back of the hard palate. The suture of connection with the maxillary bone is always plainly seen, and is called the palato- maxillary suture. In glancing at the bone from its posterior view, it is seen very markedly to resemble the letter L. Studying it in detail, we may re- mark, first, the spine, situated at the base of the interpalatal suture, and which gives attachment to one of the motores uvulae muscles; passing toward the vertical portion, the concave character of both 42 ORAL DISEASES AND SURGERY. nasal and palatine faces is observed, the former much more marked than the latter. This nasal concavity is seen to end at a crest or ridge on the vertical portion. This ridge is the most posterior articular surface of the inferior turbinated bone, and the space below it is a part of the inferior meatus. The base of the vertical portion is pyramidal, and ends in a process called the pterygoid or tuberosity, its articu- lation being with the pterygoid plates of the sphenoid. At the back part of this process are seen three grooves : the middle one, wide and smooth, forms part of the pterygoid fossa, and gives attachment to the internal pterygoid muscle ; the two lateral are rough and uneven, and articulate with the anterior border of each pterygoid plate. Passing upward, the prominent feature is the sphenoid process. This is a comparatively thin plate, made up of an articular and non- articular surface, a groove and a notch. The articular surface as- sociates the plate with the sphenoid bone ; the non-articular enters into the composition of the zygomatic fossa. The groove contributes to the formation of the pterygo-palatine canal ; and the notch, closed in above by the orbital process, forms the greater part of the spheno-palatine foramen. This process also contributes, by one of its surfaces, to the lateral wall of the nasal fossa. The orbital process, resting on the sphenoidal, is composed of five plates, or surfaces, and includes a cavity. Of these processes, three are articular, two, free surfaces. The articular are the maxillary, the sphenoidal, and the ethmoidal, associating the process with these bones. The free surfaces are the orbital, forming a small part of the orbital cavity, and the zygomatic, entering into the composition of the zygomatic fossa. Looking on the inner face of the bone, we remark, first, the articu- lar process. This process or surface associates the bone with its fellow of the opposite side; above, it forms, with its neighboring piece, a ridge receiving the vomer. The body of this face seems made up of two great concavities, with a separating ridge. This ridge articulates the inferior turbinated bone ; the concavity above is part of the middle meatus ; that below, part of the inferior meatus; the ridge or crest is called the inferior turbinated crest. A second crest, situated at the upper boundary of the middle meatus, articulates the lower scroll of the ethmoid, or the middle turbinated bone. This is called the superior turbinated crest. Just below it is seen the now perfected notch in the sphenoidal process, the spheno- palatine foramen, for the transmission of the vessels and nerve of ANAT03IY OF THE MOUTH AND FACE. 43 that name. Abov^e the superior crest is seen the posterior part of the superior meatus, a horizontal groove, bounded above by the lower border of the ethmoidal face of the orbital process. The orbital process, seen from this side, presents three surfaces : the maxillary in front, the orbital above, and the ethmoidal in- ternally. The lateral surfaces of the bone are almost entirely articular. That looking front associates in its full length with the superior maxillary bone ; that looking back, with the sphenoid, through its pterygoid processes. This very full articulation with these two bones leads us to speak of the palate bone as being wedged between them, and being supported by them. The articulations of the palate bone are with seven others : the superior maxillary, the inferior and superior turbinated, the vomer, the sphenoid, the ethmoid, and its fellow of the opposite side. The muscles attached to it are the tensor palati, the motor uvulae, and the internal and external pterygoid. THE VOMER. The vomer, plowshare-shaped, constitutes a portion of the septum narium. It articulates below with the interpalatine suture of the superior maxillae and palate bones ; above, with the perpendicular plate of the ethmoid ; by its base with the laminae and rostrum of Fig. 7. — The Vomer. View of left side. 1, 1, broad groove receiving the rostrum of the sphenoid bone ; 2, 2, inferior border articiihiting with the palate plates of the superior maxillary and palate bones ; 3, posterior border, the dividing line of the posterior nares ; 4, 4, groove border receiving a narrow slip of cartilage, situated between the vomer and the nasal plate of the ethmoid bone ; 5, 5, border for the cartilaginous septum of the nose ; 6, 6, nasal surface. the sphenoid bone ; in front it associates with the triangular cartilage ; posteriorly it is seen separating the nares. The naso-palatine groove, seen running from the base, forward and downward, toward the triangular cartilage, transmits the naso-palatine nerve to the inter- palatine canal. 44 ORAL DISEASES AND SURGERY. Occasionally it is the case that the vomer is found markedly bent to one side or the other, and this to such an extent, frequently, as completely to obliterate one of the nares, requiring an operation for its relief. The vomer is also subject to syphilitic attacks, and fre- quently breaks down, allowing the arch of the nose to fall in. FiQ. 8. — Articular Kelations of Vomer. Vertical section of the face, exhibiting the osseous nasal septum. 1, frontal bone; 2, frontal sinus; 3, nasal spine of the frontal bone; 4, nasal bone; 5, nasal spine of the superior maxillary bone ; 6, nasal process of the same bone ; 7, border of the palate plate of the same; 8, incisive foramen; 9, left posterior naris ; 10, palate plate of the palate bone ; 11, nasal plate of the ethmoid bone ; 12, ethmoidal crest ; 13, vomer ; 14, left turbi- nated bone; 15, sphenoidal sinus; 16, internal pterygoid process; 17, external pterj'goid process. The articulation is seen to be with six bones ; the two superior maxillary, the two palate, the sphenoid, and the ethmoid ; also with the cartilaginous septum, not shown in the view, but occupying the triangular break. Running across each lateral face of the nasal cavities are three scrolls, known as the turbinated bones. Of these scrolls, the two upper are simply processes, or portions of the ethmoid bone; the lower is a distinct piece, and is called the inferior turbinated bone. Observing the position of these scrolls, it is remarked that each curves over a portion of the sides of the nares. The spaces thus inclosed are called the meatus. The lower or inferior of these cavities is bounded below by the floor of the nares ; above by the inferior turbinated bone. An opening seen about its middle is the ANATOMY OF THE MOUTH AND FACE. 45 outlet of the lachrymal canal. The middle meatus is the space bounded below by the upper surface of the inferior scroll ; above by the lower surface of the middle scroll. A foramen seen in this meatus Fig. 9. — Position and Eelations or Turbinated Bones. A'lEW OF THE OUTER WALL OF THE RIGHT NASAL FOSSA. 1, froiitiil bone ; 2, its orbital plate ; 3, its n.asal spine; 4, nasal bone; 5, etl)nioidbone; 6, its upper turbinated process; 7, its lower turbinated process; 8, turbinated bone; 9, process of the lachrymal bone within the position of which is the lachrymo-naeal duct ; 10, nasal spine of the superior maxil- lary bone; 11, naso-palatine canal ; 12, palate plate of the superior maxillary bone; 13, nasal process of the latter; 14, external pterygoid process; 15, internal pterygoid pro- cess ; 16, nasal plate of the palate bone; 17, its palate plate ; 18, posterior palatine fora- men ; 19, superior meatus of the nose ; 20, middle meatus ; 21, inferior meatus ; 22, frontal sinus ; 23, sphenoidal sinus ; 24, its communication with the upper back part of the nose; 25, spheno-palatine foramen ; 26, orifice of the maxillary sinus. is the outlet of the antrum. The superior meatus is the slit seen between the two upper scrolls. The distinct, or inferior turbinated bone, is a thin, spongy scroll, having a base of attachment the whole length of the lower crest seen on the nasal surfaces of the maxillary and palate bones ; the opposite, or inferior edge, is free, and lies in the middle of the in- ferior meatus. Viewed from its inner surface, the bone presents a most irregular appearance, being perforated with numerous aper- tures, sulci, and grooves, for the accommodation of arteries and veins. Two processes, the lachrymal and the ethmoid, are seen to break the regularity of the upper convexity. The anterior — the lachrymal — articulates with the inferior angle of the lachrymal bone, and with the nasal crest of the maxillary bone, thus assisting in forming the 46 ORAL DISEASES AND SURGERY. lachrymal canal. The posterior — the ethmoidal — articulates with the descending unciform process of the ethmoid bone. Turning here the bone, we see a third process, or division, as it were, made in the ethmoidal. This process is called the maxillary. It curves down- ward within the inferior meatus, assisting in filling up the antral orifice, and, in its attachment, steadies the bone firmly on the side of the nares. Externally, the general appearance of the bone is con- cave; internally, or looking toward the septum narium, it is convex. If the external surface were convex, and the processes absent, the bone might very well be likened in shape to the Indian stone arrow-head. The turbinated bone is very subject to specific inflammation, and which, without great care, is apt to end in its death. The bone articulates with four others : the ethmoid, the lachry- mal, the maxillary, and the palate. No muscles are attached to it. THE ETHMOID BONE. Fig. 10. — Ethmoid Bone- View. -Gexeral A horizontal cribriform plate of bone, with a crest along its middle; a perpendicular plate dropping down from the centre of this first piece; two little oblong square boxes, hung on either side of the per[)endicular plate, leaving the space of a narrow slit between the boxes on either side and the plate, and we have the complete idea of the ethmoid bone. Look- ing at the bone from above, we re- mark, first, the crest — crista galli it is called — giving attaciimeut to the falx cerebri. On either side of this crest is seen a depression perforated with a number of fora- mina. These depressions lodge the olfactory bulbs, and the fora- mina transmit to the nose the olfactory filaments, the three sets having corresponding foramina. A slit seen at the side of the crista galli transmits the nasal branch of the ophthalmic nerve. Looked at anteriorly, the crest is seen to terminate in two little 1, orbital surface of the lateral mass ; 2 posterior extremity of the cribriform plate, Avhich unites the lateral masses, and is de- pressed and perforated with numerous fora- mina on each side of the ethmoidal crest 3; the two oblique processes in advauce of the latter are the ethmoidal wings; 4, anterior extremity of the nasal plate; 5, the ethmoidal sinuses. ANATOMY OF THE 310 UTH AND FACE. 47 horns or wings; these articulate with depressions in the os frontis, and occasionally in a manner so imperfect as to leave an opening or foramen. When existing, this foramen accommodates a nasal vein, which passes upward, to terminate in the longitudinal sinus ; the rupture of this vein, discharging the sinus, has saved many lives in attacks of congestion. The perpendicular plate, exhibited by the removal of one of the lateral masses, is simply a thin plate of bone. This, descending in the middle line of the nose, assists the vomer in separating this cavity into two lateral halves. In front, it is received into the groove between the two nasal bones ; below, it looks downward and forward, and receives the triangular cartilage ; back of this it articu- lates with the vomer, and still farther back with the sphenoid. On each side of the plate are seen numerous grooves leading from the foramina in the horizontal or cribriform plate; these are chan- nels receiving and shielding the inner olfactory filaments. The boxes or lateral masses are very loose, and areolar-like, and constitute a series of cells. Disarticulated, many of these cells appear broken ; but when associated with the ethmoidal fissure of the frontal bone, with the sphenoidal scrolls, with the orbital processes of the palate bones, and the nasal processes of the maxillary and palate bones, the cells are found to be completed. The union of these cells, more or less directly, with the common uares, and the fact that they are all lined by a mucous membrane continued from these fossae, explain the sense of congestion and fullness known as " cold in the head." The outer surface, or face of the boxes, looks very much in color like the common clarified quill, is semi-translucent, square in shape, and very smooth. Referring to the view of the skull (Fig. 1), this surface will be seen entering into the composition of the orbital cavity. The portion of the ethmoid which receives and articulates the process passing upward from the inferior turbinated bone is a hook-like projection from the under surface of these lateral masses. It is called the unciform process, and assists in narrowing the orifice of the antrum and supporting the masses. The internal surface of each lateral mass approaches the perpen- dicular plate. At the upper part is the narrow fissure, bounded by a scroll-like process on the surface, known as the superior meatus. The scroll has received the name of the superior turbinated bone. Below this first scroll, on the same surface, is a second. This second 48 ORAL DISEASES AND SURGERY. scroll is called the middle turbinated bone, and the space below it, between it and the inferior turbinated bone, is the middle meatus. In looking at the ethmoid bone in position, it will be seen to be wedged in between the nasal, frontal, lachrymal, and maxillary- bones in front, and the sphenoid behind; below, it is supported by the turbinated, vomer, and palate bones. Blows received upon the bridge of the nose have not unfrequently carried the crista galli into the substance of the brain ; while maxillary diseases find an easy road to the base of the cranium through the nasal communication with the ethmoidal cells. THE SPHENOID BONE. The sphenoid bone, named from its wedge-like relations to other bones of the cranium, has been frequently and most aptly compared in appearance to a "bat" with extended wings and unflexed legs. Fig. 11. — The Sphenoid Bone — Upper View. 1. pituitary fossa; 2, olivary process; 3, declivity; 4, anterior clinoid process; 5, pos- terior clinoid process ; 6, posterior border of the body ; 7, cerebral surface cff the great wing; 8, articular surface for the frontal bone; 9, articular border for the temporal bone; 10, spinous process; 11, small wing; 12, liorder articulating with the orbital plate of the frontal boue; 13, border joining the ethmoid bone; 14, optic foramen; 15, sphenoidal for- amen; 16, rotund foramen; 17, oval foramen; 18, spinous foramen; 19, groove for the internal carotid artery. In looking at the disarticulated bone, we first observe a central portion or body; this body is irregularly square, and marked on all its surfaces with features which one at once infers to be possessed of anatomical significance. Extending laterally on either side from the body are two great wings ; these wings are made double by a lacerated foramen, and instead of being spoken of and described as a single pair, are mostly viewed as two pairs, — the larger portion being called the greater wings, the smaller pair the lesser wings. ANATOMY OF THE 310 UTH AND FACE. 49 The leg's, falling from the base of the cranium, are found separated by a notch into two portions, — this separation, however, being much more marked behind than in front: they have received the name of pterygoid processes. Fig 12. — The Sphenoid Bone — Front View. 1, 2, sphenoidal crest and rostrum for joining the nasal plate of the ethmoid hone and the vomer; 3, entrance of the sphenoidal sinuses; 4, small wing; 5, optic foramen piercing its base; 6, sphenoidal foramen; 7, rotund foramen; 8, orbital surface of the great wing; 9, temporal surface of the same; 10, ridge separating the temporal and spheno-maxillary fossse; 11, position of the i)terygo-palatine canal ; 12, pterygoid canal ; 13, internal pterygoid process, ending in a hook; 14, 15, external pterygoid process ; 16, spinous process ; 17, oval foramen ; 18, spinous foramen. Beginning a study of the body from its superior or cranial sur- face, attention is first naturally directed to a saddle- like depression occupying a large portion of this face. This depression lodges a little body attached to the floor of the third ventricle, the pituitary body ; hence it is called by many authors the pituitary depression or fossa; and from its resemblance to the Turkish saddle it is as frequently named the sella turcica, A number of little pits seen on the floor are foramina transmitting vessels of nutrition. On either side are two processes ; these correspond to two others, terminating the plate of bone which represents the back of the saddle. The four have been compared to the posts of a bedstead, and are called clinoid processes. Passing forward, an olive-shaped eminence is next noticed, — the olivary process; and directly in front of this, a groove or oblong fossa. This groove has resting in it the commissure of the optic nerve, and hence is called the optic groove. Passing directly forward, we find the surface terminate in a spine or projecting point; this point articulates the surface with the eth- moidal bone, and is called the ethmoidal spine ; between this spine and the optic groove is a slight eminence falling off on either side into a line of depression ; these lines lodge the olfactory nerves. Two foramina, seen on this surface at either terminus of the optic 50 OBAL DISEASES AND SURGERY. groove, are called optic foramina; they transmit to the orbital cavi- ties the optic nerves and ophthalmic arteries. From the back of the saddle the surface is seen to slope gradually downward ; this con- cave plane lodges the medulla oblongata, and terminates at the line of union with the occipital bone. On either side is situated a tor- tuous depression, in which lie the internal carotid artery and the cavernous sinus. Turning now to the anterior surface, we observe, first, a rostrum or beak, for articulation with the perpendicular plate'of the ethmoid. On either side of this beak are seen scrolls of bone, or rather lamellae, — the sphenoidal turbinated bones, as they are called. These la- melliB, we find, imperfectly close sinuses which hollow out the sub- stance of the body, and which, in articulation, are found to commu- nicate with the upper part of the nose, and frequently with the ethmoidal cells ; being lined with the mucous membrane of the nares, and subjected consequently to the sympathies of continuity. The inferior surface presents us, first, with the rostrum or beak; continued from the anterior face, this spine is received into a groove or fissure in the vomer. On either side are laminae of bone, which pass to the pterygoid processes ; these plates or laminae are called vaginal processes. Close to the pterygoid process is seen a groove, which the sphenoidal process of the palate-bone converts into a canal ; this groove transmits the pterygo-palatine vessels and pha- ryngeal nerve. The posterior surface in this bone exhibits simply a quadrilateral sawed surface, a union existing with the occipital at this point, which has required the saw for its separation. Hence it has been a common practice with many writers to consider the sphenoid and occipital as one bone, and to refer to them as the spheno-occipital bone. The Wings, which may next claim attention, are called the greater and lesser, the separation existing at the lacerated foramen. The greater wings extend laterally, and assist largely in forming the floor of the fossae which receive the middle lobes of the brain. Looked at from the encranial aspect, attention is first attracted to six foramina, — three on either side. The first of these is a round hole, and is called the foramen rotundum ; it transmits from the brain to the superior maxillary bone the second branch of the fifth nerve. The second hole is oval in shape ; hence called the foramen ovale : it transmits the third, or inferior maxillary branch of the fifth. The third, the foramen spinosum, transmits the middle me- ningeal artery. A fourth foramen is occasionally found in the great A.VATOMY OF THE MOUTH AND FACE. 51 wing, — the vesalii. When existing, it is occupied by a small vein. The general floor of these wings is concave, and marked with eleva- tions and depressions for the accommodation of neighboring convo- lutions. Turning the bone, these wings are seen to be made up of three surfaces: the encranial face, as just described; an external surface, occuj)ying, when in articulation, a place in the base of the skull ; and an orbital surface. The external surface is irregularly convex, and is separated into two portions by a ridge called the pterygoid. The superior of these two faces is seen entering into the composition of the temporal fossa for lodgment of the temporal muscle. The inferior face lies beneath the zygoma, and forms part of the fossa of this name, giving attachment to the external pterygoid muscle. Running from the postero-lateral angle of the surface is seen a prolonged spine : to this are attached the laxator tympani muscle and the internal lateral ligament of the lower jaw. • The orbital face of the wing assists in forming the outer boundary of the orbit ; it is quadrilateral in form, smooth, and concave. Below, it has a somewhat rounded border, and enters into the formation of the spheno-maxillary fissure; internally, it assists in forming the sphenoidal fissure. At the lower edge of the inner border is a deli- cate spine, giving origin to one head of the external rectus muscle. The foramina generally seen on this face are called orbitar foramina : they transmit small arteries. The lesser wings, frequently described as the processes of In- grassias, are seen on the encranial surface extending outward, over- lying at their apices the great wings. These wings are triangular in shape, having their bases associated with the body of the bone. In articulation they complete the posterior boundary of the anterior fossae of the cranium, and are lodged in the fissure of Sylvius. The fissure or slit which separates them from the great wings is called the lacerated foramen. It transmits the first or ophthalmic branch of the fifth nerve, the third, fourth, and sixth nerves, and the oph- thalmic vein The lesser wings are connected with the body by two footstalks, inclosing within them and assisting in forming the optic foramina. A process seen jutting backward from the foramen is called the anterior clinoid process ; to it is attached the common tendon of the recti muscles. The legs or pterygoid processes, seen falling from the point of union of the great wings with the body, consist of two plates, sep. 52 ORAL DISEASES AND SURGERY arated beliind by a deep notch, but united almost fully in front. The external plate is broad and curved, and forms part of the zygomatic fossa ; to it is attached the external pterygoid muscle. The internal face forms part of the pterygoid fossa, and gives origin to the inter- nal pterygoid. The internal plate has a particular interest ; it ends in a tubercle or hook-like process, which is felt in the mouth just back of the maxillary tuberosity, — the hamular process; around it turns the tendon of the tensor palati muscle, — a tendon to be divided in the operation for cleft palate. The base of this internal plate forms a fossa, the scaphoid, from which originates the tensor muscle just alluded to. The outer surface of this plate forms the pterygoid fossa; the inner assists in forming the outer posterior boundary of the nares. The base of the pterygoid process is quite broad, and in front gives support to Meckel's ganglion. The vidian canal jjasses througli it. The sphenoid articulates with all the bones of the cranium, witii the two malar, the vomer, and two palate bones of the face. The muscles to which it gives origin are the temporal, external, and internal pterygoid, tensor palati, laxator tympani, levator pal- pebrae, the recti of the eye, and superior oblique of eye. THE NASAL BONE. The figure exhibits the faces of a left nasal bone articulating with its fellow, which is its counterpart; the two occupy the quadri- ^ ,„ „ lateral space existing between the two maxillarv Fig. 13 —Nasal ' * Bone. bones and the frontal, and form the prominence known as the nasal bridge. That these bones vary considerably in shape would be inferred from va- riations in the shape of the bridge so frequently seen. Looked at from above downward, each bone is observed to be concave, while viewed from side to side, it is convex; several light grooves are commonly noticed on the surface for the accommodation of vessels ; the foramen seen about the centre transmits a small vein. The inner surface reverses relations with the outer — being convex from above below, concave from side to side. Its onh^ feature of interest is a groove for the lodgment of the nasal nerve. The borders of the bone are three articular and one free. The Anterior view or THE LEFT XASAL BOXE. 1, frontal border ; 2, nasiU border; 3, niiixil- lary border ; 4, lower border ; 5, nasal fora- men. ANATOMY OF THE MOUTH AND FACE. 53 superior, serrated and somewhat narrow, fits' in the frontal notch, forming the fronto-nasal articulation. The lateral border is bev- eled, at the expense, above, of the internal plate, below, of the external, and fits with corresponding bevelings of the nasal pro- cesses of the maxillary bone. Internally, or mesially, the bone articulates with its fellow of the opposite side, being prolonged below into a crest, which forms a part of the nasal septum, and articulates with the nasal spine of the frontal above, and the ethmoidal perpendicular plate below. The lower border is free, at least so far as any bony articulation is concerned, giving attachment by a thin, sharp edge to the lateral cartilage of the nose. A notch, seen at the centre of this border, transmits the nerve occupying the groove on the inner surface. THE MALAPv BONE. Fig. 14.— The Malar Bone. The malar, or cheek bones, may be likened to two bony pads laid on either lateral aspect of the face for the purpose of influencing a general convexity. Each bone is ir- regularly quadrilateral, supported above by articulation with the frontal, sphenoid, and superior maxillary bones ; in front by the malar process of the maxillary ; posteriorly by the zygomatic process of the temporal. The bone presents two surfaces, four processes, and four borders. The external surface, convex and smooth, presents little of interest ; the fora- men, seen upon this face, is some- times replaced by two or more ; they are simply the orifices of canals, trans- mitting unimportant vessels. The surface, in relationship, is mostly covered by the orbicularis palpebrarum muscle, while the zygomatici have origin from the lower and inner aspect. The internal face is concave, and assists in forming, above, the temporal fossa, below, the zygomatic. It yields partial origin to both the temporal and masseter muscles. Of the four processes, the orbital is the most interesting ; turning at right angles with the external face of the body, it assists in form- OUTERVIEWOF THE RIGHT MALAR BONE. 1, external or facial surface; 2, malar fora- men ; 3, frontal process; -t, 5, orbital bor der; 6, maxillary border; 7, zygomatic process; 8, temporal border; 9, inferior border. 54 ORAL DISEASES AND SURGERY. ing a portion of the outer wall of tlie orbit and orbital ridge. The frontal is thick and serrated, and articulates with the external angu- lar process of the frontal bone. The ma.x'illary is rough, and trian- gular in shape, and attaches the bone in front. The zygomatic is sharp and flat, and forms part of the yoke overlying the ridge sep- arating the zygomatic from the temporal fossa. The four borders are the orbital, the maxillary, zygomatic, and temporal. These borders correspond with the relations named, but have no interest apart from the processes. THE LACHRYMAL BONE. Fig. 15.— The Lach- rymal Bone. Looking at the view, or, much better, at the articulated skull, the lachrymal bone is seen to occupy a position of some prominence in the composition of the orbit. A ridge on its anterior surface divides the bone into two parts : one part, called its orbital face (bounded above by the orbital face of the horizontal plate of the frontal bone ; laterally, by the os planum of the ethmoid ; below, by the orbital surface of the maxillary bone), enters into the compo- sition of the orbital cavity. The face, to the inner side of the ridge, is smooth and concave, and articulates with the nasal process of the maxillary bone, internally, and with the lach- rA'mal process of the turbinated, below; these three bones in their union form the ductus ad nasum, or lachrymal canal, transmitting the tears to the inferior meatus. The bone, by its internal or nasal surface, enters into the composition of the middle meatus, and assists in closing in the anterior ethmoidal cells. Like the external surface, it is divided into two faces, the line of division being a depression corresponding with the ridge on the opposite surface. Only one muscle has its attachment to this bone, — the tensor tarsi. External view of the right lachrymal bone. 1, orbital surface ; 2, lachry- mal fossa; 3, small process bounding the latter inte- riorly ; 4, frontal border ; 5, ethmoidal border ; 6, max- illary border ; 7, process articulating with the tur- binated bone. THE HYOID BONE. The OS hyoides is the bone situated on the anterior part of the neck between the chin and sternum. In shape it somewhat resem- ANATOMY OF THE MOUTH AND FACE. 55 bo, point, hav- (93) 94 ORAL DISEASES AND SURGERY. ing two points ; molares, from mola, a mill ; denies sapientiae, teeth of wisdom, — so called from being developed in mature life. Fig. 3S. reriiiaiK-iit tcetli iil Miperior jaw. Nos. 1 and 2 of Fig. 38 represent the incisor teeth of the upper jaw, and Nos. 1 and 2 of Fig. 39, the incisor teeth of the lower jaw. These teeth may be described as possessed of chisel-shaped bodies rest- ing upon conoidal roots ; or viewed from the surgical aspect, they are to be considered as two cones, the bases of which abut just beneath the free margin of the gum. In number, the incisor teeth are eight — four I'lMiiiiiiu-iit tcftli ut interioi- jaw. above and four below ; these are classified as central and lateral. The central incisors of the upper maxilla are fully one-third greater in breadth, and, indeed, in general bulk, than the lateral ; a condition found reversed in the inferior jaw, where the laterals are larger than the central, although not to the same extent of difference as above. In length, the superior central teeth are, on the average, one inch; the laterals of the same jaw, from one-third to a fourth less. Below, while the depths of the crowns are found to cor- respond, the root of the lateral is a trifle longer. The crowns of the superior incisors are slightly convex in front, markedl}^ con- cave behind, often, indeed, having on this face a central depression, DENTITIOy. 95 which, from imperfection in the enamel covering, frequentl\^ becomes the seat of caries. The inferior incisors, both central and lateral, partake more of the wedge shape. The enamel of the incisors, being most markedly exhibited in the superior centrals, is thickest at the cutting face, and gradually declines toward the neck, where it terminates in an abrupt line of convex aspect in front and behind, the convexity looking toward the root. At the sides, the enamel forms Lateral view of the upper and lower permanent teeth. 1, first incisors; 2, canines ; 3, first premolars ; 4, middle molars. a concave line, the concavity looking toward the free edge. The line of the enamel corresponds with the periosteal relation, and in the firmness of the ring-like fibres of this tissue exhibits the con- centration of the sac, which, before the eruption of the teeth, en- velops the whole crown, only a portion of which has been absorbed in the eruptive act. The Cusjndati — canines, eye, stomach (3) teeth — represent the carnivorous expression in our species. These bodies, spear-shaped in general form, terminating in an. obtuse point, are convex in front, and are apt to vary in shape behind. Very strong and fixed, they serve the lower animals in seizing and tearing their prey. The roots are the longest of all the teeth, and are very slightly flattened cones. The superior of these teeth are called eye teeth; the infe- rior, stomach teeth. 96 ORAL DISEASES AND SURGERY. Fio. 41. The Bicuspidati — premolars — (4 and 5) have rounded crowns, with a double-cusped grinding surface and intervening sulcus. The roots of these teeth are decidedly flattened, and iu the anterior are apt to have a longitudinal division which frequently separates the single fang into two parts. Occasionally, though ver}" rarely, these teeth will be found to have three distinct roots. The Molars (6 and 7) have crowns of cuboid shape, are four-cusped, and roughened, for purposes of trituration. The superior have each three conoidal roots; two of these are situated antero- posteriorly ; the third, somewhat flat- tened, looks toward the palatine aspect. The inferior have two roots, the inter- space being buccal and lingual. The Denies Sapienliee (8) are in re- alit}^ the third molars; they dilfor, how- ever, in being somewhat smaller, and in having commortly but a single root, al- thougli this root may be recognized as a blending of the roots distinguishing the other molars. It commonly curves back- ward. The names of the teeth, expressed in the singular number, are, incisor, cuspi- datus, bicuspidatus, molar, dens sa- pientiae. Figs. 41 and 42 show teeth in sec- tion. In the centre is a cavity, occu- pied by a pulp, the tooth-pulp : that which is its analogue, a periodonteum, envelops the roots. These membranes are the nutrient vehicles of the organ, holding and conveying the blood-vessels and nerves. Yariations in the shape and relationship of the pulp cavity are matters of surgical interest, as not unfre- quently a near approach to the neighborhood of the surface allows its exposure by a very limited caries. A tooth is divided into three pai'ts: a crown, root or fang, and neck. The crown of a tooth is the exposed part ; the fang, the part A'Er.TlL'AL M.lTI'.iV 111- A .M"LaU TO'JTII, indderatc'ly niagiiifii'd. 1, enaiiiel, the lines of which indicate the ar- rangement of its columns; 2, den- tine, the lines indicating the course of its tubules ; 3, thin lamina of the dentine forming the wall of the pulp cavity, the dots indicating the ori- fices of the dentinal tubules; 4, cement. TuANSVKnst; skition uf a mdlar TOOTn OF TUE NATURAL SIZE. (^Tlie CUt is made through the body of the tooth.) 1, dentine; 2, enamel; 3, cavity. DENTITION. 97 Fig. 43. which associates it with the jaw ; the neck, the intermediate part. A tooth is composed of five structures : 1, pulp ; 2, dentine ; 3> enamel ; 4, crusta petrosa, or cementum ; 5, periodonteum. In the centre of the section (Fig. 43) is exhib- ited the pulp enlarged by the microscope : this body is shown to be a mass of delicate con- nective tissue, in which ramify blood-vessels and nerve-filaments. See Figs. 44, 45. It has no enveloping membrane proper, as will be understood in the study of odontogeny; it is the original papilla, or tooth germ. Through the vessels of this body, the inter- nal structure of the tooth is nourished ; in its death the tooth loses its translucency, becoming discolored and opaque, — being, indeed, devitalized, except as nourishment is received from the periodonteum. The pulp of a tooth is so highly endowed with nerve- matter that the slightest touch suffices to pro- voke the most exquisite pain. Dentine. — The dentine, or dentinal portion of the tooth, is marked 2 in the diagram (Fig. 43). This substance is called, also, the ivory. While histological dispute exists as to the real constitution of this structure, a full surgical signification is found in accepting it as a fibro-calcareous stroma, tubular in character. These tubuli, commencing at the enamel membrane, the original tunica propria (see Dentition), ap- proach the pulp, opening into the cavity by capillary mouths, and thus receive the halitus which is their nutrition. The tubuli of dentine are in some instances almost straight, at other times curvi- linear. In the neighborhood of the enamel they are dichotomous and trichotomous. Figs. 46 and 47 show these varieties of tubes. Fig. 49 shows the tubes in transverse section. (For mode of forma- tion of dentine, see author's views on Dentition.) Enamel. — No. 3, Fig. 43, exhibits the position and relation of the enamel as a cap to the crown portion of the tooth. This structure is almost entirely inorganic in its composition, containing but about two per cent, of animal or living matter ; it is hard, flinty, brittle, and decreases in thickness as it passes from the cutting T Vertical section of a cuspid tooth. 98 ORAL DISEASES AND SURGERY. face to the neck of the tooth. Id composition, enamel is made up of a series of hexagonal fibres, having a double direction, by which Fig. 44. Dental pulp, maguified. Fig. 45. Nerves of deutal pulp. each becomes strengthened bv its fellow as it is crossed and recrossed, one set undulating outward, another crosswise. The nutrition of Fig. 46. 1, tubuli of dentine; 2, enamel. the enamel is received through the tunica propria. (See Dentition.) Cementum, or Crusta Petroaa. — Fig. 43 (1) exhibits the rela- Fig. 47. Vertical section of thf fang of a canine tooth, exhibiting the structure of the den- tine and cement. 1, inner extremities of the dentinal tubules ; 2, outer extremities of the tubules, terminating in interspaces at the boundary of the dentine; 3, cement; 4, lacunae like those of bone. Highly magnified. / DENTITION. 99 tion of the cement as a sheathing to the fang. This structure so closely resembles bone proper as to be liable to the diseases of that Fig. 48. %r FiG> 49. Three ejiamel columns, highly magnified; exhibiting the six-sided prismatic and waving character. Section of ewmel, highlj' magnified, at right angles to the course of its columns ; exhibit- ing the six-sided character of the latter. Fm. 50. structure, and possesses all its chemical elements. A thick cemen- tum contains well-marked Haversian canals and Purkinjean corpus- cles or lakelets. (See manner of its formation in Dentition.) Periodonteum. — This is the analogue of the periostea of the com- mon osseous structures. It is a composition of fibrous tissue, serving the double purpose of attaching the teeth to their alveoli and support- ing the external vessels of nu- trition. At the neck of a tooth it is found dense and resist- ing ; toward the apex it atten- uates to softness and delicacy. Interglobular spaces. — Fig. 50 exhibits what are termed interglobular spaces, as seen in the dentine of certain teeth : these spaces possess much sur- gical interest, as it is to be presumed they represent an imperfect development, and thus explain the rapid break- ing down of many teeth. In an exhaustive paper on this subject, b}^ Dr. J. H. McQuil- l^ijf (see Dental Cosmos, vol. vi/i. p. 113), that gentleman remarks, ** As evidence of the [practical bearings of these investigations, it may be well to direct attention to the fact that the existence of the spaces in teeth which 'nave completed their growth must be regarded as an abnormal condi- Interglobular spaces. 100 ORAL DISEASES AND SURGERY. Hon, predisposing such teeth to decay, and that when, either by mechanical action, as by a fall or blow, or by the penetration of external caries, such spaces are reached, the disease here would run riot ; hence the importance of care on the part of patients and oper- ators to have the most minute cavities filled ; for though reached only through a microscopical opening, the result would be the same, while, if protected from the action of external influences or the ex- citing causes of decay, this predisposition might remain dormant for a lifetime, as is sometimes the case with other diseases." Relation of the Teeth ivith the Jaw. — The teeth associate with the jaw through the intervention of a peculiar cellular bone described as the alveolar processes. This structure, as has been seen, is hol- lowed into pits corresponding with the shape of the roots accom- modated by them. In some persons this process is very spongy, in others it almost resembles in density the cortical portion of the bone ; in proportion to this density are teeth found loosely or firmly fixed, and it is also a matter of experience that in proportion as this process is solid are the teeth resistive of disease. This arises, of course, from these organs corresponding with the nature of the bone, and being to such extent isolated from systemic impressions. No stronger proof could be afforded of the constitutional or vital relationship of caries. We may from such general consideration pass to an examination of the subject of the process of the development and growth of the teeth. CHAPTER T. DENTITION — CONTINUED. In the foetus of six weeks is to be observed, at the border of the palate, a groove occupying the position of the future teeth. This groove is called the primitive dental ; scattered along the bottom of it are certain fine papillae, which, in their development, are found gradually to assume the shape of the crowns of teeth. As these papillae grow, the groove is converted into a series of distinct folli- cles for their accommodation by the growth of septi between the papilla, which septi soon begin to ossify, to assist in forming the bony sac or alveolus common to the perfected teeth. It is seen, however, that the septi complete only a circumferential boundary, the summit of the papilla being exposed. Before, however, the papilla has assumed the form of the tooth, the upper soft margin of the pit enlarges and falls over, forming an operculum or lid. The tooth thus forming is generally regarded as a cutaneous production, and would seem to be a modification of the hair or nail. If such inference is an error, and this body is not such a production, it is plainly enough seen that the papilla, being sab- mucous, enveloped or overlaid by the mucous membrane lining the primitive groove, must, in its development, either rupture this envelope, or assume and modify it. Now, what is the state of the case ? According to the observations of Goodsir, and the opinion of Todd and Bowman, "the tooth papilla must be regarded as homologous with, or answering to, the tactile and hair papilla of the skin, and it would therefore be expected that its main part would consist of a peculiar submucous tissue, covered by a homogeneous basement membrane, and surmounted by a tissue answering to the epithelium. The substance of the papilla is, at first, a congeries of granular nuclei, dispersed irregularly through a firm, homogeneous, subgranular matrix or blastema, in which vessels and nerves are by degrees developed This is bounded by a definite transparent membrane, on which rests a reflection of the epithelium lining the sac, modified in structure so as to present a series of columnar, (101) 102 ORAL DISEASES AND SUBGERY. nucleated particles, the matrix of the future enamel." It would appear, according to these observers, that the lining and reflected layers of the epithelium become blended together, and constitute but one, which is more adherent to the sac than to the papilla; so that on opening the sac its walls generally seem unattached to the surface of the papilla, and the latter to be limited to what has been regarded as the basement membrane. The growth of the papilla, thus circumstanced, is considered by these authors as follows : " Between the columnar epithelium lining the sac and the surface of the alveolar cavity, that is, apparently in the wall of the sac itself, is found a thick, semi-transparent, pulpy tissue, which has been termed the enamel pulp. It presents toward the pulp of the tooth — that is, toward the original papilla — a series of elevations and depressions precisely the reverse of those of the dentinal pulp on which they rest, and answering mutually to these, with only the columnar epithelium intervening. The structure of this pulpy tissue is elastic, spongy, loaded with fluid albumen, but destitute of vessels. " In a vertical section of these parts, the enamel pulp is seen covered with columnar epithelium, the enamel matrix on the surface toward the dentinal or tooth pulp; while on the opposite surface the blood-vessels of the membrane lining the alveolus are seen coming up to and forming loops immediately under the enamel pulp, without penetrating it. It is further remarkable that short tubes, filled with glandular epithelium, descend among these vessels from the enamel pulp, and end by blind extremities, * How these tubes, which are evidently glandulai', can discharge their contents, it is diificult to understand, seeing they appear to open into the sub- stance of the enamel pulp. " The next stage* is that of ossification ; and the earthy matter is first deposited in the homogeneous membrane forming the dentinal pulp. The most prominent portions of the crown are the first to harden; and the ossification proceeds inward by the gradual conver- sion of the pulp into the dentine or ivory. The nucleated particles of the pulp nearest the ossifying surface are found arranging themselves in series vertical to that surface; and it appears that, in order to form these vertical series, they multiply by transverse division, much as those of bone cartilage are found to do. The earthy matters are then deposited in the indistinct cells surrounding the nuclei, so * Observations of Goodsir, Todd and Bowman, continued. I DENTITION. 103 as to form the hard and dense walls of the dentinal tubes, as well as the intercellular substance, so as to form the intertubular tissue of the perfect tooth. The cells unite endwise, and their nuclei elongate and coalesce in a manner to constitute the cavities of the tubes, and so as often to retain this mode of origin in their permanent form. " The calcification of the enamel commences on the surface of the dentine in contact with that primary osseous sheet formed from the basement membrane of the dentinal pulp. On this primary layer are minute shallow cups, closely aggregated, answering to the ends of the enamel columns and receiving them in a firmly cemented union, as the consolidation of the elementary cells proceeds. The enamel columns at a very early stage seem to consist only of a single series of nucleated particles, intervening between the dentine and enamel pulp. Those of the new row arrange themselves end- wise on the others, which they resemble in all respects, so that the enamel attains its proper thickness rather by the superposition of particle or particles successively deposited, and by the subsequent calcification of each in its turn, than by the development of its parts by an interstitial increase ; and thus it appears to differ from the dentinal pulp and to resemble the epithelium, to which it is allied. " It is from that surface of the enamel pulp which looks toward the tooth that this successive development of new enamel columns proceeds ; as they form, this tissue wastes ; but it is not probable that the pulp is converted into the columns, as the dentinal pulp is converted into dentine, because the anatomical characters of the pulp are so dissimilar from those of the columns. When first calci- fied, the enamel rods are loosely aggregated, and easily separate from one another under pressure ; but they gradually become so consolidated by the advance of the calcifying process in their inter- stices, as to make the finished enamel the most hard and indestruc- tible of all the products of organization. " The development of the layer containing the ordinary lacunae of bone, and which in the human teeth covers the fang, and is con- tinued a little way within the cavity of the root, does not seem to have been as accurately studied as that of the dentine and enamel. There can be little doubt that a membranous matrix, probably like that of the cranial bones, is laid down as the fang is developed, in which the usual steps of ossification precede the lacunae and their canaliculi, being formed from the corpuscles of the temporary matrix. "When the ossification of the dentine is so far advanced that the tooth can sustain with impunity the pressure to which it is destined, / 104 ORAL DISEASES AND SURGERY. and when the enamel is densely calcified, the eruptive stage occurs, in which the tooth makes its way through the gum. This is due to the same law of development which governs the form and position of other organs. The gum over the sac is absorbed, and the crown of the tooth is forced upward against it, chiefly by the increasing size of the fang below. *' As the development of the teeth proceeds, does that also of the alveoli: so that by the time the teeth emerge through the gums, their walls are sufficiently strong and embrace the necks with firm- ness enough to furnish a solid basis of support. Their vascular canals are developed, and especially those which convey to each tooth its interior supply of vessels and nerves. The gums and alveoli are likewise provided with vessels which play their part in the devel- opment and subsequent nutrition of the organs." These are the views of development entertained by the authors above mentioned. The later writers — Beale, Huxley, Tomes, etc. — I have not quoted, because a review renders it sufficiently evi- dent that no one of them is fixed in his deductions or conclusions. Investigations made by myself in the direction have seemed to me' to simplify the matter very much, and, indeed, to deprive it of a very great share of its obscurity. Whether these views may be nearer right than the various others held, the physiologist may for himself determine. I must be allowed to admit that I deem them irrefutable. At a certain period of foetal life, as has been remarked, a groove is observed, the progressive development of which proves it to be the primitive dental groove. This groove is lined by a delicate mem- brane continuous with the mucous membrane, indeed a part of it, — modified, but still of it, just as the conjunctival cells which pass over the cornea are really part and parcel of the common ocular conjunc- tiva. This membrane, at points corresponding with the position of future teeth, is seen to be elevated into little hills. A section through the membrane, over any of these hills, exposes a papilla. This papilla or body, closely examined, is found to be made up of a congeries of granular nuclei, dispersed irregularly through a firm homoge- neous blastema. This papilla is the rudiment of a future tooth, as observation of its development proves. It is not inclosed in a cell-wall or membrane of its own, but is a hyaloid structure or substance. The body, thus understood, is seen to lie beneath the DENTITION. ' 105 mucous membrane ; and in this membrane resides a certain amount of elasticity. As the papilla enlarges and projects itself, it becomes inclosed to all the extent possible with this mucous membrane con- tracted about the body so as to constitute a sac or cell wall, pre- cisely as the parietal peritoneum contracts about and makes a sac to the projected intestine in hernia. This sac enveloping the papilla has its continuation, as is seen, necessarily over the sides of the groove ; as, then, this groove enlarges and deepens, and finally en- velops the papilla, it is seen that the body or tooth germ gets a second sac. It is as though one should envelop his head in a double night-cap, and then bind over this a handkerchief, — the submucous structure of the lateral walls and operculum representing the hand- kerchief. At this period, the pulp, or original papilla, having attained the size of the tooth it represents, commences the process of the forma- tion of dentine. Before the attainment to full size of the papilla, there existed between it and its sac proper a halitus or fluid. This halitus, now that the congeries of cytoblasts or nucleated granules have obtained their full growth and secretive power, is replaced by a more highly endowed secretion, the work of these matured cells. This secretion, deposited against the inner sac, or between it and the pulp, contains the elements of the dentinal structure, is, indeed, the dentine, and deposits layer after layer, supported by and moulded into form by the sac. Calcification is progressive with its formation. As this deposit intrudes on the pulp, so this body contracts within itself, until, finally, by some law of nature, it stops at that certain point which maintains within the tooth a canal or cavity, and a vas- cular and nervous pulp to occupy it, — this pulp being the contracted original papilla ; the vessels of this papilla are vessels entirely analo- gous to any one of the ordinary papillae of touch, so supplied and so maintained. Why this secretion, in its organization, should assume the position of the elongated tubular cells which pertain to the structure of dentine, I have of course no idea, and it is quite enough for our purpose to say that it is a law of form perhaps not to be compre- hended, and the discovery of which would, at any rate, have but little practical signification to us. The formation of the dentine completed, the covering of it with enamel begins; or rather this deposit is, to a degree, coincident with the dentinal formation. Secreted by the same pulp which formed the dentine, the same secretion, some portion finds its way into and 106 ■ ORAL DISEASES AND SURGERY. through the primary sac. As it passes through this sac it is modi- fied, receives new elements, perhaps, which, as it is received into the second space, or the space between the first and second caps, im- presses upon it the arrangement of its particles after the hexagonal order of the enamel. Between the enamel, thus formed, and the dentine, exists the primary sac; simply the originally modified mucous membrane, which we first saw as overlying the papilla. This membrane continues its existence between these two hard bodies, and receives and modifies, for the support of the enamel, the liquor sanguinis exuded from the dentinal tubules and intertubular struc- ture. It may be called the enamel membrane. It has, of course, been much modified; it is from it that we receive the impressions of pain when becoming exposed by a break in the continuity of enamel. The views propounded and exhibited by Mr. Tomes of the primary calcification of a membrane covering the dental pulp, and which, by his assertion, forms the exterior of the dentine, can only be a microscopical fallacy. A membrane does, without doubt, exist, but it is the delicate tunica propria, and it becomes calcified only pathologically, and, when calcified, the enamel becomes brittle and dead, as thus its nutrition is cut off. The growth of the root of a tooth, as its dentine is concerned, has precisely the history of the body. It is associated with the pyramidal elongation of the papilla or pulp, which, pushing upward the crown, elongates upon itself the enamel membrane. This elonga- tion, with a greater vascularity and vitality assumed by the mem- brane as it approaches the basement vessels, modifies again the result obtained by the exudate passing through it from the dentinal pulp, the result being a nearer approach to true bone in the produc- tion of cementum. The Periodonteum is the modified external sac, lost, of course, above the neck, as the tooth has emerged through it. This is a very simple and easily understood explanation of tooth growth. The observations leading to the conclusions have been somewhat extensive, and the phenomena seem certainly indorsed by general physiological analogy. We pass here to what infinitely more concerns us as practitioners, — namely, the relations of the first and second dentitions. Of the first set, the papillae of the anterior molars appear first, the canines and incisors next, and the posterior molars last. About the DENTITION. 107 fourth month these papillae are all in their saccular envelopes, and forming behind the lids of the sacs are little crescentlc depressions, called cavities of reserve, lined with mucous membrane, and con- taining the germs of the papillae of the second set of teeth, — one to each deciduous germ. The first molar of the permanent set is markedly related to the deciduous, by having a common origin from and in the primitive dental groove ; from sacs, secondary to the capsule of this tooth, spring the reserve cavities of the second and third molars of the second set. Fig. 51. y^C ^ ^(g^^ Diagram of the mode op development op the teeth, a, section across the dental groove ; 6, papilla developed in the latter ; c, the groove deepened and processeg forming which ultimately close it ; d, the groove becoming closed ; e, dental sac containing a dental pulp, which is the rudiment of the crown of a temporary incisor ; the cavity above is reserved for a permanent incisor ; /, the crown of the temporary incisor fully formed, and the reserved cavity for the permanent tooth moving backward ; g, fang of the tem- porary incisor produced, and origin of the dental papilla of the future permanent tooth; h, eruption of the temporary incisor, and the alveoli produced for both teeth ; i, the tem- porary incisor occupying its functional positioa, and the crown of the permanent incisor developed. The eruption of the temporary set, although more or less irregular, ensues, as a rule, in the following order and time, — the lower teeth erupting first : the central incisors about the seventh month, the lateral incisors about the eighth month, the anterior molars about the thirteenth month, the canines about the sixteenth month, and the posterior molars about the twenty-fourth month. The age intervening between the first and the last eruption is considered the critical period in infantile existence- (See chapter on Associated Lesions of First Dentition.) 108 ORAL DISEASES AND SURGERY. The ossification of the permanent teeth commences, just before birth, with the anterior molars, proceeding forward, but terminating with the premolars at about the third year ; this description does not, however, include the posterior molars, which are really the last to ossify. The position of the permanent papillae, which at first are situated between the sacs of the deciduous and the gum, gradually recedes behind, falling deeper and deeper, at least relatively so, as the milk set elongates ; until, on the completion of growth in the deciduous, the germs of the permanent set are found in the common alveoli at the apices of these cavities, occupying, indeed, almost the position and physiological relations of the original papillae. At this period, whenever it may be, and it varies of course with different individuals, commences a process of antagonism : it is intended that the new shall advance and increase, that the old shall decline and diminish. The relative position of the two bodies is as follows : extending to the apices of the alveoli, and receiving at these apices the principal vessels of nutrition, are the perfected roots of the first teeth. Crowding down into these alveoli, with nutritious vessels of their own, possessed with the high vitality of growing bodies, are the pulps of the second teeth. As these pulps enlarge, so is there a corresponding enlargement in the alveoli containing them, until, finally, through such process of absorption they have fallen directly beneath the roots of the first set. Of course a pressure has been equally exerted upon these roots, and, as a result, the nutrient vessels passing into the pulp cavities, through the fora- mina at the apices, have been gradually obliterated. But do the pulps of the milk teeth die ? Not at all ; or at least not necessarily. The neighboring vascularity is very great, the requirements of the organ very small ; a sufficient supply is received from the circulation in the dentine, as well as from the periodonteum, which, to the last, continues to close in the enlarging foramina. But this does occur: the absorbent or destructive system has been given the mastery, and little by little, day by day, and month by month, the roots of the first teeth disappear, while the crowns of the second advance, and occupy the space gained, until at length, as is witnessed every day, the milk tooth drops out of the cavity, minus a root, while the crown of the permanent is seen in its place. If here we take up this throwu-off tooth, we shall find that the pulp chamber, or what remains of it, instead of having an almost complete bony envelope, as is the case in the perfect organ, has DENTITION. 109 communicated more and more largely, for a varying period, with the soft parts, guarding us, in such knowledge, against a treatment in aching milk teeth, at certain periods, which would be most appli- cable at others. To judge of the condition of the foramina of the first teeth, we compare them with periods of eruption of the second, recognizing that the enlargement, or absorption, corresponds with such advance in the permanent. The first teeth of the second set erupt entirely back of the tem- porary, and in no way interfere with them. These are the anterior or first molars, and appear commonly at about the sixth year, seldom earlier, but not unfrequently from one to several months later ; the sixth year, however, is the rule. The second teeth to appear are the central incisors, the lower a little in advance of the upper — about the seventh year ; the third, the lateral incisors, at the eighth year; the fourth, the anterior premolars, at the ninth 3'ear ; the fifth, the posterior premolars, at tha tenth year ; the sixth, the canines or cuspidati, at the eleventh year; the seventh, the second molars, at the twelfth year ; and the last, the third molars or wisdom teeth, at a period varying from the seventeenth to the twenty- fifth year — more commonly, however, about the eighteenth year. The teeth, in their eruption, arrange themselves in a physiological regularity in the arches which have enlarged for their accommoda- tion through a process of elon- gatory and interstitial growth ; ^*" if development and functional harmony have not been inter- fered with, the fully-grown or- gans are found occupying in regular relations the two jaws-, yielding perfect occlusion and articulation. (See Associate Lesions.) Articulation. (See Fig. 1.) — In examining the articulated skull, it is seen that the six upper front teeth close over and in front of those of the inferior jaw, while the external tubercles of the bicuspidati and molars of the lower jaw lodge in the sulci be- tween the external and internal tubercles of those of the upper jaw ; First and second dentition, upper and lower maxillw. 110 ORAL DISEASES AND SURGERY. thus, in the articulation, placing the external tubercles of the upper teeth external to the outer tubercles of the lower. The central incisor of the upper jaw, because of its greater width, closes not only over the inferior central, but overrides the lateral. The superior lateral overrides the cuspid; the cuspid its fellow and the first premolar. The premolars override their fellows and the anterior third of the first molar. The first molar opposes the anterior third of the second molar and the posterior two-thirds of the first. The second molar opposes the posterior two-thirds of the second molar, and the ante- rior third of the wisdom tooth. The wisdom tooth of the upper jaw, being smaller than that of the lower, finds accommodation in antag- onism by the portion of its fellow left unoccupied by the second molar. Thus it is seen that no two teeth, exclusively oppose each other, — an admirable provision, which not only guards as much as seems possible against loss of the organs from lack of antagonism, but secures the fullest results in the trituration of the food. CHAPTER YI. ASSOCIATIVE LESIONS OF FIRST DENTITION. Although it comes not strictly within the province of a work on surgery to treat of the associative lesions of the first dentition, yet it would seem that such a work could not be at all complete without, at least, reasonable reference to such conditions. When one considers the delicate and susceptible organism of an infant human being, and the fact of its usherance into a world where active causes of disease are in constant antagonism to it, he is very well prepared to understand that in the influence of the process of dentition must necessarily exist a powerful predisposing cause in- viting to attack, and, indeed, opening the portals, as it were, to enemies that otherwise might have passed harmlessly by. The calculations of Dr. Arbuthnot that, at this period, one in every ten children has its life destroyed through the associative and influenced lesions of the age, may, perhaps, not be strictl}'- in accordance with statistics at large; but the mortality is so alarm- ingly great that, to the general practitioner, no subject offers in its study more important and vital interest^. Professor Camper is authority for the statement that out of 5989 infants admitted into foundling-hospitals, only 884 were found alive at the end of the fifth year. In the first place, we have to remark that the process of dentition, while a physiological one, is yet, like that of utero-gestation, one of continuous irritation. Of the meaning of this word irritation, every surgeon and every physician has in his mind quite enough reminiscences. Irritation, then, is the matter of consideration in all of these associative lesions; if happily, in such cases, we could exactly appreciate and exactly control such irritations, we should of course abort or resolve the results. It is not, however, by any means to be esteemed that all infantile diseases are influenced by, or indeed even remotely associated with, dentition: mistakes of such nature are quite too frequently made, and infants are tortured, and in many cases have the existing dis- (111) 112 ORAL DISEASES AND SURGERY. ease aggravated, by the lancing and cutting which follow. It is very true that irritation from this cause has not always an associ- ated external local manifestation ; but such manifestation is, I think, much more frequently to be found present than absent, — at any rate, it should alwaj's have its full share in the diagnosis. It will of course be taken for granted that dental irritation is influenced to a most marked extent, all other things being equal, by the slowness or rapidity of the evolution of the teeth. Thus, such equality existing, we would not anticipate from the eruption of a single tooth the trouble of five or six, and such a difference in evolution is so common that it may be said of some children that they cut their teeth in mass, while with others it is a process of the greatest regularity and harmony. Again, the physical condition and age of the child are matters not without much significance. A delicate infant suffers more, as a general thing, than a robust one; while premature dentitions are at- tended with more danger than late ones. In taking into consideration the influences of this process, we are not to forget either the vary- ing degrees of susceptibility manifested in different individuals, as thus we are led to appreciate the fact that judgment is not to be founded alone on the extent or degree of local manifestation. Some children are preternaturally susceptible to stimuli, and these are not at all necessarily of the weak and feeble class; others, on the contrary, are so obtuse, even from earliest age, as to be very little influenced by any ordinary or common cause of irritation. To the experienced physician, the appreciation of associated or abstract dental irritation should not be a matter of difficulty. He sees and he does what is to be done, — what only can be done ; if the treatment fails, the fault resides not in the practice. In the first place, to understand dental irritation, one must be familiar with dental evolution ; this, of course, is the understanding of the physi- ology of the subject. We know the varying periods of eruption, and we are thus at once led ver}^ directly in our researches. If we find a source of offense, as manifested by a tumid, congested gum, we have only to pass a lancet down to the confined tooth, and, having done this, may expect and hope for relief from any general trouble which has been engendered by the just liberated organ. If we look into the mouth, and see no manifestations of offense, it is generally the case that dentition has nothing to do with a trouble which may have influenced the search, — not always, however, for it has been inferred that dentition may be a source of reflected trouble, while itself presenting no local signs. Still, such cases are very ASSOCIATIVE LESIONS OF FIRST DENTITION. 113 rare, and when existing depend on great rapidity in evolution, either as a single tooth is concerned or the simultaneous advancement of a number. Many teeth, rapidly advancing at the same time, could very well be esteemed as a source of constitutional offense, not only as diverting in such direction 'an excess of the vital force, but also in local irritations induced in neighboring structures, and which might not at all be evident by any external signs. In these latter cases the physician can do nothing but increase, by indicated means, the ability of the system to endure the irritation ; such means being more frequently found in tonics than in sedatives. In the weak, strict attention is to be given to diet, to exercise, and to cleanliness. The character of the clothing is also of much consequence. If the milk of the mother is not properly nutritious, other means are to be taken to nourish the child. In cases where there seems simply an excess of irritability, such susceptibility is to be lowered by the withdrawal of everything ca- pable of fostering it ; this will pertain to the lodgment of the child, and to its food, drink, clothing, exercise, etc., matters which would at once strike the observant practitioner. Disturbance provoked in the alimentary canal, and fever induced through the process of teething, when existing conjointly with acute disease, of whatever character, necessarily aggravate such disease, and increase by just that much the attending discomfort or danger; hence the recognized increased mortality in the exanthemata occur- ring at this period. The diseases, if they may be so called, directly associated with and dependent on abnormal dentition, and having, therefore, neces- sarily their cure more or less intimately associated with the correc- tion of the primary lesion, are — 1. Localized Stomatitis. 2. Irritative Fever. 3. Diarrhoea. 4. Spasms. 5. Eruptions on the Skin, especially of the Scalp and Face. 1. Localized Stomatitis. — The first indication in this condition, dependent on advancing tooth eruption, consists, most likely, in a sense of titillation or itching, — as, before any local sign is visible, the child is found disposed to rub the parts with anything coming into its hands, seeming most comfortable when biting upon hard substances. Slavering is also associated with. this stage. After a time, tumefaction of the gums is observed, and this inflammatory 8 114 ORAL DISEASES AND SURGERY. action circumscribes or extends itself on the same principle as the vaccine areola, — that is, as influenced by constitutional or local cir- cumstances. If several teeth are attempting eruption at the same time, and these are situated at opposite sides of the cavity, then the probability is that the inflammation will be a diffused one. If, on the contrary, the irritation is confined to a single tooth, and there is in the habits of the child no particular inflammatory tendency, then it may reasonably be anticipated that the area of congestion will be very circumscribed. The shape and extent of face in the erupting tooth have not seemed to me to have as much to do with the amount of irritation as one would naturally infer to be the case. I have certainly seen quite as much trouble from an erupting incisor as in the case of a four-cusped molar. Bad and degenerating inflamma- tions are always associated with constitutional conditions. Thus, in scrofulous children it is sometimes the case that a semi-gangrenous ulceration is the result of cutting a tootii which it is quite troublesome enough to manage; while in children of a mercurio-syphilitic cachexia such a condition will be even aggravated, the gums and continuity of mucous membrane looking as if it was impossible to keep the parts from breaking down into general ulceration. AVhen tume- faction of the gum is dependent on tooth eruption, and the child is of healthy condition, a certain evidence is found in the glistening character of the swelling: the part immediately over the toother teeth looks stretched and feverish. This tense look is nearly always present, and may, under all circumstances, be esteemed an indica- tion demanding the use of the lancet.* In unhealthy conditions this glistening is not commonly present, its absence being dependent on the flaccid, relaxed condition of the gum tissue. Here, as im- plied, the congestion is of more diffused character ; the part and associate parts are turgid and soft-looking. You esteem, in looking into the mouth, that scarification would be of service, but that it is demanded for a sense of general relief, rather than for a strictly acute local condition. Lancing in the first of these cases, if properly per- formed, yields an almost instantaneously good result ; in the second, such relief is gradual, and most likely inconsiderable. In the first, it is all-sufficient to the cure ; in the second, the constitutional indi- cations are soon felt to be of much more consequence than any local requirements. * The application of the tincture of beHadonna to a gum thus congested is a source of much relief. A full saturation of the bromide of potassium is also an agent of more or less comfort. ASSOCIATIVE LESIONS OF FIRST DENTITION. 115 To lance the gurus of a child, let the surgeon seat himself directly in front of the nurse, the height of the knees of the two parties cor- responding. Let the nurse now take the child on her lap, support- ing its whole body, excepting the shoulders and head, which are to rest upon the knees of the operator. In this position the nurse con- trols perfectly the legs and arms of the infant, while the surgeon has complete command of its head, and can examine and operate upon its mouth at his convenience. The face of the child should look toward the window, or, if night is the time of operation, the light of a candle or a lamp may be employed. A tooth should be lanced in consideration of its shape. Thus, if it be any of the anterior six teeth, either of the upper or lower jaw a single incision made sufficiently deep to feel the lancet strike upon the enamel is all that is required. This incision should be made across the mouth, or on the line of the cutting edge of these teeth. With the posterior teeth, the crucial form of incision is demanded : such form will alone relieve the advancing cusps, and afford the result desired. Concerning hemorrhage, it has not been my experience that any special danger is to be apprehended. I certainly never hesitated to lance the gums of a child on this score, and never met with a case that gave me any particular trouble. In ordinary cases, the loss of a little blood is rather to be desired than otherwise; while if a hemor- rhagic diathesis exists, the local application of strong alum-water or of bayberry -powder will generally be found all-sufficient for its con- trol. A little cobweb, as found in the cellar, wet with borax-water, and then dipped in bayberry-powder, will in ninety cases out of the hundred control the bleeding when laid over the incision, — the ap- plication to be secured by passing over it, if necessary, one layer of a delicate roller. A constitutional medicament, of good effect in these cases, will be found in the Erigeron Canadense, — one drop of the tincture to be given in a little water, each minute, until the bleeding ceases, or until twenty or thirty are taken. Opium and lead act very happily in combination. The dose of each must of course be small. A very good formula is as follows : B. — Pulveris opii, gr, ^ ; Plumbi acetatis, gr. j ; Aqufje rosiB, giij. Sig. Tablespoonful to be taken each half-hour, p. r. n. 116 ORAL DISEASES AND SURGERY. Touching a bleeding gum with Monsel's solutions, or with nitrate of silver, is, in my experience, dangerous practice. The only alarm- ing cases of hemorrhage I have ever seen have been the results of these applications. It is true that such effects may rest rather with the operator than with the agents ; but it is seldom that one seems to succeed in using them with sufficient cleverness and localization. They are certainly much more apt to do a great deal of harm than an}^ reliable good ; secondary hemorrhages are common to them, and, when ensuing, are always of a character much more difficult to manage than the primary trouble. Another matter in this connection particularly worthy of note, is the influence on the hemorrhage through the sticking propensity of infants. This is to be obviated by passing a roll of rubber or other convenient material across the mouth, and so confining it that, while it shall not fret the little patient, it will destroy the ability to make a vacuum. This manipulation is very simple and easy of accom- plishment. The ordinary soft india-rubber ring may be cut in the middle ; tie a piece of string or tape to each end, pass the rubber across the mouth, and fix the tapes on the back of the neck ; an hour or two will be found quite sufficient to retain the apparatus in the mouth. Cases of localized stomatitis, having association with the strumous, scorbutic, or syphilitic cachexia, require, as suggested, a treatment external to the cau.se exciting it; the child must be built up; the inflammation passing quickly into an adynamic type demands for its cure stimulation rather than depression ; or, to express the require- ments more justly and explicitly, a local treatment must be quieting and perhaps refrigerating, while tonics, combined with the mineral acids, will be required constitutionally. A child eight years of age, of marked scrofulous condition, tissues relaxed, abdomen pendent, was presented at one of my clinics, suf- fering with trouble in the oral cavity. Making an examination, the mucous membrane of the palatine aspect of the superior jaw was found angry and uncomfortable-looking, no tension at any point, but the whole membrane turgid, and yet flaccid-looking. In searching for the cause of trouble, the age of the patient directed a first atten- tion to the position of the first bicuspid teeth, the lateral incisors being erupted and in position ; exploration with the lancet — the deciduous molars had been removed long before — revealed these teeth on either side, with the second bicuspid of the right side nearly ready to erupt. The ordinary crucial incisions were then made. In ASSOCIATIVE LESIOXS OF FIRST DENTITION. 117 the case of a healthy child, this would have been all-sufficient; with such a child, however, not so. Relief to some extent will cer- tainly be obtained from the incision; but the congestion will con- tinue, and it may be will grow worse, the parts seeming to lack the energy necessary to the restoration. In this particular case, and which is here noted merely as a type, the mouth was ordered to be washed three times each day with very dilute brandy and aromatic sulphuric acid. Internally, lemonade was given every two hours, five drops of brandy being added to each wineglassful. Aromatic sul- phuric acid acts very happily in these and similar cases, or nitro- muriatic acid may be administered in from two- to five-drop doses, three or four times a day. Iron, combined with an acid, as in the Ferri Chloridi Tinctura. is a most admirable medicine, given in from five- to eight-drop doses, three times a day. It is found also not unfre- quently necessary in these cases to bring the acid, in a more concen- trated form, directly to bear upon some obstinate point of ulceration; this is done very readily by means of a pine stick. Dip the point into the acid used, and employ concentrated or dilute according to the seeming requirements of the case. The acid nitrate of mercury so applied is found sometimes to act very happily, or deliquesced chloride of zinc may be used. The zinc, followed by a brush of the officinal tincture of iodine, will sometimes induce granulation as if by magic ; or tincture of iodine combined with creasote may be employed with every hope of success. ]n syphilitic stomatitis, specific treatment must be conjoined with the supporting. A combination that I use with very satisfactory effect is as follows : R. — Hydrargyri chloridi corrosivi, gr. j; Potassii iodldi, 3j 5 Syrupi ferri pyrophosphatis, ^iv. M. Sig. From a quarter to half a teaspoonful, according to age, three times a day. It not unfrequently happens, however, that a treatment which may have preceded ours has been too free in the exhibition of the mercurials ; here this medicine is no longer to be used, but, con- joined with the supporting treatment, we are to employ the chlorate of potash: 118 ORAL DISEASES AND SURGEBY. R. — Potassas chloratis, ^ss ; Aquse, 5viij. M. S. Teaspoonful, internally, four to six times a day, and the mouth to be washed with the same, ad libitum. An admirable local application in the syphilitic sore mouth and throat is made by adding- to a six-ounce infusion of white oak bark two drachms of aromatic sulphuric acid and six grains of nitrate of silver. In all adynamic conditions of childhood, it is, I presume, a com- mon experience that no better treatment is to be found thau lies in the observance of general hygienic laws. The food must be nour- ishing, and not given to repletion. Fresh air and exercise are necessities. The child should sleep by itself, or, what, as it is con- cerned, is even better, it might sleep with some young person of more robust and healthy condition. The daily use of the salt-sheet bath, with the water tepid or cold, according to the ability of the patient to bear, is an invaluable adjunct to restoration. Throw the wet sheet quickly about the person of the child, and rub until a fine glowing reaction sets in. In the use of this means, however, close attention is to be given to the daily result. If reaction is not secured, but the child grows cold, and the cutaneous capillaries con- tract unduly, then such bath is to be discontinued ; or if cold water has been used, it must be modified, even perhaps to absolute warm- ness, A good plan to adopt with this bath, is to commence with milk-warm water and advance by gradations to cold. All the functions of a child of scrofulous or syphilitic condition are to be carefully watched. If the bowels are habitually cos- tive, as is frequently the case, olive oil of good quality may be administered q. s. This oil not only obviates such a condition, but acts as a most desirable article of nutrition. If given alone, a teaspoonful or dessertspoonful, each day, administered at any con- venient period, will generally be found sufficient, — and, indeed, in many cases, too laxative. If the child is of an age to take the oil mixed with other food, much attention to the quantity employed will not be found of special consequence. In cases where the kidneys fail to eliminate with sufficient rapidity, small doses of sweet spirits of nitre may be exhibited. Buchu, where there is undue irritability of the urinary apparatus, will be found to apply very happily. A prescription which I very frequently make is as follows : ASSOCIATIVE LESIONS OF FIRST DENTITION. 119 Take of buchu one ounce; add one and one-half pints of hot water, and simmer down to one pint; when cold, strain, and give in teaspoonful doses, four or six times a day, p. r. n. Particular attention to the state of the skin is also demanded. This tissue should feel soft, not relaxed ; moist, and reasonably oily; it must be kept very cl^an, but not washed too frequently with soap. Whisky or brandy, where stimulation seems indicated, may be added to the water with which a child is bathed ; but a healthy skin is to be made rather from within outward, than from without inward — that is to say, a skin which does not properly perform its offices, in- dicates, as a general thing, some derangement ulterior to itself, so that the local attention implied is never to be esteemed but as adjunct treatment. It has not unfrequently happened to me to observe that a stomatitis having apparently a local signification has immediately disappeared on the correction of a trouble existing in the skin. This is markedly seen in the retrograde exanthems. Angina simplex, simple inflammation of the fauces, is not un- frequently dependent on irritations existing or having origin in the oral cavity. Here the trouble is one of continuity of structure, and its relief is found, of course, in the cure of the exciting trouble. Angina simplex, or the extension of the oral inflammation, is generally first made evident in difficulty of swallowing. Examination reveals the throat red and congested, the degree being influenced by the con- dition of the patient. Sometimes this congestion is so great as to make the act of deglutition an impossibility; even fluids taken into the throat will be ejected through the nostrils. The uvula oc- casionally will be enlarged to an extent, as the result of effusion into its cellular structure, which seriously endangers the respiration of the patient, compelling, indeed, in many cases, the amputation of the organ. In some instances degenerating aphthous patches (an- gina aphthosa) appear upon various parts of the mucous membrane ; these denote that the inflammation is adynamic in its type, and are, I think, always a matter of concern, just, indeed, as a phagedenic chancre is a cause for more alarm than a simple sore, implying a degenerative tendency and absence of vital force. An aphthous ulcer is a patch of varying signification. It is the form of ulceration and exudation so frequently seen in weakly, broken-down women. The niicroscope insists on the aphthous exudate as a fungous growth ; it has, however, as yet failed in designating an antidote. Angina simplex, it has been remarked, when dependent on any oral 120 ORAL DISEASES AND SURGERY. trouble, may be expected to retire upon the removal of the immediate cause. This, however, is not always the case, as is witnessed in the adynamic types, or in children of very full or sanguine temperament. In these cases, a treatment must be pursued as implied in the indi- cations. If the continuance of such inflammation depends on a surcharged condition of the vessels, general or local depletion will be found demanded. Three or four Swedish leeches, or twice as many American, may be put upon the upper part of the throat; the number to be graduated to the strength of the patient and the urgency of the case. A treatment preliminary to this, and one which in my own practice I always employ, when the case is not especially urgent, consists in reducing the volume of blood, by the administration either of diaphoretics or the valine cathartics. Epsom salts, a teaspoonful in a wineglass of water, will carry much fluid from the blood of a young child ; or the spirits of Min- dererus — covering the patient warmly until diaphoresis is produced — given in teaspoonful doses, every ten minutes, will be found to sometimes very quickly break up such inflammations. Hot pedi- luvia are not to be neglected ; the feet and legs of the little patient, kept in hot water for the space of a quarter of an hour, will, in very many cases, be all-sufficient for a cure. A less speedy but fre- quently very successful way of treating angina, consists in divert- ing, as it were, the seat of irritation ; thus, by the admmistration of nitre we may send it to the kidneys, or with tartar emetic throw it upon the skin. R. — Spiritus ammonise aromatici, Spiritus setheris nitrosi, aa ^ss. M. S. Give from five drops to a teaspoonful, according to age, every three or four hours. The ammonia in the above prescription drives the congesting blood forward, while the nitre directs it toward the kidneys. An emetic will not unfrequently break up a sthenic sore throat. In the case of children, syrup of ipecacuanha answers every purpose. It may be given in doses varying from a half to a full teaspoonful, according to age, every ten or fifteen minutes, until the desired result of emesis is obtained. If, conjoined with the local inflammation, we have a sympathizing by the system at large, as manifested in fever, febrifuges are to be employed. The following combination will be found happily adapted to such indications : ASSOCIATIVE LESIONS OF FIRST DENTITION. 121 R. — Liquoris potassse citi*atis, siij; Spiritus ajtheris nitrosi, 5ss ; Pulveris antimonii et potassae tartratis, Morphise acetatis, aa gr. j. M. Of this mixture the dose for aa adult would be a dessertspoonful every two hours ; for an infant one year of age, from five to eight drops might be given, being diminished or increased according to efifect. Overdoses produce sick stomach. Diet. — This should of course be light, as in all sthenic inflamma- tions. The child may be limited to the breast alone ; or if age or circumstances will not permit of this, gum-water, or other light and UDstimulating food, should be alone employed — that is to say, should be alone employed while the grade of the inflammation Is running upward. Ice-cream is an admirable food, particularly when eaten slowly and continuously. By continuously, however, is not meant that great quantities are to be taken, but that a reasonable portion be made to last as long as possible. Eaten in this way, it is refrigerant not only to the inflamed part over which it necessarily passes, but to the system at large, lowering th^ heat of the whole body, and thus quieting the disturbed circulation. Chronic Angina. — Inflammation of the fauces, running into a chronic condition, in children, may perhaps always be considered as depending on some constitutional predisposition. In these cases the glandular bodies seem to be most markedly the seat of trouble. Granulations are generally prominent over the mucous membrane, this tissue being covered with a mucoid or muco-purulent secretion. Ulcers are very common, and not unfrequently are of such degener- ative tendency as to threaten the continuity of the parts. A dis- agreeable association, connected nearly always with a neglected angina, is the chronic enlargement of the tonsil glands. I have been compelled to operate in these cases, as every slight cold would so swell up these bodies as to render respiration almost as difficult as in asthma. I have just now under treatment a little girl, in whom, from this cause, these glands are so enlarged that respiration during sleep is accomplished only by an effort that it is absolutely painful to listen to. Of course the case is curable by excision or the cauterant; but to this neither parent nor child can be brought to submit. The sense of tickling and rawness in the throat, in chronic angina, is another source of discomfort; the patient is constantly kept coughing and hawking. This is induced not unfrequently 122 ORAL DISEASES AND SURGERY. through the dryness of the membrane, and again as a result of the irritating nature of the secretions, or it may be dependent on ulcera- tion. From whatever cause arising, however, I have never found anything better adapted to its temporary relief than gum arable or the jujube troches held in the mouth and allowed slowly to dissolve ; or a gargle compounded as follows may be used ad libitum : R. — Tincturse iodinii composites, gtt. xl ; Acidi carbolici, gtt. vj ; Glycerine, 3j ; Aqu^e, svij. M. Brushing the part with the tincture of belladonna, or with a saturated solution of the bromide of potassium, is sometimes found to abort the severity in these cases very speedily. Difficulty in hearing is another frequent association of chronic angina, — the ex- planation being found in the inflammatory thickening of the Eusta- chian tube. Pain in the act of swallowing is the result of a lymph exudate in the submucous cellular tissue. This it is which gives the irregular thickening so observable about the posterior wall of the pharynx. Chronic angina, if not dependent on any specific constitutional conditions, would be most rationally treated by stimulation, local or general, or both, as would seem to be indicated. The ordinary domestic remedy of a red-pepper gargle, if judiciously used, not unfrequeutly produces a speedy cure. Unhappih^ however, domes- tic medication is too apt to be carried to excess, a,ud thus adds to, in place of subverting, a disease. If a true uncomplicated chronic angina presents in a child, — and it will not do to deny that such eases may exist, — let the patient first be treated with a lotion com- pounded as follows : R. — Tincturae capsici compositse, oSS ; Aquae, 3viij. M. If a few applications of this gargle should not effect a change, let nitrate of silver be added, in proportion of one-half a grain to the ounce. If even this should not result in the desired change, then it will be well to esteem that a general medication is indicated. First we set about to correct any functional disturbances that may be present, and follow such corrections with tonics. Muriated tincture of iron is an admirable medicine, where the system seems to require ASSOCIATIVE LESIONS OF FIRST DENTITION. 123 building up; quinine, in the majority of cases, may be given in addi- tion, with a very happy effect. R. — TincturiB ferri chloridi, 5'U 5 Quinise sulphatis, gr. x. M. S. To be taken in from three- to ten-drop doses, according to age, three times a day. Where treatment, as just indicated, shall fail, alterative medica- ments of the various classes may be tried, — alum-water, tincture of iodine, weak dilutions of creasote, acid nitrate of mercury, chloride of zinc, solutions of lead, etc. Constitutional vices must receive a full share of attention. I have presumed to imply that in children affected with chronic angina the cause is always found to exist in such direction. Scrofula is by far the most common of these vices. A scrofulous child is liable to almost any description of physical de- generation. Now, scrofulous degeneration is rather a difficult thing to describe, the conditions being so diversified and varied. A child descended from consumptive parents is degenerate, — it is not amiss to say scrofulous. A scrofulous child has not necessarily always a special distinctive type as in general signification is hereafter de- scribed. It may, for example, have white, delicate skin, tumid abdo- men, non-compact, pouting lip, and the languid, listless gait. It may have every belonging of the most marked lymphatic tempera- ment ; or, on the other hand, a scrofulous patient may look as if possessed of all the characters of a vigorous constitution. I do not know what better to do, in cases of this kind, than to make a general observation of antecedent and present conditions and found a treatment accordingly. Syphilis, it has been inferred by some writers, lies closely, or it may be in the distance, as the root of such conditions; but if this should be the case, a treatment anti- syphilitic is not necessarily implied. This peculiar vice may have lost itself in a general degenerative condition, just as an injury, which has of itself gotten well, may yet be the cause of broken health and physical adversity, — just, indeed, as phthisis may suc- ceed syphilis, long since inferred to have been cured. In all such cases we can only hope, in the correction of ill conditions recognized as existing, to find the good Ave require. We may philosophize and reason, but if nothing functionally wrong is perceived, we must have recourse to a somewhat empirical treatment, building, as we say, the patient up. lu other words, there are no specific means of 124 ORAL DISEASES AND SURGERY. cure ; therefore we resort to such general tonics as experience has demonstrated to be useful. Cod-liver oil, cream, mixture of sperma- ceti and milk, preparations of iron, infusions or tinctures of the bitter barks, as the Peruvian, serpentaria, gentian, etc., are medicines to be employed in these cases. 2. Irritative Fever. — Irritative fever, fever from the irritation of teething, is a direction of infantile trouble ver\^ frequently demand- ing the attention of the physician. It may not be amiss, for the benefit of the student, to recall that by irritative fever we mean fever the result of something that produces overexcitement. This, it is true, would also be a definition of inflammatory fever, the two conditions being, as we understand, really one and the same, except in degree. Now, the irritative fever of dentition is, as a rule, a rapid fever — that is, it appears and disappears quickly; the lancing of a gum causing it very frequently almost instantly to vanish: not always, however, for it can readily be understood that such a dis- turbance of the functional conditions could be excited as to make a return to an equilibrium much less probable than production of some organic change. All febrile conditions in children of a' sthenic type are attended with much restlessness; but the fever of dentition is markedly so. Muscular excitability is a prominent association ; the sleep is broken ; thirst is very great; the appetite is impaired and irregular, the child taking the breast rather for the relief obtained from the moisture of the milk than from desire for food ; the pulse is not unfrequently driven to an incredible rapidity; the face is flushed and burning; the eyes are congested and protruded. Convulsions, and not unfre- quently death, mark the climax. The disturbance effected in the system, as has been remarked, will be found in proportion to the local irritation, and the age, con- stitution, and general condition of the patient. The marked mo- bility existing in the nervous structure of infants I'enders the brain peculiarly susceptible; it is therefore a most common association to find the feverish infant flighty, and perhaps entirely out of its head; while if febrile disturbance, consequent upon dentition, supervenes when other diseases are in progress, such diseases will be commonly much intensified. The diagnosis of dental irritative fever is not always an easy matter, and simply because the fever is irritative, and not inva- riably inflammator\' — that is to say, the local disturbance is con- fined to the vis vitae, and does not involve, to a perceptible extent, ASSOCIATIVE LESIOXS OF FIE ST DENTITIOX. 125 the local vascular system. We look into the mouth, but see no swelling of the gums, no evidences of inflammation ; yet the trouble is there, and it may be that it is only by incision that the fever is to be controlled; the diagnosis must therefore necessarily not unfrequently be of a differential character. To aid us in this, Ave not only consider the absence of other causes of irritation, but we have a marked assistance in our knowledge of the varying periods of tooth eruption, and of the causes advancing or retarding such evolution. Where dental evolution is inferred to be the cause of a febrile manifestation, and incisions do not seem to be demanded, we are to resort to ordinary general treatment. Lemonade, prepared with crushed ice, is a most grateful and refrigerating febrifuge; the neu- tral mixture, made fresh, by simply adding the carbonate or bicar- bonate of potassa to lemon-juice, is another excellent medicine. This addition may be made to a full saturation. Or a refrigerating mix- ture, as follows, may be prescribed, and administered pro re vata in teaspoouful doses: R. — Liquoris potassse citratis, 5iij ; Potassii bromidi, 5j ; Aquae, Sj. Much relief is commonly given by sponging the skin when it is very hot, using water and alcohol, or water and cologne, or water and vinegar. Bathing the wrists in cold water is another source of great comfort. Bromide of potassium alone is an admirable prepa- ration to administer in febrile conditions. To children it may be given, dissolved in strong, ice-cold lemonade, in doses of two grains or more to the tablespoonful. Tartar emetic, added to these doses in the proportion of the fortieth of a grain to each, assists its quiet- ing influence. Where the pulse is much excited, and the infant is of sthenic condition, tincture of veratrum viride may also be added, one drop to each dose; in the use of this last agent, however, the effect as its action on the circulation is concerned is to be watched Avith care. Emetics are highly valued by some. Cathartics may also be used to good purpose, the sulphate or carbonate of magnesia being employed, as preferred. When, in defiance of treatment, a fever of irritation continues, our efforts are to be directed to effects that may be produced outside of the ordinarv functional disturbances. The extension of inflammation 126 ORAL DISEASES AND SURGERY. by continuity, where, for example, severe and unyielding inflamma- tion resulting from dentition exists, may produce pharyngitis, paro- titis, bronchitis, pneumonitis, gastritis, or it may excite to take on morbid action the brain, the heart, the liver, or, indeed, any organ of the body. When such sequelae occur, we are to treat the parts involved, as in any common inflammation, just, indeed, as we have been treating the unyielding fever, except that we may feel the necessity to make such treatment more vigorous; it maybe that under such circumstances we will find the local or general abstrac- tion of blood an absolute necessity. In these cases it is not to be forgotten, however, by the prac- titioner, that, conjoined with the original cause of inflammation, some other may exist ; thus, a malarial influence may have been lying in abe3'ance, and needed but the depression, the result of the dental trouble, to allow of its asserting itself; or it may be that some half-corrected tendency to congestion is, by the excitation, entirely undone. Such associations are constantly to be considered if treatment is to be successful. This excitation of morbid action is well demonstrated in the association, with dentition, of diarrhoea and the cutaneous eruptions; while the treatment, wherever the secondary irritation shall exhibit itself, is recognized to have a common character. 3. Diarrhcea. — The alimentary mucous membrane being con- tinuous from the mouth to the anus, it will be at once recognized that a localized inflammation could render irritable the whole tract. It is thus that diarrhoea, or, indeed, more commonly all the symp- toms of cholera infantum, associate with difficult tooth eruption, and it is thus that to cure a diarrhoea or an attack of cholera infantum we have so frequently only to cut down upon a certain confined tooth or teeth. I am led, however, to infer that it is quite too common a practice, during the period of dentition, to ascribe to this process not only every diarrhcea, but the numberless other functional irregularities which may happen to occur at such period. Diar- rhoea, or this combined with vomiting, has many causes apart from the influences of tooth eruption. The stomach of an infant may be likened to an enlarged portion of a common tube, and not only this, but it is a vertical, or almost vertical, tube ; hence a child overfed needs only to be inverted to have the milk run from the orifice of the tube. Again, the mucous membrane of the intestines of an infant is tender and susceptible ; excess of food, or food not easy of digestion, II ASSOCrATIVE LESIOXS OF FIRST DENTITION. 127 irritates this menil)rane, and, by the relationship of tissue, excites to action the middle coat of the tube, yielding discharge or diarrhoea. Crapulous diarrhoea may thus be somewhat continuous, for the reason that, unassisted, the contractions may fail to relieve the canal of the source of offense, and thus their continued efforts keep up the continued discharges. Worms irritating the canal are the frequent cause of diarrhoea. In hot weather we generally have an increase in diarrhoea cases; and not only is the irritation thus induced not limited to the intestinal tract proper, but the liver as markedly sympathizes ; hence the frequency in these months of cholera infantum, the excess of bile being thrown both ways. En- teritis, from follicular ulceration in typhoid conditions, may induce and keep up a diarrhoea in a child as it does in an adult. Tabes raesenterica is a cause of diarrhoea in the scrofulous infant. Syphilis may ulcerate and irritate the intestinal tract, just as we so frequently see such irritation in the mouth. These allusions are sufficient to remind us that diarrhoea is not a disease, but only a symptom, and that, whether occurring in the dentitional or any other period, it may have, as its provocative, a great variety of sources or lesions. When a diarrhoea depends on a dental origin it is perhaps always a condition of vascular perversion, and is entirely direct in its nature ; the erupting tooth or teeth inflame the mucous membrane of the mouth, and, by the continuity of tissue, the irritability ex- pends itself over the intestinal portion of the structure. It is well to remember that in diarrhoea of this character there is much or little nmcin, according to the state of the inflammation, and much casting off of epithelial scales ; but there is, of course, nothing diagnostic in such phenomena, because of their not being peculiar to a par- ticular form or character of inflammation. We are to look at the mouth and at the throat ; if there is a local condition of irritation and inflammation, and if the vascular derangement extends as far as we can follow it, we have reasonable grounds for inferring that in the teeth resides the origin of the trouble, particularly if, having examined the system at large, we fail to discover other lesions. I do not desire, however, to be understood as asserting that it is only in this way we have dental diarrhoea, for I well know there is another way, and that is through the second of the legs of Bichat's tripod. I very well know that there is an influenced innervation, and that, if the bowels of an infant are weaker than its lungs or its brain, such deranged innervation will there expend itself. I have seen the diarrhoea of such deranged innervation 128 ORAL DISEASES AhW SURGERY. relieved almost instantly by an incision into a tooth-cyst, and yet there was no redness, no swelling, nor any other evidence of local ex- citability. These cases are, however, rare, and have their analogues in the reflex spinal irritations. The diagnosis must necessarily be somewhat differential in character ; yet, where a case is at all ob- scure and the circumstances are urgent, it is commendable practice to make incisions over the positions of teeth whose periods of eruption correspond most nearly with the time of operation. It is very well, however, and indeed necessary, to remember that a mucous membrane may be inflamed, in varying localities, without having intermediate sanguineous disturbance. Thus a stomatitis and an enteritis might be present at the same moment; the one de- pending on local dental disturbance, the other upon a cause or causes of entireh^ dissimilar nature. Now, in a case of this kind, having associative diarrhoea, it will plainly enough be seen that any treatment directed to the stomatitis would not (except as a similarity Jn practice might pertain to both troubles) affect the enteritis. To recognize these cases, antecedent conditions must be inquired into. Colds or atmospheric vicissitudes will, most fre- quently perhaps, be found an explanation of the disturbances. The cutaneous circulation, as a result of some injudicious exposure, has been depi'essed, and thus the enteritis has been forced upon a part having the least ability to resist the inrolling wave. In some in- fants, restless and nervous in their natures, a predisposition to enteric irritation seems to be inborn ; the slightest disturbance reacts in this way. It may not be that diarrhoea is the result, but the trouble exhibits itself in some evident wa}^ The milk of a nurse is occasionally the source of a diarrhoea. Infusoria and crystalline substances will be found frequently, on examination, in such milk. Here a cure would be obtained only by a change from such diet to one which would be healthy or uormal, — good cow's milk, diluted or pure, according to the age of the infant, being the best substitute. Other causes of diarrhoea, to be considered in connection with a supposed but doubtful dental source, are debility; hepatic derangements, interfering with the venous circulation ; an increased peristaltic motion through mental emotions, as anger or fright; a rheumatic or scrofulous diathesis; malarial influence, etc. Diarrhoea from dental irritation, if inflammatory by the continuity of relationship in the membrane, generally demands the lancet alone for its cure ; the operator should free the advancing tooth or teeth. ASSOCIATIVE LESIONS OF FIRST DENTITION. 129 If, however, on the removal of such cause, the effect does not sub- side, the invoked and persistent irritability is to be treated on such principles as commend themselves. Sweet oil and paregoric, admin- istered internally, I have found to act very happily. To each tea- spoonful of the oil add from five to twenty drops of the opiate, according to the age of the little patient. Heating applications to the abdomen are very useful ; for example, a sinapism made as follows : Flour, ^ss; Mustard, 5j ; Ginger, 5ij ; Black pepper, 5ss. Mix these together with a little vinegar, and retain against the skin until the part is well reddened. It is not at all necessary to blister the surface. Another and perhaps a more comfortable mode of treatment is to give small doses of Dover's powder, or, what I prefer, the liquor potassse citratis, in conjunction with minute doses of tartar emetic. R, — Spiritus tetheris nitrosi, sss ; Liquoris potassce citratis, 5[\ ; Antimonii et potassae tartratis, gr. ^. M. Give in ten- to fifteen-drop doses each two hours. This combination serves to direct the irritability to the surface, and, by a relief thus afforded the affected part, not unfrequently yields a cure. If the inflammation has anything of a sluggish or passive char- acter, the spirit of Mindererus will act happily, Half-teaspoonful doses each two or three hours should be given. Diarrhoea from dental irritation, not inflammatory in character, is to be treated in consideration of its nervous relation ; and just here is the condition in which the bromide of potassium acts most satis- factorily. It may be given in five-grain doses, dissolved in water, or, if the practitioner does not like to commence in the infant with such a dose, he may try if less will answer his purpose, and increase pro re nata. Less than five grains, however, I do not think will do much good, unless, indeed, the child is very young. Spirit of Minde- rerus, sweet spirit of nitre, and the camphorated tincture of opium also act most satisfactorily in these cases. They may be given in 9 130 ORAL DISEASES AND SURGERY. such proportions as seem indicated. An ordinary prescription would be about as follows: R. — Spiritus Mindereri, sij; Spiritus aetheris nitrosi, 5ss; Tincturae opii campboratse, 5ij- M. S. About twenty-five drops each two hours. The following combination is a valuable one, when other sources of irritation, not perhaps thoroughly appreciated, exist in conjunc- tion with the dental trouble : R. — Hydrargyri chloridi mitis, gr. ij ; Pulveris opii, Pulveris ipecacuanhas, aa gr. j ; Magnesiae carbonatis, gr. xij. Divide into eight powders, and administer one after each opera- tion, if profuse ; otherwise, each two, three, or four hours, according to judgment. 4. Spasnis. — To appreciate the cause and condition of spasms and convulsions in early childhood, whether influenced or not by the excitements of dentition, one has but to consider the restless mo- bility of the cerebro-spinal system at such age. If, at an early period of life, we examine the gray matter of the spinal cord, Ave are struck with its development when compared with the similar sub- stance in the cerebral portion of the encephalic mass. To express ourselves differently, the ganglion of excito-motor or reflex action we find to be much in excess in its development, and not only so, but sensitive and susceptible, as its offices are concerned, to the last degree, — a result most likely of the necessity for the motion of growth and development existing in the members of a child ; such a sj'stem may be compared to a tensely-strung instrument, responding to the slightest touch. The difference between a regular and irregular motion is the dif- ference between an ability or disability of the cerebellar gray matter to perform its functions of co-ordination ; the difference between a co-ordinated and an irregular motion is the difference of spasm ; and if we carry it to the disability of the cerebral mass to influence, it is the difference of convulsion. Spasm, then, may be defined to be irritation, direct or indirect, of ASSOCIATIVE LESIONS OF FIRST DENTITION. 131 the spinal cord or of its terminal outshoots or nerves. This founda- tion-principle appreciated, the further consideration of the subject is not at all difficult. Very true it is, that there may be causes of disturbance that we cannot discover ; but the results, and the mean- ing of them, are not thereby rendered obscure : it would be only the cure that would be delayed or denied. We are prepared, then, to recognize in what way dental evolution is a cause of spasm : it is precisely as it is a cause of diarrhoea, as it is a cause of fever; but the reflected irritation in the latter case expends itself on the muscular system rather than upon the mucous or vascular. The cure, or the mode of cure, suggests itself: first, we are to remove the condition of irritation ; second, if the parts do not quickly soothe and quiet themselves, we are to help them. To meet the first indication we simply lance the gums. 1 do not think that in these cases we are to be influenced entirely by local manifesta- tions of congestion: we should cut freely down upon teeth whose periods of eruption suggest them as being the source of offense. Take a pledget of cotton, and, saturating it with a solution of atropine sulphas, thrust it, by means of some delicate instrument, into the cut you have made. This is quite equal, at least as such a case is concerned, to the more common subcutaneous injection, and tends to quiet the disturbed nerve filaments. Or the bromide of potassium, as before suggested, may be used; or, drying the gum with a napkin, the smallest possible quantity of the extract of belladonna may be rubbed over the part, or it may be touched with a point of nitrate of silver. If yet the spasms should persist, some general effect on the nervous system at large must be secured. Tinctures of valerian and gentian in equal parts, given in ten-drop doses, repeated pro re nata, will sometimes act most satis- factorily. If this should not answer, the bromide of potassium, internally, may be employed. The bromide, cantharides, and cam- phor, as recommended by Dr. Chambers in epilepsy, constitute an admirable combination : B. — Potassii broraidi, gr. iij ; Tincturse cantharidis, gtt. iij ; Misturfe camphorae, gtt. x. M. Sig. Repeat this in a little water, p. r. n. If, after proper trial of the above, — say a few hours, — the irrita- bility fails to be subdued, the inference will be that our diagnosis 132 ORAL DISEASES AND SURGERY. has been a mistake, and that dentition has not been wholly, at least, in fault. At this point we see the necessity of glancing at other causes of irritation which may exist. Many children incline to nervous dis- turbance from anaemia ; this we know to be a quite common cause of such derangements. An anemic condition might not of itself, in a special case, induce spasm, but assisted by a conjunction with a second irritant, the two together could excite to the condition ; and one removed, the other could very well resist a curative agent. A glance here shows us why the sedative has not effected the cure ; let us add iron to our prescription, and a very few more days will give a different result. Perhaps the condition of a child is just the reverse ; instead of being anemic, it is plethoric. Give to this child repeated doses of some suitable saline mixture, and conjoin with the bromide of potassium quarter-grain doses of calomel; or, if you do not wish thus to medicate, diet closely for a few days, — give nothing but the breast, and this only in the daytime ; or, if the period is that of second dentition, deprive it of all but vegetable food, with water for drink ; a cure w^ould most likely follow such treatment. Lack of good, fresh, pure air; unwholesome food; deficient or improper clothing ; sleeping with debilitated persons ; the milk of the nurse ; articles of food not easy of digestion ; hepatic derangements ; worms in the alimentary canal ; influences passed from mother to infant; and numberless similar conditions, are ex- citing and predisposing causes of spasm and convulsions; and all demand, in every case, their share of consideration, if we are to be successful in treatment. Spasm resulting from the congestion of nerve centres, however induced, is not unfrequently tonic in its character ; the child may lose all consciousness ; it passes into the state that we call convul- sion. In these cases results must be obtained immediately ; we mu.st relieve the overburdened part. How ? By derivation. Try first a hot foot-bath ; let it be as hot as the skin will bear. Inclose the steam of the water so that it shall envelop all of the child but its head ; compel it, if possible, to take teaspoonful doses of the spiritus Mindereri. The steam, or the steam and mixture in conjunction, will soon compel profuse perspiration, and thus secure a double derivation. Such treatment will, most likely, relieve the congested part; at least it has generally proved reliable in my hands. If it should not answ^er the intention, then a vein may be opened, or leeches may be applied. The opening of a vein in such cases I have ASSOCIATIVE LESIONS OF FIRST DENTITION. 133 never had occasion to resort to, but it is good practice, and is recom- mended by the best writers. The pediluvia and derivation by perspiration, I thinlc, however, will be found reliable. If, after con- sciousness is restored, the pulse continues rapid, with fullness, give one-drop doses of the tincture of veratrum viride, or i*elax the S3's- tem generally by doses of tincture of lobelia or the syrup of ipecacu- anha. Ten drops of either of these medicines, repeated as indicated, will very well answer the purpose. Keep the child now cool, and guard against every source of discomfort. An instructive and suggestive case where epilepsy had its irritant in dental irritation is described in the Medical Record by Dr. Na- thaniel Field. The paper states that a small boy, about five years of age, while apparently in good health, was suddenly attacked with an epileptic fit, from which he soon recovered. The parents were much surprised at the occurrence, and were unable to account for it. About two weeks afterward he had another strong convulsion, last- ing several minutes; but it passed off without any constitutional disturbance. No cause for the attack was discovered by the relator or other practitioners. In a day or two the fits returned, and were repeated at short intervals for about ten days, during which time it is asserted that he must have had a thousand. Every resource in the power of Dr. Field was exhausted, and three eminent medical professors examined the child from the crown of his head to the soles of his feet, but no local irritation was discovered. After carefully watching the commencement of the paroxysms, he observed that the muscles of the left side of the face invariably began to twitch on the recurrence of a fit. After a convulsion had passed off, and while in a state of unconsciousness, he raised the upper lip, and found the corona of the second canine tooth, instead of having caused by a just relation the absorption of the root of the deciduous tooth, had passed behind it, and had forced it through the alveolus and gum into the lip. The gum was now slit vertically and the old tooth removed. In less than an hour the convulsions began to subside, and before the day was over they had entirely gone, and never again appeared. Passive congestions are sometimes a cause of infantile spasms ; these are not difficult to distinguish from the acute or active con- ditions, the languor and sluggishness markedly contrasting with the turgidity and fullness. Again, they are distinguished from the active state in their results, these being not immediate, but medi- ate. Passive congestions depend on some obstruction in the circu- 134 ORAL DISEASES AND SUBGERY. latory apparatus, and are, perhaps, more frequently associated with the chylopoietic than with any other system. Stagnations may also occur as a result of some interference with the respiratory office, or they may be the result of the action of some directly sedative poison. Wherever and however they exist, they are to be removed, if pos- sible, by meeting and combating the cause, which, of course, is the philosophy of cure. "In cases of pure irritation," writes Dr. Wood, "besides removing the cause, it is proper to diminish the nervous susceptibility and to control the cerebral irritation by diffusing the excitement over the whole system. To meet the first indication, narcotics may be em- ployed ; and none is more efficacious than opium, which, to diminish its stimulant influence, may be combined in some instances with ipecacuanha. Hyoscyamus, lactucarium, or conium may be substi- tuted, if on any account thought preferable. But before resorting to these remedies, the practitioner must be very sure of his grounds. He must be quite convinced that it is nervous irritation, and not active congestion of the brain, that he has to encounter. The second indication, above alluded to, is to be fulfilled by antispasmodics, administered by the mouth, the rectum, or the skin, and by the use of tonics, of which the metallics are-deemed most efficient. Of these the oxide of zinc has perhaps enjoyed most reputation, though the chalybeates should be preferred in anemic cases. Should the digestion be impaired, and the system at large feeble, the simple bitters or quinia might be preferable to the metallic tonics. These remedies may often be combined in the same prescription. Thus, opium or hyoscyamus, assafetida, and either oxide of zinc, carbonate of iron, sulphate of quinia, or extract of gentian or quassia, may very properly go together. The cold or shower-bath, cautiously used, may also serve to strengthen the nervous system. Fresh air and nutritious diet of easy digestion are important. Any derangement in the hepatic secretions should be carefully observed, and treated with minute doses of calomel, blue pill, or mercury with chalk. When the disease .depends on intestinal spasm, great advantage will often accrue from the use of laudanum, with assafetida or spirits of ammonia by the mouth, the injection of musk into the rectum, the application of a mustard cataplasm, or blister over the abdomen ; and if, as often happens, the bowels are distended with flatus, from the introduction of a catheter into the colon, and drawing off the air by means of a syringe. Should the disappearance of an eruption have preceded the convulsions, efforts should be made to restore it ASSOCIATIVE LESIONS OF FIRST DENTITION. 135 by friction with croton oil or other active irritant. In urgent cases a blister might be produced, by means of a strong solution of am- monia, on the surface previously affected. " In frequently recurring convulsions, resisting other measures, and threatening life, the practitioner would be justified in resorting to the inhalation of chloroform, which will often quickly quiet the spasms, and, if reapplied with each return, may obviate the danger until the tendency is past. It has the advantage, moreover, over other narcotics, of not congesting the cerebral centres,, though the danger of fatal prostration from its use must not be forgotten.* " Even when asphyxia or apparent death may have resulted from the convulsions, hope should not be abandoned ; but efforts should be made by artificial respiration to restore the functions of the lungs, and consequently that of the heart." Finally, on this subject, I may direct attention to the connection between the troubles we are considering and the predispositions of an hereditary nature, so often found in association. When these deteriorative conditions exist, it is a necessity for success in treat- ment that we consider and combat them. 5. Eruptions. — That the skin of childhood should be the subject of irritative changes is certainly only what is to be expected, and that variations in condition do most frequently occur is as true as that they are thus expected. Certain general considerations of the subject give us, I think, the key-note. Thus, in the beginning, a momentary thought directed to the great change which must result in the passage from intra- to extra-uterine life, would naturally lead to the anticipation of a cuta- neous hyperemic condition at once to be developed. In intra-uterine life we not only have the delicate and susceptible skin lubricated with the soft, bland smegma, but pressure on any and every part is jealously guarded against by the surrounding amniotic fluid. A single minute, frequently, and the most irritative changes occur : the waters pass away, the uterus crowds and presses upon every part of the child, while the outside world, still less considerate, receives it on its birth, its atmosphere stimulating and irritating, its rough points jagging and abrading, while unnecessary and too fre- quently ill-advised appliances and applications add to the common discomfort. Cutaneous hyperaemia — erythema, as it is generally called — is a * It is found safer to combine with it u portion of sulphuric ether. 136 ORAL DISEASES AND SUBGERY. child's primary skia trouble. Such an erythema is certainly nothing more nor less than the variegated blush of an overstimulated circu- lation. Perhaps if the smegma were left undisturbed for a few hours, just as nature smeared it ov^erthe body, or until the skin had become somewhat accustomed to its new atmosphere, such hyper- semia would be avoided ; but as such excitability seems to do no immediate harm to the child, neither nurse nor mother, I imagine, would be found satisfied with such an arrangement. But does this hypersemia do no harm ? Does it not provoke an excitability in the skin which would be better absent? Certainly children are most susceptible to cutaneous impressions, as witnessed not only in colds so easily taken, but by the variety of local manifestations, to the relief of which the practitioner is so frequently called. Dental irri- tations pertain to these troubles only as they act as excitants to the existing predisposition, or as they keep up an excitability which overmasters the corrective force natural to the vis vitae. Hyperfemia running into an excess is inflammation. Inflammation of the skin finds a primary expression in the term Dermatitis. A dermatitis has secondary signification, as it presents peculiarities which lead us to look for reasons for such expressions. Thus, one inflammation in the skin is a simi51e sthenic increased vascularity, having the phenomena of redness, heat, pain, and swelling. A second is not regular and honest in its expressions, but throws out claw-like expansions, and looks dusky and threatening, throwing^ to the surface, here and there, blebs of serum. We distinguish this second from the first by the subterm erysipelas, or erysipelatous inflammation. Then we have an inflammation which presents the peculiarity of studding the face of the skin with pustules, and this derangement we distinguish by the term pustulas or pustular inflam- mation. Another form covers the inflamed surface with vesicles ; another throws out groups of nodules, — papular; another circum- scribes its redness to patches, — rashes ; another presents raised or elevated patches, — urticaria, etc. All have alike the primary sig- nification of a perverted circulation, but differ in presenting dis- tinctive phenomena, these marking differences in local or constitu- tional circumstances. That dental irritation develops or creates the distinctive features in a skin disease is sheer nonsense. All that such irritation can have to do with the matter is that it exhausts the system, just as any pain exhausts and tires us, and reduces, as remarked, the ability of the vital force to guard or protect itself against an enemy or enemies ASSOCIATIVE LESIONS OF FIRST DENTITION. 187 in waiting at the threshold. It does not make the enemy, it only lets him in by weakening the bars. That a skin disease is thus introduced, and continued in an ability to resist applied medication, is true beyond the shadow of a doubt ; and it is for such a reason that the consideration of dental irritation, in connection with infantile skin diseases, is most important ; and yet this study, as the evolution of the teeth is concerned, differs in no wise from its stud}'" in relation to stomatitis, diarrhoea, or spasm, as certainly any intelligent mind must at once appreciate. It does differ, however, as far as a collateral treatment is concerned, and such treatment implies the study of skin diseases, as in works on Dermatology the subject is presented. It comes within our prov- ince here, however, simply to state some generalizations in such a direction, — an idea, if the reader pleases, as to the mode which such an investigation might be entered upon to compel it more readily to yield to us its secrets. A thousand complex scientific terms would scarcely exhaust the vocabulary of the dermatologist of the signification he has for the varieties and modifications of pathological skin phases. These diversified conditions, however, are found to revolve around eight centres. The centre of each is to be esteemed the nucleus or pith of the divisions ; the subdivisions are but radii of the common substance. All skin diseases belong to one of eight orders: 1st. Pimples. 2d. Scales. 3d. Rashes. 4th. Bullae. 5th. Pustules. 6th. "Vesicles. 7th. Tubercles. 8th. Spots. 1. Pimples — Papulae. — Small and pointed elevations of the cuticle, with an inflamed base — very seldom containing fluid, seldom sup- purating, and commonly resolving as scurf. Three primary divisions of papules are made: strophulus, lichen, and prurigo. Secondary dixnaions. — Strophulus intertinctus. S. albidus, S. confertus, S. volaticus, S. candidus. Lichen simplex, L. pilaris, L. circumscriptus. 138 ORAL DISEASES AND SURGERF. L. agrius, L. livldus, L. tropicus. Prurigo mitis, P. formicans, P. senilis. P. pudendi muliebris. 2. Scales — Scaly Diseases — Squamae. — Scales or laminae form upon the skin. Scales are of various forms, — in some cases, as in pityriasis, resembling a scurf; in other cases, as in ichthyosis, being broad and flattened, and bearing likeness to fish-scales. To mark the various prominent differences, four varieties are enumerated : Psoriasis, Lepra, Pityriasis, Ichthyosis. Subdivisio7is. — Lepra vulgaris, L. alphoides, L. nigricans. Psoriasis guttata, P. diffusa, P. gyrata. P. inveterata. Pityriasis capitis, P. rubra, P. versicolor, P. nigra. Ichthyosis simplex, I. cornea. 3. Rashes — Exanthemata. — Irregular, variously figured patches, appearing on various parts of the body, leaving interstices of a natural color, and terminating in exfoliations of the cuticle. The designation is generally limited to efflorescences originating in fevers, as for example measles and scarlet fever. Bateman, however, includes, and perhaps more philosophically, Erythema, Urticaria, and Purpura in the division. The first division is, then, according to Bateman, Rubeola, Scarla- tina, Urticaria, Purpura, Erythema. Subdivisions. — Rubeola vulgaris. Scarlatina simplex. S. anginosa, S. maligna, Urticaria febrilis, U. evanida. TJ. persistans, U. conferta, U. subcutanea. U. tuberosa. Purpura simplex, P. hsemorrhagica. P. urticans, P. senilis, P. contagiosa, Erythema laeve. E. papulatum, E. tuberculatum, E. nodosum. 4. Bullee. — A condition in which effusion occurs on the true skin, separating the cuticle in the form of blebs or blisters. An effusion developed by a blister comes justly in its consideration under this head, for it is surely not less a bleb because a blister has pro- duced it. The difference between such a bleb and one resultant from an erysipelatous inflammation is that one has strictly a traumatic signification, while the second is a systemic offense. Blebs or bull« have three primary classifications: Erysipelas, Pemphigus, Pom- pholyx. The subdivisions are into Erysipelas phlegmonodes, E. cedema- todes, E. gangraenosum, E. erraticum, Pompholyx benignus, P. dinu- turus, P. solitarius. ASSOCIATIVE LESIONS OF FIRST DENTITION. 139 5. Pustules — Pustulse. — An inflammation of the skin, resulting in the formation of purulent matter, which accommodates itself by throwing up little circumscribed tumors. Whether one or many of these pustules rise on a common inflamed base depends on the fundamental or exciting* cause; and because the conditions which produce pustular inflammation vary, so have we various names by which to distinguish and appreciate these causes. Five primary pustular inflammations exist : Impetigo, Porrigo, Ecthyma, Variola, Scabies. The subdivisions are numerous, depending on peculiarity of fea- tures. Impetigo figurata, I. sparsa, I. erysipelatodes, I. scabida, I. rodens, Porrigo larvalis, P. furfurans, P. lupiuosa, P. scutulata, P. decalvans, P. favosa, Ecthyma vulgare, E. luridum, E. cachecticum, Variola, Scabies papuliformis, S. lymphatica, S. purulenta, S. cachectica. 6. Vesiculse — Vesicles. — Vesicles differ from pustules in con- taining lymph — they look like little water pimples, although it is very frequently the case that the contained lymph is quite opaque: the end of a vesicle is by scurf or scab. There are seven primary varieties : Varicella, Vaccinia, Herpes, Rupia, Miliaria, Eczema, Aphtha. The subdivisions are Varicella lenticulus, V. conoidge, V. globate, Herpes phlyctsenodes, H. zoster, H. circinatus, H. labialis, H. prae- putialis, H. iris, Rupia simplex, R. prominens, R. escharotica, Eczema solare, E. impetiginodes, E. rubrum, Aphtha lactautium, A. adultorum, A. angiuosa. 1. Tubercula — Tubercles. — These are small, hard, circumscribed tumors — they may be fixed in a state of integrity, or they may be degenerative. There are eight kinds of these tumors — or, to express it differently, there are eight distinctive differences: Phyma, Ver- ruca, Molluscum, Vitiligo, Acne, Sycosis, Lupus, Elephantiasis, Frambcesia. Among these, subdivisions seem only necessary with acne and sycosis. Thus, there are three peculiarities in acne, Avhich are marked by the terms Simplex, Indurata, Rosacea. In sycosis. Sycosis menti, and S. capillitii, designating the location of the tubercles. 8. Macula — Spot — Mother-Mark — Freckles or EpUelis — Nasvus. These eight classifications, after Bateman, with his subdivisions, make out of skin diseases all that concerns a present consideration 140 OJiAL DISEASES AND SURGERY. of them. It is for the student to comprehend the primary divisions, as their pathological differences are concerned ; the radii, or subdivi- sions, will be found to take care of themselves. Without an under- standing of the general subject one could scarcely expect to appre- ciate any accidental or positive dental relations. The subdivisions will be remarked, on examination, to be simply as family surnames distinguishing one child from another ; it is true, of course, that there are peculiarities of character, just as each child is peculiar, and by such peculiarities are these modifications' on the primary condition named. Now, it is not by any means common to asso- ciate all these conditions with dental irritations ; yet it is certainly true that any one of them may have such association: therefore, if the student would understand one he must understand all. CHAPTER VIL ANOMALIES OF SECOND DENTITION AND THEIR srRGICAL RELATIONS, Understanding and appreciating the characteristics and relations of a normal dentition, we are prepared to pass to the consideration of abnormal or pathological conditions. Such conditions may be justly grouped under the head of anomalies. Anomalies in second dentition may be classed under seven heads: 1st. Teeth common to the age, but erupting external or internal to the arch. 2d. Teeth denied space in the arch, because of natural or surgical interference with the process of maxillary enlargement. 3d. Germs developing in positions where their product must remain encysted. 4th. The production of supernumerary teeth. 5th. Third dentitions. 6th. Teeth the periodontea of whose fangs are in association with the periosteum of the sinus maxillare. 7th. Germs with heterogeneous development. These seven conditions, then, because they differ from a just or normal dental evolution, we call anomalies. Anomaly First. — A tooth external or internal to the alveolar arch not unfrequently gives origin to an ulcer or locates epithelioma. Yet close as is this primary to the secondary lesion, and evident as such relationship would seem to be, I have known ulcers of the tongue, lips, and cheeks treated for months — of course, without suc- cess — where it has never seemed to strike the practitioner that the tooth could have any association with the disease ; indeed, in one case, where the patient was remotely connected to myself, death was the result of a cancer located in the cheek from this very anomaly. A second case, having a fatal termination, has occurred in my own practice, epithelioma of the cheek having been located through the irritating influence of a wisdom tooth out of position, and which seems to have been entirely overlooked. (141) 142 ORAL DISEASES AND SURGERY. Note. — Even where there is excess of room, the permanent teeth not unfrequently erupt irregularly ; indeed, this applies so directly to the inferior incisors, that it may almost be said to be the rule rather than the exception. Unless, however, specially indicated, it is the best practice to leave them to nature; they will almost always be found to come right of themselves. I would be understood as classing them with the anomalies only as derangement is marked and permanent. Anomaly Second. — Teeth denied sjw.ce in the arch. This anomaly has perhaps the largest associative pathological connection. I have remarked that this lesion, if we may term it such, is more frequently the fault of the surgeon than of nature. If, for one mo- ment, we refer to the physiological relations existing between the first and second dentures, we may find that it is within our power to prevent the many ills that follow so frequently in this train, and simply by doing little, or, more commonly, nothing. The deciduous dental arch is filled, as we are all aw^are, com- pletely by its ten teeth. The second or permanent set is to com- prise in number sixteen, and each tooth certainly quite as large again as its predecessor. This increase in number and size of the teeth, it is evident, must be provided for in an enlargement of the alveolar arch. This provision is always attempted by nature in the process described by the physiologist as the elongatory. I will illustrate this process of maxillary enlargement by con- sidering the ten milk teeth as so many wedges placed in a springy arch. This arch it is designed to lengthen by additions to either end. If, now, these wedges should be removed before others were ready to take their place, it is evident that the elongation, being made at the ends, would, to a greater or less extent, be counter- balanced by the springing together of the parts at the sites of the removed wedges. The process of maxillary, or rather alveolar, absorption, is truly represented by this retraction of an arch. In proportion to the number of deciduous teeth removed prematurely, will be the curtailment in size of the arch, at least of its alveolar face. Let us, then, look at the results of such abridgment, — approximal caries of the teeth, periosteal troubles, trismus, odontocele, necrosis, the violent inflammations attendant on the development of the dentes sapientiae, etc. Note. — If there is a pathological Pandora's box, it is certainly the lesion of an overcrowded maxillary arch. ANOMALIES OF SECOND DENTITION. 143 Such condition is made evident to the practitioner the moment he looks into the mouth of his patient: the teeth are jammed into the most uncomfortable-looking positions ; the deformity, however, mostly existing in the front of the mouth, — either the central in- cisors override, or the laterals are thrown back, or otherwise the cuspidati take the tusk position, standing out prominently from the arch, the bicuspidati occupying too anterior a location, approxi- mating, indeed, not unfrequently with the lateral incisors. Treatment. — To abort the ill consequences of such a contracted arch, extract at as early a period as possible the first bicuspidati of either side. This very simple operation will frequently not only secure against secondary lesions, but will occasionally correct the most annoying deformities. Let it be remembered, however, by the practitioner who prefers prophylactic to operative surgery, that on his treatment of the deciduous mouth depends, in a measure, the health and comfort of the adult. If I am asked what is to be done with the deciduous aching tooth, I may answer that it should have been filled on the first appearance of decay. This is a matter which no parent can afford ever to neglect. In the armamentum of the oral surgeon are plastic- materials, easy and painless of introduction, which can be entirely depended on to perform the service required of them. Equal parts of chloroform and tincture of aconite, applied to an aching nerve on a delicate pellet of cotton, will sometimes instantaneously relieve this form of toothache. Another admir- able application is the atropias sulphas, dissolved in water, in the proportion of six grains to the ounce ; such a preparation, while very effective, is to be used, however, with reasonable care. An exposed pulp in the deciduous tooth is, however, so constantly subject to irritation, that every indication calls for its destruction. The necessity is unfortunate, but the demands are persistent, and the removal of the part seems the lesser of two evils, between which the practitioner is compelled to choose. The application of arsenic, however, to such an exposed pulp has come to strike the experienced as questionable, and, as it is not a necessity, it will be found best perhaps to restrict the use of this agent to the permanent teeth. A deciduous pulp may be destroyed by touching it a few times with a fully saturated tincture of iodine, or with either of the Monsel's solu- tions of iron. (See chapter on Odontalgia.) Arsenical applications are, however, frequently employed, but 144 ORAL DISEASES AND SURGERY. unless a practitioner is vqvj conversant with the physiolog-ical change that occurs in the fangs of these teeth, he had better not I'isk this means ; if, however, he feels prepared to employ such an escharotic, he can prepare no formula better than the following: R. — Acidi arseniosi, Morphise acetatis, aa gr. x ; Creasoti, q. s. to make a thick paste. This is a paste quite universally employed for destroying the pulps of adult teeth. To apply it to the milk tooth, take a piece not larger than a pin's head, and, dropping it lightly into the cavity, cover loosely with cotton ; the part is washed out with warm water after four or five hours. I would not leave such a preparation in a deciduous tooth over five hours ; and if absorption of the fang had advanced to any extent, even one hour might be too long. Employ it fearlessly in the adult mouth, only remembering that you deal with arsenic ; but with the child too much caution cannot be exercised. The central incisors of the deciduous set of teeth should (a normal life continuing) last until the seventh year; the laterals until the eighth ; the first deciduous molar until the ninth year; the second until the tenth ; the deciduous cuspid until the eleventh ; and let it be remembered that the most posterior molar teeth that are in the mouth at the sixth year are the first permanent molars, and that these teeth get their place in the jaw without displacing any of the deciduous. For an account of some of these secondary lesions, together with treatment, see future pages. Anomaly Third. — This anomaly is remarked by examination of the classes of teeth erupted. Teeth all erupt in pairs, so that one is not likely to be deceived. The anomaly is not unfrequeutly the result of interference with the development of the germ of the perma- nent through non-absorption of the root or roots of the deciduous teeth. Example. — A deciduous central incisor erupts — as the rule — about the seventh month, and is succeeded by the permanent at the seventh year. Now the physiological relation existing between the two teeth is as follows. At the time when the deciduous has attained its fullest development the germ of the permanent is at its apex, (See Fig. 52.) Retrograde metamorphosis now commences in the ANOMALIES OF SECOND DENTITION. 145 fang of the deciduous, while, in an inverse ratio, the development of the permanent advances. It sometimes happens, however, that no process is set up for the taking away of these deciduous fangs, and, as a consequence, the permanent are compelled to make alveoli for themselves ; this they generally do by emerging posterior to the deciduous ; but, as can readily be imagined, odontocele or encyst- ment is not unfrequently a result. Note. — Sometimes, long after the period at which the second dentition is usually completed, the incisors, as would seem to be natural, may be remarked, each occupying its respective alveolus. Yet here we may have odontocele. One of the incisors that we see is a milk tooth. This anomaly could, however, deceive only the very superficial observer, the difference in the classes of teeth being sufficiently marked. Because of this non-absorption of deciduous fangs, arrest in the development of the permanent sometimes occurs. It is really quite a nice point in practice to give advice in such cases ; if you direct the extraction, aud no tooth comes to replace the one lost, you will be sure to get a good deal more censure than you could possibly deem yourself deserving. There are a number of conditions to take into the consideration of such a case, the most prominent of which is the existence or non- existence of the anomaly in a hereditary point of view. I am acquainted with a family where continued integrity on the part of certain front deciduous teeth, conjoined with the non-appearance of the permanent, has been a striking peculiarity as far back as the ancestors can be remembered. Ability to advise, in such cases, can only be gained by a careful study of the laws of dentition and idio- syncrasies. Surgical Relations. — In an examination of any obscure tumor of the maxillary bones, examine the dental arch ; if a deciduous tooth occupy the place of a permanent, the existence of odontocele may be reasonably inferred. Anomaly Fourth. — Supernumerary Teeth. — These teeth differ from all others in being doubly fully conoidal ; this is the rule. It is, however, to be remembered that we meet with exceptions. Har- ris mentions having seen them so resembling the natural teeth as "to make it impossible to distinguish which should be called the supernumerary;" as for myself, I have never met with such decided exceptions. An encysted condition of these bodies obscures very much the 10 146 ORAL DISEASES AND SURGERY. recognition of their existence. In diagnosing diseases of the mouth, we must bear in mind that we have such odontoceles. The study of the evolution of such teeth is very interesting, but, of course, con- cerns the physiological rather than the surgical author. We may remark, however, that they do not seem to be necessarily a dermatic production, and the appearance of them in the mouth is as unac- countable as their association with ovarian and other remote tumors. Surgical Relations. — With the exception of the relation of super- numerary teeth to tumors, we have only to deal with them as they so strangely present themselves in the mouth. Let me give an example of such practice. A patient presents himself and tells you that there is a piece of bone working out through his mouth; and, truly, an examination will seem to verify his assertion. But there is one point which, if observed, will never mislead. Necrosis is always preceded by, and is associated with, tumidity of the gum. The eruption of a supernumerary tooth is very gradual, and, so far as my experience goes, is never associated with inflammation. To extract such teeth, wait until they have emerged to the base of the cone; or, if such waiting does not seem desirable, carefully force sharp- pointed forceps through the bone until you may be able to grasp this base, then with a rotary motion you may easily pull them away. Their alveoli need no attention. Anomaly Fifth. — Third Dentitions. — I would not be understood as referring here to that extra development sometimes occurring in young adult life, and yet the mention of the existence of such an anonmly is, perhaps, desirable. Thus, Columbus reports that one of his children had three sets of teeth. Valerius Maximus and Pliny relate similar facts. A son of Mithridates is said to have had two, and Hercules three. I myself have seldom seen this anomaly, and incline to think that its existence, in these modern times, is not co- extensive with the ancient period. I have certainly had quite five hundred persons tell me that such and such tooth or teeth were the third of the class, but examination, in almost every individual case, has satisfied me they were mistaken ; this anomaly has, however, surgically, little or no signification. Third dentitions, as here referred to, are those which are asso- ciated with advanced age. The student will recognize their phys- iology when I classify them with second sight, etc. The lesions of this anomaly are what might be termed associative — that is, we are occasionally so deceived by them as to be led falsely to in- terpret engorgements, congestions, etc. AN03fALIES OF SECOND DENTITION. 147 A single case will illustrate the anomaly. An individual, aged sixty-five, applied to Dr. Chapin Harris, suffering with pain in the gums and jaws. No local lesion was at all discoverable. A tenta- tive treatment was resorted to. The apparent disease went on, however, entirely uninfluenced by the experimental medication, until at last it attained an intensity positively excruciating. In twenty- one days the mystery was explained by the eruption of a third set of teeth. The report of another case is, at the time of this writing, appearing on the pages of various journals describing a new and full dentition in the person of a gentleman eighty years of age. Anomaly Sixth. — Association of the odonto-])erioHteum ivith the membrane of the antrum of Highniore. It will be remembered that the easiest entrance to the maxillary sinus is through the palatine fang either of the second or the first molar tooth. It is, indeed, as I well know from experience, a very common thing to find the roots of these teeth perforating the cavity. Remembering this association of parts, it will be seen that many conditions, which may have been deemed obscure, are thus made very plain. Dr. Harris, who seemed a close observer in disea.ses of the mouth, went so far as to say that two cases, mentioned by Bell and Bordenave, were the only authenticated exceptions where ab- scess had formed in this cavity at any other point than that at which it had been penetrated by the root of a tooth. A case mentioned in Braithwaite, from the practice of a Mr. Louis Oxley, of London, illustrates most happily the relations of this lesion. A young woman, of rather strumous habit, complained of a dull, aching pain under the orbit. The pain lasted from three to four months, attended by a gradual elevation of the orbital surface of the maxilla. The eye above this surface became at length so affected as entirely to lose its functions. At this stage of the case she was directed to use leeches and blisters behind the ears, and to employ drastic purges. After three months' blindness, the patient first perceived a discharge, from the right nasal fossa, of a thick, purulent fluid. This discharge had existed, he says, eighteen months, when he first saw the case. An examination of the mouth at once revealed the cause of so much misery, and the removal of three roots, in a state of periodontitis, was the simple means by which two most important organs regained their proper functions. The nasal opening of the maxillary sinus, it is known, is, in a healthy condition, almost closed by the duplicature of membrane lining the turbinated and neighboring bones; congestion of this 148 ORAL DISEASES AND SURGERY. membrane not unfrequently closes it entirely. Thus secretions ac- cumulate, giving alarming and threatening disfigurements to the face. The weakest points in the osseous boundaries of this cavity are, the floor of the orbit, the hard palate, the tuberosity of the bone, and the canine fossa. Any accumulation would necessarily be most apt to vent itself at one of these four points, unless atresia of the duplicated membrane alluded to should occur, and which is not commonly the case. Note. — My own experience regarding acute abscess of the antrum is, that in the great majority of cases the pus seeks to vent itself through the floor of the cavity. After the inflammatory action has passed to the suppurative stage, you will notice a swelling in the roof of the mouth at the side of the mesial line, corresponding to the diseased cavity: this is the abscess pointing, and, if left to itself, will be sure to make an ugly opening. Such a result will be found particularly undesirable if there should be any specific virus linger- ing in the system. But wherever this abscess should tend to point, it is of course desirable to abort it. If the assertion of Harris is true, concerning the almost invariable dental origin of this abscess (and certainly my own experience, so far as it goes, confirms him; for, while I have seen many cases of this kind, I have yet to meet with one where the treatment indi- cated was not primarily of a dento-surgical character), we turn naturally to the alveolar arch, seeking there the source of offense and defense. For a single moment, then, let me direct attention to a few dental lesions of the most practical character, and without the ability to recognize which, the practitioner will assuredly find him- self at sea. Because, when you turn to this dental arch, you find it entirely clear of teeth, and healthy-looking, you are not hastily to conclude that the primary lesion is not in such direction. You are to re- member that fangs of teeth are not unfrequently broken oft' in an attempted extraction, and that when so broken, particularly if very deep in the socket, the practitioner is not unapt to leave such pieces alone. Now, it is easy to understand that a fang so situated maybe the source of extensive disease, and yet the gum over it be without break in its continuity, and perfectly healthy-looking. The relation, in such a case, of the fang, is with the antrum, — it need necessarily have no external sinus. Make here an explorative incision along the gum down to the bone. If, happily, you come to a cavity,'you will have hit on the origin of the trouble ; but if you find nothing, ANOMALIES OF SECOND DENTITION. 149 you have made only a simple incised wound, which left to itself will heal in a few hours. Again, because the part may have its usual complement of teeth, and each tooth should seem to be perfectly healthy, you are not to turn hastily ayay. There may be in one of these teeth a dead pulp. To satisfy yourself on this point, take up a delicate steel instrument, and strike with it each tooth separately, directing your patient to note any difference in the sensations; if he should start when you strike a particular tooth, my veracity for it, you have found the primary lesion. But still again, the lesion may be here, and yet the patient not express the anticipated pain. Take now a hand- mirror, and, placing your patient full in the sunlight, reflect the rays over tlie teeth, by placing the glass back of them. If in the arch is a dead tooth, you will remark an opacity in it not belonging to its neighbors : this is the offense ; extract it. If a tooth has a plug of metal in it, take the filling out: the cavity will, not unlikely, be found to communicate with the pulp chamber. If, now, we study periodontitis, the student will be prepared to make the most of the cases which we shall have to consider under various heads associated with such lesions. Periodontitis. — Periodontitis, peridentitis, pericementitis, dental periostitis, as the condition is variously designated, implies inflam- mation of the membrane associating the root of a tooth with its alveolus. Periodontitis, like inflammation in general, may exist either in the condition of activity or chronicity. The active form of the condition is most frequently found as the expression of direct local irritation ; the chronic, as the result of systemic influences. Acute or active periodontitis, if not resolved or aborted, has a history which associates it with parulis. It commences commonly with a dull, heavy, gnawing pain in the parts affected : this is the signification of simple vascular excitement. As the grade of the inflammation advances, pain increases with it. The tooth seems to the touch of the patient to project beyond its fellows, and really does so. Occlusion of the jaws gives pain, which pain so grows in severity that the whole attention of the patient becomes directed to the avoidance of the contact. Finally, when not arrested, the action goes on to the suppurative condition, — the state of abscess; and 150 ORAL DISEASES AND SURGERY. this pus, discharging through a sinus which it creates for the con- venience, — generally opening upon the gums opposite the diseased point, — establishes the condition of parulis. Chronic periodontitis — subacute, as it might with as much pro- priety be termed — has a history markedly distinguishing it from the sthenic form : its causes are manifold. Mercurial ulitis is perhaps among the most frequent of .the causes. Scorbutus is another very common cause, being abundantly expressed in every neighborhood where much pork is eaten to the exclusion of a mixed diet. From the exanthems many cases have origin : of such causes scarlatina seems the most provocative ; rubeola follows this in frequency. The phosphoric impression, as seen in connection with the workmen in match-factories, is a cause familiar to every surgeon. Neul'algic reflections certainly beget irritability in the peridental tissue, and which, in cacoplastic states of the blood, may degenerate the nutri- tional changes. Rheumatism and gout, as toxical conditions, are fre- quently found from clinical experimentation to be the irritants support- ing a resisting periodontitis. Uterine reflections, particularly from the menstrual relation, are other causes. Age is a common cause, — old people losing their teeth by a degenerative condition of this membrane, which allows the organs to loosen and drop out; or the same result is found frequently to coincide with tubular consolidation of the fangs, the excess of nutritional work thrown thus upon the periodonteuni exhausting finally the excitability of this membrane. Accumulation of tartar, as it is called, is a common and frequent cause of chronic periodontitis. Chronic periodontitis — existing as a primary form — difi"ers diag- nostically from the acute condition in the absence of the sthenic expressions. The tooth or teeth affected grow sore, tender, and elongated, but the progress is so slow as not to make the oflFense of sufficient import to the comfort of the patient to invite any vigorous antagonism, the expression commonly being that associated with the chronicity so frequently succeeding the acute form ; the parts are recognized to be in the state of disease, but the condition is suf- ficiently bearable to be endured. The acute and chronic forms of periodontitis find constantly a combined relation. Thus, the constitutional ofi"enses are found capable of provoking the active condition, while local offenses, as instanced in salivary calculus, conjoin not unfrequently with the chronic state. Chronic periodontitis, except as associated with the acute form, is ANOMALIES OF SECOND DENTITION. 151 not found to tend to parulis, but when degenerating to the forma- tion of pus, has the discharge about the neck of the diseased tooth or teeth. The importance and frequency of periodontitis rendering the con- dition one most necessary to be thorough!}^ understood, advantage may be taken of the present and succeeding chapters to direct atten- tion to the subject in the required detail. First and most commonly, it will be seen that the acute form of the condition we study depends on preliminary disease in the dental pulp, this organ being in a state of profound inflammation, affecting the periodonteum by its continuity of relatioi>ship, or otherwise being dead, and proving the source of offense by its post-mortem changes and influences. In any and every case of acute periodon- titis which presents itself, whether exhibiting the very first expres- sion of a scarcely noticeable uneasiness, or the tooth being so elongated and tender as to render the slightest touch unbearable, attention is to be directed to the condition of the pulp cavity. If this, as is frequently the case, is found exposed, and the pulp dead or absent, then it is at once — no evidence of other vice, either consti- tutional or local, being seen — to be inferred that the trouble is that of an open, free inflammation, demanding for its relief common antiphlogistic medication. Where a pulp cavity is found closed, the tooth being undecayed, or otherwise having in it a tilling, a first indication directs an open- ing into the pulp chamber, no hesitation being necessary, as in per- haps all instances in which a tooth has become thus tender to the touch, the pulp, if not found actually dead, will be in such a state of congestion that its destruction has been insured. If, however, it is desired to attempt the abortion both of pulpitis and periodontitis, the plan suggested of uncovering the organ will be the wisest which may be pursued, as thus depletion could be practiced with the most immediate effect, and medication find direct application. Instances, however, present — and these are much the most numerous — where the periodontitis depends on a preliminary operation in which the pulp of a tooth has been purposely destroyed and removed, its place being occupied by metal as in what we are to study as a root-filling. Here it is not unlikely the trouble depends simply on the excess of work thrown upon the periodonteum from the abstraction of the pulp life ; or it may be that the tooth is unable to endure the thermal changes resulting from the presence of the filling material ; or per- haps some particle of the pulp was not removed, which, disinte- 152 ORAL DISEASES AND SURGERY. grating and decomposing into its gaseous elements, has provoked the inflammation through pressure upon the parts about the foramen ; or, still again, it may be that a slight twist of the cotton or gold, or whatever may have been used to fill the root, has been forced through the foramen. The consideration of a condition of this nature calls always for the exercise of individual judgment aside from ordi- nary rules. If a pulp cavity has been well and scientifically treated, it would scarcely seem necessary or desirable to undo what had been done ; as having been properly done, with all collaterals considered, it is not to be esteemed that undoing and doing over could improve mattei's. We would therefore naturally consider the periodontitis as the lesion, and consider this alone. If, on the contrary, there is doubt of the operation, — if there is reason to infer that any portion of the pnlp remains in the cavity, or that a twist of the filling has passed the foramen, — then a first indication lies in such direction. Accumulation of tartar provoking periodontitis would not be diffi- cult to distinguish, and the indication for its removal would be self- suggesting. False occlusion, another cause of periodontitis, calls alone for its appreciation to an observation which considers the common articu- lation. A tooth which, from any cause, strikes prematurely, is certain to succumb to the irritation if the offense be continued for any length of time. In such relation, the condition of newly-placed fillings is to be considered. A plug is never to afford the feeling of special contact. When a filled tooth becomes sensitive in its periodonteum, a very first attention is wisely directed to the contact ; should the metal be unduly prominent, it will, most likely, be at once noticed by an indentation seen upon its surface. Should this, however, not exist, the surface may be rubbed over with a little pulverized pumice-stone, so as to remove the general polish : the contact of the opposing tooth, if now it unduly touch, will distinguish itself by the polish it affords. Teeth unduly occluding from false articulation are to find remedy in the file, which is to cut away from the unaffected organs (or, if seemingly necessary, from the one which has expressed the irritation) such portion as shall remedy the defect. Still another cause of periodonteal inflammation, not unfrequently met with, results from accidents in the use of escharotics, which, having been applied to a cavity for the destruction of the dental pulp, have escaped and fallen around the neck of the tooth. A similar result has ensued from application of caustics to the gum for the arrestation of mucous oozing, or hemorrhage. Still again has ANOMALIES OF SECOND DENTITION. 153 such inflammation been provoked by ligatures used with the rubber dam, or by forgotten rings of rubber tubing or thread. In Fig. 53 is exhibited such a ringed tooth, where the cause of a defying abscess was only discovered after extraction. The relation of ring and tooth is just as when removed from the mouth. Still another cause of periodontitis, but one happily apt to tend to rapid self-cure, is found in the process of wedging. -piQ 53 All teeth are made more or less sore through such mani- pulation, and the soreness expresses inflammation. Such wedging, however, employed in the mouths of old persons, or with those of bad constitution, may well result in the necessity for a medication, aside from the removal of the cause exciting the trouble. Taking it for granted that any and all existing sources of irrita- tion have been removed, an acute periodonteal inflammation, taken in time, may in nine out of twelve cases be aborted as follows. Pass a lancet several times through the gum down to the alveolus; let the patient hold water in the mouth, so as to prevent the formation of clot, and provoke free bleeding. As soon as the vessels and capillaries have disgorged themselves, paint the parts heavily with tincture of iodine, to which has been added one-fourth part of tincture- of aconite, both being of the ofBcinal strength. The philosophy of this treatment is sufficiently evident not to need explanation. A routine plan followed commonly with satisfactory results in incipient periodontitis is as follows : Place the feet of the patient in very hot water. Apply just in front of the ear a fly-blister of the size of a silver dime piece, and upon the nape of the neck a second, the size of a silver dollar. Admin- ister internally twenty-five grains of the bromide of potassium, having combined with it five drops of the tincture of veratrum viride, — this combination to be repeated in four hours, if relief be not sooner obtained. Lance the gums freely with a very sharp lancet, and afterwards keep cotton applied, saturated with the fluid extract of Hamamelis Virginicus ; of which the best is the preparation known as Pond's, or this combined with equal parts of the phenol sodique. This treatment, if all local cause of offense has been removed, will seldom fail. It is found well to retain the feet in the hot water until the patient grows faint or breaks out into a perspiration. In the plethoric, in addition to the above course, half an ounce of the sul- phate of magnesia may be given in a goblet half filled with water. In the employment of the arterial sedatives in periodontitis, as in 154 ORAL DISEASES AND SURGERY. an inflammation of any other part, regard is always to be had to the condition of the pulse, such medicaments being alone indicated in the sthenic conditions, and acting- here with an efficiency and influence sometimes quite magical. Of such sedatives few seem possessed of the virtue of veratrum viride. I am well satisfied that it is in very many cases all that is needed in the treatment. Hydrate of chloral is another of this class of agents highly commending itself. That it, however, possesses sedative qualities dangerous in extent is scarcely to be doubted. To commence its exhibition in doses of not over ten grains is to err on the safe side. It is, however, on the bromide of potassium that every dependence is to be placed : it maj' be given in doses varying from ten grains to one drachm, or even one hundred grains, twenty grains being the ordinary dose ; this is to be pre- scribed in water, and may be repeated each two, four, or six hours, as seems indicated. As adjuncts, leeches are occasionally to be employed with great benefit. If the inflammation is associated with the lower maxilla, they may be applied below the jaw ; or, if objection be not made by the patient, they may be used as in the ui)per jaw, being applied directly to the gum. A very simple plan of treating incipient periodontitis, and which will frequently be followed by immediate relief, consists in making a minute blister upon the gum overlying the affected root, through an application of a saturated solution of iodine. Lead-water and laudanum, as used so commonly in general surgical practice, is found a valuable refrigerant lotion to the inflamed parts, being applied on a pledget of cotton placed between the gum and cheek. A satisfactory combination will be found as follows: R. — Plumbi acetatis, 5j ; Tincturee opii, sss; Aquae, §x. M. To protect the inflamed tooth from contact with its neighbors, resort is to be had to a cap placed over adjoining organs. To this end, gutta percha is commonly employed, being easy and instantane- ous of application, requiring alone that a piece of the material about an inch square be softened in a flame and moulded over the parts, a mouthful of cold water hardening it into the required resistance. An instrument, however, more delicate, is found in a cap of silver, as devised by Dr. J. H. McQuillen. (See Fig. 54.) Such a cap is quickly made by the mechanical dentist, he requiring alone an ANOMALIES OF SECOND DENTITION. 155 impression of the tooth or teeth proposed to be capped, and which is secured in a moment by pressing over and around them a small lump of softened beeswax. Ad acute periodontitis resisting the various means here suggested, the attack increasing in severity, the surgeon finds himself compelled to abandon antiphlogistics, the indication being to advance the condition to the suppurative point Fig. 54. as quickly as possible. To this end, heating and exciting medicaments are required; warm water is to be held in the mouth, or a weak dilution of the tincture of capsicum may be employed ; about twenty-five drops to an ordinary-sized goblet of warm water will be found sufficiently stimulating. Tlie domestic application of a roasted split fig to the gum increases the heat of the parts and invites suppuration to the surface to which it is used. Pursuing a natural course, the attack ends in the forma- tion of pus and the establishment, commonly, of open parulis. The appreciation and treatment of chronic abscess, whether founded on the acute form or arising as a primary condition, are to be found in a recognition of the indi(;ations of the associated condi- tions. These the reader will find considered with all fullness and clinical care in the chapters on "Alveolar Abscess," "Diseases of the Gums," "Necrosis," and " Odontalgia," to which he is referred. Anomaly Seventh. — Germs of Heterogeneous Development. — It occasionally happens that the dental germ, instead of arranging its parts according to the ordinary laws of its nature, assumes the most fantastic and heterogeneous shapes, giving such a variety of appearances that only a close attention may appreciate its dental character. Tumors of complex kinds are thus occasionally pro- duced, and, unless appreciated, are necessarily the source of much anxiety both to surgeon and patient. In an admirable memoir by M. Forget, crowned at the Academy of Sciences, Paris, in 1859, are illustrations of cases both of this seventh and the ordinary anomalies. I present them to my readers as being studies than which it would be time wasted to search for better. 1,56 ORAL DISEASES AND SURGERY. PLATE I. Fig. 1. — h. Osseous tumor united to a molar tooth (a). Fig. 2. — a, b. Section of the tooth and of the tumor. Fig. 3. — a, b. Dental tumor formed by the anomalous development of the first two molars. a. Summit of the tumor, b. The root of the tumor. Fig. 4. — a. Cyst of the right branch of the inferior maxillary bone, the cavity of which is made visible by the circumferential resec- tion of its external wall. b. A molar tooth inclosed in the osseous tissue, and en relief u'pon the bottom of the cyst. c. External wall of the cyst, inverted. d. Condyle and neck of the jaw. e. Summit of the coronoid apophysis, with the insertion of the tem- poral muscle. Fig. 5. — Upper jaw of a horse ; view of half of the palatine face. a. Osseous cyst developed in the interior and right side of the jaw; it includes the tumor represented by Fig. 6. b. Right canine, thrust backward and inward toward the medio- palatine line. d. Alveolus of the left canine tooth. e. Osseous perforation, conducting to the interior of the cyst. Fig. 6. Intramaxillary osseous tumor (natural size) ; it was contained in the cyst represented in Fig. 5. Fig. 7 (300 diameters). — Represents a part of the section of the tumor shown in Fig. 6. This tumor appears to be formed entirely of the cement or osseous substance surrounding the dental root. It is an exostosis of the dental cement. This exhibits the struc- ture described in the explanation of Fig. 4, Plate I. a. Vascular canaliculi of the osseous substance of the tumor (Havers' glands). The tumor is traversed by these as in the normal osseous substance, — only they are more rare, more scattered, and more irregularly distributed. b. Osteoplasts disposed circularly, or nearly so, in a concentric manner around the Haversian canal, but less exact and evident than in the normal condition. c. The osseous substance, properly so called, in which the osteo- plasts, or characteristic cavities of the osseous tissue, are excavated. IPIi-A-TE I. m %2 F,p (157) /^-* "* '— ^ (158) ANOMALIES OF SECOND DENTITION. 159 PLATE II. Fig. 1, Represents a cyst occupying the whole extent of the right half of the body of the lower jaw, and of the coronoid apophysis. The external wall of the cyst has been removed, and permits a view of the cavity, bounded by the internal wall b, which remains. a. The wisdom tooth, developed in an anomalous fashion in the base of the coronoid apophysis. c. Dental canal, open through the whole of its extent. It does not communicate with the cavity situated above it. Fig. 2. — d. Right side of the inferior jaw, affected by the rarefying osteite. a. Large molar tooth encysted in the bone. b. Interior of the cyst, with a black bottom, representing the mem- branous tissue that lined its surface. Fig. 3. — Same cyst, open at the side of the mouth. It reproduces (a and b) the aforesaid anatomical arrangements. Figs. 2 and 3. — c, c. Three incisor teeth, the canine tooth and the first two molars, removed from their position, and retroverted one upon another. JPXjJ^TIE] XX, (160) :px.-a.tei XX. n (161) 162 ORAL DISEASES AND SURGERY. PLATE III. ANOMALIES IN POSITION OF THE TEETH. Fig. 1.— a. Incisor tooth retroverted, and directed toward the intramaxil- lary symphysis. Fio. 2,—c. Canine tooth developed in the thick part of the floor of the nasal fossa;, where it forms a prominence : the root is directed for- ward. b, b. Section of the maxillary sinus. d. Nasal spine. a, a. Posterior edge of the nasal fossag. Figs. 3 and 4. — Two other examples of anomalies in the position of the teeth. I IPXiJ^TiE III. (163 I=Xj-A.TE III, i\ 1G4) ANOMALIES OF SECOND DENTITION. 165 PLATE IV. Fig. I. — a, a. Second grindiog tooth of a horse, natural size, with considera- ble development of the roots, transformed into two spheroidal swellings. b, h. Portions of the maxillary bone sheathed in the tumor, and broken in its extraction, c. Orifice conducting to the interior of an intradental cavity. d, d. Circular groove corresponding to the alveolar arch, and form- ing a sort of strangulation between the tuberosity a and the swelling e, which is underneath. /. Inferior surface of the crown of the tooth. Fig. 2. — Microscopic examination of the tumor (300 diameters). — Eepresents part of a thin section of the tumor shown in Fig. 1. The tumor was formed jointly by a hypertrophy of the dental ivory and a hypertrophy or exostosis of the cement, the greatest part being formed of the substance of the cement. a, h. Represents the ivory in its canaliculi — not ramified in this section — and terminating near the union of the ivory and enamel, c, d, e. Exhibits the mammillated arrangement seen in the cement at certain points of the surface of union with the ivory or dentine. This arrangement, often very elegant under the microscope, is also met with in the normal teeth. g, h. Osteoplasts, or characteristic cavities of the cement. They are especially remarkable for their size in all the preparations taken from this piece. /. Proper substance of the cement, or bone, in which the char- acteristic cavities are excavated. It is here, as always, homo- geneous; little transparent, except when it is reduced to very thin laminae. IPXi^^TE IV. 166) IPXjJLTS "V". Efi \, b Fi^.z (167) 168 ORAL DISEASES AND SURGERY. PLATE V. Fig. 1. — Intramaxillary bone bearing the two permanent incisors (a, a) superposed, and exhibiting an anomalous development. The alveoli of the same infantile teeth are partly destroyed; this sec- tion formed the deposit. Fig. 2. — Tumor of the ramus of the inferior maxillary bone, affected with moUities ossium. At the surface are many openings of encysted abscesses; and the last molar, the crown of which extends slightly beyond the alveolar edges, and is developed in the thick part of the base of the coronoid apophysis. Fig. 3. — Section of the ramus, showing the numerous abscesses that exist throughout its whole extent. :f>IjJ^te 'V. Co.. ( 169 ) CHAPTER VIII. THE TEETH AND THEIR DISEASES. ALVEOLAE ABSCESS. Periodontitis, or inflammation of the alveolo-dental periosteum (considered in the previous chapter), when not successfully com- bated, has as its termination alveolo-dental abscess. To this con- dition, as a distinct one, attention may now be directed. Alveolar or dental abscess has of course the history of an inflam- mation and suppuration anywhere in the body, having nothing peculiar to its history, except as such peculiarities associate with the anatomical characteristics and influences of the parts involved. It is a condition in which a tooth, diseased to the suppurative point in its enveloping membrane or periodonteura, is discharging, through some convenient orifice of exit, pus secreted by or formed in such membrane. The local features of alveolar abscess may be described in a very few words. At the apex or somewhere about the root of the affected tooth, a degenerative thickening of the mem- brane occurs, — the old pyogenic membrtwie, as it was termed. This, in its unhealthy condition, becomes shreddy and stringy, failing to organize the lymph constantly exuded or effused by it. The degeneration of this lymph is pus. As such membrane grows thicker and softer, and such pus accumulates, it becomes evident that space and vent are made necessities ; thus ab- sorption, through the pressure, is effected, and the matter, sooner or later, finds egress, giving generally that peculiar fistule in the gum, known as parulis or gum-boil ; the most vulnerable wall of the surrounding osseous parietes yielding first, thus giving the (170) Fig. 55. Sac of abscess as com- monly met with in dental parulis. , THE TEETH AND THEIR DISEASES. 171 direction and locating the fistule. The morbid process exhibited in an inflamed root-membrane consists in the accompaniment of the hyper^emia by a hyperplastic state of the tissue-cells, these cells increasing not only in number but also in size. In this change it is that we find the explanation of the shreddy periodonteum seen more or less markedly upon all abscessed roots. A recognizable hyperemia is not, however, a necessity for the excessive proliferation of connective-tissue cells ; hence it is that epulic tumors frequently have origin in such hyperplasticity of the odonto-alveolar periosteum where expressions of vascular change have never been observed. The formation and confinement of pus in a cavity so obstinately closed as the alveolus of a tooth must necessarily inflict the severest suffering, and such pain is so constant an attendant of the condition, and is of such almost unbearable character, that any means calcu- lated to abort or limit its persistence is to be hailed as a boon. I take it for granted, judging from observation, that it is the severest form of odontalgia. The condition of acute pain, however, is con- fined to the period intervening between the accession of the acute inflammatory attack and the escape of the pus; the period, properly speaking, of periodontitis, — a period lasting from two days to ten : abscess fully formed, pain becomes limited to soreness. The treat- ment of the perfected alveolar abscess is very simple, at least as the indications are concerned ; consisting in the breaking up of the cyst and sac, and exciting an action of sufficiently healthy character to fill with granulations, of organizable force, the fistule. The appreciation of the cure of alveolar abscess begins of course with the treatment of the acute periodonteal trouble, of which it is seen to be simply a result. This was considered in the previous chapter, leaving here little to add, except that if such means as were recommended fail in securing resolution, more formidable, if thought desirable, are to be brought into requisition. As periodontitis is so frequently aborted by scarifying the gums freely and deeply, and, after the congested vessels have relieved themselves, constringing the parts by applications of strong tincture of iodine, so parulis can very frequently be anticipated by the fol- lowing trifling operation : With a sharp scalpel make a slight cut through the soft parts at the apex of the affected tooth ; next take up a spear-pointed drill and pierce through the outer plate of the bone into the cavity in which the sac is being developed, break up this sac, and, by means 172 ORAL DISEASES AND SURGERY. .% of a delicate tent, keep the wound patulous for a few days. This little operation, I am well assured, through a pleasant experience, commonly spares the patient upon whom it is practiced days of the excruciating torture which belongs to the formative stage of this disease. The philosophy of it will, I think, be at once recognized. Judgment is demanded, however, as to the time when such puncture is to be made; it is to anticipate the moment at which pressure from accumulation commences. I cannot here help excepting to the common practice of ordering warm fomentations to the face in incipient abscess ; such practice is very objectionable, and not unfrequently results in scars which much deform the patient. If the practitioner should not desire to adopt the operative suggestion offered, let him order a roasted fig or raisin directly to the affected part ; either of these will do equally well the work of the poultice. Leeches, general blood-let- ting, vigorous antiphlogistic medication, any and every means that promises any good, should come between the periodontitis and the abscess. The anomalies of alveolar abscess, if such a term might be applied to conditions not at all infrequent, may perhaps be best studied through the medium of examples. I select a few from my own practice and that of others. If, happily, they may serve to throw light on any obscure case at present perplexing some young practitioner, I shall feel well repaid for the trouble of collecting them. A few years ago I saw, in consultation with a Dr. B. of this city, Mrs. , who had been afflicted with a running ulcer at the apex of the chin for four years. During this period the lady had been under the care of some five or six different practitioners, and had twice been operated upon for supposed disease of the bone. Suggesting that the origin and cause of this fistule might be found in some diseased tooth, I was assured that these organs had been most carefully examined, and that there was not an unhealthy tooth in the mouth. A superficial examination seemed to verify the truth of the assurance. Not satisfied, however, by such examination, witli a steel instrument I commenced striking each tooth separately ; the patient thought that in the left inferior lateral incisor she experi- enced a sensation differing from that of the others. Placing her now in the full sunlight, I reflected the rays over the teeth by means of a hand-mirror; this test satisfied me that THE TEETH AND THEIR DISEASES. 173 the incisor alluded to had lost its pulp, — it showed a slight opacity. I was now convinced that the disease was alveolar abscess, and predicated on the examination that an opening made into the aflfected tooth would discover the death of its pulp ; this was done, and the tooth found dead, as anticipated. The offending organ was extracted, some necessary local attention given the sinus, and the patient was well in a week. Comment on this case scarcely seems necessary; and yet it may not be amiss to suggest the explanation of the deceptively healthy appearance of the dead tooth. When the pulp of a tooth dies, discoloration of the enamel is the common result, this discoloration being caused by the absorption of the dead matter by the tubuli of which the dentine is made up. Occasionally, however, the opacity is so slight as to be scarcely perceptible, and this depends on the dense character of the tooth, — not unfrequently the tubuli being so occluded as to destroy their capillarity : the dead pulp is not therefore taken up. A very vas- cular tooth, having a dead pulp in its cavity, will soon be turned almost black. A tooth in which the death of the pulp has been sudden discolors always more markedly than where it has been pre- ceded by a chronic inflammation, an explanation being found in the absence of that renewal of the process of calcification which in the chronic condition is apt to occlude the tubuli. A dead tooth, however, can always be distinguished by the tests given. The pathology of this case may be summed up very briefly. The death of the pulp provoked periodonteal difficulty. The inflammation, nncombated, resulted in alveolar abscess. The pus, after inducing by its presence the absorption of the bone, dissected its way under the soft parts down to the apex of the chin, where it discharged itself, — the abscess passed into the chronic stage ; the annoying and formidable fistulous ulcer was of course, because of its character, rendered incapable of being healed by any directly local treatment, or that not addressed to the true seat of trouble. In another consultation I saw a Miss B , a young lady, nine- teen years of age. In this patient, a fistule in the very centre of her hard palate had existed for some two years, giving rise to great uneasiness (as it had refused to yield to much treatment), a cancer- ous cachexia existing in the family. The denture in this mouth was also so complete as not to have attracted observation, every 174 ORAL DISEASES AND SURGERY. tooth being perfect, with the exception of a single molar, which tooth had a small filling of gold on its grinding face. The filling in this tooth was removed, and the pulp found dead. Extraction was resorted to, and in three or four days all discharge had ceased. On the sixth day the patient was dismissed cured. It is not at all uncommon to find the sinus of an alveolar abscess venting itself somewhere on the cheek. This is too frequently the result of inviting the matter to the surface by the warm applications made to the side of the face. When pus thus seeks the surface it should be vented from the inside. While support to the parts toward which it is pointing is to be given by means of a compress saturated with a refrigerating styptic, alum- or lead-water being indicated, — anything answering the purpose which tends to con- tract or shrivel the skin, — a plain compress is never to be used, as this expedites the absorption which the indication is to abort. The puncture of such an abscess is a very simple matter, and will fre- quently be successful if the pus should have found its way even so far externally as to have but the skin between it and the atmosphere. Care must, however, be taken not to wound the facial artery or the duct of Steno. Abscesses, associated with the wisdom teeth, sometimes pass in the direction of the parotid region ; in these cases it is not uncom- mon to find the orifice of the fistule as low down as the clavicle, the unyielding character of the parotid fascia— a continuation, as it will be remembered, of the deep cervical — compelling this lengthened dissection. A form of alveolar abscess, which may lead to false diagnostic premises, exists in cases where, from the relation of a diseased fang with the maxillary sinus, the discharge empties itself into this cavity, to be in turn voided into the naris. (See Diseases of An- trum.) Another and indeed very curious result of alveolar abscess is the formation of osseous cysts on the side of the jaws; the pus, instead of inducing the ordinary absorption, is provided for by the expan- sion of the outer plate of the bone. These cysts give little or no sense of fliuctuation or crackling on pressure. There is no appear- ance of surrounding inflammation; the soft parts covering them do not differ in any respect from the adjoining tissue. I have found such cysts or tumors generally associated with teeth in which the pulps have been destroyed and the fangs filled with metal. They form sometimes very rapidly, — that is, when compared with tumors. THE TEETH AND THEIR DISEASES. 175 for which they may be mistaken. I have treated them where the cyst has enlarged to the size of a half hickory-nut in a few months. This rapid growth is particularly diagnostic. The easiest treatment of such cysts would be of course the extraction of the ofl'ending tooth ; but they are also to be cured by opening them transversely and stuffing the cavity with lint saturated with tincture of iodine, or some other stimulant ; the cyst is thus obliterated, and the sac at the end of the fang destroyed, through the healthy reaction which the treatment excites. These cysts are not to be confounded with the sub-periosteal exudates frequently found overlying the site of diseased roots. Mr. Smith, in illustrating a lecture on alveolar abscess, notices the following cases from his practice: A few years ago, he says, a middle-aged man asked his opinion about a fistulous sore which opened on the middle of his whisker of the right cheek. Mr. S. introduced a probe, and finding that it came in contact with the fang of the last molar tooth of the upper jaw, persuaded the patient to allow him to extract it, on the promise that he should be well in a few days. On the tenth day the gentleman wrote, by post, to say that the discharge ceased the day the tooth was extracted, and that at the time of writing it was perfectly well. He relates the case of a young woman who came under his charge at the infirmary, with a fistulous sore in the fore part of the throat, within an inch of the sternum. It had been discharging upwards of a year. On probing it, the instrument could be passed in the direc- tion of the molar of the lower jaw on the left side. On inquiry, the patient said that eighteen months before she had a tooth drawn, but the fangs had been left in the jaw. Afterward an abscess formed, which descended lower and lower until it burst midway between the sternum and pomuni Adami. Mr. S. extracted the stump, it still discharged for a week, when it got well without other treatment. Mr. S. alludes also to a case where a horse had been condemned to the knacker's yard, as being afflicted with the glanders, having a foul, offensive discharge of purulent matter from the nostrils, and being in the last stage of emaciation. A veterinary surgeon, finding that it could not masticate its food, examined its mouth, and detect- ing a carious tooth in the upper jaw, extracted it. The discharge ceased ; the horse soon began to thrive, ftnd got well. Mr. Fieischraan (Britiah Medical Journal) relates the following example: "Miss Rose S., a little girl, aged five years, had been 176 ORAL DISEASES AND SURGERY. troubled about three months with a constant, though not profuse, discharge of slightly-purulent mucus from the right nostril ; it ap- peared to be the sequel of a cold. The mucous membrane, so far as it could be examined, was healthy, and there were no indications of any morbid growth. She was ordered a strong injection of gallic acid, and took, concurrently, small doses of the sesquichloride of iron. The only advantage she derived was that the discharge lost its purulent character ; in amount it remained about the same, though the treat- ment was long persevered in and other local astringents tried. I suspected," says Mr. F., "there must be some undiscovered local irritation. Not being able, on careful examination, to find anything wrong in the nasal passages, I looked to the condition of the teeth, and finding the right upper canine carious, removed it. The dis- charge was much lessened on the next day, and in the course of a day or two disappeared altogether." Mr. Fleischman, although he does not seem to see that his case is simply one of alveolar abscess, but offers it as "a good illustration of reflected irritation," truly remarks that it " teaches us that the fons et origo mali is not always just where we might expect to find it." I have had, in my own practice, several cases where the pus of an alveolar abscess discharged itself from the nares; but the dis- ease, in every case in which I have seen it, where the sinus passed in such direction, was associated with the central incisor teeth. It is, however, to be inferred that other of the teeth might associate sinuses with the posterior aspect of the nares, dripping their dis- charge behind the veil of the soft palate, a number of such cases being indeed on record. Abscesses of this nature are not unfrequently associated with the eruption of the wisdom teeth. The arch being too small to accom- modate the advancing organ, it becomes, as a matter of necessity, an agent of irritation; inflammations of the most severe nature are thus oftentimes provoked, inducing, too commonly, trismus and abscess. (See Trisviuii Deutium.) Abscesses from this cause generally dis- charge about the neck of the tooth; they may, however, void them- selves in other situations, as, for example, upon the face or neck, A case illustrative comes this moment to my mind: — Dr. D., a medical gentleman, suffered for some time with heavy, dull pain in the right ; half of his lower jaw, and which was attributed to two of his teeth, much decayed, but which, however, had been treated and plugged. Inflammation of a severe character finally developed, and, in defiance TBE TEETH AND THEIR DISEASES. 177 of all treatment, I'an on to abscess, which abscess discharged upon the cheek. The pus voided, relief, of course, was obtained. The sinus, however, continued to discharge, and, at the time of my being- consulted, the ulcer had become a source of much annoyance as well as deformity. This case had been examined by various friends of the gentleman, and, while all pronounced it alveolar abscess, all associated it with the treated teeth. The removal of a developing wisdom tooth, a single cusp alone of which presented, caused the fistule to heal in a single week. A complication sometimes met with in abscess discharging upon the cheek, and of which it is most important that note should be taken, consists in a relation of the sinus with the duct of Steno. I have in the past few years met with a number of cases of this nature, and by the operation required for salivary fistula have been enabled readily to cure them after the failure of every device not entertaining an appreciation of such condi- tion. It is to be impressed that such fistulas deceive in the very limited salivary discharge, thig fluid being easily overlooked in its relation with the pus ; my experience would lead me to infer that the opening into the duct may not unfrequently be of the most diminu- tive calibre. Where such a case is recent, it is proper to attempt a cure through the granulative process, trusting by such means to cover in the break of the duct ; to accomplish this, no better means may be employed than daily touching the parts with tincture of iodine or with crystals of the chloride of zinc, it being of course understood that the dental relation of the disease has been previously cured. If such means fail, and this will be found the most likely, then an operation is required. (See Salivary Fistule.) Alveolar abscess also not unfrequently exists where the discharge is exclusively through the foramen of the tooth, this orifice being enlarged. The gums in these cases may be unaffected, affording no •signs of disease, the evidence of the discharge being perhaps alone in a peculiarly disagreeable taste experienced by the patient. To cure these cases, it may be sufficient to throw the required injec- tion through the canal of the tooth ; but, should this fail, the method of entering the cyst through the alveolus is to be tried. To so enter such a cyst, a very delicate trephine may be employed, or, what commonly answers every purpose, a spear-shaped drill may be used. Incising the gum over the apex, the drill is simply to be rotated into the cyst; precaution, however, is to be taken that none of the bony particles be allowed to remain, adding their quota of offense. This is guarded against by the free use of the syringe. 12 178 ORAL DISEASES AND SURGERY. An alveolar discharge, which may be termed false abscess, is met with frequently in association with alveoli into which salivary cal- culus is intruding. In these cases no difficulty is to be experienced in the diagnosis; the discharge is seen about the necks of the affected teeth, the gum is more or less puffy, and the irritating de- posit is evident enough. To cure cases of this kind, it is commonly necessary only to scale or cut away the offending agent, and, after making a few incisions through the congested and debased gum, stimulate the parts by such applications as may seem indicated. Few medicaments are more reliable in this direction than the dilute aromatic sulphuric acid, or this combined in equal proportions with the tincture of capsicum. It is found, however, not unfrequently the case that the deposit has so destroyed the sockets of the teeth that no cure is possible outside of extraction. (See Salivai'y Cal- culus.) Chronic alveolar abscess, resisting local treatment, is to be viewed commonly as of constitutional association. In persons who are laboring under the effects of a mercurial poisoning, the cases are found most resistive ; indeed, in many instances, it is felt to be use- less to make any attempt to save the affected teeth, the organs being absolutely thrust from their sockets and falling into the mouth. Where not too loose, however, the gums are to be incised every few days in the vertical direction, and attempts made to resolve the turgidity and puffiness by paintings of the tincture of iodine and capsicum, alternated with washes of chlorate of potash and cologne. B. — Potassae chloratis, 3ss; Aquae Colon., 5j ; AquEe, §vij. M. Sig. Use many times daily. Internally the chlorate of potash may be directed in doses of fifteen grains, repeated three times daily. R. — PotassiB chloratis, Jiij ; Aquae, sviij. M. Sig. Tablespoonful as a dose. The rheumatic diathesis is to be recognized as at least a predis- posing cause to alveolar abscess, and one which at times forces itself upon attention in treatment of the condition. As this toxical THE TEETH AND THEIR DISEASES. 179 influence is recognized as having- aflSnity with periosteal tissue, so there is no reason to doubt that occasionally it is the resistive agent in the cure of such conditions. A similar view will also be found to hold good of the malarial poisons, and, indeed, it very well may be, of all the other toxical conditions. Not at all that it is to be afiBrmed that such poisons have necessarily, in all instances, a direct relation, but that, being depressent to the system at large, they antagonize that reparative influence, without which the parts may not restore themselves; precisely, if an illustration be needed, as a venereal ulcer, however proper and vigorous the local treatment, refuses to be made well until systemic influences are considered and antagonized. Gout is another constitutional predisposition to chronicity in alveolar abscess, just as it is a frequent excitant to pulpitis ; and an abscess which refuses to respond to any direct medication yields, with such predisposition, to a few doses of colchicum. Defying abscesses of this nature are oftentimes found to give way to the alterative influence of a week at the seashore, or a trip to the mountains. In chronic abscess the discharge must necessarily continue so long as the periodonteum remains in its pathological state. It is there- fore always necessary in association with any systemic treatment which it may be desirable to adopt, to break up the local condition. To accomplish this, no better means can be employed than to tear the sac to pieces by means of a delicate, soft excavator passed through the sinus. After such breaking up of the sac, the part is to be syringed daily with an aqueous or vinous dilution of the ordi- nary officinal tincture of iodine, — about half and half of either being a good proportion. Another most excellent agent is found in the chloride of zinc. Of this salt, a solution of three grains to the ounce of water may be employed, a tent of cotton being saturated and carried into the cyst, or, charging with a few drops the ordinary hypodermic syringe, the fluid may be thrown into the sinus. Other local medicaments are found in nitrate of silver, sulphate of copper, tincture of capsicum, permanganate of potash, in the passage of the electro-galvanic current, in carbolic acid, in creasote, in alcohol, et hoc genus omne. Where an abscess discharges itself exclusively through the pulp canal, the very best plan of treatment is to make a counter-opening in the gum and proceed as directed for the abortion of the acute state of the disease, using, besides, injections and tents until all discharge 180 OEAL DISEASES AND SURGERY. ceases; or, if objection exists to this, it will sometimes be found to answer to carry into the canal threads of silk saturated with the medicament selected. Another and a better mode than the use of the threads is, however, to introduce into the canal a plug of gutta percha, in which a hole is to be made of a size just sufficient to re- ceive the nozzle of a delicate syringe. Thus directed and controlled, injections may be forced through the foramen. Any treatment, however, except that by the counter-opening, will seldom be found satisfactory. A tooth having such discharge through its canal, and thus inca- pable of bearing a filling, may have such filling retained without response by making the counter-outlet through the alveolar wall. Such a treatment I have frequently adopted with much satisfaction, having success in saving the tooth where, without the puncture made through the gum and bone, thecavit}^ would not have endured the plug for half an hour. An explanation of chronic alveolar abscess where no medication can possibly avail is found sometimes in a twist of gold which has been thrust through the foramen in the act of filling the root. With this cause I have several times met, although never appreciating it until exhibited in the extracted tooth. An alveolar abscess connected with the teeth of scrofulous chil- dren will not unfrequently result in a necrosis exfoliating the sur- rounding process. A case of this kind, coming quite lately under my notice, resulted in the loss of quite half of the right superior maxilla; while a second case, occurring in a mercurialized man, destroyed the whole bone. A chronic alveolar abscess is not unfrequently found resistive to treatment as the result of the mechanical cause of a malarticulation, which keeps the affected tooth continuously worried. This is an offense for which we are always to examine, as it is readily induced by changes which may have occurred from the inflammatory asso- ciations. Any single tooth, however healthy, striking in its artic- ulation before its' fellows, will become thereby diseased. This is often enough witnessed where, in filling teeth, the metal has not been sufficiently dressed down, and is thus unduly impinged upon; such teeth becoming sore to the touch, even to the result, when the cause is not appreciated and removed, of irritating the part into abscess. Abscess associated with the temporary teeth is always to be looked on with concern, the irritability and excitability of the young THE TEETH AND THEIR DISEASES. 181 jaw being so great that any addition to the excitation of the dentinal period is found commonly to prove more than the force of the parts can antagonize, — thus resulting not unfrequently in extensive dis- organizations. Should abscess in the temporary tooth have asso- ciation with any of the exanthems, the immediate removal of the organ is made a necessity. Indeed, these infantile abscesses, how- ever associated, are never to be allowed to run on, but, if not speedily responsive to medication, should be cured by extraction of the offending tooth or teeth. As is involved the principle in the treatment of an alveolar abscess, it is required simply that the practitioner recognize pus as protoplasmic degeneration : matter breaking down because of an inability to organize into living tissue. Whatever shall afford or add the lost force must prove the cure of the abscess. To this end all deteriorative local causes of offense are to be removed. If a tooth contain a dead pulp, such pulp is to be extirpated ; if it unduly strike its neighbor, as just alluded to, such false occlusion is to be remedied ; if irritation be kept up by subjection of the membrane to foreign agents of offense, as a habit of biting improper articles, cracking nuts, untying knots, cutting threads, etc., subjection of the parts to rapid and great alternations of heat and cold, as in the use of ices and hot drinks, these and any other causes of offense are to have consideration. General indications are to restore healthy innervation, circulation, secretion, and excretion, by such medication, hygienic or otherwise, as shall tend to allay irritation, increase plasticity through tonicity, and restore normal action. To such an end, besides the local medi- cation which may be required, resort, as indicated, may be compelled to the employment of specifics, nervines, alteratives, astringents, and antiseptics. In one sentence, we are to recognize and appreciate the indications, local and general, and meet them. When this has been done, and yet a cure is not secured, the only remaining ques- tion is between the extraction of the affected tooth or teeth, and the risk of such consequences as osseous caries or necrosis. CHAPTER IX. THE TEETH AND THEIR DISEASES. ANCHYLOSIS OF THE JAW. Under the heading of diseases of the teeth we may study the subject of anchylosis, inasmuch as in a knowledge of the associate lesions of these organs, in such direction, we seem to start from the most elementary foundation. Anchylosis of the iaw(ayxu).o<;, crooked), trismus (r/)jCw, to gnash), finds its general nature and characteristics exhibited in the condition as seen in the common articular system. A special study may therefore be beneficially preceded by a review of the subject at large. By anchylosis is meant stiS'ness in an articulation, such stiffness varying to absolute immobility. The terms true and false, complete and incomplete, are emploj^ed to express two common groups under which a variety of forms are classed ; the first being applied to a state of fixedness in the joint, the second where more or less motion exists. A clinical division, however, and one the practical utility of which every practitioner is soon found to recognize, is consideration of the lesion as reference is had to its intra- or extra-articular char- acter; that is, whether the disease is within, or without, the joint. Intra-articular anchylosis implies change in the articular relations, arthritic inflammatory action leading to plastic effusion, which effu- sion has necessarily a varying history. Imprimis, a stiff joint may depend on a simple sj'novitis ; the ease of the patient compelling quietude in the part. It may associate, again, with lengthened disuse of the joint, as compelled in fracture-treatment, such fixed- ness acting as the abstraction of the natural stimulus of the part found in its motion, thus resulting in a dryness which becomes in time the excitant of an inflammatory exudate, with tendency to organization favored by the immobility. Arthritic inflammatory action is the history of all inflammatory action, and is to have con- sideration from such common standpoint. In any inflammation, a matter which first calls for consideration is (182) THE TEETH AND THEIR DISEASES. 183 the character and nature of the disturbance. Such a consideration applies particularly t,o arthritis ; for whether the action arises from local or constitutional causes makes nearly all the difference in such prognosis as we may feel inclined to offer. Local arthritis is expressed by any cause of offense of local char- acter that may be discovered to have provoked the lesion ; of such offenses we may instance blows, luxations, fractures, immediately neighboring lesions, inter-articular bodies. Arthritis of constitutional relation finds its diagnosis in the ab- sence of local sources of offense, and in the presence of cachexia: scrofulosis, syphilis, rheumatism, gout, cancer, and the sang calcine. The rheumatic, gouty, and scrofulous arthrosia are very familiar exhibitions in such a direction. Complicated Arthritis. — This refers to a provocation into action, by some local irritant, of an abeyant cachexia. Enough instances of such complications are found in the hip diseases of children arising from falls, and of cancers located through local injuries. Inflammation in a joint has primarily a double diagnostic signifi- cation of much concern to the surgeon; that is, the inflammation may involve the joint proper, bones, cartilages, or synovial membrane ; or it may be confined to the latter exclusively. In synovitis proper, the prognosis is much more favorable than in true arthritis, provided the attack be acute in character and the treatment timely. Synovitis in its incipiency is attended by excess in the natural seci'etion of the membrane, associated with more or less serum ; such excess, by overfullness of the articular cavity, inter- fering markedly with freedom of motion. Passing into a chronic state, the neighboring parts are soon involved, and what is to be the result depends as much on the circumstances of the case as on the care and skill employed in the treatment. Efl'usions in synovitis are readily distinguished, the serous, associated with all the phenomena of acute inflammation, — the parts being red, heated, painful, elastic, and fluctuating. The plastic exudate, appearing after the acute action has passed, is dull, doughy, and pitting, and divested of active associations. An attack of synovitis may be, and indeed commonly is, sub- acute in character, that is, it may be a long while in developing itself, and this, even when it is the result of local injury. The first symptom attracting notice is apt to be a sense of stiffness after rest, this being most observed in the morning; succeeding this is pain, with the stift'ness prolonging and fixing itself; swelling will now 184 ORAL DISEASES AND SURGERY. perhaps be first observed, the heat of the part increasing- with the distention ; suffered to progress, suppuration of the membrane may be the result, and with it the complete destruction of tbe joint. A better and, happily, more frequent result is found in a cure of the inflammation through the exudative process, such exudation seem- ing to afford the necessary relief to the over-distended vessels. With such a result obtaining, the care of the surgeon becomes directed alone to the exudate, the absorption of the serum is to be compelled, and through passive motion and the judicious employ- ment of the sorbefacients, the plastic lymph may not be allowed to associate its bands with parts that shall afford it the capability of organization. Acute synovitis, if disassociated with cachexia, may commonly be quickly resolved into a subacute condition; to obtain such result, however, treatment is to be directed with much judgment ; if purely local, the attention required will most likel}^ be one vigorously anti- phlogistic;* if conjoined with cachexia, local sedation is to have associated with it a cionstitutional specific medication, or a treatment of stimulation and invigoration as may be indicated. A common treatment for an acutely inflamed joint, whatever the parts involved, might be laid down as follows: Put the feet and legs in water, as hot as can be borne; administer a full saline cathartic, or a diapho- retic; apply a lead-water and laudanum lotion to the inflamed part; bleed with the lancet, or, locally, by leeches; depress the circulatory force by the administration of arterial sedatives, and restrict to a low diet; use counter-irritants; any or all of these means being employed according to the indications of the case, an exception to the use of the pediluvium existing in inflammation of the inferior joints. An inflam- mation, having its acuteness broken, is often happily terminated by painting the parts with the tincture of iodine, or with the muriated tincture of iron combined with quinine and the tincture of cinchona, as recommended on another page for erysipelas, or with diluted Monsel's solution of the persulphate of iron, and afterwards, if deemed necessary,. enveloping the part in the lead and laudanum lotion. Where structural change is feared as the result of eflnsions, the mercurials may be administered and pushed to the least percep- tible evidence of their impression. It is seldom the case, however, that a result is not better without than with these : it is not to be * A cure almost magical in the rapidity witli which it results is sometimes secured by cauterizing the surface with the solid nitrate of silver. THE TEETH AND THEIR DISEASES. 185 doubted that through the injudicious use of this medicine many joints have been depressed to suppuration, which, without it, would have escaped. When, in defiance of treatment, suppuration occurs' in a joint, the pus formed is to be got clear of as speedily as possible. To effect this, it is perhaps not possible to adopt a better plan than the subcutaneous valvular puncture, to be made by using a delicate tenotome. Such a valve may be opened as often as the pus reaccu- mulates. At this stage it is also that we may resort to direct stim- ulation with prospects of good results. Yet what is to be the precise nature and extent of such stimulation is not so easy to suggest, each case having, most likel}^ some special indication. The principle of the means, however, would be found in anything that should arouse the parts to a higher and healthier grade of action; stimu- lating embrocations, hot or cold douches, strapping, painting as before suggested, passive motion, or even, it might very well be, in- jections into the joint itself,^— a means that might save the articula- tion where all others should fail. Synovitis having a systemic origin demands that the treatment consider the specific indications. If syphilitic, gouty, rheumatic, or strumous, medicines which experience characterizes as most antago- nistic to these conditions must be conjoined with the local means. Thus, while giving every attention to the affected joint, we direct a medication to the cause at large. Arlhritis. — By arthritis is meant the inflammation of the common structures of the joint; here the danger of ill results is proportion- ally greater than synovitis as extent, of parts is involved. An arthritic inflammation may be general, involving all the components of a joint, and of such severity of grade as to run quickly into sup- puration and destruction of the parts, or, on the contrary, it may prove so slight as not to amount to anything more grave than a temporary congestion resolvable by a few hours of rest and seda- tion. Between these two extremes are found all the phenomenal associations of inflammatory action. An arthritis in the fullness of its history might be thus described: First, a sense of stiffness in the joint, with increasing uneasiness, — the stage of simple vascular excitement. Second, the development of the sense of heat, the parts swelling and becoming intensely painful on the slightest motion, — the stage of active congestion. Third, fixed engorgement, the pain persistent and of a heavy character, skin a dull red or white, accord- 186 . ORAL DISEASES AND SURGERY. ing as the inflammation may or may not have traveled to the sur- face, — the stage of stagnation. Fourth, the destruction and breaking down of the involved parts, — necrosis, as evidenced in morbus cox- arius, — the stage of suppuration and devitalization. Fifth, hectic fever from exhaustion, or pyemia from pus poisoning. Sixth, death. The treatment of arthritis proper is precisely that indicated and employed in synovitis. To limit and control inflammatory action is the principle of the cure. The vigor with which such a treat- ment is to be directed depends, of course, on the indications of each special case, these presenting, as suggested, every shade of char- acter. If an inflammation, in deflance of the immediate antago- nists employed for its control, pass onward in its grade to the efi'usion of lymph, as recognized by the doughy, pitting character of surrounding parts, then the danger of anchylosis, on the one hand, or of the degeneration of this agent into pus, on the other, is the matter which presses for attention and concern. Passive motion of the gentlest character is to be resorted to, together with the employment locally of sorbefacients, combined with such general medication as the particular case may appear to demand. If the mercurials seem essential, the practitioner will seldom find himself at fault in combining tonics with them. This will most certainly be found to hold true in all cases associated with asthenia. Tlie character of cases in which it would seem to ray judgment that the mercurials are admissible, and, indeed, in some instances, positively necessary, is that where the trouble occurs with the robust and vigorous. In cases of this class their good effects are occasionally markedly observed ; but even here, if they be employed too freely, the harm done quickly overbalances the good. When a mercurial is used, the effects produced are to be watched with the closest attention, and never is it to be inferred that, because good eflects are observed from the gentlest of ptyalisms, a pushing of the medicine will expedite the cure. No greater error than this can arise ; a result is not unapt to be pus, and the destruction of the joint. Another matter, not to be overlooked in the employment of this medicine, is its cumulative nature. A man may take a mercurial for a week or a month without apparent effect, when suddenly the most profuse ptyalism will exhibit itself I have seen this again and again with patients under treatment for syphilis. Rheumatoid Arthritis. — For a medical paper treating most fully on this condition, the reader is referred to Reynolds's System of Medicine, vol. i. p. 913. THE TEETH AND THEIR DISEASES. 187 Trismus. — This term has its application alone to the anchylosis of the temporo-raaxillary articulation ; it expresses the simple lock- ing or fixing of the jaws. As there are many causes or conditions involved in such locking, so, of course, we have conjoined terms expressive of such different lesions : trismus traumaticus, including tetanus, — the locked jaw from wounds and other local external inju- ries; trismus dentium, arising from associative dental lesions; tris- mus nascentium, or trismus neonatorum, — infantile tetanus. In strictness of application, the term trismus, however, applies only to gnashing, spasmodic, or nervous lockjaw, and is without true expres- sion or meaning when applied to other forms. It might be best viewed as referring to the medical rather than to the surgical aspect of the lesion. Tetanus — from tsivw, to stretch — is a disorder of the nervous system, presenting its manifestations in spasms, and affecting in nearly every instance the muscles of mastication, thus producing gnashing, or, it may be, locking of the jaws. Tetanus is decidedly a nervous disease in its expressions, and is primarily confined to the true spinal system, being produced in some individuals by the most trifling injuries, many cases being on record where the simple extraction of a tooth has sufficed to provoke it. The terms opisthot- onos, emprosthotonos, and pleurosthotonos are employed, together with trismus, to designate the groups of muscles implicated in the derangement. Tetanus is divided into traumatic and idiopathic, and into acute and chronic; the first following wounds and other injuries, the second arising without assignable cause. The first form is usually acute in character; the latter is apt to be chronic, and, to the extent of its chronicity, amenable and responsive to treatment. As predisposing causes of tetanus, the experience and observations of Baron Larrey would seem to give cold and dampness prominent positions. Dr. Kane, in his Arctic Explorations, alludes to the death of two of his men from tetanic spasms, after being exposed to intense cold. Extreme heat is certainly another of such predisposing causes, tetanus being as common in the very hot as in cold temperatures, both extremes acting, most likely, by provoking centric nervous irri- tation. Symptoms. — Tetanus, although sometimes coming on suddenly, has more commonly a premonitional history. Instances are recorded where the spasms have arisen almost simultaneously with the recep- tion of a wound. Such cases are, however, exceedingly rare, and 188 ORAL DISEASES AND SURGERY. indicate a predisposition whicli renders the disease almost neces- sarily fatal. On the other hand, it is exceedingly common to find the condition remaining in abeyance until the external wound has completely healed. A case of this latter character came only a short time back under my own immediate observation, where a lady, while searching in a barn for eggs, accidentally ran a rusty nail into her knee, not, however, penetrating the articulation. Four days after the reception of the injury, with the break fairly healed, eni- prosthotonos supervened ; yet the spasms quickly disappeared upon the opening of the wound with a bistoury and the introduction of a delicate tent, thus compelling a filling up of the parts from the bottom. The irritation of a nerve radicle by its being caught and compressed in a cicatrix is a reasonable explanation of neuralgia and tetanus supervening on the liealing of a punctured or lacerated wound, and seems to have had an example in this case. Commonly, tetanus exhibits its approach, as suggested, in a gradual manner. Attention is first directed to a sense of general malaise ; then supervenes stiifness of the movements of the lower jaw, as though the muscles were exhausted. This stiffness, in- creasing to soreness, extends to the muscles of the neck. The mouth becomes dry and sore ; mastication grows painful, and swallowing difficult, a sense of spasm and suffocation resulting when these offices are attempted. Eventually the masseters, tem- porals, and pterygoid muscles become stiffened and bulging; the orbicularis puckered and contracted ; the eyelids are closely approxi- mated; the zygomatici are liable to become fixed, thus giving a peculiar expression known as the Risus Sardonicus. Following these symptoms, almost any of the voluntary muscles may become implicated, the abdominal group, particularly the recti, corrugating and knotting themselves. Colicky symptoms soon supervene, in- duced by spasms of the muscular coat of the bowels; or difficulty in respiration may arise, from spasms of the diaphragm. Opis- thotonos, emprosthotonos, pleurosthotonos, or, it may be, a most un- yielding trismus now develops, according as the force of the irritant may select special groups of the muscular system upon which to expend itself. That tetanus does not implicate the ganglia of special sense, but is confined to the spinal cord, medulla oblongata, and cerebellum, is demonstrated in a clearness of the intellect which continues during the attack. The bowels, in tetanus, are commonly found obstinately consti- pated, depending on the general derangement of the alimentary THE TEETH AND THEIR DISEASES. 189 canal; and motion, when it does obtain, is accompanied with fetor of a most offensive character and great persistence. The bladder may be closed by spasm of the muscular fibres of its neck, or these may be so relaxed that complete incontinence exists. The tongue, when involved, tends to be thrust forward, and is thus often lacer- ated in the spasmodic occlusions of the teeth. Acute tetanus seldom has a greater duration than four days, the patient perishing either from asphyxia in a spasm, or otherwise from exhaustion. Chronic tetanus, on the contrary, runs on day after day, most frequently eventuating favorably. One is impressed with the sense of a battle, in which nature properly supported may reasonably be expected to win. Pathology. — Because of the absence of definite pathological lesions, more or less diversity of opinion exists concerning the conditions of this disease. Sporadic or traumatic cases, where tetanus has shortly supervened upon injury to a nerve, naturally direct attention in such direction. Investigations into nerve-relations, however, prove so unsatisfactory that there seems now quite a tendency to revive the humoral origin, a view maintained with all earnestness by Rose, and favored by both Billroth and Dr. Richardson, the latter sug- gesting that it may eventually prove to be the result of the absorption of some septic material. " In this disease," says this author, "the poison, in my opinion, is first developed in the wound as the result of decomposition. Thence carried into the circulation, the new substance, without any necessary increase of its own parts, excites a zymosis, ending in the production of an alkaloidal or alkaline body, which has all the power of exciting the symptoms of spasm as much as strychnine itself." Billroth inclines to ally the condition with tlifi infectious, phlogistic. " It is known," he says, " that, by blood- poisoning with strychnia, severe spasms, and with alcohol, psychical disturbances (drunkenness), may be induced ; hence it is very possi- ble that this disease may result from poisoning with a peculiar sub- stance, only very rarely formed in wounds, and thence absorbed." The .symptoms of tetanus indicate irritation of the spinal medulla. Rokitansky describes, from autopsies made by him, evidences of vas- cular relations of this substance as exhibited in the development of young connective cells. Other observers, however, have failed to find these expressions. The reviewer of the article Tetanus in Reynolds's " System of Medicine" (see Britiah and Foreign Medico- Ghirurgical Bevieiv, 190 ORAL DISEASES AND SURGERY. vol. xiii.) says, " The author does not attempt to trace any connec- tion between the acknowledged causes, cold and damp and wounds, and the production of such a fearful consequence in only a few cases. With regard to its relation to hydrophobia and analogy of the latter to that of snake-bites, may not the connecting link between chilled wounds and spasmodic paroxysms be an animal poison gen- erated in the wound during the process of healing? and being an animal poison, therefore poisonous in extremely minute doses ? and being an animal poison, therefore latent in the system for long periods ? and being an animal poison, therefore specially fatal to the nervous sj^stem ? The greater tendency in punctured and closed wounds to cause tetanus is very suggestive of the needle-like ser- pent's fang, and the frequent triviality of the dog's bite, which are more deadly the less blood flows." Holmes (in his chapter on Tetanus ; see vol. i. p. 330), after a review of the morbid anatomy, as referred to by various observers, remarks the obscurity in which the pathology is involved. "Some," he says, " are seen to affirm tetanus to be an irritation of a peculiar kind, affecting the excito-raotory apparatus ; that the irritating cause may be excentric at the extremity of, or in the course of, the afferent spinal nerve, or it may be centric within the spinal canal itself. Some consider it to be an exaltation of the polarity of the cord and medulla. Others, again, maintain it to be identical with inflamma- tion of the spinal cord and medulla oblongata, and adduce cases of inflammation of such structures as inducing symptoms of tetanus." Principles of Treatment. — " If the difficulty of ascertaining patho- logical conditions, upon which all rational indications of cure should be based," says Dr. Copland, " be so great in this malady as not to have hitherto been overcome, can it be a matter of surprise that the means which have been resorted to, both by physicians and sur- geons, in its treatment, have been most opposite in their effects, the most different in their nature, and in every respect most empirical and uncertain ? • In this state of our knowledge, it would be better to leave nature to her unaided efforts, to observe closely and accu- rately what is the true procession of changes and of their manifesta- tions, and to ascertain the seats and the extent of lesion as soon after death as may be attempted with propriety." The treatment that has most commonly suggested itself seems to be that of anaesthesia, opium and chloroform being much depended on. Of the former medicine as many as twenty or more grains have « THE TEETH AND THEIR DISEASES. 191 been used in the course of a day, or a correspondence in the subcu- taneous use of morphia. The greatest gain in treatment seems to be to prolong the disease into chronicity, thus wearing out, as it were, the force of the active cause. Bilh'oth refers to the use of warm potash baths, and the application of strong irritants along the spine, large blisters, moxse, but does not feel that experience tends to indorse any of them. On the contrary, referring more particu- larly to the chronic cases, he suggests that the patient be allowed to remain as quiet as possible, guarded against all injurious influences, especially from physical or mental excitement, the general aim of the treatment, he thinks, being to alleviate the acute course and make it more chronic, as this gives more hope of recovery. Of the internal remedies that have been employed, almost every class and description have been tried, without, as yet, any result in the way of a specific or an approach in such direction. " Altera- tives, in the shape of the varied preparations of mercury, large doses of fixed alkalies, solutions of arsenic, etc. ; diure'tics, in the form of tincture of cantharides, oil of turpentine, given in frequent and large doses so as to irritate the urinary passages or to occasion bloody urine ; sedatives, such as digitalis, tobacco, nicotina, hydrocyanic acid, aconitina; anodynes and narcotics, as opium, morphia, bella- donna, colchicum, cannabis indica, ether and chloroform internally and by inhalation ; stimulants and antispasmodics, including musk, ammoniacum, camphor, turpentine, assafetida, castor, wine, and other stimulants ; tonics, such as quinine, bark, strychnia, iron, zinc, etc. ; hygienics and dietetics, as support, milk-diet, etc. ; injec- tions into the veins of solutions of opium, stramonium, etc. ; tra- cheotomy and laryngotomy. The calabar bean in sufficient doses to paralyze the voluntary muscles has been affirmed to be attended with marked success, although it has, on the other hand, failed very fre- quently." (Alfred Poland, Holmes's "System of Surgery.") The treatment of tetanus by woorara has of late excited some attention, mainly through the work of Mr. Morgan. According to Demme, this most powerful poison has out of twenty cases resulted in eight cures. It is recommended by Spencer Wells, Broca, Chas- saignac, and others ; the dose is given as from one-eighth to one-half grain to an adult. To one not familiar with the action of woorara, it would seem necessary to recommend great caution in its employ- ment. Most interesting experiments have been performed with woorara upon the lower animals, particularly a series in 1858 by Dr. J. J. Woodward. 192 ORAL DISEASES AND SURGERY. The use of the calabar bean has come to be much relied on in the United States. Eighteen cases are reported by Dr. Eben Watson in which this medicine was used, yielding ten recoveries. The dose varies with the effect produced in controlling the spasms. The action seems to be that of a direct sedative to the spinal cord, patients, while under its influence, commonly taking food with ease. One grain may be commenced with as a dose, increasing the quantity 2?ro re nata. The new preparations hydrate of chloral and croton-chloral have in them considerable promise in this direction. A peculiar action from this latter agent is found, that at first a high degree of anaes- thesia in the head is produced, while sensibility in other parts of the body remains intact. The second stage is, that the spinal cord loses its function, and reflex excitability is everywhere extin- gui.shed. During this stage, i)ulse and respiration remain unchanged. Tiie third stage, which is induced by large doses, is characterized by paralysis of the medulla oblongata, and death. Animals may, however, be kept alive by artificial respiration, because the function of the heart is not interfered with ; while the ultimate effect of hydrate of choral is to paralyze the heart. The local treatment which has been had recourse to in tetanus consists in laying open wounds, their thorough cleansing, and the application of antiseptics; division of nerves, the application of counter-irritants, the employment of sedatives, ice-bags to the spine, cold and warm shower-baths, electricity, attention to inflamed and suppurating wounds, etc. Trismus Nascentium. — Lockjaio in new-horn children. — The fre- quency of this condition, and its fatality to a particular order of infantile life, make its study one of interest and importance to the practitioner. It is decidedly a disease associated with the period of the desiccation and phenomenal change occurring with the coi'd and umbilicus, and is found confined, therefore, to the time associ- ated with these changes, — never occurring before the second day after birth, and seldom after the fourteenth. Tetanus, of which this is a form, has its expression and association exclusively with the nervous system of organic life, — the excito- motor. That trismus nascentium is therefore a special disease, is not to be entertained for a single moment ; it is simply tetanus occurring from generally evident causes in the newly-born, and is to have the consideration and treatment of the disease as found any- where else. Wherever the nervous system of organic life exists in THE TEETH AND THEIR DISEASES. 193 exquisite deve]opment, and wherever it is excited from any cause to excess of expression or action, there is found the danger of trismus. Hence in infants of the negro race, and particularly those born of parents of less than average intelligence and resident in hot cli- mates, the condition is found most widely to prevail. In the southern section of the United States, and in the West Indies, the mortality of infantile deaths from this single cause is estimated by some observers at not less than twenty-five per cent. ; while it is affirmed that in the equatorial regions of South America in some years more than half the infants born fall victims of this disease. In an epidemic form in which it is found occasionally to prevail, the mor- tality of certain neighborhoods has amounted to four-fifths of the births. That trismus nascentium is not confined, however, to the hot lati- tudes is to be inferred, not only from the report of many cases else- where, but from its oneness with tetanus proper. According to Dr. Holland, it is very prevalent on the southern coast of Iceland, also at St. Kilda, one of the western islands of the Scottish coast. In Elbing, .Prussia, cases are announced as occurring frequently, thirty-seven being recorded from I8G3 to 1865 in a population of twenty-seven hundred. In Dublin, the disease has prevailed so alarmingly that at one time, for a limited period, nineteen-twentieths of the infantile deaths occurring in the Lying-in Hospital of that city were from this cause, the death-rate being one to every sixth child born. Being attributed to ill ventilation and the absence of proper hygienic requirements, attention was at once directed to these pro- phylactics, with the result of decreasing the rate to one in nineteen. Symptoms. — Like the manifestations of the disease as exhibited in the adult, the prodromous period may be deficient in signs sufficiently marked to attract ordinary observation. The child may seem rest- less and more excitable than usual, but this is apt to be attributed to any other than the true cause. A few hours, or it may be days, jn intervene, when the infant, apparently anxious for the nipple, is found unable to take hold of it. This, together with an occasional ^mothered cry, as if the child was in distress, first brings it under Fthe notice of the physician. If now the jaws be examined, more or less rigidity will be found to exist, the masseter muscles seeming the ones principally aifected. Y From these the expression n)ay extend to any others, and does Y 80 in a very few hours ; or it may be that the first manifestation of |ki muscular involvement is exhibited in spasm, the jaw being shut with 13 194 ORAL DISEASES AND SURGERY. a snap which has, in instances, partially amputated the tongue ; or the spasm may affect some muscle of the limbs or trunk. Such commencement of the active stage of the disease is, however, infrequent. In the fully-developed stage of infantile trismus the spasms are found quite frequent. The agitation of the child is very great. The smothered scream which it emits is peculiarly painful, — itself spas- modic in character from affection of the respiratory muscles. The little sufferer foams at the mouth ; the fists are tightly clinched; the feet are flexed upon the ankles, with the great toe abducted ; the head is drawn back by the cervical muscles ; the surface grows livid, the infant dying in the paroxysm, or, otherwise, either receiving respite in which relaxation ensues, or sinking into death through coma. The duration of the disease is commonly about two days; but cases are recorded where death has not occurred until the third week of the attack. Causes. — First, there may be assumed to be a predisposition (though this need not of necessity exist), such predisposition being impressed on the child in utero by the hot and foul air and common filthiness of habit which, from its inception, have attended it iq the person of the parent who has borne it: this finding proof in'the fact that as the condition of parents has been improved, so has trismus diminished, the disease finding its habitat almost exclusively amidst the squalor and poverty of the lowest and least intelligent classes. Other predisposing causes are found in any and all relations of de- pressing character. Thus, hot moist days, followed by cold nights, have been sufficiently recognized to be among the most efficient of the predisposing cajases, the explanation being found in the inter- ruption of the functions of the skin. Miasma, no doubt, contributes its quota through its depressing action on the nervous system, — tetanus being associated with the period of reaction. In papers published in 1846 and 1818, Dr. J. Marion Sims ad- vanced the view that the cause of trismus nascentium lay in a pressure exerted on the medulla oblongata and the nerves originating from it, produced by displacement of the cranial bones, and espe- cially the occipital, such displacement occurring in the parturitive effort, and capable of being corrected ; but that the cases observed by him w^ere exceptional, and not common, seems clear enough by the universal denial of his premises, following observations elicited by the publication of his views. Whatever, then, maybe a predisposing cause of infantile trismus. THE TEETH AND THEIR DISEASES. 195 the chief exciting- one is found in association with the umbilical cord: and first this associates with the tying and excision of it. A cord cut with a dull blade may be thus put into a condition of irritability, Avhich, reacting upon a highly predisposed system, might bring on an immediate attack of spasm. An ill-strangulated cord may be classed as the second of the offending causes. A common habit with midwives among the poorer classes is to wrap the parts with packthread. This is not only an inadequate protection against hemorrhage, as in my experience I have several times had occasion to witness, but it is irritating to the parts even in the remote aspect of its relation with the general system, and may readily arouse the abeyant irritability. The umbilical cord separates from the body, physiologically speaking, as does the stem from the ripe fruit. When such is not the character of the disjunction, the conditions are to be expressed as pathological, being associated with more or less inflammation, ulcer- ation, and local irritation. The ordinary period required for the separation of a funis is from three to six days. During this period the parts should be kept enveloped in a fold of old half-worn linen, prepared as a dressing by snipping a piece out of the centre after the manner of the Maltese cross ; the cord to be passed through this hole, and thus, by its envelopment, separated from contact with the person of the child. In hot climates, such dressing, combined with oil, or antiseptics, is the more necessary, as the danger is to be guarded against of having the parts serve as a habitat for the deposit of larvae, — a not infrequent cause in itself of tetanus. Treatment. — From the constitutional standpoint, nothing more may be done than is to be inferred from the- directions given in general tetanus. Anodynes, antispasmodics, anaesthetics, and altera- tives, these we may try ad libitum, but the result will amount to very little if any unappreciated or unremoved cause exists in the way of local irritation. Attention is therefore to have a first direc- tion to the umbilical region, and such attention, if directed in the incipient stage, may not unfrequently result in aborting the attack. If an ill-incised cord be found, make at once a fresh and clean cut nearer the body. If the cord is indififerently strangulated, remove at once the ligature, and replace with a well-waxed silk thread, or otherwise place a new ligature nearer the body. If separation of the funis is not progressing with its usual physiological harmony, then treatment will be needed as indicated. Cleanliness is to be strictly enjoined, and vascular action is to be stimulated or depressed, 196 ORAL DISEASES AND SURGERY. as required, — not as indicated by tbe pulse, for this in tetanus affords very little guidance, but, as implied, at the seat of local offense. Among negroes, as remarked by Dr. James S. Baily, vvliose oppor- tunities for observation seem to have been extensive, "the unclean- liness and unsuitableness of the umbilical dressings are by far the most common of the exciting causes of the disease. Among these people infants are found not only fetid with the ammoniacal smell of the urine with which they are wet from morning until night, but are loaded with fecal matter, so thoroughly saturating the appendage of the funis as to render its drying impossible. In consequence of tbe sphacelated condition of the cord, it gives off the material of death and decay, which, being deposited in direct contact with the active absorbents, must necessaril}^ act as a fearful causation." This gen- tleman, who, during a residence in Texas, was able to collect and make notes of two hundred cases, tells us that in his experience he has never observed a case of lock-jaw when due regard was paid to proper instructions in reference to the management and dressing of the umbilicus. Tumefaction and redness without suppuration are always, he thinks, expressions to excite apprehension, and are to receive immediate attention. Quoting a Mrs. , a lady living on the Brazos, in Texas, observation is directed to the value of a mush poultice applied to the navel immediately after birth, to be continued until the falling off of the cord, or while any signs of in- flammation exist, the lady asserting that with such practice employed with her own servants they have never lost a case. This, however, evidently applies to the use of the poultice as a prophylactic, — a direction, indeed, in which the physician finds himself most useful. TRISMUS DENTIUM. In the chapter on Dental Anomalies we studied the process of maxillary enlargement, and understood how that process was, in part, counterbalanced by an untimely extraction of the deciduous teeth. It was further shown how certain derangements of the dental organs were a common, if not a necessary, sequence to such abridgment of the arch ; and, among other ill effects, reference was made to the impossibility of a natural and healthy evolution of the wisdom teeth, and to conditions favoring periodonteal inflamma- tion. In this section we are to consider lock-jaw as it has a signifi- cation exclusively surgico-dental. Such dental signification, however, will, I apprehend, outside of THE TEETH AND THEIR AIS EASES. 197 tetanic conditions proper, be recognized to have the widest relation- ship to the lesion, and, indeed, if my experience has not been un- commonly one-sided, it will be found to have the very closest rela- tionship; for I incline to think that, in every twenty cases of local trismus, eighteen have, as the primary lesion, periodontitis, in some of its varied forms. We have considered the retraction of the dental arch. "We will now look at such lesions as this retraction has engendered — lesions pertaining to the subject under consideration. The troubles of an individual afflicted with a contracted dental arch are most apt to begin at about the fifteenth or sixteenth year of age. If you look into such a mouth you will find the teeth crowded together in most uncomfortable-looking positions. The last molar of the lower jaw you will see, quite likely, jammed into the ramus; while the same tooth of the superior jaw will be found occupying the very extreme of the tuberosity of the bone. At this period, unless, fortunately, the teeth are possessed of un- common resistance, you will find them breaking down from approx- imal caries; while, as the result of such caries, combined with the crowded condition of the fangs, the alveolo-dental periostea enter into a subinflammatory state, and become as ready to take on acute disease as is tinder to respond to a spark. If, then, interference with the elongatory process has been such as to yield these troubles when only twenty-eight teeth have erupted, it is plain to infer that the development of the four dentes sapientiae must proportionally add to the difficulties. And only by appreciating the character of such trouble can we fit ourselves to abort its lesions. These lesions are periodontitis, alveolar abscess, stomatitis, ostitis, necrosis, trismus, etc. In the chapter on Anomalies, it was remarked that all dental trou- bles arising from retraction and diminution of the maxillary arch could be guarded against by a timely extraction of certain of the permanent teeth ; and from this we might infer that troubles arising from an advancing wisdom tooth might also be provided for on the same principle, namely, by extracting the second molar, thus se- curing the required alveolus. These pathological conditions, and the remedial and prophylactic indications so plainly written over them, it would seem impossible, because of their very simplicity, to overlook ; that they are over- / 198 ORAL 3 IS EASES AND SURGERY. looked, however, is too evident, from their many secondary lesions which the surgeon finds himself constantly called on to treat. The view was advanced that the majority of the cases of trismus would be found to have, as the primary lesion, some periodonteal trouble. Of course I would be understood as not including trismus neonatorum, or any trismus traumaticus, the lesion of which was self-evident. A child might get a severe burn on the cheek, and trismus be a result of the innodular tissue, which would close up the break in the continuity. Anchylosis might exist, the sequence to articular disease, as we have studied. Traumatic tetanus affect- ing the muscles of the jaw has, as we know, a primary lesion com- bined with peculiar nervous disturbances, which would give the diagnosis. But it is to the numberless cases of so-called idiopathic trismus I allude, and to the cases of trismus which have evidently a local signification alone ; that signification not being always very evident, or otherwise associated with so many complications as not to be readily distinguishable. Reports of case after case of unappreciated local trismus come to our attention, — of the lesion being referred to this cause and the other cause, — the treatments being as various as the diagnoses. Many of the inferences thus presented are, without doubt, just and reliable ; but I would give it as a reliable experience that where, personally, I have had the opportunity of seeing such cases as would seem to be their parallel, I have mostly been able to point out to the practitioner exhibiting the case, as the primary lesion, some dental disturbance, simple or obscure. In the epitome of Braithwaite, vol. ii. page 191, is a case, the diagnosis and treatment of which will serve as an example. Dr., Sellers, the practitioner who reports it, ascribes the trismus to a complication of inflammatory and nervous derangements. Now, while I might have found myself wrong, yet from the history, and from the age of his patient, I chould have expected, had I seen the case with him, to be able to point out that an ulcerated sore throat, to which he alludes, had its primary lesion in a periosteal trouble of the alveolo-dental membrane ; let the reader, however, draw his own inference. I will compare with this case one from my own practice. Dr. Sellers's Case. — Acupuncture in Protracted Lock-jaiv. — The patient, twenty-five years of age, unmarried, had for years been sub- ject to attacks of suppurating sore throat, in which the jaws often became nearly immovable for two or three'days before the discharge 4 THE TEETH ASW THEIR DISEASES. 199 of matter. Iii 1826, she had a severe attack, from which resulted complete lock-jaw, accompanied with hysterical symptoms, which attack yielded, after six weeks of treatment, so far that she could put a teaspoon in her mouth. After nearly a year, the jaw again be- came completely fixed, without accompanying sore throat, and the same treatment, with galvanism, was tried without efifect. Although unequivocally connected with hysteria, there was reason to think, from the inflammatory action with which the disease set in, that the affection was not purely spasmodic, but was kept up by the rigidity of the muscles closing the jaw produced by inflammation ; in consequence of which the antagonistic muscles had become in- adequate to the effort of opening the mouth under the mere influence of volition. It was this view of the case which made Dr. Sellers think it more reasonable, in making trial of the needles, to insert them into the muscles opening the jaw, in the expectation of exciting them to such a contraction as might overcome the rigidity of their antagonists. On each of the two following days two needles were inserted, one on each side of the mesial line between the chin and the hyoid bone, the eSect being short, convulsive efforts. The teeth began to grate on each other, and the jaw was drawn from side to side, not by single alternate contractions, but by severe convulsive move- ments on one side, followed by a nearly equal number toward the other side, interrupted occasionally by a momentary opening of the mouth to the extent of about two fingers'-breadth. The convulsions continued after the needles were withdrawn; ceased and became renewed again after a few minutes, and returned spontaneously in the evening on both occasions. Some increase of voluntary power over the jaw followed both applications of the remedy. After each trial of the acupuncture some improvement was observable ; but, as the spontaneous convulsion was almost always followed by a slight loss of motion, the progress made was slow. The needles were usually inserted to the depth of half an inch, and sometimes to the depth of an inch. The acupuncture, together with leeches, was used for ten days, by which time the patient could open the mouth two fingers'- breadth and chew soft substances. She then went into the country for five weeks, by which she derived great benefit; but, being ex- posed to cold and wet on her return, had another severe attack, the 200 OBAL DISEASES AND SURGERY. consequence of which was the loss of much of the voluntary power over the muscles of the jaw. The needles were again resorted to, with the same effects as before; but the pain produced by the spasms was greater, and lasted longer, while the spontaneous convulsions recurred several times in the evenings after each of the first trials. As leeching did not succeed in mitigating these con- vulsions, the temporal artery was opened with the desired result, and with the effect at the same time of restoring, to a considerable extent, the sight of the right eye, which she almost lost with the first attack of lock-jaw. A second detraction of blood from the same vessel diminished the force of the attack so much as to permit the acupuncture to be used twice a day. Nine days after the re- newal of the operation, the jaw had recovered its natural extent of motion. The aphonia, which had come on at the same time as the affec- tion of the eye, was completely cured by a smart shock of elec- tricity. The case referred to as from my own experience occurred in the practice of a friend, — my relation with it being in a consultation. Its history is as follows: For a period of several years the patient, Mary C, twenty-four years of age, had been troubled with attacks of sore mouth and throat whenever she unduly exposed herself; these attacks had always associated with them partial loss of voice and general ex- citation of her whole nervous system, while her jaws were invaria- bly stiffened to a greater or less extent, according to the severity of the attack. On each of these occasions she had depended for relief upon domestic treatment or homoeopathy. At the period, however, of her coming under the care of my friend. Dr. W., she was suffering from such severe trouble as to decide her usual attendant into dismissing the case. Her jaw had remained so firmly locked for a period of six weeks that it was with difficulty a knife-blade could be introduced between the teeth. This particular spell had come on as usual ; but the patient said there was something about it which made her think that her teeth were implicated ; she could not say what tooth or teeth, but thought it was one or more in the lower jaw. Now, whatever was to be discovered as the primary lesion in the case, its surgical feature, as it presented itself to our attention, was an extra-capsular mass of coagulated lymph about the temporo- maxillary articulation, which overbalanced the influence of the de- THE TEETH AND THEIR DISEASES. 201 pressor muscles, holding' the parts, of coarse, in a state of false anchylosis. I asked the patient if, when these attacks came on, her face had not always swelled more or less. She said that it had. I asked her if the cheek had not always a stiff, hard feeling in it, which wore away gradually after such attacks. It was so, she told me. Dr. W. agreeing with me that the speediest way of overcoming the trismus was by mechanically breaking up the adhesions, I pro- cured a pine stick about a foot in length, tapering, wedge-shape, from an inch and a half base. The thinnest portion of this wedge was, after much trouble, passed between and across the dental arches, and, after being forced a little farther on, the stick was turned on its axis, the adhesions yielding before the strain. Thus the mouth w^as opened at least an inch, and we w^ere enabled to explore this cavity for the lesion upon which the trouble depended. So far this case will be seen to similate closely that of Dr. Sellers, — sore throat, aphonia, hysteria. Now, here we found 'all the trouble emanating from a wisdom tooth projecting, as it were, from the very angle of the jaw, and half covered in by an operculum of gum drooping over on it from the ramus. The tooth of course we at once removed. The patient was then dismissed for the day, a sorbefacient being directed for external application. The next afternoon, at four o'clock — no inflammation having super- vened — we completed, by our mechanical appliance, the unlocking of the jaw. In a week the patient was dismissed well. She has since had no return of her spells, and I am perfectly sure will not have. I think a parallelism between these two cases will be recognized; but should the reader disagree with me, the study of them will not, I trust, be without its profit. One of the most severe cases of inflammation of the mouth, throat, and face, combined with a bad trismus, 1 have ever seen, was in the person of a medical student in the office of a Dr. C, of this city — the primary lesion being such a half-erupted wisdom tooth as has been alluded to as being found in the preceding case. This gentle- man, when I first saw him, had been suffering for two or three weeks. The operculum of gum had been split up on two different occasions. Antiphlogisticsin every form had been resorted to. The patient came to me under the anticipation that nothing could save him from necrosis of the anjrle of the bone. 202 ORAL DISEASES AND SURGERY. I gave this man one and a half pounds of ether ; it seemed im- possible to get him into an anaesthetic condition, his physical suffer- ing was so great. Prying his mouth open, just sufficient to introduce the key of Garengeot, I extracted, with much difficulty, the offending tooth. In three days he was again attending to his studies. This peculiar lesion of a half-erupted wisdom tooth may well claim a moment's attention. Many a practitioner has been so deceived by the anomaly as to have been led widely astray in the study of his cases. Where this condition exists, you will notice, on looking into the mouth, that only the anterior face of the tooth has fairly erupted, the other two-thirds being overlaid by the integuments of the ramus. You infer that the development is not yet perfected, and conse- quently it does not even occur to you to associate disease with the parts; but this tooth, only a single cusp of which is through the gum, may have caries extending into its pulp-cavity, or may be the seat of the most aggravated periodontitis. It is the common im- pression that wisdom teeth decay early ; that they are not a sub- stantial class of teeth. The fact is that four-fifths of the wisdom teeth which decay so early have been destroyed by this operculum of gum. The explanation is very evident. The decomposing epi- thelial scales, and other debris of the mouth, combine in the acidity engendered of their disintegration to irritate the bony structure of the tooth, thus quickly destroying its integrity. I am sure that I have seen more than a thousand cases illustrative of this fact ; and if any practitioner will take the trouble to dissect off this fleshy lid — the proper treatment, by the way — and examine with a delicate probe the sulci of such teeth, in nine cases out of twelve he will find caries. Such a lesion will at once be recognized to have important second- ary relations. For example, I have myself been consulted time and again by persons who have been sufferers for a considerable period from what has been pronounced and treated as neuralgia. Their teeth had not escaped observation, but had been examined and pro- nounced sound. I have found in such mouths not unfrequently this operculum of gum overlying the wisdom tooth. This I have dis- sected off, exposing compound caries. I have extracted such teeth, and the patients have been instantly relieved of their neuro-odon- talgia. Again ; these fleshy cups, catching and holding, in contact with the soft parts, insoluble particles, as often found mixed with the food, THE TEETH AND THEIR DISEASES. 203 will provoke periostitis, or even ostitis of the angle and ramus of the jaw. I have seen the most alarming- inflammatory attacks thus provoked. The tooth in these cases, as I have somewhere else re- marked, will always be found responsive to the stroke of an instru- ment. Its periodonteum being inflamed, common sense would direct that it be at once extracted ; but such extraction is occasionally among the almost impossible things. A tooth so affected will not uufrequently have but a point erupted not larger than the head of a pin. In these cases the best thing that can be done is to extract the adjoining molar; this relieves the pressure on the ramus of the jaw, and gives room for the posterior tooth. It will commonly yield a cure. Trismus, depending on such lesions, is not uufrequently the only external evidence yielded of the existence of the condition. The jaw stiffens and relaxes, as an odontalgia will come and go. In such ephenjeral cases it is not at all unlikely that the trismus is exclu- sively a nervous action, or reflected irritation, — slight and ephemeral local inflammatory action being the irritant. Wisdom teeth erupt from the seventeenth to the thirty-fifth year; commonly, however, at about the eighteenth year. Some years ago I treated a case of trismus, the history of which may be given as a very common one: The patient, David B., a farmer, after doing a hard day's work, and getting much overheated, threw himself down, just at early even- ing, in a cool outhouse, to rest. Here he fell asleep, not waking until near midnight. The next day he felt a soreness in the left su- perior alveolar arch, which soreness increased for two or three days ; after which it deserted the teeth and passed to the antrum. Then commenced a swelling in the integuments of the face, which advanced until it shut up completely the left eye. The jaws began to stiffen, and ended, after three or four days more, in complete immobility. I was called to the case, after the lock-jaw had existed nine weeks, the patient having barely been able to support life by putting his mouth into a basin filled with soup, and sucking the nutriment through his teeth. During this time he had been seen by seven different practitioners, no one of whom had seemed to appreciate his case, or, what perhaps is more probable, none of whom had been willing to assume the trouble of it. The patient had never told any of these gentlemen about the soreness first felt in his teeth, and no one of them had ever questioned him in this direction; his single complaint was of a great weight about bis cheek. 204 ORAL DISEASES AND SURGERY. The diagnosis of the case was, primarily, periodontitis; this in- flammation, by a double continuity of structure, had extended into the maxillary sinus, and to the integuments of the face. The inflam- mation of the antrum had been sufficiently severe to result in abscess ; abscess of the alveolo-dental membrane, and of the lining membrane of the cavity. The inflammation of the face had resulted in the exudation of lymph, which lymph in a state of coagulation was the cause of the trismus. A first eS"ort was directed to getting into the antrum, which I felt well assured was filled with pus. This was done by prying out the second molar tooth with an elevator, pushing it into the mouth (from which, with some trouble, it was afterward gotten out); the extraction was followed by profuse discharge. The patient described the relief as being immense. I removed this particular tooth, not because it was more carious than its fellows, but because it was somewhat loose, and thus gave evidence of the diseased condition of its roots. Again, it is through the alveolus of the palatine fang of this tooth that we find our/ easiest and best road to the antrum ; in this case, as is seen, the fang communicated with the cavity. On the day succeeding the evacuation of the abscess, the patient expressed himself as entire!}^ free from pain, his only trouble being the anchylosis, which had not, as yet, relaxed in the least. To the touch, all the parts about the articular extremity of the inferior maxilla seemed completely indurated. I hesitated to at- tempt the breaking up of the parts mechanically, fearing that thereby I might do injury to the important vessels which are associated with the head of this bone, — the internal carotid and internal maxillary arteries. The induration was of course extra-capsular, and of sufficient extent to have bound the jaw from the glenoid cavity to the anterior border of the masseter muscle ; passive motion was resorted to, but employed very gently. Blisters and sorbefacients were depended on The case progressed very slowly, the patient having to come to my office every day for fifteen days ; at the end of this time, but after removing other diseased teeth from his mouth, he was dismissed cured. When one is called to a case of trismus of any standing, the anchylosis being the result of inflammatory action, question may arise as to the propriety of mechanically breaking up the adhesions. The condyloid extremity of the maxillary bone is assuredly not the stanchest part of the body, and there are anatomical relations THE TEETH AND THEIR DISEASES. 205 whicli it would not be at all pleasant to disturb: these things are for the surgeon to decide upon. So far as I, individually, am con- cerned, I now use mechanical force in all cases that come under my care, premising of course that the case is one where, from inflam- mation, the trismus depends on effused lymph. I am willing to run the risk for the great and immediate good yielded ; some considera- ble experience in this direction assuring me that such risk is materi- ally influenced by the manipulations. Of course I do not mean to recommend that attempt should be made to open the mouth to its greatest capacity with a single turn of the lever employed, although there are cases where such practice would be very commendable. I have so opened the mouth man}^ a time, but not in cases of long standing. Generally, the force should be applied with gentleness, gain a little one day, and a little the next ; it takes but a very short time to open a mouth in this way; besides, if your force is applied with such judgment as not to provoke vascular action, you will arouse to co-operation the absorbent system, the excitement acting as a stimulus to it, and it will be found to do its part vigorously. A person will not unfrequently be attacked with trismus after the dental operation of inserting a pivot tooth. Here the lesion is more than likely inflammatory in character, and the treatment is to be directed accordingly; the root of the tooth is in a state of periodon- titis. Cases of pure tetanus, however, have had origin in such an operation. Where the lesion is inflammation, the parts are sore, and tender to the touch. A person will sometimes be attacked with trismus after the plug- ging of a tooth with metal ; the attack comes on suddenly; it is a reflex nervous action, and is always to be esteemed Of dangerous import. The conducting facility of the metal irritates the nerve periphery in the pulp; this irritation is referi'ed to the Gasserian ganglion, and thence reflected to the muscles of mastication. To prove the existence of this lesion, direct the patient to hold cold water in contact with the tooth. To treat a case of this kind, remove the metal ; when the irrita- tion has subsided, be sure that before refilling, a non-conducting sub- stance shall be placed between the plug and the floor of the cavity; or, because of the thinness of the bony septum, it may be desirable to destroy the pulp. Spasmodic trismus, very persistent, may result from the emplo}^- " ment of two different metals in the operation of tooth-plugging; galvanic action is the consequence, and the nerve is subjected to a 206 ORAL DISEASES AND SURGERY. most harassing irritation. To test for this trouble, increase the action by holding silver and zinc against the plug. This test, how- ever, will irritate any super-sensitive pulp into a state of excitement, and is an admirable search-warrant for obscure lesions of this organ. The treatment consists of course in the removal of the plug, and the medication, if required, of the irritated pulp. So I might extend over many pages the consideration of dental lesions in connection with trismus. I have, however, written enough, I presume, to direct a proper attention to the subject. To recapitulate: It is suggested that many of the cases of so- called idiopathic or obscure trismus will be found to depend on con- ditions associated with the dental arch. That to insure permanent relief, the treatment must include the primary lesion. That such primary lesions as are described in the chapter on "Anomalies" are always distinguishable. That where it is desirable to extract an offending wisdom tooth, and such extraction seems too difficult to attempt, the removal of the tooth immediately anterior to it will not unfrequently be found to meet the indications. That the immobility of the jaw, where acute inflammatory action exists, is to be treated on general antiphlogistic or phlogistic princi- ples, according as it seems probable or improbable that the inflam- mation may be resolved. That when the acute action has passed, adhesions are to be broken up by mechanical force carefully applied. That mcchanico-dental lesions are not to be overlooked, but are to be searched for, and discovered secundum artem. Trismits Traiimaticus. — This is that anchylosis, true or false, intra- or extra-articular, dependent on local injury received. Of such injuries we have, of course, a great variety. Blows inducing inflam- mation are among the common causes ; a not infrequent cause, and one difficult to be combated, resides in severe burns; sloughs from the undue use of the mercurials, as exhibited in gangrena oris, are to be enumerated ; in short, we might instance any condition in which the locked-jaw depends on conditions of a local signification attended with solutions or irregularities in the continuity of the structures. A case just dismissed in my own practice, in the person of a boy twelve years of age, had the anchylosis dependent on false articula- tion, the result of injury done the glenoid fossa three years before THE TEETH AND THEIR DISEASES. 207 by a blow upon the chin. The force of this blow being carried to the joint, a chronic inflammation had resulted in a filling up of the cavity on a level with the articular eminence. While in this peculiar situation, a species of irregular cavity had formed, which partially accommodated the condyle, compelling, however, dislocation when- ever the jaw was forced open beyond a certain point. In this case a fair cure was obtained by a tri-weekly manipulation of the bone, resulting, as I infer, in a better-adapted fossa through absorption. To procure such motion as seemed demanded, frequent luxations resulted, — causing at first not unfrequently much trouble in the re- duction. This patient has been advised to watch any tendency to contraction Avhich may appear, and to keep it counterbalanced by rolling corks between his teeth, — an excellent means, by the way, where the expense of instruments prevents their purchase. The use of common bottle-corks as a means of overcoming false anchylosis I have employed for some time with the most satisfactory success. Beginning an operation with one of a diameter to be readily introduced, increasing sizes are to be rolled, one after the other, between the teeth, into its place. Timid children will permit the use of corks, who entirely resist the screw. At a late clinic of the University, a young man presented himself with the lower jaw so fixed that only by pro- foundly etherizing him was it possible to pass the blade of a common table-knife between his teeth. This condition, which had existed for two years, had resulted from a blow received upon the cheek involving in an inflammatory fixedness the masseter muscle. This case was treated, first, by subcutaneous section of the muscle, followed by the daily use of the screw. Through the use of this instrument there is no doubt of his being kept comfortable. He is directed to employ it daily, and never to allow the jaws to deny the introduction of two fingers. Without doubt, it will be found that eventually such modification of the contracted muscle will result that a fair cure may reasonably be anti- cipated. The section of the muscle in this case had of course but the meaning of a8"ording the use of the second and true means of cure, namely, the daily stretch- ing of the part. Fig. 56. 208 ORAL DISEASES AND SURGE BY. Fig. 56 represents the instrument employed in the stretching pro- cess, and which has been furnished the patient for daily use: it is one devised or modified by the ingenious cutler to the University clinic, Mr. Kolbe, and surpasses any other form with which I have acquaintance : by simply turning the handle, the blades, as seen in the drawing, are gradually separated. The power residing in this instrument is sufiBciently great to break up any anchylosis, true or false, I have ever seen : any jaw could be broken with it. A neces- sary addition, however, to the instrument, as now constructed, rs felt to be required in the handle being made of metal rather than of wood, with the further addition of a transverse bar to afl'ord a more convenient application of the force. I feel that I cannot too warmly commend this instrument as the very best now in use ; it will fulfill the requirements of any case to which such application of force is indicated, while the most careless patient may be intrusted to use it on his own jaws. Cases of false anchylosis will most frequently be found extra- rather than intra-articular ; or where the condition has existed for a long time, say for a year, then it is reasonably to be inferred that the two conditions are combined, that is, that that portion of the articular cavity which is not used has been modified by nutritional changes. Wherever, however, the lesion of a false anchylosis is situated, the philosophy of its re- lief consists in the practice of pas- sive motion, — it is really only another expression of the mode of cure of urethral stricture: operation maybe necessitated, but it is only to be prac- ticed in cases of urgent necessity. Besides the instrument commended, various others have been devised for the purpose of passive motion. Figs. 57 and 58 show two other forms of such instruments. Fig. 57 is that known as the wedge of Scultetus. Fig. 58 is a modification, as is seen, of such instrument: neither of these deserves mention as compared with the instrument of Mr. Kolbe. In sections of the country where the mercurials are freely used, anchylosis from sloughing is not uncommon ; it is frequently found in Fig. THE TEETH AND THEIR DISEASES. 209 these cases that the mucous aspect of the cheek has been converted intoadense unyielding fibro-cellular cicatrix, which resists all attempts on the part of the depressor muscles to antagonize it. In cases of this kind, instrumental aid is found most applicable, and, if properly and judiciously persisted in, will eventuate in satisfactory relief. Another local cause of anchylosis is found in bridges of bone asso- ciating neighboring parts, commonly the edges of the glenoid cavity with the neck of the lower jaw, or it may be that the relation is between the two maxillary bones. These bridges are not unfre- quently to be broken and their absorption secured through dilata- tion conjoined with passive motion and the use of sorbefacients. In no cases, however, is it more desirable to guard against inflam- matory results, and therefore such procedure is to be conducted with the same care as is felt to be necessary in breaking up anchylosis in the knee- or elbow-joints ; a principle being, to make haste slowly : fracture of the neck luay readily attend rough manipulation. Should such an accident occur, the desirability of making a false joint may have consideration : if a diagnosis exhibits complete fixedness of the head of the bone by a bony relation, then nothing better might be attempted than the creation of such false joint, union being prevented by passive motion, and inflammation combated through the agency of antiphlogistics, local and general, as might seem demanded. Cases occur where the only possible prospect of relief is found in the production of such a false joint by operation particularly di- rected to that end. Such mode of procedure suggests itself on review of the famous operation made many years back on the femur of a sailor, by Dr. J. Rhea Barton, in which a flexed limb was restored to usefulness by the removal of a V-shaped wedge, thus allowing the leg to be extended. Both Rizzoli and Esmarch, acting on such principle, have been able to report satisfactory results. The operation as practiced by the first-named of these gentlemen consists in simply dividing the jaw by a delicate saw — the chain saw may be employed — in front of the lesion. Esmarch removes a V-shaped wedge, the base being below, such passive motive being at once exercised as shall prevent union of the separated parts. Practicing either of these operations, the surgeon will become sat- isfied that they are only to be resorted to in the absolutely compul- sory cases. A case illustrative of the practice of Rizzoli is thus recorded : " At the time of admission of patient into hospital the left cheek U 210 ORAL DISEASES AND SURGERY. was more depressed than that of the opposite side, and an explora- tion being made along the horizontal ramus of the jaw, the fact was established of the loss of osseous substance near the posterior angle of the jaw. The finger, when introduced inside the cheek, was also stopped by strong adhesions of cicatricial tissue, and the teeth were to be found in their alveoli, all except the two upper incisors, the ab- sence of which allowed of the introduction of some liquid nutriment. " The patient being seated, and her head supported against the breast of an assistant, while another drew down the lower jaw, the operator made an incision in the cul-de-sac which united the lip and gum of that side, exactly at the space which corresponds to the second and third molars; this incision divided not only the mucous membrane, but also the subjacent soft parts, so as to lay bare the lower border of the jaw; by this wound was then introduced the straight and blunt branch of the bone forceps, which embraced the internal border of the jaw, so that the cutting edge of the instru- ment was easily placed on the outside. A slight force only was necessarily required to completely divide the maxilla at one stroke, and thus restore to the jaw the motion which had been lost for eight years. The operation is alluded to as not being interrupted by any complications, either during or after its performance. The patient, a girl, is reported as being quite cured, able to separate her jaws widely ; to chew her food, to eat, drink, laugh, and speak, as in her normal state." A case of bony anchylosis presented in the clinic of the Pennsyl- vania Hospital, operated on by Dr. T. G. Morton, has the following history. It serves excellently well as a type of practice in its direction. "Charles H. Robinson," says Dr. Morton, "aged eight years, was brought to me in October, 1869, from Tallahassee, Florida, with an anchylosed condition of the jaws. In 1865 the child had been mercurialized for a long-continued bilious remittent fever; following this, very serious and extensive ulceration of the mucous membrane of the mouth resulted, and a slough on the left side of the face opened a communication through the cheek at a point corresponding with the second molar tooth, and whicli involved the parotid duct, through which for a considerable period saliva freely flowed ; an abscess behind the ear also developed, which discharged for a long time. The health of the child was very seriously impaired, and there was almost an entire arrest of bodily development. With the closure and final cicatrization of the parotid fistule and the healing of the THE TEETH AND THEIR DISEASES. 211 ulceration of the mouth, permanent bony closure of the jaws followed, and for nearly five years the child had been fed entirely upon liquid food. On examination, I found the boy irritable, puny, and quite feeble. The spleen was greatly enlarged and quite hard ; complete osseous anchylosis formed the bond of union between the upper and lower jaws near the ramus on the left side, corresponding apparently to the seat of the original slough of the soft parts. The cicatrix was here firmly attached. On the right side of the mouth there was no attachment of bone and soft parts; the finger or probe could be readily insinuated between the alveoli and the cheek ; the teeth were very brittle, irregularly notched, — and many had crumbled off, leaving numerous openings through which the child received nour- ishment. Generous liquid diet and the comp. syr. of the phos- phates were prescribed. "Oct. 6. — Admitted the boy as a private patient into the Pennsyl- vania Hospital. "Oct. 8. — After etherization, an attempt was made to force the jaws asunder with a dilator, but the teeth were so friable that this was abandoned. A curved incision was then made through the cheek to the angle of the mouth on the left side, and the flaps were dissected up. This exposed a bony bridge, extending from the upper to lower maxilla, about an inch in breadth and an inch and a half in length and of considerable thickness and extreme density. There was apparently no articular trouble. Cutting forceps made but little impression on the deposit, and the bridge was then removed by the saw. After the removal of this, the dilator was introduced and the jaws separated one and six-eighths of an inch. The external wound was united by silver sutures, and healed kindly ; extreme dilatation was kept up by plugs of wood for several days. The lad's general health continued to improve, and he was able to mas- ticate his food quite well, which was a source of great pleasure, not having tasted solid food for so long a time. Recovery was rapid, although prostrated from loss of blood at the operation ; yet he improved daily, and was discharged November 6, 1869, cured. One year afterwards he had good motion in his jaws. I have not since heard of his state of health." In such conditions of anchylosis as depend strictly upon cicatrices, the propriety is always to be considered of a plastic operation, which, removing the deformed tissue, shall replace it with that which is normal, secured from some convenient part in the immediate neigh- borhood. If the cicatrix to be replaced be small, adjoining portions 212 ORAL DISEASES AND SURGERY. of tlie cheek may furnish the required material; if, on the contrary, it be large, the neck will have to be depended on, or it may seem pre- ferable to employ the Italian method of taking a flap from the arm. The principle of the operation consists in mapping out on the part from which the flap is to be made such extent and shape of surface as shall replace that designed to be removed. The cicatrix being dissected out, and all bleeding checked, the flap as marked is raised, leaving it attached alone by its pedicle ; and when hemorrhage in this also has been controlled, and the surfaces begin to glaze, it is carefully to be turned on the pedicle into its new position, and, being fixed by stitches, is to receive the attention required by wounds in general. The space left by the removal of the flap is to be drawn together by stitches, adhesive strips, or other convenient means. Before undertaking a plastic operation, however, nothing is more necessary than to possess an appreciation of the reparative and nutritional powers of the patient. To operate on a person in a typhoid state, or on one the plasticity of whose blood is destroyed by the influences of syphilis, scrofulosis, scorbutus, or mercurializa- tion, would be simply to court failure. "Many cases of the disease atrasia oris, or closure of the mouth, are reported as presenting themselves to the notice of those attend- ing the medical charities of Calcutta. It would appear that there are here two very common forms of this disease : one in which the mucous membrane covering the front of the ramus of the lower jaw has been inflamed, and, subsequently contracting, causes closure of the teeth, without narrowing, to any considerable degree, the opening of the lips. If the history of these cases be traced, it will be found that they have generalh^ resulted from the cutting of the last molar or wisdom tooth having caused the gum to inflame. The other kind of closure results from the indiscriminate and excessive use of mercury by native practitioners. The ulceration of the mucous membrane lining the gums and cheeks succeeds to the ptyalism so produced, and, on the inflammation subsiding, the opposed ulcerated surfaces unite and cause the jaws to be closed, and the opening of the mouth to be contracted. Both Dr. Fayrer and Dr. Partridge, surgeons to the charities, are accustomed to remedy the first accident in the same manner, by dividing the firm contracted band of mucous membrane with a knife (one of the tenotomy knives generally being found to be most convenient), and then forcing open the jaw by an extending trivalve speculum. With a little attention to dressing, this plan generally succeeds. In the other species of atrasia oris a similar plan was at first adopted. The adhesions were divided by a narrow THE TEETH AND THEIR DISEASES. 213 knife, the jaws forced open by the speculum, if necessary, and lint dipped in oil was pushed in to separate the recently-cut surfaces. But the disease treated by this way alone had so great a tendency to relapse, that in a recent case Dr. Fayrer, in addition to the above, divided the skin at the angles of the mouth in a direction downward and outward ; and though at first this occasioned a most lachrymose expression to the man's countenance, it ultimately perfectly suc- ceeded, and he left the hospital cured." " Professor Reina has had occasion to observe four cases of a new form of morbid closure of the mouth, due, not to anchylosis of the articulation of the jaw, but to hypertrophic tliickening and indura- tion of the membranous muscular tissues of one or both cheeks. Syphilis, scrofula, or the irregular and violent extraction of a molar tooth, were the causes of this alteration, and the closure led to much difficulty of respiration and speaking, and interposed an obstacle to the introduction of solid food into the mouth, from which resulted the various consequences of insufficient nutrition. " To remedy this deformity. Professor Reina divided, by means of a bistoury, the hypertrophied tissues, repeating the incisions whenever they became necessary, and incising transversely the mu- cous membrane, from the angle of the jaw to the commissure of the lips. The buccinator and orbicularis oris were entirely divided ; it became necessary, also, more than once to divide the anterior pillar of the velum palati and the glosso-staphylinus muscle, and in such case the operator was, moreover, obliged to relax the corresponding side of the tongue, which adhered to the interior of the gum. The arterial hemorrhage was combated successfully by compression. " With the help of conical pieces of cork introduced between the teeth, the abduction of the jaws was facilitated, at the same time that an obstacle was interposed to the union of the divided parts. Finally, the diatheses were combated by general treatment, mercurial or iodized, according to the special indications." Concluding this consideration of fixedness in the jaw, a resume of the subject exhibits as causes of the condition, — 1st. Spasm ; the treatment being of constitutional consideration. 2d. Anchylosis by muscular induration ; the treatment being by local medicaments, combined with the employment of the dilator. 3d. Osseous anchylosis ; the treatment beirtg the breaking up by section or otherwise, if permissible, of the bony bridges. 4th. Cicatricial anchylosis ; the treatment being by dilatation and by plastic operations. CHAPTER X. THE TEETH AND THEIR DISEASES. CAKIES. Caries of the teeth being a disease so destructive to comfort and to liealth, and withal so common as to possess its illustration in almost every human mouth, makes the subject felt as one claiming earnest investigation and attention. Caries of a tooth, most simply expressed, is corrosion of its sub- stance : the disease may occur on any part of the surface of the crown or even the root, but as a rule is found to originate on parts possessed of the least self-cleansing characteristics. Thus, it is most common to the sulci on the grinding faces of the molars and bicuspidati, to the posterior depressions met with so frequently in the superior incisor teeth, and to the proximal faces of the teeth generally. Caries is a disease of chemico-vital relation, and is unfortunately most markedly of congenital association and predisposition : indeed, so true is this, that it may be prognosed that the offspring of parents afflicted in this way will be in like manner afflicted, and that, on the other hand, the children of parents possessing good teeth will be in like manner favored. So constant is this analogy in the teeth of parents and child, that in most instances it extends to the very shape and arrangement of the organs, deformity insuring deformity, and regularity regularity. One parent alone may influence for good or evil. Hereditary dental caries finds its explanation in likeness of condi- tion, this being of local or constitutional signification, or more com- monly a conjoining of these ; such teeth being not only imperfect in development in one or more directions, — in shape, in deficiency of enamel-covering, in non-calcification as exhibited in the existence of interglobular spaces, in position, in tubular circulation, in nerve endowment, — but in an equal number of cases in lack of physiologi- cal harmony, either in surrounding secretions or in the offices of (214) THE TEETH AND THEIR DISEASES. 215 nutrition : any or all of these may be the conditions, as, indeed, re- sultant from them are all cases of caries. Health in the dental organism depends : 1. On circumstances associated with the original formation. 2. On the shape of the teeth, their relation to each other, and their self-cleansing- features. 3. Constitutional conditions. 4. Character of agents in contact with the teeth. 5. The absence of mechanical destructives, as salivary calculus, the bands of artificial dentures, etc. 6. Accidental influences. Condition 1. On circumstances associated loitli the original for- mation. To appreciate the reasons explaining the inability on the part of certain dentures to fulfill the intentions of their creation, we are compelled to consider, not unfrequently, influences and associations apparently far remote from them. That the student may be made familiar with the principles involved, without which, indeed, he might not otherwise than mechanically treat carious teeth, it is proposed to invite his attention to that study and understanding of the subject which practice will demonstrate as the exhibition of it in a clinical fullness. It is to be assumed, as a premise, that like begets like ; therefore may unhealthy parents not fail to impress upon their offspring that which is of their own constitution. Of these impressions, some we find ourselves able readily to appreciate; others are obscure. As examples, we may refer to cachexias, evident enough in their indi- viduality as exhibited over the general system ; again, to a transmis- sion which illustrates itself alone in the direction of the teeth, the individual at large being otherwise healthy. These two type con- ditions exhibit themselves to every observer. Of the cachexise pertaining markedly to the matter of our investi- gation, we have three, — scrofulosis, rickets, syphilis ; cachexias so widely associated with asthenic conditions, so adverse to the healthy performance of the nutritional functions, that without an under- standing of their expressions one might not hope to antidote their multitudinous sequelae. Because, therefore, of the marked impor- tance of the cachexias, viewed in hereditary association, the student is invited to complete, by reference to the proper works, the epitome here presented. 216 OBAL DISEASES AND SURGERY. DISTINCTIVE FEATURES IN TYPICAL CASES OF EACH CON- DITION. Scrofulosis. — Temperament lymphatic ; abdomen tumid ; com- plexion flat and pasty; lips and alae tumid; saliva stringy ; breath insipid and offensive ; mucous membrane markedly deficient in cir- culating activity, and much disposed to degenerative inflammatory action ; lymphatics enlarged and prominent, especially those of the cervical and mesenteric regions, with great disposition to suppura- tion ; bones very loose and spongy in their areolar tissue, often fatty, breaking down on slight provocation into caries and necrosis ; teeth, alike with the bones, deficient in inorganic material, loose in the character of the intertubular structure, more or less deficient in the integrity of the enamel cap ; the animal matter very susceptible to the irritating influences of the unduly alkaline oral fluid; the pulp pabulum cacoplastic to an extent which almost completely stagnates the tubular circulation, thus antagonizing nutrition; conditions of dental health adverse without and within. Rickets. — Physical force deficient ; habits sluggish ; mentality small, with precocity ; large head, more commonly broad than long; abdomen prominent and heavy; leanness ; general debility, with indigestion; puffiness of the extremities; skin muddy; thin- ning of cranial bones, together with a plastic thickening of other flat bones and enlargement of the extremities of the long bones ; tendency to aplastic infiltrations of the viscera ; the teeth late in erupting, slightly attached to their alveoli, non-resistive of external ofi"enses, which act easily to a chemical disintegration of them, and most apt by slight causes to be pushed from their sockets. Syphilis and Mercurio- Syphilis. — Stagnant complexion ; lean- ness ; atony of the skin and muscles; susceptibility to skin-afiTec- tions; poor and scanty hair ; interstitial keratitis, with interlaminal corneal lymph effusions; stomatitis; tendency to iritis; the teeth more or less notched on their cutting edges, with pittings of the enamel ; mucous membrane passively congested and easily breaking down into ulcers, which ulcers have pasty bottoms; seroplastic effusions into the submucous Schneiderian tissue, interfering with respiration, inducing in the patient constant sniveling ; eruptions on the skin of a coppery-red color; periosteal indurations, with sub- periosteal aplastic exudates ; suppuration of organs, as the liver, THE TEETH AND THEIR DISEASES. 217 thymus, testes; caries and necrosis of bones, particularly the turbi- nated and the maxillae, and of the teeth. ScROFULOSis — Scrofula. — This is a constitutional condition having its recognition in the cacoplastic conditions common to it and begotten of it, the manifestations of malnutrition being most frequently met with in the skin, mucous membrane, hip- and knee- joints, and in the lymphatic glands, which latter, in their suppuration, present most markedly the feature of a cheesy degeneration. Scrofula is commonly an inherited cachexia, but may, through depressing circumstances, be engrafted into any constitution. Bad and ill-nourishing or insufficient food, continued exposure to impure air, intemperance, excessive venery, mental anxiety, the effects of severe courses of medication, secondary effects of poisons, — these and similar causes may induce the cachexia. A marked scrofulous hereditary transmission has its expression in the type case given, but from this it is to be esteemed as shading into the greatest variety of aspect. Two primal expressions are clearly to be recognized. These are the fair and the dark; to be again sub- divided into the fine and the coarse. The fine is the disease as exist- ing and exhibiting itself in the sanguine temperament; the coarse is the typical case, as exhibited in the sluggish lymphatic. It is well just here for the reader studying this disease from the standpoint of 'dental caries to exclude the fair variety, and to place it under the head of Tuberculosis, — a distinction in the conditions which one most practically recognizes as relation with the health of the teeth and general digestive apparatus is concerned ; the typical form being markedly provocative of dental disease ; the fair variety exhibiting its manifestations in the viscera, and most particularly by deposits in the lungs, leaving the teeth quite exempt from a"ny impression. Hence in persons aEFected with phthisis it is not uncommon to find the most beautiful and perfect dentures. It is to be remembered, however, we are writing of predispositions, and not of manifestations from active or recent conditions ; of impressions made on the teeth during the stage of formation and development, and not of impressions made by the acquired disease on teeth whose period of growth might have been associated with such vigorous and health-yielding life that the result is not to be easily overcome. Scrofulosis of the lymphatic type expresses that condition of a system in which morbid actirtn results on the slightest provocation. Every part seems lax and incapable of self-sustenance. The slightest 218 ORAL DISEASES AND SURGERY. injury produces inflammatory action, yet of a grade requiring for its control stimulation rather than depression. In a word, it is a condition in which the vitalizing principle has no proper proportion- able correspondence with the matter of the body. Hence the char- acteristic sluggishness, — the body is only half living, and was so born, — the parents before it lacking that fullness of force neces- sary to the vitalization of the offspring. No single tissue has been harmoniously constructed, the production being to an extent an abortion. Perhaps the student will possess himself of a clearer conception of scrofulosis if we deny to it the name of a disease, and associate it alone with the idea of cachexia; and this, if we exclude from the relation tuberculosis, with its peculiar deposit, one inflicts no vio- lence in doing. It is thus, from clinical ol)servation, I have been led for myself to consider it, and such understanding seems best to conduce to antagonizing its relations. We view the house as one ill built and of poor materials, and do what we can to remedy the deficiency. It is a condition in which attempts at specific treatment have no signification: there is no special condition to combat. With tuberculosis, the case will most likely prove to be different. In conjoining the axioms that "excitement must terminate in exhaustion," and that "from nothing may nothing come," we may, I think, find the precedents and conditions of scrofulosis. In an ani- mal body are so much matter and so much vitality. As the vis vitse may be abstracted from one part to minister to the excitation of other parts, so necessarily must both come to suffer ; the first from an over- stimulation which begets hypertrophic degenerations, morbid plastic formations capable of organization, thus compelling alteration in physiological expression ; the second, from exhaustion through the absence of its correlating force, thus denying the changes neces- sary to the fulfillment of functional life, — breeding, «.of necessity, debility. Over-stimulation, with its consequent exhaustion, finds exam- ples in the intemperate, the venal, and the gluttonous. Children begotten of these in the days of their exhaustion, are apt to be possessed of evidences of the vices. Exhaustion, on the other hand, is found a primary condition, being a result of exposure to influeiic(!S debilitating in themselves; as, for example, to poisons, deprivation of proper food, insufficiency of clothing, to lack of cleanliness, being rll housed, unhealthy employ- ment, continuous subjection to mental disquietude or oppression. THE TEETH AND THEIR DISEASES. 219 excessive secretions and discharges, deprivation of light and sun- shine, etc. We are to assume that the disease we study is not a materia peccans in the blood, but, as Billroth expresses it, " a debility of the organization." Dr. C. J. B. Williams, while admitting no dis- tinction between scrofulosis and tuberculosis, yet describes the condition as "a degradation of the nutritive material from which old textures are renewed and new ones formed, in that in its origin it differs from the normal plasma or coagulable lymph, not in kind, but in degree of vitality and capacity of organization." What cacoplastic lymph is, we appreciate. What tubercle is, we do not know ; the highest authorities, in such direction, are still at issue concerning not only the origin, but even the nature, of tubercle. Whether, therefore, tubercle is or is not an expression of struma, we are, in our present connection, not concerned to discuss. Proto- plasm, lymph, is the basal nutritive agent; plasma is not self-creat- ing or of itself, but a product of vital force acting on materials taken for the nourishment of the body. That organs be normal, pro- toplasm must be normal. The diseased protoplasm of degraded parents — more particularly, perhaps, that of the mother — may not afford that nourishment which is the proper life of a child; on the contrary, it associates its own degradation with all with which it may come in association. Following such line of view, it Avill be recognized that we may not have any marked distinction between scrofulosis and the hereditary manifestations of syphilis, of the mercurial vice, or of other parental adynamic transmissions; and, therapeutically viewed, this premise we believe to be the proper one, — the principle of treatment being found the same, — this being tonic medication, and having no spe- cificity to which it is to be directed. If, however, special organs be specially affected, this would of necessity direct to them particu- lar attention, and the treatment, as the part affected is concerned, would, in local requirements, differ, — as, for example, whether we might have to combat caries of the bone or caries of the teeth ; the constitutional treatment may, however, only be the same, and from such aspect, what would be the cure of the one would necessarily tend to the same result in the other. Unfortunately, however, as the teeth are concerned, from the low grade of their vitality, and, consequently, the inactivity in their molecular changes, counter-im- pressions are long in being made ; therefore, in the constitutional caries of these organs, too much attention cannot be given to the local relations. The fluids of the mouth are, if adverse, to be neu- 220 ORAL DISEASES AND SUBGERY. tralized to the required non-antagonism. Cleanliness is to be par- ticularly insisted on, and all cavities are to be filled or filed away, as may seem indicated. Rachitis — Innutrio Ossium. — A constitutional disease, having its predisposition in hereditary transmission : characterized by non- solidification of the growing layers of bone, by the formation of medullary cavities in the older or more mature bones, thus render- ing the bony laminae thin and Ijrittle (Yirchow), and by excess in the formation of phosphoric and lactic acids, with great excess of the earthy phosphates. It is not to' be maintained that rickets is a constitutional disease, save in the sense of predisposition. Neither is it to be affirmed that it possesses a constancy of expression which allows of a common formulary for a description of its diagnostic signs ; on the contrary, the expressions vary from the most simple manifestations of a disturbed nutrition to a specific alteration in the bones, which renders them, from lack of inorganic constituents, incapable of performing their functions. Indeed, it is probable that degrees of rickets may quite frequently present themselves and yet be overlooked. While, as suggested by Hillier, the secondary diseases, such as bronchitis, collapse of the lungs, atrophy, measles, hooping-cough, or convul- sions, are recognized, the primary disease, which renders these sec- ondary conditions fatal, is quite ignored. As rachitis is congenital, or as it associates itself with the denti- tional periods, so are manifested the effects of the condition upon the health of the teeth, — these organs being delayed in their development, disposed to caries, and not unfrequently of such loose relation to their sockets from aplastic softening of the peridental tissue as to be dis- placed by slight force: the periodonteum, and also the pulp, may be affirmed to present evidences of the common amyloid degeneration as seen in the viscera, particularly in the liver and spleen. The delay in the cutting of the teeth is simply delay in development, the albuminoid pulp lacking organic force to secrete dentinal tissue; while, as is to be inferred, that which is made is of such imper- fect organization, so mottled with uncalcified spots, — interglobular spaces, — as to be rendered quite incapable of resisting that excess of lactic acid found in the secretions coming in contact with it. History. — Rachitis is a disease having perhaps in all cases the association of hereditary predisposition, yet, like scrofulosis, exist- THE TEETH AND THEIR DISEASES. 221 ing ill such variety of aspects and in such states of modification as to make it not easy of recognition through any constant signs. These modifications are of a twofold nature. First, the character of the hereditary impression. Second, the associative surroundings and conditions of the patient. Sir William Jenner, whose lectures on the subject are worthy of all respect and attention, speaks of this disease as " without question the most common, the most important, and, in its effects, the most fatal of all that exclusively affect chil- dren." Hillier (Meigs and Pepper) presents a table showing the proportion borne by the number of cases of this disease to the total number of out-patients treated at the Hospital for Sick Children, London, from which calculation exhibits that of 128,656 children treated during thirteen years (1854-66) not less than 8419, or 6.5 per cent., were rachitic; and in some years the proportion of such patients rose as high as 9 per cent. In London hospitals and in the other great hospitals gathering in the poverty and degradation of any large city, such percentage does not strike us as at all a matter for surprise. It must be recognized, however, as is to be inferred from home observation, that such statistics designate the disease as included in its diversified phases. The cachectic state preceding the osseous manifestations of rickets is not generally to be noticed at birth, but develops commonly during the process of the first dentition, seldom appearing at a later period than during the time of the active stages of the second. The incu- bation precedes, however, the manifestations of the cachexia, residing, as we incline to believe, in an original molecular impression : at least it is only thus that we find explanation of the organic impressions found in the structure of the deciduous dentine and enamel. The relation of rickets with scrofulosis is found in the pre-associa- tion of the two conditions. Thus, " Whatever tends to produce debility and anaemia in a mother, as too frequent pregnancies or prolonged lactation, renders it probable that her next-born children will be rickety." Jenner states "that it is very common for the first, or the two or three first-born children, to be free from any signs of rickets, and yet for every subsequent child to be rickety ;" which he explains by the fact " that among the poor the parents are generally worse fed, worse clothed, and worse lodged the larger the number of their children ; and among the rich and poor alike, the larger the number of children, the more has the constitutional strength of the mother been taxed, and the more likely is she to have lost in general power," (M. and P.) 222 OBAL DISEASES AND SURGERY. Predisposition in a child may be overbalanced by its prophylaxis. Thus, children of wealthy parents, even where the antecedents are very unfavorable, may escape the evident expressions of rickets as the result of hygienic antagonisms, just as adverse conditions are found to prove exciting causes to its development. It is indeed because the most characteristic expressions of this disease — namel}^, affections of the skeleton — are so influenced by outward circum- stances, that eminent observers have in some instances come to deny its existence among the better classes ; though this differs much from the statement of Jenner, who asserts that he has very often met with it among the children of the very wealthy. We think, however, that it is to be made a cardinal point that the disease is not neces- sarilv to exhibit its osseous complication to have existence, and that its prodroma are as much the condition (in abstracto) as is the observable softening itself. The relation of rickets with hereditary syphilitic disease is affirmed by Vogel, who professes to base the deduction from wide clinical inquiry. Such relation is, however, denied by Sir William Jenner, the denial being founded mainly on the following facts : " The parent who infects his offspring (with syphilis) has usually contracted the syphilis before marriage, and the children first begot- ten after infection are those who suffer (from inherited syphilis) ; while, as a rule, it is only the younger children of a family that suffer from rickets." Sir William Jenner is also doubtful as to the health of the father affecting the child, but throws the weight of his influence in that scale which attributes the disease to insufficient nutrition : thus suggesting the inference of the direction in which lies its prophylaxis, and as well indorsing, without intention, the oneness of cachexia. Mr. Lonsdale expresses himself as having invariably found " that in all rickety children the parents have had little or no milk for their supply, and have been obliged to feed the children either partially or wholly with food other than the milk of the mother. The mothers observe that the children never grew properly from the first, and it is mainly the improper nature of the supplementary food given by hand which impairs the health of the child. The rearing of the children of the poor in London is thus described by Sir William Jenner: " For the first two or three days after birth their tender stomachs are deranged by brown sugar and butter, castor oil and dill-water, gruel and starch-water. As soon as the mother's milk flows, they are, when awake, kept constantly at the breast; and well for them THE TEETH AND THEIR DISEASES. 223 if they are not again and again castor-oiled and dill-watered, and even treated with mercurials. After the first month, bread and water sweetened with brown sugar is given several times a day, and during the night the child is, when not too soundly asleep, con- stantly at the breast. As soon as the little ill-used creature can sit erect on its mother's arm, it has, at parents' meal-time, 'a little of what we have,' — meat, potatoes, red herring, fried liver, bacon, pork, and even cheese and beer daily, and cakes, raw fruit, and trash of the most unwholesome quality as special treats, or as provocatives to eat, when its stomach rejects its ordinary diet. Then, instead of being weaned when from ten to twelve months old, the child is kept at the breast when the milk is worse than useless, to the injury of the mother's health, and to the damage of its after brothers and sisters, in the hope that thus keeping it at the breast may retard the next pregnancy." (Holmes.) According to M. Guerin, there will commonly be in rickets a period of at least six months before the practitioner may feel assured of the exact character of the case, or fairly distinguish it from other diseases to which the prodroma are common. The incubative stage is characterized by irritations of a gastro- intestinal character. The stools are irregular, being sometimes scanty, but more commonly profuse, marked by absence of bile, not unfrequently being of leaden color and most offensive in odor. Some- times, however, and this more particularly in the beginning, the discharges are greenish, of a serous or watery consistence, with a smell which has been compared to that of rotten meat. The .child is found to run down as from a chronic diarrhoea. A marked symptom soon supervening, and one which is not un- frequently the first that suggests to the practitioner the peculiar nature of the disease, is profuse perspiration of the head. These perspirations weaken the child very rapidly, and, when in progress, the evidences of congestion are to be observed in all the neighboring vessels, — veins and arteries. Associated with this sweating, and more or less synchronous with it, is a general soreness of the body, the little patient in many cases lying motionless for hours, rather than endure the discomfort of moving. Such soreness has always more or less connected with it a desire on the part of the child to be cool, even in winter; such patients seeming most comfortable when lying entirely uncovered, — a fact sutBciently demonstrated in hospital wards. 224 ORAL DISEASES AND SUBGERY. The deformities of the head in rickets are thus distinguished by Sir William Jenner:* 1. By thickening of the bones. This is usually most perceptible just outside the sutures, the situation of the sutures being indicated by deep furrows. 2. By the length of time the anterior fontanelle remains open. In the healthy child, it closes completely before the expiration of the second year. In the rickety child, it is often open at that period. 3. By the relative length of the antero-posterior diameter of the head. 4. By the height, squareness, and projection of the forehead. The first two of these peculiarities of the rickety head are the result of the affection of the bones; the last two are chiefly due to disease of the cerebrum. The succeeding conditions are those which associate themselves with bone disease. The process of dentition (Holmes) is invariably arrested or de- layed ; and if the teeth are formed, they soon decay, or they early fall from their sockets, the incisors frequently being lost before the second molars of the first set have made their way through the gums. So important is the knowledge to be derived from the progress of dentition, that Sir William Jenner lays down the following rule of practice : " If a child pass over the ninth month without teeth, you should carefully inquire for the cause. It may be that an acute illness has retarded dentition. It may be (and this is infinitely the most common cause of late dentition) that the child is rickety. Fail not, then, when called to a child in whom the teeth are late in appearing, to look if it be rickety, for if you do fail to look for rickets, you will most likely attribute to the irritation of teething symptoms which are the consequences of the rickety diathesis, — the late dentition in rickets being in itself merely a symptom of the general disorder. The rickety deformities ma}' be very trifling, and yet the teeth con- siderably retarded in their development." The inorganic constituents of bone — the earthy phosphates — are sometimes found in great excess in the urine, a case being recorded by Mr. Solly where such excess was fourfold. It is perhaps, how- ever, as frequently the case that the deficiency in lime-salts results * Medical Times and Gazette, 18G0. See also Holmes's System of Surgery, vol. i. THE TEETH AND THEIB DISEASES. 225 from non-ingress of these materials, without change in the egress ; while a hypothesis founded on the observations of Marchand attributes the absence of the phosphates to their dissolution by lactic acid. This is effected, as inferred, by the lactic acid changing the carbonate and phosphate of lime into the soluble lactate, which in this state is capable of being taken up and carried from the system ; or, when not removed in this way, it might be possible for the organic basis of bone to be dissolved by the inflammatory neoplasia with a breaking down of the chalky substance, whose molecules might either be dissolved or carried away. In rachitis, according to Yirchow, the bones are histologically formed, except that the bone-cartilage has no chalky salts, — or, at least, little in proportion to their requirements. Billroth directs attention to the effect of the dyscrasia upon dentition. The treat- ment he regards as of that general nature which pertains to the building up of the health of the patient. As food, it may not be well to use too freely of bread, potatoes, mush, or flatulent vegeta- bles, but the child is to partake freely of meat, eggs, milk, and all nitrogenous diet. Billroth, in discussing the use of preparations of lime, expresses a doubt as to any benefit that may arise from their employment, deeming it not impossible that rachitis may be a disease of digestion in which such preparations may not be absorbed, — which view is indeed a common one among American physicians. A rachitic child should be daily bathed in salt water, lukewarm or cold, as seems most suitable ; the dress should be adapted to the season ; and daily exercise, active or passive, is to be taken in the sunlight and open air. The use of cod-liver oil has the recom- mendation universally both of European and American practitioners. Yogel asserts that rickets may be cured by the use of cod-liver oil alone. Rickety children tolerate the oil well, and are usually found to become fond of it. Iron and the vegetable tonics are almost always found useful; while beer or wine in limited quantities, grad- uated to the age and condition of the patient, will sometimes be found to meet the indications most admirably. Syphilis. — Yiewnng the relations of this disease with the health of the teeth, we necessaril}^ embrace, or, indeed, perhaps more fully treat of, the association of the mercurial poison than that of syphilis itself, inasmuch as the two are found so constantly combined that it may be esteemed a matter of some doubt if the single rela- 15 220 ORAL DISEASES AND SURGERY. tion is ever met with in the hereditary aspect. I use the term in the fullest sense of heredity, not embracing the cases in which a foetus receives inoculation in passing over an unhealed vaginal chancre, or where the father, having incipient secondary manifesta- tions, extends such to the impregnating sperm. That the syphilitic poison impresses of itself the growing teeth is made evident by the very frequent imperfect development of these organs found in association with the disease, and which, outside the specificity, may not well be accounted for. I allude to the notching, the pitting, and the small size, — conditions which may fairly be presumed not to have special relation with the second of the poisons, inasmuch as this renders its expression in that general molecular depression which is seen in the lowered vitality of the parts at large, and which has just been considered under the head of scrofu- losis. The pittings in the enamel of the teeth, and the irregularities of the cutting faces, represent expressions believed to be found only in connection with hereditary syphilis, and which it seems proven may be transmitted to the third generation. These deformities are seen most generally in the second set alone ; the first are liable to early decay, but not so much to the malformations. The impres- sions are confined to the anterior six teeth, and vary from the most marked examples to scarcely perceptible irregularities of the cutting edges, or an occasional depression seen here and there upon the anterior face, or it may be the posterior, — most frequently, however, upon the anterior alone. Observations will be found to greatly vary concerning the existence of any constancy in phenomenal expres- sions of the teeth in this relation. The diagnostic signs and conditions of acquired syphilis, it is to be taken for granted, are known to the reader. With these we have nothing to do, inasmuch as the influences we consider are those impressed in utero. I think I will be borne out in the assumption that it is only in earliest infancy that syphilis expresses itself with that distinctness which, outside of the history, renders its diagnosis reliable ; and, further, that parents-afflicted with the advanced tertiary stage of the disease do not transmit the disease with diagnostic individuality, but rather that in the term scrofulosis lies its expression, that the con- dition of the syphilides is the state in which the transmission retains specificity, — the tertiary stage expressing the exhaustion of the disease in the molecular degeneration induced of it, — and that when THE TEETH AND THEIR DISEASES. 227 transmitted in such secondary stage, its continuous course in tiie child is apt to be the same as that in the parent. As a syphilitic impression has been made on the foetus with the condition of the parent or parents most closely allied to the first of the secondary manifestations, so will the child exhibit raslies, or the graver expressions of mucous inflammation. Thus, without per- haps proper attention to such data, it has become common to write of the confounding of the secondary with tertiary manifestations, — a confusion that does, however, without doubt, occasionally e.xist, owing to the general slighter resistive force of particular infants, just, indeed, as the same confounding of conditions is not unfre- quently met with in the adult. The expressions of the transmission of uncomplicated syphilis show themselves commonly by the third week ; although instances enough occur where the child is born with such evidences ; or the little patient may live for a year without any sign of the disease ex- hibiting itself, — seldom longer, however. Hereditary syphilis differs of course from the acquired in having no primary stage. As in my own observation I have met with the condition, the most common manifestation is found in that morbid congestive state of the Schneiderian mucous membrane, which, as in a common cold, yields what the parents call snuffles, being universally attributed to the child's having a cold. Unfortunately, however, such colds do not tend to self-cure, but in very many instances, perhaps in a majority, produce changes in the nasal relations which result in a flatness of the bridge of the organ, bearing the sign throughout life, and which is justly to be esteemed as markedly diagnostic of the hereditary association. A child afflicted with this disease may, without doubt, be born plump and apparently vigorous ; but such vigor, as remarked by all observers, proves evanescent. After a few days, or weeks, or, it may be, months, the child will begin to emaciate, the skin wrinkles from absorption of the underlying fat, the face shows discolorations, and a peculiar expression of premature age comes on : this expres- sion of age is so marked and persistent that it will be found to characterize every child, young or old, afflicted with transmitted syphilis. I have this moment in my memory the faces of a number of little girls who are in the habit of occasionally presenting them- selves at my clinic, and, although the eldest is not over thirteen, they have, all, the demure expression of years quite in advance of them. Yet such expression, 1 remark, seems influenced by the stage of 228 ORAL DISEASES AND SURGERY. their affection, those afflicted with bone-troubles being usually older- looking (in proportion to their years) than others presenting alone the skin-manifestations. The appearance of pemphigus soon after birth, associated with the ordinary early symptoms, is deemed by experienced observers very diagnostic. Interstitial keratitis with iuter-laminar lymph-elfu- sions is associated alone with the hereditary form of syphilis, — iritis being an expression of the acquired form. In hereditary syphilis the manifestations are sj^nmetrical ; in the acquired form they are rarely so. The manifestations of the hereditary form run one into the other; those of the acquired tend to remain distinct. From this necessarily limited discussion of the hereditary vices we pass to that aspect of the subject which considers tlie relation of developing teeth with nutritional instrumentalities. In viewing, from a systemic standpoint, the composition of the teeth, we have primarily to remark that the component parts are formed from and preserved by the chemico-vital relationship exist- ing between blood and parts to be nourished. We recognize, and know, that in the fluid which we denominate blood resides the element of nutrition, and that as this material is well or ill adapted to meet the requirements of the different tissues, so are these tissues found to be in vai'ying states of health. We infer that blood, rich in the elements of tooth-structure, is capable of yielding good teeth, provided the process of assimilation resides to a proper extent in the part to be built up and nourished : so that the study of caries, from the constitutional standpoint, consists in looking at the condition of the blood and the amount of vital force residing in the teeth themselves. A tooth in its composition is made up of cementum, dentine, enamel, and pulp substance. Excluding the pulp substance, we find, with some variation, the relative proportions of organic and inorganic matter to be as follows : Cementum. Organic matter 29-27 Inorganic matter.. 70-73 The character of this inorganic material we find, by a more com- plete analysis, to be as follows : phosphate of lime, fluate of lime, carbonate of lime, phosphate of magnesia, salts. The composition of healthy blood yields the following analysis: Jontine. Enamel 28 70 3 -.59 71 30 96-41 THE TEETH AXD THEIR DISEASES. 229 Water 780 15 Fibrin 210 Albumen 65 09 Coloring matter 133 00 Crystallizablefat 2-43 Fluid fat 1 31 Extractive matter 1 70 Albumen, in combination with soda 1 26 Chlorides of sodium and potassium ; carbonates, phosphates, and sulphates of potash and soda 8-37 Carbonates of lime and magnesia ; phosphates of lime, mag- nesia, and iron; peroxide of iron 4 oO 100000 In a healthy and normal condition of the human system we find always the existence of a relationship between the requirements and material of supply which should, and which does, afford proper tissue ; where, then, such conditions exist, the teeth, caeteris paribus, are perfectly formed, and, as constitutional relations are concerned, are healthily preserved. In the study of the pathological conditions of these organs, we are to discover, if possible, wherein the harmony of demand and supply is or has been interfered with ; and that we may look at the subject from the most comprehensive standpoint, we must study not only hereditary complications which may exist, but are to understand as well the direct relations of the developing organs. This brings us to the subject of nutrition proper. In this connection, I know of no one who has given a more exhaustive attention to the subject than the late James Paul, M.D ; and I recognize that I could not afford the subject better expression than by embodying the substance of a paper read by that gentleman before the Medical Society of Mercer, N. J. The views cannot receive a too careful study. "The subject," says Dr. Paul, "is, not only in a physiological point of view, one of interest, but in its application to the preserva- tion of health — the tendency to improve the general condition and physical constitution of the human family inhabiting this great con- tinent — a continent abounding, as it does, in all the productions which a bountiful Creator in his beneficence bestows on man — cannot be otherwise than of great and paramount importance. " At a period now somewhat remote, the celebrated naturalist BufFon, alluding to the animals of this continent, advanced the fol- lowing opinions: 230 ORAL DISEASES AND SURGERY. " 1. That the animals common both to the Old and the Xevv World are smaller in the latter. " 2. That those belonging to the New are on a smaller scale. "3 That those which have been domesticated in both have de- generated in America. "4 That, on the whole, it exhibits fewer species. "These opinions Mr. Jefferson, in his 'Notes on Virginia,' under- took, and, it is generally considered, successfully, to controvert ; yet, however repugnant to the general idea the opinion as to the tend- ency of those animals which have been domesticated in America from other countries to degenerate, it is an undeniable and much-to- be-regretted fact that the human family, and more particularly the female portion of that family, have declined in the vigor and strength of their physical constitution. " I wish not to be misunderstood : I say it is a melancholy fact, too well known to the observant physiologist, that increase of strength and development of frame have not been attained by the intermarrying of members of the human family of different nations on tiiis continent; but the reverse is too observable ; the physical frame of the female sex has degenerated, — calling loudly for the aid of science to arrest an evil of so much magnitude. " Let us for a moment contemplate the female form, as seen on this broad continent. In no country in the world are children more fair and beautiful ; and as the young girl grows up to womanhood, we see in her a full realization of that being forming in the hands of Divinity, portrayed by the poet, as seen by Adam in his dream : " • Under his forming hands a creature grew, Manlike, but diflerent sex; so lovely fair That what seemed fair in all the world, seemed now Mean, or in her summed up, in her contained, And in her looks.' "We see this young and lovely being — the forehead well de- veloped, the countenance, rather elongated, I'elieved of the harsher outline of some of the European nations, with fragile form and small yet well-developed bust — flitting for a few short years among us, and then — yes, then — there comes a change. Ere five-and- tvventy summers pass, thts flower begins to fade — the rounded form shrinks — the bloom of health decays; and if she escapes the fell destroying angel's deathlike grasp, a wreck of former self remains. "Why should this be so? The robust of other countries come THE TEETH AND THEIR DISEASES. 281 to this continent. They live in comfort; their food is excellent in quality; their progeny is like themselves; but even now, in the very first generation, does the degenerating process make itself manifest, — the teeth begin to decay; and girls, while yet children, have to visit the dentist to have them cleansed, scraped, and plugged. "Now, this brings us at once to the head and front of our subject ; and if we can point out the first cause of this decay of what should be as strong as adamant, it may be the means of helping us in our investigation. That there is something radically wi'ong in our sys- tem of rearing the young, to which this misfortune is in a great measure owing, I am free to confess is my firm opinion. I would indeed it were in my power, in pointing out the evil, to be as suc- cessful in detailing the cause, that we may apply the remedy. Still, although perhaps unable to accomplish all I wish, my observations may not be without their weight, and induce others, more observant, more scientific, and more competent to the task, to follow up an investigation so fraught with advantage to our fellow-beings. "It is certainly to be deplored that the females of this continent, descendants of European parents, should be so much afflicted with caries of the teeth, the decay of parts formed of substances which enter into the composition of some of our hardest minerals, — marble, bone-earth, and fluor-spar ; and this decay unfortunately occurs in early life, — in girls yet at school ; and many a young woman, ere she has attained a marriageable age, has had to replace the natural with the unnatural though more enduring enamel of the artist's formation. This ought not to be: God made all mankind alike; in no portion of the earth are nations found who lose their hands, or feet, or tongue, or eyes ; and there can be no cause why the inhabit- ants of this land should lose their teeth. It is not so in the olden countries from whence the progenitors of the present race have come ; nor is it so in the West India islands, which may almost be considered as part of this great continent. So excellent is the struc- ture of the teeth of savage nations, that some tribes in Africa, I think the Mocoes and Mandingoes, file all the front teeth, so that they shall be separated and form sharp points, the better to tear the uncooked animal food. "One cause of this affliction is, in the minds of many, attributed to the great and sudden changes of temperature experienced on this continent, — the thermometer rising and falling twenty, thirty, and even forty degrees in twelve hours. But if attributable to these 232 ORAL DISEASES AND SURGERY. sudden changes, we know that sudden expansion by means of heat, or sudden contraction by means of cold, causes the particles of which bodies are composed to tear themselves asunder; consequently, to crack, break, and fall in pieces. But this is not the case with the teeth of our females; a caries or decay commences most generally in the side of the tooth, extending to the enamel, which is some- times involved in the destruction; at other times it is left a crust or shell to snap and break off in small pieces, when unable to resist the pressure of whatever may be placed against it ; besides, the teeth are for the most part sheltered from these sudden changes, and kept at a temperature nearly amounting to blood-heat at all seasons. I do not think we can place the general destruction of the teeth, and consequent affliction of the females of America, to this cause. I fear we must rather look for it to constitutional weakness, and this constitutional weakness to a deficiency of the inorganic or earthy constituents being taken into the system, more particularly at an early period of life.* "If I am correct in this opinion, — and reason, philosophy, and a thorough examination of physiological facts in both the animal and vegetable economy, tend far to bear out these views, — then if we would try and correct this lamentable state of things, let us com- mence at the very beginning, and make ourselves acquainted by examining the structure and composition of the teeth, and then we shall be more able to understand what is required to aid nature in their formation and consequent preservation. " First, then, let us make ourselves acquainted with the structure and composition of the teeth. The teeth are nearly allied to bone in structure ; both having earthy deposits, intermixed with fibres and cells of gelatin, which, by consolidation, gives form and strength, in the case of bone, to bear the weight of the various parts and afford protection to the diff"erent organs of the body; and in the case of teeth, to cut and grind the food required for the formation, sup- port, and reparation of its various parts. "Now, teeth are compo.sed of three different substances, and these three are disposed according to the purposes required of them ; they are cementum or criista jMrosa, dentine (known as ivory in the tusk of the elephant), and enamel. The cementum or crusta petrosa * Experiments have demonstrated that teeth may be changed instantly from iced to boiling water without cracking the enamel. Injury to the teeth from thermal changes would arise rather from irritation inflicted on the pulp. THE TEETH AND THEIB DISEASES. 233 corresponds in all essential particulars with bone, possessing its char- acteristic lacunae or small cavities, and being traversed by vascular medullary canals, whenever it occurs of sufficient thickness ; it is the first covering of the young tooth, and may be said to invest the fang of the tooth which enters the alveolar process of the jaw. The dentine, or ivory, consists of a firmer substance, in which inorganic or mineral matter predominates, though to a less degree than in enamel. It is traversed by a vast number of very fine, cylindrical, branching, wavy tubuli, which commence at the pulp cavity and radiate toward the surface. The diameters of these tubuli, at their largest part, average about 1-10, 000th of an inch ; their smallest are immeasurably fine; so much so, that they cannot possibly receive blood, but it is surmised that, like the canaliculi of bone, they imbibe fluid from the vascular lining of the pulp cavity, which aids in the nutrition of the tooth. The enamel is composed of solid prisms of fibres, about the l-5600th of an inch in diameter, arranged side by side, and closely adherent to each other ; their length corresponds with the thickness of the layer which they form ; and the two sur- faces of this layer present the ends of the prism, which are usually more or less hexagonal. In the perfect state, the enamel contains but an extremely minute quantity of animal matter. In the centre of the tooth is the soft pulp cavity, which affords a bed for the blood-vessels and nerves which supply it with life and sensibility. "i shall not enter more minutely into the structure of the teeth, but may briefly state that, like all other structures of the animal body, the component parts are derived and deposited from the blood, by that mysterious and incomprehensible power that selects and deposits the necessary constituents in the formation of the several portions, according to the use required. "Now, in the composition of the teeth, we have first the division into organic and inorganic or earthy matter; and we find that the several substances which enter into the structure of the teeth differ chiefly as to the earthy matter contained in each. "Chemical analysis of the incisors, or front teeth of man, shows that they contain in one hundred parts of each, as follows: Cementum. Dentine. Enamel. Organic matter 29 27 28-70 3 59 Earthy matter 7073 7130 96-41 100- 100- 100- " These proportions will occasionally differ ; in some individuals 234 ORAL DISEASES AND SURGERY. the organic constituents having less than here stated, amounting in the dentine only to 21. The analysis of bone, however, gives a much larger proportion, — viz. : Organic matter 32-56 Earthy matter 67-44 100- "Let us now take a more complete analysis, showing what earthy constituents enter into their composition. Analysis of the molar or grinding teeth of man, and of the bones of the arm and leg of a man of forty, shows the following proportions: Dentine. Enamel. Bone. Inorganic matter: Phosphate of lime, with traces of fluate of lime 66 72 89 82 54-61 Carbonate of lime 3 36 4-37 9-41 Phosphate of magnesia I'OS 134 107 Salts, etc -83 -88 2-85 Organic matter 28 01 3-59 32-56 100- 100- 100. " Thus we see the very great proportion of certain earths that enter into the structure of the teeth and the bones of man, the chief substance being the phosphate of lime, familiarly known as bone- earth. We find, too, that whereas in ordinary bone the phosphate of lime constitutes only 54 parts in 100, in the enamel of the teeth it is nearly 90 parts in 100; while the carbonate of lime in bone amounts to 9-41, in the enamel of teeth it is only 4'3'7, — the enamel being literally almost a mineral in substance, having only 3.59 parts of animal matter in 100. ^ "Thus the teeth, to be strong and durable, require a large quantity of earthy ingredients, particularly lime, to enter into their composition. Let us inquire whence it is derived ; and for this we must examine the blood. " To allow of such deposits from the blood, it is first necessary that they should be held in solution in that fluid. The blood circu- lates to every portion of the body by the action of the heart, which forces a certain quantity — say two ounces at every contraction — into the aorta or great canal leading from the left ventricle. The aorta divides and subdivides into innumerable branches, which are made to ramify to every part of the body, until the extreme branches end in capillary tubes or vessels, the calibre of which is so small as \ THE TEETH AND THEIR DISEASES. 235 not to allow the red globules or corpuscles of the blood to enter them, but which allows the serous portion to traverse every part of the organized structure, holding in solution all those constituents necessary and requisite for the formation and reparation of its several parts. " In the serous portion of the blood, then, we find contained the constituents required for the composition of bone and teeth, — analysis of 1000 parts of healthy human blood giving, according to M. Lecanu, the following proportions: Water 780-15 78558 Fibrin 2 10 3-57 Albumen 6509 69 41 Coloring matter 133-00 119-63 Crystallizable fat 2-43 4-30 Fluid fat 131 227 Extractive matter, uncertain 1-79 1-92 Albumen in combination with soda 1-26 201 Chlorides of sodium and potassium ; carbonates, phosphates, and sulphates of potash and soda... 837 7-30 Carbonates of lime and magnesia; phosphates of lime, magnesia, and iron; peroxide of iron.... 2-10 1 42 Loss 2-40 2-50 1000- 1000- "We see by this table, if we subtract or take away the proportion of water, amounting to tSO parts, and the coloring matter, amounting to 133, we sliall leave scarcely 90 parts of organic and earthy ma- terial, the salts and earths forming upwards of a 10th, — the salts being in proportion to the earths as 4 to I. " Having then shown the constituent portions of the bones and teeth to be in the blood, the next consideration is, whence are they derived ? "Before entering on this subject further, let us for a moment take a broader and more comprehensive view of what must be most interesting to mothers, and of great consequence to the well-being of the infant generation, in a short time, in a very few years, to become in their turn the mothers and fathers of another generation. "The question then presents itself, what is the nourishment or food best adapted and necessary to the wants of an infant, that the foundation may be laid for a strong frame and vigorous constitution ? For here, we must recollect, is the starting-point in by far the ma- jority of instances. We know that in some cases disease is hered- 236 ORAL DISEASES AND SURGERY. itary, that the offspring unfortunately inherits from the parents constitutional defects ; but we also know that more misery, suffer- ing, and constitutional derangement are entailed on children by want of care and improper food in the first years of life, by which their hopes of health are blasted, and they are doomed to struge'le through a weary life, to be hurried at last into a premature grave. "Now, that the frame — that is, the bones, muscles, and other portions — of the infant may be fully developed, it is necessary that it should be supplied with nourishment containing all the constitu- ents required for this important undertaking. And this nourish- ment, by the all-wise ordering of Providence, is contained in the milk secreted from the mother's bosom. " The infant is entirely dependent on the nourishment derived from its mother, and nature has wisely ordained that the secretion from the mother is its very best food ; for we find in the composi- tion of milk — that is, healthy milk, derived from healthy blood — all those ingredients we have hitherto traced as requisite in the formation of the bones and teeth, and not only these, but every con- stituent required for the life and growth of the individual ; milk containing the albuminous, saccharine, oleaginous, saline, and earthy compounds requisite and necessary for the health, strength, and de- velopment of the infant child. "An analysis of cow's milk gives the following proportions of the various constituents ; that of human milk is not so elaborate, but contains the average of observations taken at fourteen different times from the same individual, by Simon. Cow's Milk, by M. Haidlen. Water 87300 Butter 3000 Casein 4820 Milk sugar 43-90 Phosphate of lime 2-31 Phosphate of magnesia -42 Phosphate of iron ■. -07 Chloride of potassium 1-44 Chloride of sodium -24 Soda in connection with casein -42 1000. THE TEETH AND THEIR DISEASES. 237 Woman's Milk, by Simon. Water 883-6 Butter 25o Casein 34 3 Milk sugar and extractive matter 482 Fixed salts 2 3 1000. Maximum of Minimum of 14 observations. 1-t observations. Butter. 54 . 80 Casein 45-2 10-6 Sugar and extractive matter 62-4 39-2 Salts 2-7 1-6 "Now, although these amounts will no doubt vary, under every variety of circumstances, according to the health, exercise, pasaions, and food of the mother, yet they show that healthy milk contains all the requisites for the nourishment of the infant; but then it must be healthy milk, secreted from healthy blood, and that blood must derive these ingredients from the food consumed. " Cow's milk differs from that of woman in the proportions of some of the constituents: it abounds more in butter, but particularly in casein, or cheese; and, on the other hand, human milk abounds niore in the saccharine principle, or sugar of milk. Now, this points out a circumstance from which great benefit may be derived. It is of very frequent occurrence that infants are deprived of the natural nourishment of the mother, and diverse opinions are given relative to the food of infants by persons who really know very little about the matter ; one recommends a milk diet, another that the infant must be fed on starch and sugar. " Now, to enable the infant to receive a nourishment in every re- spect similar to the mother, the knowledge of the various propor- tions which we obtain by chemical analysis enables us to rectify and produce milk very analogous to human milk from that of the cow, by diluting it with water in the proportion of about half as much again ; that is, to a pint of milk should be added half a pint of water that has been boiled, which will reduce the cheese principle to the proper proportion ; add a small portion of cream to restore the proportion of butter, and then add sugar until the whole is dis- tinctly sweetened, and we have a compound in every respect similar to the milk from the human breast. 238 ORAL DISEASES AND SURGERY. "To understand the subject of nutrition, let us remember that food should, or must, embody two great principles : one to nourish, the other to give heat to the body. And food, when consumed, is applied to one or the other of these purposes. Now, in the process of digestion, the constituents of the food are separated, and arranged in three classes: " 1st. All that portion derived from animal food, eggs, the curd of milk, the gluten or adhesive portion of wheat and other grain, and whatever in animal or vegetable food can be rendered into albu- men — of which the best example that can be offered in illustration is the white of egg, which is in reality nearly pure albumen — and the principle is therefore called albuminous. " 2d. All that portion of the food derived from vegetables, starch, sugar, etc. that can be converted into sugar in the process of diges- tion. This principle is therefore called saccharine. " 3d. All the fat, butter, oil, etc. which, when deprived of the other substances, is left in the state of oil, and therefore called ole- aginous. "Now, of these three the albuminous is the nutrient, and the saccharine and oleaginous are the calorifacient, or heat-giving ; and chemical analysis shows that they vary in composition. ALBUMINOUS. OLEAGINOUS. Eggs. Wlieat. Mutton fat. Carbon 55000 55 01 78-996 Hydrogen 7-073 7-23 11-700 Nitrogen 15 920 15 92 Oxygen -| 9 304 Sulphur I 22-007 21-84 Phosphorus ) SACCHARINE. Starch, Sugar Sugar Cane arrow-root, from starch, of milk, sugar. Carbon 44 40 37 29 40 00 42 301 Hydrogen 6-18 6 84 6-61 6-384 Oxygen 49-42 55 87 5293 51-315 "It will be observed that the albuminous or nutrient differs from the saccharine and oleaginous, in containing nitrogen, and sulphur and phosphorus, with carbon, hydrogen, and oxygen, while the latter contains only carbon, hydrogen, and oxygen, — nitrogen being re- quired in those compounds which give strength and formation to the frame. THE TEETH AND THEIR DISEASES. 239 " Now, the albuminous or nutritive, being that portion which affords nourishment to the body, contains those constituents re- quired in the first place for the formation and giving strength to the .different portions of the body, and, when fully developed, of repair- ing the general waste continually going on in the system, whether from the usual wear and tear, fractured bones, or the ravages of disease. And the saccharine and oleaginous — the calorifacient or heat-making — to keep up a continual supply of fuel, as it were, that the bodv may be kept of a regular and proper temperature ; for all are no doubt aware that there is a continual supply of carbon, or, in more simple language, of charcoal, required to keep up the natural temperature of the body; and what is not required for immediate use is stored away in the form of fat, to be called into action as occasion requires. " We have seen in the analysis of milk that that fluid contains butter, cheese, and sugar; consequently we can understand how an infant can thrive so w^ell upon it, — the cheese or casein* of the milk containing the nitrogenized or nutrient principle, which, to- gether with the earths and salts contained in the milk, goes to form the bones, muscles, and the different tissues of the bod}', — the sugar, which, we have seen by the analysis, contains a large quantity of carbon in its composition, going to keep up the temperature of the infant, while the butter, in the nature of fat, is stored away in a healthy infant, filling up every vacant interstice, causing a round- ness and plumpness, the pride and joy of the happy parent. " Now, let us mark the difference of the babe that has been denied a milk diet, and is doomed by ignorance to be fed on starch and sugar. We will recollect that these two substances are composed of carbon, hydrogen, and oxygen only. By a process of digestion which I need not here enter into, such food is converted into sugar, the carbon of which becomes the fuel by which the temperature of the body is kept up ; there being no principle in the food to give albumen, there is nothing taken into the stomach upon which the * Carbon Hydrogen. Nitroscen.. Oxygen Sulphur } Anal.vsis of Alb- iVinous substances found casein from in whej after coagulation fresh milk. wi tb an acid. 54-82.5 54-06 7-153 7-15 15-628 15-89 21-73 22.394 0-86 240 ORAL DISEASES AND SURGERY. gastric fluid can expend its solvent powers; the infant is, therefore, much troubled with acid eructations, and the stomach becomes weak and irritable. The want of the nutritive constituent of the food, and the earths and salts, etc. necessary and essential for the forma- tion of the bones and teeth, show a lamentable deficiency in the child's development ; and there being no fatty matter to be laid up, the body is emaciated, the countenance is ghastly, the flesh and in- teguments hang soft and flabby over the bones; no absolute disease can be detected; the child is ravenous and hungry, and the unfortu- nate babe descends to the tomb a spectre and an object of the most pitiful description. This is no fancy sketch, but one too often met with in the ordinary walks of professional life. And why is it so ? Simply because the composition of the human frame, the component parts of our food requisite to produce that frame, and the process of digestion and nutrition, are so little understood. "We now advance from infancy to childhood ; and this is a period when the greatest attention is required in supplying nutriment to aid nature in the great work of developing the body. The child is now deprived of the maternal secretion, and dependent on food pre- pared for its use by the hand of man, — perhaps living in a city, and deprived of pure and wholesome milk from the cow. And we know there is a vast disproportion in the quality of milk when the cow is country-fed on the natural productions of the farm, and when city- fed on slops and grain, the refuse of the brewery. " It is at this age that the great proportion of bony substance is deposited; those of the extremities are lengthened, become more compact and stronger, and the substance of the teeth is deposited in the cells of gelatinous tissue. How necessary is it, then, that this subject should receive the utmost attention of parents! It has hitherto been too much the custom to leave all this, as belonging entirel}'^ to nature, as a thing we had nothing to do with. We have been too much in the habit of considering that nature furnished her own materials, and man had nothing to do with her operation. The potter cannot fashion the bowl without the clay, neither can bone be formed without earth : nature must be supplied with the material, which, although offered in the most incongruous forms, she has the power of decomposing, selecting from, and supplying for the various purposes required : one portion, as we have already stated, to act as fuel in keeping up the temperatm-e ; another portion she selects to add to the flesh, the muscle, skin, and different tissues; and the earths which are held in solution she carries away by vessels THE TEETH AND THEIR DISEASES. 241 adapted for that purpose, and deposits them atom by atom, until they are so compressed, so strongly compacted together, as to become what we call solid bone, — and all this so wonderfully wrought that, as we have seen, small tubes are left in the hard, stony formations both of the bones and of the teeth, that nourish- ment may be supplied them, holding in solution the material of which they are composed, that the natural waste and decay may be replaced and injuries repaired. "It is to this nutrition, and to the earthy matter of which the bones and teeth are composed, a deficiency of which is attended with results so deplorable, that I particularly wish to call attention. " To what can we attribute the calamity which too often befalls the young? I allude to distorted spines, where the bones com- posing the spine, instead of forming a column, allowing the body to be erect and dignified, are zigzag in their course, causing one shoulder to bulge out, and the opposite side to bend or double upon itself. This deformity has been long understood to arise from a deficiency of lime in the composition of the bones of the vertebrae, allowing them to fall, press upon, and injure each other, destroying the beauty of the fabric and the health and comfort of the indi- vidual. " Now let us take a glance at the inhabitants of two countries, natives of which are no strangers on this continent. I take them as examples, because the food of the common peojyle of those coun- tries is well known to be of the most common kind. I allude to natives of Scotland and Ireland, — the principal food of one being oatmeal, and of the other ^o^a^oes. We have heard a great deal of the famishing poor of those countries, and particularly of the latter, of the misery and wretchedness seen in every hovel ; and there cannot be a doubt that famine walked through the land when the blight and rot despoiled them of their potato crop, on which for so long a period they depended as the great article of food. Now, allowing all this, — allowing, in the best seasons, the chief article of subsistence has been potatoes for breakfast, dinner, and supper ; — glad indeed many of them to get a little animal food once a week to dinner, or even far more seldom, — I now ask, what number, in the thousands of emigrants from that country who yearly arrive at our ports, are there that show a constitution weak, fragile, and wanting in physical strength ? Many, no doubt, arrive worn down by disease and suffering, and in the last stage of debility; but let them recover from that state, and the robust frame and healthy con- 16 242 ORAL DISEASES AND SURGERY. stitution will be again developed ; the bones are strong, the teeth undecayed, and the muscular energy only wanting opportunity to display itself; — in fact, when we wish to denote strength in woman, we use the familiar phrase, ' strong as an Irishwoman,' and all this from being reared on potatoes* But then, if we examine the analysis of the potatoes, we shall find contained in 100 parts of dry potatoes, — Carbon 41 1 Hydrogen 5-8 Nitrogen ) 4g.j Oxygen ) Ashes 50 "Here we see that potatoes not only contain the nutrient but the earthy constituents. " But we have a stronger and more healthy race yet, from Scot- land and the north of Ireland, who are generally descendants of the Scotch, and continue, in a great measure, the same means in rearing the young. Now, a principal — I will not say the principal — food of the youth of Scotland, high and low, rich and poor, except in the larger cities, among those who class themselves as more refined and more civilized, but who number few in proportion, consists, for breakfast, at least, of oatmeal, — that is, porridge and milk ; and milk, potatoes, and wheaten, oaten, or pease bread, or bannocks, at other times of the day. Animal food among the poor is a rarity, a meat dinner on Sunday only being common. Even among the youth of the better class, butcher's meat, or animal food, is by no means a principal article of subsistence. And I would particularly remark that Scotch oatmeal (the oatmeal generally used throughout Scot- * According to a memorial presented to the French minister, on the pro- portions of nutriment of the means of living, by Dr. Glaser, we find potatoes taking no mean rank. NUTRITIVE ELEMENTS. 100 lbs. wheat bread contains 30 lbs. " flesh ■ . " 21 lbs. " fresh beans " 80 lbs. ^ " peas " 83 lbs. [casein and starch. " lentils " 94 lbs. J " potatoes " 25 lbs., albumen, starch and sugar. '" carrots " 14 lbs. "» beets " 8 iijg^l albumen with sugar. THE TEETH AND THEIR DISEASES. 243 land) is coarse, and contains much of the bran whicli invests the oat, — containing, as it does, a large proportion of the earthy con- stituents required for the production of bone. Analysis of 100 parts of dried oats gives — Carbon 5-07 Hydrogen 6-4 Oxygen 36-7 Nitrogen 2-2 Ashes 4-0 "I may here casually remark, that the advantage to be derived from this wholesome food iuis not escaped the observation of her Majesty, Queen Victoria, who appears in tlie multiplicity of her public duties not to lose sight of the equally sacred duties of a mother ; and we hear of her son, the heir to the crown of Great Britain, being as fond of his oatmeal porridge as the meanest peasant child in Scotland. " I rather doubt if parents generally have given to this subject the attention to which it is entitled. I trust, however, that those who have followed me thus far, may be impressed with its irapoi*- tance. We cannot shut our eyes to the complaint which so gen- erally prevails of decayed teeth ; and a moment's reflection will call to mind the number of the young and beautiful who are prematurely hurried to the tomb, ere yet the bud has expanded into the full- developed flower. Nay, comparing the two countries, the statistics of life and death communicate to us also the important fact, that while the greatest mortality shows itself in England in infancy and childhood, on this side the Atlantic it is found at a more mature age. " Neither has the tendency of the physical organization of woman on this continent to degenerate escaped the observation of one of our greatest medical philosophers in this country,* who regards this retrogression as a national calamity, and impresses upon his students the importance of the subject, and the propriety of their attention in attempting to arrest it; and he particularly specifies the great object to be gained in the use of bran-bread made from unbolted flour. On this head 1 shall have more to say hereafter. "With these observations, let us now direct our attention to what can be offered in remedy of this evil. "We have already stated that in no country in the world are * Prof. Samuel Jackson, of the University of Pennsylvania. 244 ORAL DISEASES AND SURGERY. children more beautiful or more lovely — healtliy in complexion, quick, smart, and intelligent — active, sprightly, and playful in their disposition. Now. in**the period from infancy until the child becomes mature, — let us, at all events, say until thirteen or fourteen years, and even to a more advanced age, — there is a continued growth, — a continual deposition of organic and inorganic or earthy particles, which are required for the formation of bone, teeth, flesh, and every part of the human body. I have shown that the essential ingredients for these several formations are all found in the milk of the mother; consequently, as long as the infant is deriving nourish- ment from the mother, she ought to partake of good, wholesome, nourishing food, that the blood, deriving these principles from the food, may be able to supply them in turn to the milk from which it is secreted. So long, then, as the child is thus nourished, so long is it safe, and the rudiment or foundation of a robust frame is laid. And if we are to expect, in future life, tlie stalwart frame of man, or the enduring, firmly-knit, compact, and healthy physical constitution in woman, the organic and inorganic or earthy compounds of which that frame is composed must not be denied. Nature must be sup- plied, or nature will fail. "It is not for me to dictate to any parent what shall be the food of his child: it is enough that I point out for their information what may be required to give what in common language is called 'bone and sinew' to their offspring. It is necessary, then, that the food of children shall contain: " 1st. Aliment having the calorifacient or heat-sustaining prin- ciple. And this is contained in quite sufficient quantity in the usual food, — in milk, wheaten bread, potatoes, arrow-root, Indian corn (as mush, hominy, or corn-bread), in most vegetable matter, and in sugar. "2d. Aliment containing the nutrient principle. And this is con- tained in animal food, — the lean of beast, bird, and fish, — in milk, eggs, wheat, rye, potatoes, beans, etc. "And 3d. Aliment containing the inorganic or earthy constitu- ents, — on which depends strength of frame, and from which are formed the bones and teeth of the individual. And these are con- tained in milk, eggs, animal food, and particularly in' wheat, rye, oats, potatoes, etc.* - * On this subject, I extract the following from Carpenter's Physiology, p. 488: "These substances are contained, more or less abundantl}^, in most THE TEETH AND THEIR DISEASES. 245 " Of the inorganic constituents contained in wheat (and the same may be said of the other cereal grains) I have ah-eady alluded to the benefit to be derived from using bread made of unbolted flour. On this subject allow me to refer to the difference of flour having much of the bran i-emaining, and superfine flour, or that in general use throughout this country, and on which Prof. Johnston has made the following curious but practical observations. Examining wheat and flour, as to the amount of the nutrient or muscular matter, the fat-forming principle, and the bone and saline material, contained in grain in different states, he found — Muscular matter. Fat principle. Bone and salt. In 1000 lbs. of whole grain 156 lbs. 25 lbs. 170 lbs. " " fine flour 130" 20" 60" " " bran 60 " 700 " " Taking the three substances together, according to Prof. John- ston, of a thousand pounds, the three substances contain of the in- gredients mentioned, — articles generally used as food ; and where they are deficient, the animal suffers in consequence, if they are not supplied in any other way. Thus, common salt exists, in no inconsiderable quantity, in the flesh and fluids of animals, in milk and in eggs; it is not so abundant, however, in plants; and the deficiency is usually supplied to herbivorous animals by some other means. Phosphorus exists also in the yolk and white of the egg, and in milk ; and it abounds not only in many animal substances used as food, but also (in the state of phosphate of lime or bone-earth) in the seeds of many plants, espe- cially the grasses. In smaller quantities, it is found in the ashes of almost every plant. Sulphur is derived alike from vegetable and animal substances. It exists in flesh, eggs, and milk ; also in the azotized compounds of plants; and (in the form of sulphate of lime) in most of the river- and spring-water that we drink. Iron is found in the yolk of egg and in milk, as well as in animal flesh ; it also exists in small quantities in most vegetable substances used us food by man, — such as potatoes, cabbage, peas, cucumbers, mustard, etc. Lime is one of tli£ most universally diffused of all mineral bodies; for there are few animal or vegetable substances in which it does not exist. It is most commonly taken in, among the higher animals, combined with phos- phoric acid : in this state it exists largely in the seeds of most grasses, and especially in wheat-flour. If it were not for their deficiency of lime^ some of the leguminous seeds (peas) would be more nutritious than wheaten flour ; the proportion of azotized matter they contain being greater. A consider- able quantity of lime exists, in the state of carbonate and sulphate, in all hard water." 246 ORAL DISEASES AND SURGERY. Whole grain. Fine flour. Of muscular matter •. 156 lbs. 130 lbs. Of bone material 170 " 60 " Offat 28 " 20 " 354 lbs. 210 lbs. "Accordingly, the whole grain is one-half more nutritious than fine flour.* It also shows the very great proportion of bone mate- rial — that is, earthy constituents — contained in the bran ; no less than 700 out of a thousand parts, or a little more than two-thirds of the whole. Now, by reference to the same work, we find, in a com- munication from a Mr. Bentz, the ditference in weight of a barrel of flour without the bran, and when only the outer coating of the wheat is taken off. He says, 'The weight of the bran or outer coating would, therefore, in the common superfine flour, constitute the ojfal, weighing only 5^ lbs. to the barrel of flour, while the ordinary weight of offal is from 65 to 70 lbs. to each barrel of flour ; showing a gain of from 59| to 65 lbs. of wheat in every barrel of flour." Now, if we estimate the earthy constituents to be two-thirds of the offal or bran, we must consider that there is an actual loss of these im- portant constituents, which might be reserved, in every barrel of flour, of 40 lbs. "Again, if we estimate (according to the average of the consump- tion of flour to the amount of population, as one barrel to each indi- vidual) that every child shall consume annually only half a barrel of flour, then we find that by the use of the superfine flour, as com- monly used in families, the child is deprived yearly of twenty pounds of those earthy substances which are required to form the bones and the teeth. When we speak of a child consuming half a barrel of flour annually, it appears a large quantity; but when we reduce the same to a daily allowance, we find that it is little more than 4 oz. or 4^ oz. ; and every parent must know that this would be a very small amount to limit children to. Yet we see how large a quantity of the bony material would be added if unbolted flour was used instead of the present superfine flour. I ma}^ here add that the oatmeal used in Scotland, already referred to, contains the bran or inorganic con- stituents, while the oatmeal used in England is deprived of it. Now, this is a great loss of the most valuable constituents in only one of the principal articles of the food of children; and if we allude to another article, which is largely used on this continent, — I mean * Patent Office Eeport, 1847, p. 116. THE TEETH AND THEIR DISEASES. 247 Indian coi"n (and I may also add the fat of meat, both of which, children, if allowed, will partake of very freely), — we shall find that both of these abound more in the calorifacient or heat-sustaining principle, and for the deposition of fat, than the nutrient, and that they are quite deficient in the earthy material of lime, — that material on which so much depends the proper structure of the teeth. An- alysis of Indian corn shows the following composition, — as taken from Mr. Salisbury's prize essay read at the New York Agricultural Society for 1849 : Whole kernel. Starch 50 G4 Sugar and extractive 7 46 Sugar 1-50 Fibre 6-28 Matter separated from fibre 0-05 Albumen 8 64 Casein 1-70 Gluten 4-56 Oil 400 Dextrine or gum 4 84 Water 10-22 99-89 Ash of the kernel, constituting about two per cent. Carbolic acid a trace. Silicic acid 1-450 Sulphuric acid 206 Phosphoric acid 50 955 Phosphate of iron 4-355 Lime 150 Magnesia 16'530 Potash 8-286 Soda 10-908 Chloride of soda 0-249 Organic acid 3-400 97-000 " This is a most elaborate analysis, — far more minute than any analysis we have had of any of the articles of food, — in fact, more minute than satisfactory; for the analysis of the whole kernel does not exhibit any amount of inorganic constituent; and when the whole is converted into ashes, we find that the lime only amounts to the one-sixth, of one part in a hundred. Now, on inquiry, I find, on the authority of a very intelligent miller of this city, that in 248 ORAL DISEASES AND SURGERY. grinding corn the bran or thin skin of the grain is detained in forming it into corn-meal ; consequently, it is deprived of even that portion more particularly containing the earthy constituents. This gentleman, in conversation, mentioned an important fact rela- tive to this deficiency of lime in corn. To the best of my recol- lection, he observed, ' This stands to reason ; for, ten years ago, all the lower part of Jersey grew excellent corn, but would not grow wheat ; but since the introduction of Ivme as a manure they have raised considerable wheat crops.' Now, the fact is, it is not the habit or food of this plant, even had lime been in the earth; and magnesia and the saline manures are recommended to the agricul- turist as best suited for its proper development. " It is generally looked upon as invidious, and one is more likely to incur odium than to receive credit for saying one word against a food which stands so high in public estimation and is so universally used over this continent. Yet it must not for one moment be sup- posed that I condemn the use of Indian corn in its various forms of mush, hominy, bread, or pudding as an article of diet; far from it. But, containing, as it does, a large proportion of starch and fatty matter, rather a small proportion of the nutrient principle, and quite a deficiency of the inorganic or earthy constituents, I consider it as valuable, as a light diet, for heat-sustaining purposes only, and therefore a desirable adjunct to other food, containing more nutri- ment and a due proportion of the earthy constituents. "As an example or illustration of the want of the nutrient prin- ciple in corn or corn-meal, I may here allude to the effects I have seen in the West Indies, where, in a dearth of the ordinary pro- visions on which prisoners were fed, corn-meal was substituted ; corn-meal and salted herrings, fish, etc., constituting their food. Now, the effect was that all the prisoners lost their natural strength ; at the same time they became fat and bloated, inclining to dropsy. And this was not the effect of incarceration ; for the prisoners were engaged in road-making, trimming fences, etc., — consequently, in a healthy and exhilarating employment. " In reference to our domesticated animals, it may be asked. Why is corn so useful as an article of food to animals generally, — hoi'ses, hogs, sheep, etc. ? I have already shown that the overplus of the calorifacient food, after what may be required for sustaining the temperature, is stored away in the form of fat. Now, if we instance the horse, corn is generally, if not always, given as an adjunct to his more usual food, — hay. And we find by an analysis that grass THE TEETH AND THE IB DISEASES. 249 or haj contains not only the nutrient principle, but the inorganic constituents required in the formation of bone, etc. "One hundred parts of dry hay contain — Carbon 45-8 Hydrogen 5-0 Oxygen 38-7 Nitrogen* 1-5 Ashesf 90 100- "Thus, the hay gives to the animal strength in bone and muscle, while the corn supplies additional heat-sustaining properties, and lays by, in the form of fat, the overplus as a reserve. The harder the horse is worked, the more corn he can bear ; the great propor- tion of the carbon being carried off by the lungs, and the hydrogen and oxygen, as water, in exhalation and perspiration. But if the sajue quantity is given to a horse at rest, it overloads him with fat, which in his case accumulates more internally, or around the internal organs, and will, in course of time, induce disease; while in the pig, under similar circumstances, the fat is laid on externally, if I may so speak, giving the rich fat pork of our markets. And here I would again remark that no farmer would consider it necessary or essential to give corn to a young colt or horse, until required to work ; nay, so careful is nature in appropriating just so much and no more of any constituent that may be required, that the food of the young horse should be more nutritious than heat-sustaining, and that there shall be no superfluity to store away fat, we find by analysis that the milk of the mare has little or no butter — in fact, only traces of it — in its composition. | What a lesson in the animal economy is here given, and what a practical illustration of the re- quirements of the young of that and other animals ! "Again, it may be contended that among the beautiful children we see on every hand, there is no want of those who are fat and * Fifteen pounds of such hay, containing oz. 3 095 of nitrogen. f These ashes having a good proportion of lime. X Analysis of mare's milk : Water 896 3 Butter traces. Casein 16 2 Sugar of milk, extractive matters, and fixed salts 87*5 1000- 250 ORAL DISEASES AND SURGERY. hearty. It is Moi fat we want; it is bone and muscle, with so much fat only as shall give firmness to the flesh and plumpness to the figure. Fat, although it enters intimately into union with the other component parts gf bone and muscle, cannot be transformed either into the inorganic constituents of bone or teeth, or into muscular fibre. These must be contained in the food consumed, in the first place, and thence transferred to the blood. "How necessary, then, how important it is, if we expect to give strength and vigor to the constitution, that the food, in the tii'St years of infancy and childhood, when the formative process is going on, should receive some further attention than has hitherto been given to it! and if our youth, — if our young females have hitherto been deprived of the necessary constituents for the full development of every portion of the body, — can we wonder that a woman should be the delicate and fragile being she is, or that by the decay which assails the teeth in early life she should be deprived of an orna- ment of so much value ? If this state of things can be altered, — if the physical constitution of woman in America can be saved from further degeneracy, — a purpose may be effected of consequence even in a national point of view; for it is to the healthy and vigor- ous constitution of woman that we must look for a race of hardy, vigorous, and enterprising freemen. " In conclusion, I would briefly state that this is a matter in which professional aid can avail little ; it lies at the door and must be the work of parents generally. It is for them to understand the great value to be attached to the food on which their children sub- sist, — that it shall be wholesome and nutritious, and abounding in the earthy compounds so absolutely necessary to their proper de- velopment. If the chief articles of food have hitherto consisted of compounds made of superfine flour, corn-meal, and the fat of meat, let there be substituted in their stead bran-bread, milk, eggs, the lean of meat, and potatoes; let more attention be given to the nu- trient quality of the food ; let there be no deficiency of those articles containing the earthy material, that the bones and teeth shall not be deficient in' those constituents so necessary in their composition and structure ; and I should be inclined to hope that the evils which now exist will be lessened, and the physical organization of suc- ceeding generations be equal to that of any nation upon earth." From these hereditary and primal associations of dental caries we may now feel ourselves prepared to pass to local considerations ; THE TEETH AND THEIR DISEASES. 251 and this brings us to the second of our premises, — namely, the shape of the teeth, their relation to each other, and their self-cleansing features. Fig. 59. — Superior Dextal ArcH. Fig. 60. — Superior Dkntal Arch. On examining the two arches, Figs. 59 and 60, the observer will instantly be struck with the decided difference presented. In the first. Fig. 59, is represented a denture which, mechanically speak- ing, may be pronounced perfect, every tooth having a harmonious relation with its fellow, and each individual tooth being perfect in itself. 252 ORAL DISEASES AND SURGERY. In the second of the diagrams, Fig. 60, the artist has exhibited imperfections which, in truthfulness to nature, have been extended to every individual tooth, even to the crowding and wedging of them which are so frequently to be seen. Examining the molar teeth, the grinding faces are seen more or less pitted. These sulci are generally found uncovered at some point by enamel, an imperfection so common as to render these less resistive than their fellows. Hence caries is most frequent in this class. Particularly is this the case with the denies sapientiae, an operculum of gum being too often found an added cause of offense. To write any exact description of the irregularities of the faces of the molar teeth would be impossible, owing to the diversified aspects presenting them- selves. Sometimes such sulci are double, crossing each other at right angles. Frequently a single depression will separate the face into two principal cusps, and, running over the side, will terminate in a pit. Still again a single deep sulcus will occupy the very centre of the grinding face, the four cusps being more or less associated and ranged around it, ring fashion. In still other cases, a multitude of pits will cover the surface : on a single face I have counted as many as fifteen. The bicuspidati, for a similar reason, are markedly subject to be attacked These teeth not only decay from their cutting face, but, because of a peculiar flatness characteristic of their proximal sur- faces, are more frequently attacked upon the sides than even upon the grinding surface above. The next in the order of liability are the incisors of the upper jaw. Observation of the diagram exhibits a flatness on the pala- tine face of these teeth, which in many instances falls into a positive sulcus. These pits it is impossible to keep clean : hence an antagon- ism which results in caries. The surface of these teeth most liable, however, to suffer from caries, is the proximal. This in many instances finds explanation in the constant abrasion here going on as the result of motion produced by the act of mastication, the enamel being literally worn or cracked away. In other instances, a species of pocket-like flatness is found near the necks, in which is lodged and retained the debris of diet. In still other instances, the dentine becomes deprived of its protecting enamel as the result of lateral pressure, such pressure being increased with the development of each new tooth ; this applies most particularly when the relation of ap- proximal contact is a limited one and not diffused over the face of the tooth at lartre. THE TEETH AND THEIR DISEASES. 253 The inferior incisors and cuspidati are tlie teeth least disposed to decay. An explanation of such exception seems found in the shape of these organs and in their being- fully surrounded by an antiseptic saliva. The wisdom teeth, universally viewed as being most predisposed to caries, derive such tendency from a twofold direction. Developing at a period when the formative force is losing vigor, these teeth are commonly deficient in the amount of that inorganic mate- rial which constitutes what might be called the mechanical resist- ance of the dental organs : in structure they are found, comparatively speaking, loose, while their general resistive power is low; they might, indeed, be likened to the osteophytes which form after bone operations, and which represent so imperfectly the tissue replaced, being found unable to resist antagonisms not at all injurious to properly-formed tissue. Again, as a local signification is concerned, these teeth, making their appearance at a period when all the other teeth are formed, find so little room in the arch as to render the process of eruption difficult, slow^, and in some cases impossible: hence not only is a chronic morbidity engendered, but the face of the tooth is in many instances so long overlaid by an unabsorbed operculum (see diagram) that a perfect pocket exists, constantly filled by ingesta. Condition 3. Constitutional Relations. — This is the purely medi- cal aspect of the question : it considers the varying changes in the individual as manifested in the changes of dental health, — whether such relation resides in altered nutrition of the organs or in the production of adverse associated expressions. An example is fur- nished in the condition of utero-gestation, a second in dyspepsia, a third in the anemic diseases. The common proverb, " for every child, a tooth," has passed into general acceptation : statistics demonstrate that women lose their teeth in a twofold proportion to men, and that child-bearing women lose them in a threefold proportion to single women. Teeth which, up to a period of pregnancy, never required attention, will, in some in- dividuals, be attacked by a malignancy of carious action that shall quickly destroy a whole denture; such caries having the twofold signification of a perverted nutrition and antagonistic local action. An all-important question here presenting itself is the cure. To esteem this as residing in plugs of gold, and to so practice, is to find one's self resting^ upon a staff of reed. The matter, primarily, is 254 ORAL DISEASES AND SURGERY. solely one of nutrition ; not that necessarily phosphate of lime or other special material is demanded; the patient may have of such agents quite enough, both for teeth and foetus ; but the presence of agents of nutrition is not nutrition. Repair in living tissues resides in that function, as expressed by the physiologist, " by which nutritive matter, already elaborated by the various organic actions, loses its own nature and assumes that of the different living tissues, to repair their losses and support their strength." Here lies the indi- cation : it is, to correct the morning sickness which compels the stomach to refuse its food ; to keep cleansed an alimentary canal which, because of perverted secretions, is denied the office of its lac- teals, the whole economy thereby, Tantalus-like, being starved, even with plenty around; it is to antagonize the perversions of appetite, which, refusing proper pabulum, craves substances injurious to the health at large ; it is to control nervous irregularities. To express the requirements in one sentence, it is to secure, and to preserve to the system, that assimilative force through which it may be enabled to add to its ordinary functional work the new labor demanded. Dyspepsia and anaemia, as causes of dental caries, have the same general constitutional signification as found in the condition just referred to. To enter into a discussion of these relations would, as is seen, carry us necessarily over the grounds of general medicine, — a domain with which it has been taken for granted the reader is familiar. Condition 4. Character of Agents in Contact with the Teeth. — The idea, as commonly held, that caries of the teeth depends exclu- sively on the existence of free acids in the oral cavity, is, to the mind and experience of the writer, a proposition which needs but little correct observation to limit it to very circumscribed boundaries. If any one hundred mouths be taken, having in them carious teeth, and the ordinary test by litmus-paper be made, four-fifths of them will be found neutral, if not alkaline. Alkalinity we would infer, then, to be a more common association of caries than acids; and of the truth of such position experiment will show that there can be little doubt. It is, however, a truth that the presence of any alkali may result in the formation of an eroding acid in a depression or sulcus, and it does this precisely as the same effect results in decaying woody fibre, — namely, by enabling substances to absorb oxygen which do not in themselves possess such power, or possess it to a very limited extent. Thus, perhaps in every mouth in which THE TEETH AND THEIR DISEASES. 255 the fluids are alkaline, carbonic acid will be found in the debris of decaying teeth. Mucous Dej^onits. — Every one who has occasion to make observa- tions in the mouth has met most frequently with that condition of the mucoid secretion in which this fluid is glairy and tenacious, alkaline to the test, and not unfrequently offensive in odor, — a con- dition universally associated, when a habit, with dental caries, and, indeed, with general dyscrasia. Teeth in such a mouth are univer- sally covered with a film, and this so persistent that the ordinary use of the brush fails to disperse it, while the common dentifrices have alone the signification of a temporary good. Teeth so diseased find relief alone in acids, not only locally employed, but internally administered. A system secreting such mucus may be said to labor under the dyscrasia of super-alkaline poisoning, the agent having its point of exhibition most markedly in the mouth. It is really the condition of oral typh fever, — a typhoid condition expressing itself in this particular secretion, pre- cisely as in other instances accident might have directed it to the degeneration of the glands of Peyer or of the liver. A poi^n is in the blood, and by means of the circulation is diffused throughout every part of the system ; that it expends its force most markedly on certain parts is not unlike the expression of disease in general. If the blood of a patient laboring under this typh condition be examined under a microscope, it will be found that the normally- shaped red disks are diminished in number as compared with what are known to the pathologist as " the melanosed" corpuscles ; that is to say, as expressed by Chambers, " the dying or dead disks, shriv- eled and small, of a dark color, with black specks in them, and with gimped edges." But what is this typh poison, it may be asked? Unfortunately, the nature and scope of the present volume limit an answer to the simple elements of one of the most interesting questions in medicine. By typh poison is meant the existence in the blood of a super-alka- linity, which tends to dissolve the blood-corpuscles and to defeat the ends of tissue-metamorphosis. This poison, according to its quan- tum, depresses to death, as seen too often in cases of typhoid fever, or it may expend itself in a simple deranged vitality, as witnessed in the stringy mucus now under consideration. How this poison enters the system, necessarily provokes much discussion. That one of its inroads, however, is by the stomach, is not to be doubted, seeing that in epidemic typhoid fever an emetic at the beginning of 256 ORAL DISEASES AND SURGERY. an attack seldom fails to lessen the force and extent of the impression, such emetic seeming to act mechanically by emptying the stomach, thus preventing all the poison which had been received into that viscus from being taken up ; while still again it is observed that during the prevalence of such epidemics, those who smoke and chew tobacco, and thus eject their saliva, are least apt to be attacked. That, however, the typh poison may be generated from within, is scarcely to be doubted. In such chronic cases as associate with dental caries, this is the direction, no doubt, of the production ; and yet the condition may reside in a subacidity, the alkalinity being what might in proper health be normal, but which is in excess from the deficiency of a neutralizing acid. Unable, however, to devote a greater space to the consideration of a question well worthy a chapter in itself, we leave the subject with this hasty glance, extracting the deduction that the prophylaxis of caries in this direction is found in the free use of acids. If to tjje mind of any one this may need con- firmation, let a deduction be drawn from any two cases of ordinary typhoid fever, — one being treated with alkaline medicines, the other with ^ids. In seven cases out of ten, the patients treated exclu- sively with the first will die ; seven out of ten treated with acids will recover.* As a systemic medicament, let, therefore, the following be pre- scribed : R. — Acidi hydrochlorici diluti, gtt. x; Syrupi, 5ss; AqusB, 5j- M. S. — To be repeated from one to three times a day, as may seem required ; or it might be that even five drops of the acid would be found sufficient for the requirements. In cases of typhoid fever, I have administered as many as twenty-five drops as a dose, repeated every three hours for two weeks. Conjoined with the acid it will be found serviceable to employ the quiniae sulphas, — a grain pill once or twice a day, according to the length of time it is proposed to continue the medicine. A very good plan is to direct thirty pills : R. — Quinise sulphatis, gr. xxx; Extracti gentianae, 3j- M. * This assertion is founded on observations made in daily attendance on quite a number of patients during an epidemic lasting nine months. THE TEETH AND THEIR DISEASES. 257 To be divided into pills No. sxx ; one or more to be taken each day. Asa mouth-wasb, the following combination will be found appli- cable : B. — Tincturae capsici compositse, 5ij ; Aquae Coloniae, 5ij ; Spiritus vini, §ij ; Tincture quillai, siss ; Tincture gentianae compositae, §j; Acidi acetici diluti, §ss; Acidi carbolici fluidi, ^ij. M. S. — To be used by saturating a tooth-brush which has been first dipped into water. Where much ofFensiveness in odor is associated with this in- spissated mucus, it may be necessary to use a gargle of the per- manganate of potassa or of the aqua chlorinata. For the former, a very good proportion would be as follows : • B. — Potassae permanganatis, gr. xv; Aquae, o^iij- M. S. — Use as required. Still another most excellent preparation for such disinfection is the phenate of soda ; indeed, by many, preference is given to this article above most others. It is used diluted with water in such proportions as seem demanded to meet the indication of the special cases prescribed for, — ordinarily one part of the phenate to ten parts of water. Acid Secretions. — That the common oral fluids are occasionally to be found of an acidity sufficiently strong to be injurious to the limy structure of the teeth is not, of course, to be denied. When such state exists, it is easily to be demonstrated by furnishing the patient with a few strips of litmus-paper, which are to be wet with the fluids of the mouth at varying periods of the twenty- four hours. In the morning, immediately upon rising and before taking fluids, is the test perhaps of most signification. If such test reddens the paper for a series of mornings, an antacid indication would seem to be fairly established, and local prescriptions, some- thing in combination like the following, may be directed : 17 258 ORAL DISEASES AND SURGERY. R. — Aqus6 calcis, siv ; Tincturse cinchonse, Tincturge pyrethri, aa ^j ; Tincturse quillai, gij ; Potassse cbloratis, 5j ; Aquae chlorinatse, 5ij ; Spiritus vini, 5j ; Tincturi^ gaultherise, q. s. M. S. — To be used with the tooth-brush. Or, R. — Potassfe chloratis, 5ss ; Aquae, giij ; Tincturse capsici compositse, 5'j 5 Aqu» Coloniae, 5j I Tincturse quillai, siss; Olei limonis, vel verbenae, vel gaultheriae, q. s. M. S.— To be used with the brush. If it prove more convenient to employ poAvders, something like the following will be found to answer the required purpose: R. — Cretae praeparatse, Iridis Florentince pulveris, aa ^ss; Ossis sepiae pulveris, 5ij ', Olei limonis, q. s. M. Or, R. — Cinchonae rubrae pulveris, 5ij ; Capsici pulveris, gr. x; Potassae chloratis pulveris, 5j 5 Pulveris aromatic!, 5'j ; Saponis castiliensis pulveris, ^j ; Magnesiae carbonatis, 5ss ; Iridis Florentinae pulveris, ^j. M. Conjoined with the local antacids, attention is likewise demanded to the functional, or it may be organic, conditions producing the acids. Different derangements of the general health will exhibit different acids. Thus, in one mouth will be found the uric, in an- other the lactic, in still another the nitrous, etc. These productions have their constitutional meaning and indications. As examples in THE TEETH AND THEIR DISEASES. 259 such directions of practice, the presence of uric acid in the mouth, as in the urine, would be most apt to be found associated with deficiency in respiratory action and with circulatory sluggishness. Lactic acid in the saliva would almost certainly indicate the con- dition of diabetes, although diabetes does not necessarily yield lactic acid to the saliva. Formic and acetic acids found continuously in certain mouths have been made quickly to disappear through treat- ment directed to an existing leukaemia. Farasites. — The parasitic theory of dental caries holds good only as fungi, animal or vegetable, are added causes of deterioration. Lodged in a cavity of a tooth of soft structure, these no doubt act the part of destructive agents, by insinuating themselves into the tubular and intertubular spaces, interfering with and counter- balancing the resistive efforts of dentinal consolidation, and serving as sponge-like bodies, to hold in contact with the parts agents alike injurious with themselves, lowering also the resistive vitality through an appropriation of nutritional pabulum. To destroy these fungi, few agents will be found more reliable than what is known as the dental carbolic acid soap. This soap should be used twice a day, and particularly is not to be neglected on retiring for the night. Powders also serve an excellent purpose, removing the offense mechanically. Acid washes, as suggested, may also be prescribed. Dr. Aitkin, of Edinburgh, recommends the production in the mouth of sulphurous acid through a solution of the sodae sulphis : B. — Sodae sulphitis, 5j ; Aquae, f5J. In proportion as the secretions are acid, the salt is decomposed, the sulphurous acid being set free. This disengaged acid will, it is affirmed, destroy the parasites in twenty-four hours. In the case of a family of children where parasitic offense was associated most markedly with putrescent caries, a change quite wonderful in its character was produced by alternations of acid and alkaline washes. Either of these, by itself, failed utterly in any satisfactory result. I was led to infer, therefore, that two orders of fungi harmoniously existed, — the one impressible by acids, the other by alkalies; and the result of the treatment certainly seemed to verify the conclusion. The fluids of all the mouths were neutral. The Protococcus dentales, very minute organisms, are referred to by microscopists as being most frequently found in carious dentine, 260 OBAL DISEASES AND SURGERY. although it is not at all uncommon to meet in profusion the spi- rilla, amoebae, monads, etc. The following examinations, made by Dr. Joseph G. Richardson (author of the " Handbook of Medical Microscopy") on the first five patients coming into the office of the author after completion of the required arrangements, will be read with interest: Specimen I. — Patient, young lady. Mouth remarkably healthy- looking; gums hard ; had lost no teeth ; cavities very few in num- ber; oral fluids neutral; teeth clean; no tartar or other collections, specimen examined being a particle of carious dentine. Examination with a one-twenty-fiftb-inch objective, giving with the No. 1 eye- piece a power of about twelve hundred diameters, showed multi- tudes of bacteria and short leptothrix filaments, all, however, quite motionless. Specimen II. — Old lady. Teeth breaking down in every direc- tion ; diffused collection of pasty debris; gums soft and unhealthy- looking; epithelial cancer involving left half of lower lip, and pass- ing around the commissure to upper lip ; patient very deficient in vital force. Specimen examined being debris from the side of an inferior cuspis, against which rested the disease. Exhibited long bundles of leptothrix filaments, consisting of from five to fifty my- celial threads, each about one-ten-thousandth of an inch in diameter, and sometimes attaining the enormous length of one-tenth of an inch. These fibrous-looking bundles were interlaced and imbedded in a large amount of granular stroma, apparently composed in great measure of bacteria and bacteridia, as many of the former could be seen in very active movement around the margins and in the inter- stices of the masses. Specimen III. — Patient, young lady. Mouth in the highest degree healthy-looking ; had lost no teeth ; very few cavities, and these all filled beautifully and perfectly with gold ; fluids neutral ; no tartar. Specimen examined being a mere particle of debris found between the inferior central incisors. Showed also great numbers of comparatively short leptothrix filaments, among whose interstices floated, in molecular (Brunonian) movement, multitudes of bacte- ridia and nearly motionless bacteria. A few of these minute organ- isms manifested voluntary action, which continued in certain instances for at least thirty -six hours after removal from their parent mouth and immersion into the three-quarter per cent, salt solution. Specimen IV. — Boy with hare-lip. Oral fluids alkaline, stringy, and tenacious. Specimen examined being carious dentine from a THE TEETH AND THEIR DISEASES. 261 lower molar. Showed immense numbers of bacteria, short leptothrix filaments, chains of spores, and occasionally a specimen of spiril- lum. These fungi were especially abundant around the margins of dentine scraped from the cavity; and, as they were not accompanied by salivary leucocytes, it is probable that they did not proceed from the saliva, but had developed within the tooth. Specimen V. — A molar tooth with a large cavity in its side was extracted from the mouth of fifth patient, a scrofulous lady, with most unpromising teeth, and, after being split open, was subjected to examination. The branch of the cavity, extending into one of the fangs, was filled with a soft spongy mass, which, under the microscope, was seen to be composed of long interlacing filaments of leptothrix buccalis, such as were found in Specimen IT., and to be swarming with bacteria. A portion of the cavity at the edge of the split surface was scraped clean, and thin sections of the still firm but diseased dentine were made with a strong sharp knife. These fragments, when examined with a power of twelve hundred, were seen to be associated wnth many bacteria and filaments of leptothrix, the latter of which seemed in several instances to occupy the dentinal tubules and to project from their fractured extremities. Although being then, of course, without movement, it was difficult to say with absolute certainty that the structureless fibre-like bodies were actually portions of the vegetable growth. Electro-chemical Relations. — Every observer must have remarked how much more common is caries to moist than to dry mouths, and how much more common is the failure of an approximal plug at the base-wall than elsewhere about its circumference. These conditions have been discussed by Mr. Kencely Bridgman, L.D.S., in a paper on the electro-chemical action of metallic substances upon the teeth, with an exhibition of experimental research and learning which commends his views to the most respectful consideration. "While investigating," says this observer, "the action of voltaic electricity upon organic compounds, it was observed that all defects of metallic fillings in the teeth could be represented by results ob- tained out of the mouth. That decay might be, and probably was, a chemical action, every one was quite ready to admit; but how it could be electro-chemical did not appear to be in the slightest de- gree comprehended. The immediate effects of chemical action could easily be recognized as such ; but the previous electric condition giving rise to this chemical action required a somewhat intimate 262 ORAL DISEASES AND SURGERY. acquaintance with the laws of physical forces to render its presence appreciable ; and, consequently, the only valuable portion of the theory has hitherto been left in abeyance." A basal experiment upon which the deductions of Mr. Bridgaian are founded is as follows: "A rod of absolutely pure zinc, three and a quarter inches long, after being thoroughly amalgamated with fresh distilled mercury and drained, and weighing four hundred and eighty-seven grains, M'as placed half its length in cold dilute sulphuric acid, and the other half exposed to the atmosphere, in the same position as the ordinary plates of a battery. In a very short time bubbles of hydrogen made their appearance over the whole surface exposed to the acid, and after forty-eight hours the metal was found to have lost upwards of ten grains iu .weight. This loss, however, was by far the least important part of the results obtained. The immersed portion of the metal had not been acted upon uniformly over its whole surface ; but the action had been greatest at the surface of the liquid. At the same time the exposed portion had become covered with patches of crystalline sulphate of zinc, high and dry upon the projecting portion of the metal. Therefore, not only had chemical action been exerted between the metal and the acid and the Avater decomposed, but there was the additional evidence that the metal itself had become polarized." Associated with this first is the repetition by Faraday, copper being used instead of the amalgamated zinc, the color of the crystals and the coloring of the acid affording more conspicuous evidence of the results produced. "A piece of stout copper wire being placed similarly in acid, the latter very soon gave signs, by the coloring it received, of the copper commencing to undergo solution ; and, after having been suffered to remain undisturbed for twenty days, it presented the appearance above the acid of a bushy rod, the portion exposed to the atmos- phere becoming coated with a layer of minute and beautiful crystals of sulphate of copper, extending from near the top to within three- sixteenths of an inch of the liquid. At this intermediate portion a greater amount of chemical action had been induced, corroding the wire about half-way through and forming a neck tapering upwards." That the action which arises between the metal and the acid is due to polarization is evidenced by the following proceeding: ''A similar piece of copper wire, wholly submerged in the acid, so as to entirely exclude any portion of the metal from coming in contact THE TEETH AXD THEIR DISEASES. 263 with the air, has remained for many months without imparting; the sHghtest tinge of color to the liquid ; but on suffering the fluid to evaporate, so as to bring the upper end of the metal near to its surface, the instant the slightest portion becomes exposed to the atmosphere chemical action immediately commences." There is thus, where no sufficient normal affinity exists between the metal and the liquid to effect the decomposition of water, a power imparted, by the metal being polarized by the atmosphere, which renders it then capable of accomplishing it. " The atmosphere," says Mr. Bridgman, " in its normal state being electro-positive, renders, by a well-known law of induction, bodies opposed to it electro-negative. The exposed end of the cojiper is, therefore, thus rendered electro-negative, and the acid, by the same rule, being electro-negative also, the immersed end of the metal be- comes electro-positive. It is an established rule that bodies to be electro-decomposed must first be rendered electro-positive; and it is also a part of the same rule that bodies receiving an addition of matter must first be made electro-negative. Hence the exposed end of the metal has become negative and received the crystallization, while the immersed portion, being positive, has been acted upon accordingly. "The appearance, however, of the crystallization upon what was at first the dry end of the metal requires particular attention. It is one of the special effects of electrolytic action that fluids pass to, and accumulate at, the negative pole. Obeying this law, the acid imme- diately begins to ascend and spread itself over the surface of the unimmersed end of the metal. But now we have another special provision, which demands the most careful and attentive considera- tion, as it constitutes the first step in the resulting chemical action. "One metal placed in two dissimilar fluids, as the air and the acids, acquires the same condition that two dissimilar metals, or one metal non-homogeneous, assume when exposed to the air : each has become polarized, and rendered amenable to chemical action. Water, being a compound of gases chemically combined, can have its gases uncombiued only by equal degree of force being antago- nistic to them; and consequently the decomposition of water must be preceded by some other arrangement. 'Now, the atmosphere, being only a mixture of gases, or gases merely in a state of mechanical admixture, which admits of their being readily separated on the slightest interference, supplies the initiatory steps by which de- composition can be effected. " The first immediate effect upon a polarized metal is to drive 264 ORAL DISEASES AND SURGERY. the oxygen of the atmosphere to the positive end. Its combination with the metal, in oxidating or rusting it, is a chemical action deter- mined by the electro-polar condition ; and it has been established by Faraday and others that this chemical union is invariably accom- panied by a development of electricity, which in its turn can be made to produce electro-chemical results of an equal degree in another direction. " The greater amount of action taking place at the neck of the copper wire will now be readily comprehended. The oxygen of the atmosphere has been driven toward the positive end of the metal ; but its progress has been arrested by the acid surrounding it. The thin fibres, however, rising from its surface, being soon saturated with the oxygen, and presenting the latter in its most favorable form for acting upon the metal, facilitate its oxidation, and con- sequently accelerate its solution, and render the ascending acid saturated and ready for at once becoming a crystalline deposit, while little or no solution has been effected in the acid below. "It must be kept in mind that an electric state is not a fixity, but is relative, and depending upon attendant circumstances. Thus, if the copper wire had been subsequently inverted, the immersed end, which is now positive, would then have been rendered negative, and vice versa; or had the acid at any time been filled up to the top of the tube, the exposed portion only, however small that might be, would have remained negative, the surface of the liquid determining the line of demarkation between them. "Let us now apply these facts to the mouth. The external epi- thelial layer of the gum is constantly throwing off its worn-out cells, and by this wasting process it determines its electro-positive state, while the crown of the tooth, as a continuation of the epider- mal layer, partakes of the like condition. Were the teeth wholly and constantly submerged, and protected from the air, it is probable that, like the copper wire beneath the acid, they too might i-emain intact. But as the air is constantly passing into the mouth, or even through it in the act of breathing, they are thus, having one end exposed to the air and the other to the fluid moistening the gum, subject to the same polarizing influence as the metals. " The negative portion of the polarized tooth being represented by the portion of the wire exposed to the atmosphere, it will be at once comprehended why tartar accumulates upon certain parts only of the teeth, and how it is enabled to creep over the surface and adhere with tenacity. THE TEETH AND THEIR DISEASES. 265 " In the case of the partly-submerged wire it has been shown that the principal amount of electro-chemical action takes place near the surface of the fluid, this point determining the line of demarkation. Hence in the mouth this line may be taken as the existing free edge of the gums. The moisture accumulating here, in the event of any electro-chemical action taking place, it would necessarily be imme- diately above that line, and consequently the substance of the tooth directly above the gum would be attacked. We see this actually taking place in the peculiar decays so common at the exterior or anterior basal area of the molars, and also on the same part of the upper incisors. "In the interstitial divisions, the moisture accumulates between the teeth by capillary attraction, and in connection with this we have approximal decay as one of the commonest forms occurring. The oxygen is attracted to the part, and produces the acid so in- variably present, while, by electrolysis, the lime is abstracted and removed to another part, or carried away in solution. By such electrolysis," Mr. Bridgman thinks, "every other phase and phe- nomenon of decay is to be traced and explained." Yiewing the matter strictly from the standpoint of a chemist, our author has overlooked vital resistive force. We trust we have, however, completed this portion of his subject for him, and thus afforded him a required support in the chemico-vital aspect of his subject in which his foundation seems lacking. We may here follow Mr. Bridgman in his consideration of filling- materials. "In a prize essay," he says, "I have shown that an amalgam filling in the side of a tooth having one edge near the gum generates acid at the latter point. This is due to polarization. A body of metal having its two ends or opposite sides exposed, under different circumstances, becomes polar, and in proportion as there is any substance to be acted upon by oxygen, so is the amount of chemical action regulated. Thus, a metallic plug in an approximal cavity, or in the external basal area of the molars, will have the cervical edge continually wet, while the upper part may be comparatively dry; and hence will be assumed the two conditions as represented by the intermediate and exposed portion of the wire. It has often been lamented that, however carefully and well these fillings may have been done, there is the ever-recurring annoyance of finding, in a few years at the most, and not unfrequently in a few months, that the sides of the plugs and baso-caval surface have become defective ; 266 ORAL DISEASES AND SURGERY. showing that, although all the defects may have been removed in the first instance, the cause has been retained. "With the entire range of metals and metallic compounds, it maj be taken as a fact that from gold to copper and zinc it is only a question of degree, for the one cause affects them all more or less. In respect to this, gold is unquestionably the best by very far, as being one of the least oxidizable ; but even with this, certain pre- cautions are essential to success. The one indispensable condition is that there shall he no lodgment for moisture at any point of its circumference. The edge of the plug must be made as perfect as possible, and no fissures communicating with it may be suffered to remain ; for, if there be, electro-chemical action will be certain to recommence. "With amalgams, this precaution is, if possible, even more impor- tant ; but with these there are other points requiring attention. The composition of amalgams is a subject which has never yet been systematicall}'^ investigated, and those now in use differ considerably in character. " Zinc and copper, and their various alloys, with tin and silver, etc., form the hardest amalgams ; while gold, silver, palladium, and pla- tinum form only imperfect amalgams, which never acquire sufficient hardness to resist friction. In the latter, too, the mercury readily oxidizes and produces discoloration, while some of the former pass very quickly from oxidation to the acidifj'ing stage, and thus soon reproduce the electro-chemical destruction of the dentine. "There is another and more serious objection still to be urged against some of the more modern preparations. Amalgams hard- ening imder a state of polarization assume, in some cases, a peculiar surface-crystallization, but almost invariably possess coarser crystals. "I have exhibited," says Mr. Bridgman, "two pieces of zinc which had been amalgamated and suffered to harden, — one under polariza- tion, the other without it. With the polarized surface the metal had acquired a considerable amount of crystallization of a peculiar character, projecting above the level of its surface, together with a somewhat coarsely crystalline texture without ; while that which had been allowed to harden withput being polarized was much finer in texture, although distinctly crystalline. Two pieces of amalgam, treated in a similar manner, showed the same correspond- ing results. In addition, both the polarized metals exhibited more discoloration than the unpolarized ones, and all showed that amount of roughness inconsistent with a perfect filling." THE TEETH AND THEIR DISEASES. 267 Having- thus traced the defects of metallic fillings, Mr. Bridgman proceeds to consider whether the objections are insuperable. " There are two proceedings indicated," he remarks, " as being desirable. The one is to prevent polarization ; the other, to prevent the effects of polarization being reflected upon the dentine. The former is not by any means difficult, but it requires a thorough knowledge of the laws under which it takes place to adopt the provisions under all the different circumstances required. Insulation, however, is one of the means to be secured. This, too, is the end to be sought in protecting the dentine. Either gutta-percha, waxed tissue-paper, or allotropic sulphur — but, above all, the so-called os-stopping — forms an admirable lining for a cavity, where little success 'could be hoped for from an unprotected amalgam. It also compensates for the want of fineness in the texture of the metal." There is another point in connection with the electro-chemical action of metals upon the teeth discussed in the paper under consid- eration. "Wherever a gold band comes in contact with the exposed dentine of a tooth, injury is commonly seen to ensue, and decay supervenes if the touched part be near the gum. This is assumed to be fully explained in the experiment with the copper wire. "The gold," says Mr. Bridgman, " may touch any part represented by the blue sulphate, but at the intermediate portion — that is, that portion of the tooth just above the margin of the gum — it is fatal." Criticism on these deductions is anticipated in a recognition of the fact that the author considers special cases alone, and does not lay down a general rule. That he fairly exposes the condition of many mouths seems entirely beyond doubt ; and it must be ad- mitted that he has given a very satisfactory expression to the chemical aspect of the subject of dental caries. (See Denuda- tion.) Medicines and Articles of Food. — That medicines, even the nitro- muriatic acid so frequently prescribed as an hepatic alterative, and the muriated tincture of iron used by almost every practitioner as a tonic, are not such sources of offense to the dental organs as is gen- erally inferred, the author has come to be reasonably well satisfied Prescribing both combinations with much frequency in his clinic as well as private practice, he founds this conclusion on an extent of observation that would seem to render it entirely reliable. Not that the careless employment of such medicines is at all to be com- mended ; but the inference is meant to be conveyed that caries associated with the periods of such prescriptions has explana- 268 ORAL DISEASES AND SURGERY. tion in the conditions prescribed for, ratiier than in the medicines prescribed. Acids are not best given through glass tubes, but, being sufficiently diluted, the draught, if such care be thought necessary, may be thrown into the back part of the mouth, and swallowed in a single muscular act, after which the mouth may be rinsed with water rendered slightly alkaline by the addition of a few drops of liquor ammoniae. The system, however, which demands an acid medi- cation will seldom find its dental organs injured by the reception of a share. Chalk, in place of the ammonia water, is suggested by Dr. J. D. White, he asserting that in this article acid medicaments find their quickest and most reliable neutralization. Mercury, as a medicine, has no direct efiect on the teeth, — its action having an intermediate signification; neither have any of the potash preparations as ordinarily administered. Sugar. — As usually employed, sugar is not to be considered an agent deleterious to the teeth, as locally it can only act through its conversion into acetous acid. A too free use of the agent, how- ever, by debilitating the digestive functions, indirectly affects these organs, in common with all other parts, by diminishing the resistive force, — in other words, through malnutrition. Yinegar, lemon-juice, the malic acid of apples, the tartaric of grapes, will, all of them, in varying extent, decompose tooth-struc- ture through affinity for the lime. When, however, their action is thus iujm'ious, the fact is easily recognizable by the patient in the loss of that polish noticeable on touching the organs with the tip of the tongue ; or in the presence of the feeling which is described by the expression, familiar to every person, of " the teeth being on edge." It is not, however, to be affirmed or maintained that any of these articles, when brought in contact with the teeth under the circum- stances of mastication, with their speedy dilution by the oral fluids — always proportioned to requirements — are sources of disease to the parts. Prudence in the use of such things is, nevertheless, to be recommended to every person having teeth of loose structure, — soft, chalky teeth. Of the dried fruits, raisins may, it seems to the author, be with most reason denied ; they do without doubt rapidly corrode the teeth, and are most tenacious in their lodgment. That it is necessary to proscribe their use, except in the case of children, is, however, at least debatable. THE TEETH AND THEIR DISEASES. 269 The spiritus nitri dulcis, — a compound of the nitrate and carbonate of potassa, sulphuric acid, and alcohol, — freely used in the United States as a febrifuge, particularly with children, is credited with being a frequent cause of dental caries ; the diluted state in which the medicine is always administered, however, may lead this infer- » ence to be received cum grano salis. Condition 5. The Absence of Mechanical Destriictives, as sali- vary calculi, the bands of artificial denture, etc. See chapters on Salivary Calculus, and Dentures. Condition 6. Accidental Influences. — Under the sixth head reference may first be made to what may be termed the gymnastics of the teeth. These organs, like all others of the body, require to be used, and, when denied the exercise of their function, deterioration universally follows. Illustration of this is markedly exhibited in slop-fed cows, the teeth refused their accustomed task quickly be- coming carious and loosened ; also in the case of persons using alone one particular side of the dental arch, — the unused organs being soon enveloped in tartarized debris, and the gums becoming turgid and debased. This debasement is shown also in those who live on food which demands but little trituration. The practice indulged in by many persons of breaking the harder shell nuts with the teeth is most reprehensible, cracking and splitting the enamel, and thus exposing the more susceptible underlying den- tine, — or, even where such accidents do not occur, exciting through shock a species of chronic inflammation which lowers the resistive force of the tooth. " Dental operations," as remarked by Dr. J. Taft in his work on "Operative Dentistry," "performed at an improper time and in an improper manner, the vitality of the teeth being thus impaired, or a diseased condition being established, are to be esteemed as exciting causes of caries. Often from improper use of the file extensive inflammation of the dentine supervenes, which is sometimes fol- lowed by death of the tooth and by disease of the contiguous parts." Another cause enumerated in this volume is " sudden transition from one extreme of temperature to another." The employment of a variety of metals, as fillings, is objection- able. Particularly is it the case that amalgam and gold should not be used in conjunction. I think it will be found an exception where a healthy denture can be exhibited having these two articles 270 ORAL DISEASES AND SURGERY. promiscuously related. This stricture also applies to the case of gold plates much alloyed with the meaner metals, as with silver or copper, particularly the latter. Cleanliness is an essential to a healthy denture. Teeth should be cleansed after every meal ; to this end a tooth-pick — always to be made of wood — is to be passed through the interspaces, and the mouth afterwards rinsed with water, or water to which have been added a few drops of alcohol or cologne. As a dentifrice, to be used when required, — which will, most likely, be once each day at least, — the following combination may be employed : R. — Ossis sepiae pulveris, 5ss; Cret£e praeparatte, Jij '> Coralli albi pulveris, 3ss; Iridis Florentinae pulveris, ^j ; Carbonis ligni pulveris, 5j ; Lapidis pumicei pulveris, oU ; Olei limonis, q. s. In a mouth self-cleansing, however, where there is little tendency to the accumulation and retention of debris, it would not, of course, be found necessary to have such excess of cutting ingredients. A modification of the prescription might therefore be made : R. — Cretae prseparata^, S'j ; Ossis sepiae pulveris, 5ss; Iridis Florentinae pulveris, 3j ; Cinchonte rubrae pulveris, 5j ; Saponis albi pulveris, 5'j- M. In the treatment of any case of dental caries which may present itself, the careful practitioner first endeavors to satisfy himself of the causes, constitutional and local, influencing the diseased condi- tion ; of the constitutional causes, all, as must be inferred, aifect the integrity of the teeth which are deteriorative to the system at large. Unhappily for the denial organism, primary unhealthy impressions made upon the teeth, while in their formative or pulpy state, are apt to influence more or less their character for life, just as certain of the exanthemata, — variola, for instance, — occurring at this period, are so apt to impress permanent pittings upon the enamel. Unhealthy parents, as has been suggested, cannot possibly beget THE TEETH AND THEIR DISEASES. 271 healthy offspring. Here is a great primary antagonism. The teeth, however, are living and, consequently, changing bodies : par- ticularly is this true, physiologically, of young teeth. Constitutional treatment may thus do service even as every molecule of tooth- structure is concerned. Such treatment would of course be longer in receiving apparent response, as must be evident upon considering the relative low vitality of these organs, than treatment directed to the production of an impression on the soft parts, or on common bone ; yet, because a tooth is an organized body, because it has innervation and circulation, such treatment, to a greater or less extent, must have its influence. A first indication calls, therefore, for the consideration of causes interfering with the proper vitality of any denture coming under observation. Whether deteriorated hereditarily or otherwise, duty to the patient demands such consideration of the case. We will suppose a trouble to be hereditary. Here, if we can find in a patient the observable existence or continuance of habits of functional irregularity, or of animal habits common to the parent and which are to be esteemed of deteriorating import, our first atten- tion is to be directed to a correction. The parent may have been specifically diseased, let us suppose, by his parent, and thus the bad teeth of both father and child lie in a venereal molecular impression. Here a predisposing cause would have come from and would be still residing in the transmitted condition. Granting, then, that such mole- cules, still living, are impressible, would not judgment direct a pri- mary treatment to the production of an impression in such direction ? I have treated many a child, for skin- and other diseases, where the affliction was a true hereditary venereal transmission, and I never thought of directing medication otherwise than in recognition of such a transmission; and satisfied, as every medical man must be, that the circulatory fluid permeates tooth-structure, I treat vene- really deteriorated teeth on a common principle, and have found in the result that measure of success which has justified the conclu- sions. In other words, I have prolonged the life and health of such organs, just as are prolonged the life and health of the patient upon whose molecules is impressed the fiat of the tubercles of phthisis. Such a treatment consists, however, not necessarily in administer- ing specific or supposed specific remedies, but in viewing the system as laboring under depressing influences, either of a general or special local signification. This fact it is most important to recognize. A child, as we have studied, may have its molecules deteriorated 272 ORAL DISEASES AND SURGERY. by a transmitted mercurial impression, or a parent may have been an inebriate, and thus have debased his child in himself. The results of an excessive venery may have been transmitted. A mother, from lack of nourishing material, may have degenerated her offspring. These causes of transmitted ills, the appreciable ones, I may say, are many : all must recognize them. Improper diet to the developing child, as we have so fully studied, is plainly enough a cause of bad teeth. The state of health of such a developing child has its influence ; indeed, so marked is this, that by an observation of teeth belonging to the various periods of life, one can easily trace constitutional variations ; for just as at different periods the functions of organic life were healthily or unhealthily performed, so we find the disturbances written in the character of the teeth belonging to the period. More expressive even than this is the fact that the deciduous teeth mark, in the progress of their development, the health of the mother. That the teeth, in their formative state, partake of the healthy or unhealthy condition of the system at large, all observers admit. But here, unfortunately, the matter has been left, most practitioners acting on the premise that such impressions are never to be altered. At such a conclusion it is impossible not to express surprise. Who, in his own person or in the persons of friends, has not remarked the varying conditions of the health of the teeth ? Up to the age of sixteen I was myself a martyr to toothache ; yet about that period a change occurred, since which time I have had no trouble. Is it suggested that the teeth may have been filled ? True, they have been; but certain of the fillings came out years ago, and have never been replaced, yet the teeth are quite as good as those in which the operations remain. Similar instances exist in profusion, and yet the lesson seems unheeded. There is a constitutional treatment for the carious tooth, as there is for the carious maxilla, and from a common standpoint are the diseases of both to be viewed. It is not, of course, every case of a carious bone that demands systemic treatment, neither is it so with the teeth ; the source of offense in the one, as in the other, may be strictly, local in its character ; but ill success must ever attend that practitioner who has not the inclination to look for a primary lesion outside of things strictly local in signification. Resume. — Integrity of the teeth depends on two general con- ditions : inherent vital resistive power, and the absence of irritating THE TEETH AND THEITt DISEASES. 273 influences. A tooth may, in its vital relations, be just strong enough to resist external forces brought to bear against it, if in its construction there is no mechanical imperfection. It may, even with imperfections, be able to resist temporary injurious impres- sions. The vitality of a tooth can be elevated as the vitality of a lung is increased. The study of the vitality of a tooth, and the study of its adverse influences, is the study of vitality and the ex- pression of irritation anywhere. The treatment of dental caries is both medicinal and operative. 18 CHAPTER XI. THE LOCAL TREATMENT OF DENTAL CARIES. Caries of a tooth differs surgically from caries of bone proper in the fact of a too common inability to repair by any efl'ort of nature the injury done through the destructive influences of the disease. Not but what such repair is attempted, and indeed oftentimes suc- cessfully accomplished, as witnessed in tubular consolidation, where power sufficient exists to perfect the attempt, as seen in the process generally spoken of as vitrifaction or eburnification, a mode of natural cure and resistance which no mechanical operation, however success- fully performed, can equal. This process of secondary calcification, or eburnification, exhibits fully the inflammatory phenomena associated with dental caries, for not otherwise than as circulatory expressions is it possible to explain the phenomena: it is, in every particular, a modified repetition of the ordinary lymph exudation and circum- vallation seen in abscess, either of bone or soft parts. A tooth attacked in any part by caries expresses the stages and steps of the inflammatory process, inasmuch as at the first attack of the disturbing agent immediate alteration occurs in the circula- tion or nutrition of the part, the tubules being filled up and solidi- fied, or the attempt made, by deposit of adventitious matter, the disease being thus resisted and retarded ; conquering only when the attacking agent is stronger than the vital force which combats it. Such phenomena express to the observing mind the principles of the treatment of dental caries, i.e. to relieve the part from the agent of offense, and to strengthen the resistive ability. Passing from the first of these principles, which has been con- sidered on preceding pages with perhaps quite sufficient fullness, we proceed to the discussion of the second. A tooth attacked at a given point by irritating agencies will, step by step, break and give way before the irritant ; or, otherwise, will resist and antagonize. Resistance implies assistance, which assistance may be either of nature or of art, or of both. What- (274) LOCAL TREATMENT OF DEXTAL CARIES. 275 ever shall tend so to consolidate or protect the parietes of a cavity as to render the parts impervious and insusceptible to external agents, will save the tooth. Such result is aimed to be secured through the removal of dead and dying dentine from a cavity, and provoca- tion to tubular consolidation through the introduction of an agent exciting to the vascular system of the tooth ; the chloride of zinc being among the best of such agents, and most conveniently em- ployed in the preparation known as oxychloride. (See Filling Teeth.) Zinc so introduced into a tooth will not unfrequently be found fol- lowed by such iuflammatory consolidation that a cavity from being soft and of loose structure is seen to become solid and dense to an extent that makes it entirely self-protecting; it has become glass-like,^- in hardness : this occurs, however, only where the vital force is abj to respond to the excitation. The practitioner, aware of this met, directs a medication to the assistance of an asthenic system laboring under advancing dental caries, precisely as, under similar circum- stances, he endeavors to assist nature in caries of bone proper. In the one case as in the other, thus only may he expect to get a cure. Such principle of treatment is so in accordance with the exhibitions of nature's expression, that no medically educated ex- perience may doubt the indications. The cure of caries by 61ing finds its explanation precisely as ex- pressed in the employment of the zinc. The file cutting away the weak point, and exciting, through the exposure of the dentine, in- creased vascularity, structural consolidation results, and thus external or offending agents are shut out, precisely on the same principle as a ball may become encysted in a bone and remain for years innocuous. Gold or other ordinary agents employed in filling act to an extent in the same way: these, however, being commonly non- irritating or exciting, are not apt to be found associated with the same extent of change ; in all reasonably vital teeth, how- ever, are to be seen such attempts at resistance. A fill- ing of metal represents, and, to a degree, stands in place of, the tubular or structural consolidation. rig. 61 represents a section of carious tooth from life, exhibiting structural consolidation. In this particular case, although the cavity — being in a lower molar tooth — was large enough to contain a pea, caries was held completely in abeyance, and had been so for years, the parietes of the cavity being as hard as flint. In the local treatment of ^dental caries, three indications exist: Fig. G1. 276 ORAL DISEASES AND SUBGERY. ' 1. Neutralization of the oral fluids and the induction of a state of general health in the mouth. 2. Medical treatment of the tooth, 3. Mechanical treatment of the cavity. 1. The normal condition of the oral fluids is neutral. A healthy- saliva, in which practically is included the secretion of the mucous glands, as well as that brought into the mouth by the ductus sali- varii, is an inodorous, tasteless, slightly viscid fluid, bland, unirri- tating, subject to changes as influenced by physiological impressions, aff'ording at times an alkaline reaction, again being temporarily acid, sometimes sweet, and often, under the impressions of dry bodies, mucilaginous to a marked extent, owing this last character- istic to excess of mucus, a substance almost analogous to vegetable mucilage, having as a chief constituent an albuminoid compound, with the oflice of preserving the membranes moist and in a condi- tion fitted to the performance of their functtions.* * Messrs. Griffith and Henfrey, the able editors of the " Micrographic Dic- tionary," state, when speaking of the oral cavity : " The mucous liquid of the mouth contains, in addition to detached epithelial cells, very transparent cor- puscles about 1-2000 to 1-1500^' in diameter, consisting of a delicate cell-wall, a nucleus, with a number of minute moving molecules. We have figured these among the test objects. (Plate I., Fig. 5.) They are called mucous or sali- vary corpuscles. KoUiker regards them as a form of exudation corpuscles ; and this view is probably correct, for they may occur in the secretion of any mucous surface and have no special connection with the salivary glands ; we have found them in myriads in the urine." Dr. Joseph G-. Richardson, of this citj'. Lecturer on Pathological Anatomy in the University of Pennsylvania, claims, however, to be the first to demon- strate their true nature and origin, viz., that they are simply "migrating" white blood-corpuscles, which have become distended by the endosmosis of a fluid less dense than the liquor sanguinis. He remarks, " From my experi- ments as detailed in the same article, page 253, and briefly described on page 157 of this chapter, I condlude that 'tracing now the white blood-corpus- cle from its condition of irregular outline and amcebaform movement, as ob- served in serum and in heavy urine, when the circumambient fluid approaches the density of 1028, through its rounded form, with slightly more distinct nuclei, in the liquor puris and in urine of lower specific gravity, we find that immersed in a rarer liquid approximating to the mean density of the saliva (1005), it has an accurately spherical outline, is more than twice the magni- tude, and contains a number of minute actively-moving molecules, thus exactly resembling in all sensible characters the true salivary corpuscles ; and it therefore seems reasonably certain that the blood, under the appointed LOCAL TREATMENT OF DENTAL CARIES. 277 The analysis of the fluids bathing the teeth is to precede opera- tions upon these organs. As acidity or alkalinity is concerned, such analysis is most easily made — demanding but a few days — by fur- nishing the patient with two strips of test-paper, — litmus, as it is called ; paper colored with the dye of the plant Lichen roccella, — nervous influence, congesting the buccal mucous membrane and associated glands, moves slowly enough through their capillaries to allow some of its white globules to penetrate the walls of the vessels, as they do those of the frog's mesentery in Cohnheim's experiment [Virchow^s Archiv, Band xl., S. 38 et seq.), which, under the influence of the rarer saliva expanding them and setting free to move their contained molecules, constitute the bodies so long known to histologists as the corpuscles of the salivary fluid." [Vide Hand- book of Medical Microscopy, p. 1G5.) The demonstration by Dr. Richardson is as follows: "Placing a drop of blood from the tip of my finger," says Dr. E.., " upon a growing slide" (see Pennsylvania Hospital Ptoports, 1869), " I covered it with a thin glass and placed it upon the stage of the microscope. After finding a white blood-corpuscle showing well-marked granules, I raised the objective and arranged a fine filament of thread from the reservoir filled with fresh water to the upper edge of the cover, and a fragment of wet paper to the lower, according to the usual method for securing a constant current beneath the thin glass. On depressing the body of the instrument and bringing the corpuscle again into view, I found it still adhering to the surface of the cover, notwithstanding the torrent of red globules hurrying over the field ; and as these became paler and less distinct by reason of the diminished density of the serum, the white cell first gradually expanded and displayed its delicate wall with two rounded nuclei, then, after acquiring the magnitude of about xtVo*^ °^ ^^ inch, it exhibited the rapid and incessant movement of its contained molecules, and, finally, when its diameter reached about the y^ooth oi an inch, it burst suddenly, discharging a portion of its contents, whose outbreak resembled that of a swarm of bees from a hive, and some particles of which, actively revolving as they went, swam off to the confines of the field. On repeating the observation and allowing some aniline solution to flow in with the water after the first few moments, the nuclei were strongly stained and beautifully distinct, although the movements of the molecules promptly ceased, — in this respect, as in all the others, showing a pre- cise identity with the reactions alforded by the pus and the salivary corpuscles, as above described. It should be noted that a certain variable proportion of the white cells of the blood thus treated exhibited no moving molecules, and apparently consisted solely of nucleus and cell-wall." Since the above was in type, this doctrine seems to have been corroborated by further experiments of Dr. Richardson, in which salivary globules were again reduced to the size of the white cells of the blood, and their amoeboid movements restored, under the influence of a three-quarter per cent, solution of common salt. ( Vide paper on the Structure of the White Blood-Corpuscles, Transactions of American Medical Association, 1872.) 278 ORAL DISEASES AND SVBGERY. one piece being blue, as found in the shops ; the other made red by subjecting it to the action of a weak acid, or for this latter purpose turmeric paper may be used. Having these pieces of test-paper, the patient is to wet them, slip after slip, at varying periods of the twenty-four hours, particularly in the morning immediately upon rising and before taking anything into the mouth. If persistently the result is acid or alkaline, as evidenced by the blue slijjs being- turned red if the first condition exists, or the red slips of litmus being changed to blue, or the yellow of the turmeric to brown, if the action is alkaline, then is primarily indicated the necessity for antagonizing agents as suggested in the prescriptions presented a few pages back. When sordes are found enveloping the teeth, or where the mucus is glairy, the condition manifested by such secretions is to find cor- rection before any reasonable hope is to be indulged of saving the denture or of making mechanical operations which may have in them any special import of good. (See Mucoid Saliva.) The restoration to a state of health of gums, turgid and congested from any cause, is to precede dental operations; of such causes of ulitic troubles there are many. These will be found discussed in the chapter on Diseases of tlie Gums. In a word, attention to local or systemic indications is to precede, or have association with, as judgment may determine, the operative requirements of existing cavities of decay. 2. The physical history of a tooth to be treated demands con- sideration. Teeth so vary in character as to suggest their division into four classes. I. Teeth of the Sanguine and Allied Temperaments with Similar Hereditary Association. — These teeth are white, shading into a cream tinge which deepens as it approaches the gum and as age advances: the organs are uniform in dimensions and arrangement, are dense, and have periostea of the most resisting character, — the associated alveolar process being condensed to a corticle-like extent ; their rela- tion with the jaw is so unyielding as not unfrequently to suggest union of the parts. Tliese teeth, as justly remarked by Harris, indi- cate, " if not perfect health, at least a state which bordered very closely on it at the time of their dentin! fication, and the posses- sion of stomachs always willing to digest whatever the teeth are ready to masticate." II. Teeth having a Blue Shade. — These, without doubt, are much more common to females than to males. Constitutionally they indi- LOCAL TREATMENT OF DENTAL CARIES. 279 cate the lyrapliatic temperament. They are commonly super-sensitive, Laving a softness yet tenacity of structure that expresses dispropor- tionate excess in animal matter ; observation seems to indorse the conviction that such teeth are associated more or less in a hereditary history with struma. Certain it is, that to preserve them the most constant watchfulness is necessary, both as a systemic and a local aspect are concerned. III. Chalky Teeth. — Teeth of this class are not unfrequently to be met with having- so little mechanical resistance as to suggest their relation with plaster of Paris. As such teeth have in them- selves no resistive force, an only hope of prolonging their existence lies in the antagonizing of agents injurious to them. Thus arises a necessity of that care on the part of a person so afflicted, which is to keep him informed continuously of the state of the oral fluids, or if such care is not consistent with the character of the individual, then are antacid agents to be kept in constant use. lY. Pearly Teeth — Teeth frequently found allied with the Tuber- culous Predi.'iposifion. — Teeth of this class are commonly of great symmetry, being in harmony with the delicate stature of the indi- vidual, and akin with the organization which has produced them. The inherent force of such organs is much in proportion with, that of the common body. A treatment which tends to preserve them is that which increases the physical integrity of the individual at large, I am not aware of any peculiar local tendency to disease in them. The fluids of such mouths are commonly neutral. Teeth of the first and fourth classes seldom have indications of any required direct preparatory treatment. Teeth of the third class may only have immediate adverse associations antagonized. Teeth of the second class, however, — and these con.stitute four-fifths of all diseased teeth, — are benefited by direct local medication to a degree that is oftentimes found to be their salvation. A soft moist denture indicates non-resistance on the part of the immediate vital force (residing in the organ) to the advancing dis- ease. There is here little or no antagonizing structural consolidation. Can this be remedied ? Without doubt, in perhaps the majority of cases it can ; such remedy residing in stimulation of the dental pulp, and in affording to it a power of response. To secure such response implies combination Avith the local of general stimulation. As the first is concerned, it'Taas been implied that no agent sur- passes the aqueous solution of chloride of zinc as used combined with osteo-dentine. A soft, non-resisting tooth, in which such 280 ORAL DISEASES AND SURGERY. a temporary plug has been used, will not unfrequently in the course of a few months be found so hard that an ordinary excavator shall scarcely be able to make an impression on the dentine ; indeed, in many cases, so thorough has been the calcification that no other treatment is found necessary : the caries has been cured, the dentine vitrified.* In the employment, however, of such stimulation, it is to be in- ferred that the nicest exercise of judgment is demanded. Quite as many teeth are destroyed by chloride of zinc fillings as are saved ; perhaps the preponderance is to the first side ; but this is the fault of a practice which overstimulates, provoking inflammation and sup- puration where gentle excitation to a hypernutrition is alone de- manded. A good rule to adopt is to feel one's way, recognizing always that the extent of local stimulation is to be commensurate with the ability of the pulp to respond ; the object aimed at being to re-excite the formative capacity of the pulp, thus to oppose advancing disease by securing a calciferous barrier. Secondary indications to be met preparatory to filling a carious tooth exist in a necessity for the destruction of any fungi that may be found in the cavity, the immediate antagonism of the carbonic or other acids, or any alkali temporarily present, and the saturation of the part with an antiseptic, — warm alcohol being about the best preparation that may be used for the last purpose. By saturation is meant that the dentine be bathed in this fluid after the preparation of the part and immediately before the introduction of the filling. A person undergoing the process of having teeth filled should freely use as a rinse alcohol and water, combined in the proportion of one part of the first to four of the second. Or, where the refrigerating influences of the spirit are found irritating to the cavity, it may be replaced by the permanganate of potassa, one grain to the ounce of water. Creaaote is also justly lauded as an application to be made to the walls of a cavity just before the introduction of the filling. Or if the odor of this medicament is objectionable, it may be replaced with the glycerole of thymol, a preparation deemed to be possessed of all the virtues of the former article. * Vitrifaction, vitrified. The use of a terra signifying glass — glass-like — would in such a case seem quite as permissible as its application to one of the humors of the eye, the condition being one of glass-like hardness and smooth- ness. Eburnification, or conversion into a substance resembling ivory, is another term used to express the same condition. CHAPTER XII. THE LOCAL TREATMENT OP DENTAL CARIES. FILLING TEETH. The treatment of carious teeth by filling presents itself under the twofold aspect of simple and complicated cases. The first considers cavities, without any organic expression on the part of the teeth affected. The second associates with the cavity vital complaint of various meaning. In other words, cavities which are as holes in pieces of ivory, the filling of which is a simple mechanical manipula- tion, to be done well or ill, according to the skill of the operator, and cavities which demand, previous to their filling, a treatment fitting them to endure the manipulation. Teeth are filled or stopped with various materials, the principal agents employed being gold, tin, amalgam, chloride of zinc. Hill's stopping, and gutta-percha. The basal requirements for a filling are — ability to withstand the mechanical influences of mastication ; resistance to chemical agents ; non-susceptibility to thermal changes ; qualities to admit of ease of introduction into a cavity, and consoli- dation ; harmony in color ; and the absence of properties injurious to the structure of the tooth itself, or to the system at large. Of such different materials, the very best, as a permanent filling, is gold ; after this, tin ; the other agents mentioned being employed chiefly for temporary purposes, — for example, in the practice of army or navy surgeons, or by physicians whose inclination or duties do not afford that practice necessary to the attainment of the required skill in the use of gold or tin. The plastic fillings, as they are called, are so simple and easy of introduction, that any trouble in their use is found to reside almost exclusively in the preparation of the cavity. (See Directions.) Gold, the best material to be employed, is used in two different forms, — gold-foil, or leaf gold, and sponge gold. Gold-foil comes to the operator in leaf form, done up in books, these leaves being of varying weight from two to two hundred (281) 282 ORAL DISEASES AND SUBGERY. and forty grains, the number on the book designating the weight of the leaf. Of these different numbers, some operators prefer one, some another: it is perhaps a matter of choice rather than of real difference. Leaf foil differs also in the characteristics of adhesive- ness and non-adhesiveness. The first is, or may be made, so sticky that it can readily enough be stuck piece to piece, or welded. In this form it is now most commonly used, and maybe quite as easily attached and built upon the plane surface of a metal dollar as within the cavity of a tooth. To effect such a result, it is only necessary to keep the part and metal perfectly dry, and to use, preferably, instruments with serrated points or faces. A fault, however, fre- quently attaching to the adhesive gold, and which may result from lack of care or skill in working it, lies in a want of softness or ductility. Unadhesive foil, employed entirely by some operators, is worked with plain pointed instruments. It is used rolled up in the form of cylinders and mats ; as pellets ; twists ; or in ribbon strips : however worked, the principle of manipulation is the same, being that of wedging, one piece being supported by another. Sponge Gold. — This preparation, as implied in its name, comes in the form of a sponge or porous mass. It is most adhesive, and, as with the sticky foil, if kept perfectly dry during the process of manipulation, can be attached particle to particle, until a tooth, however broken and imperfect, can have its outlines perfectly restored. To use it, serrated pluggers are desirable, and the por- tion of the mass to be employed is to be separated or picked into small pieces by the employment of instruments rather than the moist fingers. A large piece, or a bulk of size sufficient to retain its place in a cavity, is to be first introduced and worked into a solid mass ; to this first piece particle after particle is to be attached until the cavity is filled. It is a preparation more tedious to work than the foil, and, for a perfect operation, would appear to demand much more skill, and infinitely more patience. In this, however, experi- ence seems to differ. Gold, as a preparation for filling teeth, while the most perfect article employed, is yet not without objections. It is, unhappily for this purpose, an admirable conductor of thermal changes, and when used in close proximity with the pulp of a tooth, not unfre- quently so irritates this organ as to result in its inflammation and death. Another objection lies in its color. Tin-Foil. — This is simply purified tin beaten into thin leaves. LOCAL TREATMENT OF DENTAL CARIES. 283 It is worked precisely as gold-foil, and answers, to an extent, the same purpose. It is a softer metal, and less capable therefore of resisting the wear and tear of mastication. It is still more objec- tionable in color than gold, but possesses an advantage over it in being a less sensitive thermal medium. It is also comparatively inexpensive. Like the gold-foil, it is furnished in books. Oxychloride of Zinc, Osteoplastic, Tooth-Bone. — This is a prep- aration of oxide of zinc, silex, titanium, and borax, and is in the market in the form of a whitish, coarse powder. To use it, a small quantity of the material is mixed with a watery solution of the chloride of zinc, — which comes already prepared with the powder ; and in the form of a paste, thus produced, it is packed into the cavity. The most perfect dryness is necessary to any success in its use ; and, if possible, the filling is to be protected from the fluids of the mouth for a period of several hours. This is to be accomplished, — first, by shielding the mass placed in the tooth while in the act of setting or hardening, through the careful employment of napkins and bibulous' paper ; and, second, by dissolving in chloroform a sufficient quantity of gutta-percha to make a thin paste. This, dropped from the point of an instrument over the filling, will per- fectly coat it, and remain adherent for a long while, — quite as long as is necessary. A solution of gum sandarac may be used for the same purpose. For use in very frail front teeth, this plastic preparation warmly commends itself. That it will be most apt to need frequent renewal is to be expected, but it is not unfrequently the case that by its use they may be saved for several years, while in such teeth it has an advantage certainly over gold in the matter of color. Osteoplastic has also its use as a filling for the pulp-chamber and as a non- conductor underlying plugs of metal. It is to be repeated that the highest essential to its integrity consists in keeping the material perfectly dry for as long a period as possible after its introduction into a tooth. That plugs of this material, when in relation with the necks of the teeth, are found to fail so repeatedly implies oftentimes a careless manipulation, which has allowed the filling to get moist before setting. A form of artificial dentine, known as Guillois' cement, attracting at present a good deal of attention, is a preparation which in 1856 was introduced into the commercial market in the way of imitation coral, — sleeve-buttons, shirt-studs, and similar articles being made of it. 284 ORAL DISEASES AND SUBGERY. Dental societies and individuals discussing this agent disagree much as to its merits. It is generally conceded, however, that as a material to underlie gold it is not surpassed, while many of much experience insist on recommending it as the most reliable of all the plastic materials. It is manipulated precisely as the ordinary oxy- chloride of zinc. Dr. Du Bouchet, of Paris, who is very enthusiastic in his admiration of this cement, and who claims most satisfactory results, thus describes his manner of using it: " After the cavity is prepared by thorough excavation, though it is not necessary to shape as carefully as for gold fillings, place a little more of the powder upon a glass slab than is absolutely neces- sary, and near it a drop of the liquid ; then mix into as stiff a paste as possible by means of a small platina spatula, and with which place a small quantity in the cavity, pressing it into all parts with a small inverted cone-drill ; then fill the rest of the cavity with care, and allow a small surplus to bulge out, overlapping the edges of the cavity: then dry the Qlling with bibulous paper, varnish, and leave for another sitting, at which time trim with chisel, and polish somewhat, by means of tape, and then buckskin ; or, before the filling has entirely hardened, pass a burnisher over the surface lightly a number of times, taking care not to disturb the setting; this makes the surface quite dense, and leaves it in a better condition to resist the saliva; then varnish. By means of these precautions the material has a chance of becoming ex- tremely hard before the coat of varnish has worn away, leaving it exposed to the fluids of the mouth, — its only enemies in these cases." An objection certainly lying to the use of this cement is the length of time required in setting, thirty minutes scarcely sufficing for that condition which justifies the removal of the napkin. The ordinary American compounds set in from two to five minutes. Amalgam. — This is a preparation of silver and tin amalgamated with mercury. It is made by melting together varying proportions of the two first-named metals, say equal parts, or two parts of silver to three of the tin — different persons having different formula} — and, when thus united, is comminuted by the file, and put aside for use when needed. This material is furnished by the depots ready for use, being on sale in ounce and half-ounce packages. To make an amalgam, or paste filling, as it is frequently called, take a portion of these filings, enough to correspond with the size LOCAL TREATMENT OF DENTAL CARIES. 285 of the cavity to be filled, place them in some convenient vessel, add a small quantity of mercury, rub the mass together for a few moments, and the solid grains will be found to have disappeared. Add now to the amalgam a few drops of deliquesced chloride of zinc, and again rub the whole together. As a result, the bottom of the vessel will be covered with a dirty, black, pasty mass, while the amalgam, robbed of its impurities, will present itself as a fluid ball of frost-white silver. The next step is to take this ball, and, envelop- ing it in buckskin, cotton cloth, or linen stuff, press out, with for- ceps, the excess of mercury; the result is now a semi-solid mass, which is the preparation to be used in the cavity of the tooth. To introduce this material, it is only necessary to thoroughly dry the cavity with bibulous paper or other absorbing material — supposing the cavity to have been previously prepared — and with any con- venient instrument press the paste into place, finishing it to accord with the articulating tooth. A few hours, and it will be found to have become as hard as the tooth. It may now be dressed and polished, and the operation is thus completed. The employment of the chloride of zinc as a purifying agent is not at all a necessity in the preparation of the mass, and may be omitted if not conveniently at hand. This mode of cleansing amal- gam was introduced several years back by the author, and seems to have passed into quite common use. After \Yashing away the black sediment, the mass is to be thoroughly dried with the bibulous or other moisture-absorbing paper; such drying is to be insisted on, as it conduces much to the tenacity of the mass, through an influence on the process of crystallization. None of the materials employed in the operation of filling teeth has elicited so much discussion, pro and con, as amalgam. Without doubt, it will turn more or less dark every tooth into which it is introduced, and on this single account is not to be used in the front teeth. Still again, it oxidizes, thus giving a black and repulsive appearance to the mouth in which it is placed. That it affects the general health, as affirmed by many of its opposers, is not per- haps to be accepted as true. I am not myself able to recall any decided case of such a result. That, however, used in conjunction with other metals, the influence is locally bad, can scarcely be denied, — although exceptional cases may exist. No material is in more common use than amalgam ; thousands of teeth are filled with it every day, and it is not to be denied that cases enough present 286 ORAL DISEASES AND SURGERY. where such a filling seems the only one that can be used. It is claimed that if a tooth be properly prepared, and the material be carefully introduced, an amalgam filling will last quite as long as would one of gold. Such an assertion applies only, however, where the process of structural consolidation is excited by the presence of the plug, or where the dentine of a tooth is naturally very solid. The use of amalgam seems necessitated in many cases in which gold cannot be used and w^here tooth-bone or the gutta-percha preparations might not bear the demands of the act of mastication or the action of chemical antagonists. In the teeth of soldiers, where the convenience of the service, lack of manipulative skill on the part of the surgeon with gold or tin, or the habits of most of the patients, would render the use of gold scarcely permissible, amalgam would certainly seem to recommend itself. (See strictures of Mr. Bridgman, on the electro-chemical relations of the amal- gams.) EilVs Stopping. — This is a preparation composed of gutta-percha, quicklime, and feldspar ; it is to bo purchased at any of the dental depots at a very reasonable price, and, as a temporary filling, may be highh' commended: such a plug will not unfrequently be found preserving a tooth for several months, or, it may be, years. To introduce it, it is only necessary to soften a piece of the size required by laying it upon a heated plate, and while in such plastic condition introduce it, by means of any convenient instrument, into the pre- pared cavity. Care is to be exercised that no shreds be allowed to override the orifice of the cavity, such excess being easily removed with an instrument which has been held for a single moment in the flame of a spirit-lamp, or otherwise it may be dissolved and washed away with a pellet of cotton which has been saturated with chloro- form. This agent, while nicely smoothing the filling, is thought, however, by many to render it porous and brittle. The only objec- tion that may be urged against this compound, if used in accord- ance with the indications of cases as referred to in the previous chapter, is its lack of durability. Gutta-Percha. — This agent is not unfrequently employed as a temporary filling with most satisfactory results. It is treated pre- cisely as the Hill's stopping, and, as is seen, resembles this stopping when incorporated with other materials. "Where one desires for himself to make a compound gutta-percha, it may be done by mixing LOCAL TREATMENT OF DENTAL CARIES. 287 a powder composed of quicklime two parts, very finely pulverized quartz, and feldspar, each one part; the softened gutta-percha is worked with this powder until it will hold no more without be- coming brittle. White gutta-percha is in itself, however, a most admirable temporary filling ; it adheres tenaciously to the walls of a perfectly dry cavity, and where it has been inserted with proper care may be depended on to preserve a tooth for a long time. I have seen a tooth and plug as good after two years' service as on the day of the operation. A filling of gutta-percha will commend itself above all others in very many instances. I have certainly seen it preserve teeth where the cavities were situated on the buccal and proximal faces of the molars and bicuspidati, in cases where gold had failed, an explanation of which would seem to be found in the illustration as exhibited in Mr. Bridgman's experiments. A form of gutta-percha preferred by many is that employed for making test-plates. Some of this is found exceedingly tough and resistive, and will, without doubt, make a filling which may be trusted for a long time. From this review of the materials employed in filling teeth we may pass to instruments and apparatus required in the manipula- tions. Excavators. — An excavator is an instrument designed to excavate or clean out a cavity. Excavators, while variously modified, are founded on two elementary styles : one, hoe-like in shape, cutting as drawn toward the operator, the other represented by the relation of the edge of the ordinary hatchet to its shaft or handle. Fig. 62. — Hoe Excavators and Modifications. 1 n n n n n r 288 OBAL DISEASES AND SURGERY. Hoe Excavators and MoDiFiCATroNS. Pig. 63. — Hatchet Excavators anb Modifications. II I » '" OOft fl Fig. 64. — Rose Drills and Spear Drills. 1 1 LOCAL TREATMENT OF DENTAL CARIES. 289 KosE Drills and Speak Drills. V w Examination of the diagrams gives tbe general idea of these in- struments. Unless, however, made of the finest steel, and shaped and tempered with the nicest appreciation and care, it is impossible to execute with them the requirements demanded. Excavators fit for the hand of the operator should first be able to endure the test of an unturned edge when used to cut a cavity in a piece of ivory. Drills — Rose and Spear. — Associated for a common purpose with the excavator are the spear and rose drills ; these instruments, per- fectly exhibited by the diagram, are found happily adapted to the reaming out of cavities upon tiie grinding and other exposed sur- faces of the teeth. When properly tempered, they cut with great rapidity, and while clearing the cavity tend also to give convenient shape for the retention of the filling. They are used also for the purpose of securing what are called retaining points for plugs, a matter to have consideration in connection with particular cavities. Drills, like excavators, are made with handle and point in one piece, or are fitted to separate handles, which may be made of steel, ebony, 19 290 ORAL DISEASES AND SURGERY. pearl, or more expensive material, to please the taste; the single piece is. however, commonly preferred, as being the most con- venient form. To use this instrument it is only necessary to rotate it between the thumb and finger, or, where pressure is found desir- able, the palm of the hand may be spared by receiving the butt of the drill in a socketed ring or thimble. Drills are also used associ- ated with handles, which allow of application at any angle desired. Of such stocks there are quite a variety, the most simple of which is perhaps that known as Merry's. Fig. 65 exhibits this drill as Fig. 65. Fig. 66. Merry's drill, ivory handle. Bur thimble. ready for use. Fig. 66 represents the bur thimble : this consists of an open ring for the middle or the index finger, with a socket at- tached, in which rests the end of the handle of the drill. It not only saves the hand, but the instrument is rotated much more easily. Instruments more lately introduced, and growing rapidly in favor with operators, are Green's pneumatic engine, Morrison's burring apparatus, Black's and Bonwille's office lathe and finishing drill. These are all labor-saving machines, and would seem pos- sessed of that principle which must eventually bring them into general use. While these various appliances have a common pur- pose, — namely, the rotation of instruments used in preparing cavi- ties, cutting down and finishing fillings, removing tartar, polishing teeth, etc., — the first differs from the others in having its power supplied by a bellows which is conveniently worked by the foot, — Morrison's, Black's, and Bonwille's being worked by a treadle applied as in the ordinary lathe. It is claimed by the devisers of these various instruments that not only is there great economy of time through their use, afford- LOCAL TREATMENT OF DENTAL CARIES. 291 ing to an operator the ability to fill many more teeth in a given period, but that in every respect greater comfort is secured to the patient, the instruments destroying, through rapidity of revolu- tion, — from fifteen hundred to four thousand in a minute, — the sen- sibility of dentine, relieving from the necessity of severe extension of the lips and prolonged sittings, and accomplishing besides a char- acter of work that could not otherwise be secured. An understanding of these instruments is had by referring to the Merry drill ; the new apparatus represents simply the application of power to this form of machine. The oral surgeon who may find himself closely restricted to the operations upon the teeth must certainly discover his conveni- ence and comfort consulted in employing in his practice the aid of such appliances. An objection offered against their use, but one which the manufacturers will, without doubt, shortly overcome, is deficiency in working with that trueness which enables the operator to possess Fig. 67. — Forms of Chisels used in Dentistry. /I 292 ORAL DISEASES AND SURGERY. Fig. 68. — Jack's Double-End Enamel Chisels. over his drill the desired, and, indeed, absolutely neces- sary, control. Instruments most frequently found demanded for such exposure of a cavity as shall allow manipulation with the excavators and drills, are chisels and files. All cavi- ties in proximal surfaces require the employment of these instruments. Both, as would be inferred, have a variety of modifications. But with whatever particular one an operator may find himself able most conveniently to meet the indications of his case, that is the one he is to employ. As experience has made felt the necessity for the modi- fications, so a very little practice will best show the operator which of the forms he may select to meet his purpose. Fig. 61 exhibits the style and form of chisels in or- dinary use. A modification on these chisels is known as Jack's double-end enamel cutters. Six instruments- con- stitute a set, such a set being designed to furnish " all the forms needed for freely cutting the enamel in sep- arating teeth." Fig. 68 exhibits these chisels. Still another character of chisels are those designed for opening fissures, cutting retaining points, and also LOCAL TREATMENT OF DENTAL CARIES. 293 Fig. 69. i 1 i ■ for enamel cutting, wherever applicable. Fig. 69 exhibits what are known as Forbes's gouge and Jack's paraboloid chisels, — instruments in general favor with operators, and capable of ac- complishing their work most satisfactorily. Nos. 1, 2, 3, t, 8, and 9 show the Forbes's gouge ; and Nos. 4, 5, 6, 10, 11, and 12 illustrate Dr. Jack's paraboloid chisels. Files. — Fig. TO represents a simple straight file, which is to be viewed as the base from which the varieties digress. A file of such form would at once be accepted as well adapted to separating two proximating surfaces, as, for example, the in- cisor teeth. Such plain files, while alike in general form, differ greatly in thickness of blade and depth of cut, some indeed being so deli- cate as rather to act the part of burnishers, following those of heavier cut. Plain files are employed in separating the ante- rior ten teeth, superior and inferior. A form of plain file preferred by many operators is that suited to a common carrier. Fig. Tl represents such a file and carrier. A form of separating file in common use, without doubt the most convenient, and the least expensive, is exhibited on a fol- lowing page. (Fig. 79.) These are to be procured in packages of assorted sizes. Separating files, so modified as to be adapted for convenient use with the back teeth, are also shown. (Fig. 85.) Having thus exhibited the instruments necessary for the exposure and preparation of a cavity, we pass to the study of the manipula- 294 ORAL DISEASES AND SURGERY. tions ; and first we consider the most simple of cavities, i.e. a hole more or less round, situated on the grinding face of a molar tooth. In Fig. "72 are exhibited a number of these simple cavities. Sulci, so presenting, vary in the extent of the underlying decay as influ- enced by the structure of the organs in which they are found. In teeth of dense material, for example, they will seldom be found larger within than at the orifice. On the contrary, where the dentine is loose and non-resisting, as found in classes two and three, a very Fig. 70. — Separating File. small orifice will not unfrequently be found to lead to most exten- sive disorganization. To prepare such cavities for filling, an operator may use either excavator or drill, as may be preferred : perhaps the most simple means is found in the drill: selecting a size suited to FiQ. 71. mmmmmmmm Fig. 72. the orifice, the operation consists simply in reaming out the hole, the single precaution being observed of having the common diameter of the cavity as large as the outlet; to have it a trifle larger is better, as thus a filling is retained with greater security. In cases where, after breaking through the orifice, a large cavity is seen to exist, drill after drill of increasing sizes may be employed, thus making the circumference of the orifice correspond with the cavity being made within. Or in such cases as present a resisting enamel the orifice is to be most conveniently enlarged through the use of the chisel. Selecting one of suitable size, the operator, little by little, chips away the operculum until the circumference of the diseased dentine is exposed ; this accomplished, it remains only to refer to the drill or excavator. In using a rose drill, the precaution is to be taken of avoiding the evolvement of discomforting heat ensuing from rapidity of rotation, which is to be done by careful drilling, or otherwise the fre- quent dipping of the instrument in cold water. Simple cavities on grinding face of molars. LOCAL TREATMENT OF DENTAL CARIES. 295 Fig. 73 represents cavities frequently found on the posterior face of incisor teeth. Such cavities correspond closely in their mode of preparation with those just described. A peculiarity occasionally observed, however, exists in the tendency of a delicate line of disease to start from the bottom of the common cavity, making its way directly toward the pulp-chamber: where such line is found, it is neither necessary nor desirable to associate it with the first cavity otherwise than by a reaming correspondent with its own size : should it be found to increase greatly in sensibility as it approaches the pulp, ray own experience has satis- fied me that it is much the best plan to allow a portion of the diseased dentine to remain: harm will not be apt to „ ... . ■ r .■ ■ ' '^ Cavities on posterior face of incisors. ensue from its presence if it be disin- fected and put into a state of neutrality, such diseased neutralized dentine most frequently becoming encysted ; that is to say, when properly treated, — as has been referred to, — being surrounded by a wall of consolidated tubules, while protected of course externally by the overlying filling. Rose drills are commonly used, to the ex- clusion of other instruments, in the preparation of these cavities, although the occasional convenience of the excavator is not to be denied. Great care is to be exercised in these cases, as, indeed, in all others, to have the orifice of the cavity sharply defined in its circumference ; if it be strictly round, so much the better, as thus the material used in filling can be made the more easily to asso- ciate harmoniously with it : such union being an absolute essential to the integrity of any plug. Fig. 74. Ftg. 75. Ftg. 76. Cavities at neck — anterior Cavities found in the midst Cavities on buccal face of face^of incisors. of imperfect enamel. molars. Fig. 74 represents what may be described as the third class of cavities : they are very frequently met with in the position shown in the cut. A more common location, however, is on the buccal face of the molar teeth in a sulcus about midway of this face. When situated as seen in the drawing, part of the cavity being overlaid by the gum, it will be found most convenient to remove a 296 ORAL DISEASES AND SURGERY. portion of the carious dentine by the use of the excavator, and, thus securing a cavity, stuff it firmly with a cotton filling, which is to be allowed to project to some little extent ; this filling, as it absorbs moisture and swells, naturally throws the gum from off the cavity, thus allowing the completion of the excavation as described in the previous cases. Fig. *75 represents a condition of imperfect enamel, in which are frequently found a number of pits: if examination reveals the bot- tom of such pits to be enamel-covered, they need not be filled ; if, however, the sharp point of the instrument used for the exploration be found to stick or wedge, then the}^ are to be reamed out with the spear or rose drill. Not to treat and fill such cavities would be to allow caries to destroy the teeth. Unless of themselves running into each other, these cavities are not to be associated. Situated on the buccal faces of the molars, such cavities are to be reamed out with the rose drill. A complication frequently found to" exist is where, starting from such a -^^°" ' '• point, or it mny be in an abra- sion near the neck of the tooth, the disease extends laterally, scooping out, as it were, a cavity (Fig. 77) : here the ex- cavities on buccal .ace of molar.. cavator Is fouud most Conve- nient, while the employment of the chisel to uncover the caries is most likely made necessary. In excavating cavities of this aspect, it is common to have a slight undercut immediately beneath the enamel ; such undercut being necessary for the support of the filling. From cavities situated as just described, we pass to the consid- eration of others so related as to demand for their exposure not only ingenuity, but also such clinical data as shall show what extent of chiseling, filing, or pressure is permissible, not alone as the endurance of the teeth is concerned, but as reference shall be bad to appear- ance, and, where possible, to self-cleansing surfaces. The denture shown in Fig. 78 is a type of many often exhibiting themselves. Upon the left side are shown the teeth as involved by the caries when a patient presents himself. Upon the opposite side are represented the same cavities when made ready to receive the filling. The second and third molars of left side, however, are utilized to exhibit contour cavities. Proximal cavities are to be exposed, by V-shaped filing. This is LOCAL TREATMENT OF DENTAL CARIES. 297 tbe common rule, yet having exceptions, as will hereafter be ex- plained. A central incisor tooth, decayed upon the surface con- cealed bv its neighbor, the relation of the teeth being as exhibited Fig. 78. Fig. 79. Carious denture. in the diagram, the operation of exposure is commenced by passing a delicate separating file between the two teeth, a shoulder, however, being left at the neck, which is to prevent the future falling together of the cut faces. Space for the play of the file being thus secured, the first in- strument is replaced by a second, this latter being curved in its blade, and having a single cutting surface, which is slightly convex. With the convex file, it is plainly seen that it is only necessary to incline the free face against the tooth not to be cut, that the inclined plane looking inward shall be made to act upon the affected tooth. (See diagram.) When the decay is common to both teeth, the double filing is seen to make the Y-cut with the base backward. Looking at the central incisor on the right of the diagram, separating tiles. — (llie tiist " ... is of convex face.) the cavitv (shown ou the left incisor) is found placed on the inclined plane, all its parietes being exposed and easy to get at. This has been the result 298 ORAL DISEASES AND SURGERY. of the filing. The tooth, while widely separated from its fellow behind, affording plenty of room for operating, shows in front but the space made by the passage of the delicate separating file. This mode of separating applies to the six anterior teeth. After making the primary cut with the separating file between the teeth from the front, it is the habit with many operators to rely for the back separation principally on the chisel. If handled deli- cately, there is perhaps little doubt that this instrument is found least disagreeable to the patient, and, when used sharp and of proper curvature, it will most satisfactorily accomplish the work : the file, however, is commonly employed to finish the separation. A proximal cavity, without complications, thus exposed (see cen- tral, lateral, and cuspid teeth in diagram), nothing remains but to treat it as the simple cavities before described, — that is, cut away the carious dentine, and form the cavity of a shape to retain the filling. Such excavating is generally done with the hoe and hatchet exca- vators, the head of the patient being thrown backwards. The rose and spear drills, however, at times are here found very convenient of use, particularly where, the cavity being of saucer-shape, what are called retaining points are required. Complications. — The cavities just described are those of such limited size as to have made no alteration in the front or back faces of the teeth. From the consideration of Fig. 80. , , , ^ , . such we pass to a class as represented m Fig. 80, where, as is seen, the labial face is markedly affected. In examining these teeth, let the student draw a transverse line midway between the cavities and the gum. From this first line let him drop vertically others which shall just include the carious breaks on the faces of the teeth. Where the cavities are no more extensive than exhibited in the diagram, he will find that the file removing all between his lines will yield no deformity, but afford, on the contrary, a space possessed of healthy look and not unbe- coming singularity. As a next step, let the convex-faced file be used, cutting wider the space posteriorly so as to allow the cavity to be seen only from that surface. He has thus his cavities in the same position and relation as existing in the cases above described. A second complication on such order of cavities is where the teeth affected are so related to each other and to the arch, and the cavities of so extensive a character, as to make any alteration in LOCAL TBEATMENT OF DENTAL CARIES. 299 the outlook impossible. Cases of this kind are found where caries has extended its ravages over half the anterior face of the tooth, or where a tooth has such position in the arch that what should be the proximal surface is found looking almost directly forward, the tooth being twisted, as it were. Conditions of such expression are com- monly treated by excavating in any manner found most convenient; the original contour of the tooth being restored by the filling; other- wise such teeth may be filed in front until resisting parietes to the cavities are found, and then treated precisely as in the case of the posterior V. Teeth having the base of the V looking forward are of course objectionable, but many so treated — the fillings being very solid and highly fioished — are far from unsightly. Another class of complications exist in teeth related as in Fig. 81. Taking the central incisors as the first demonstration ; the tooth on the right Fig. 81. side of the diagram is seen to over- ride its fellow and to impinge alone near the cutting edge. In cases of this kind it is scarcely probable that either file or chisel will be found admis- sible, as it is plainly seen that no expedient will apply to prevent the cut surfaces falling again together. In exposing the cavities in these cases, — if found, as is usual, on the covered surface, — the means employed is that of pressure, either a wedge of some soft wood or a section of tough rubber tubing being employed. Of the two means, the immediate wedging by the wood is found to afford the least pain, a wedge of the proper size being driven delicately between the teeth until sufficient room to work at the cavity has been secured. Where the india-rubber is used, it is common to exert the pressure gradually, pieces of increasing size being introduced until the desired separation is obtained. Objection to such means of separating teeth lies in the soreness provoked, the subsequent operation of filling being at times rendered so painful as to be nearly if not quite unbearable. In using the wedge of wood, the separating, excavating, and filling are to be done at the same sitting. To introduce such a wedge, it is found most convenient to cut it on the end of a stick of some length, nick- ing deeply at the base of the wedge. It is thus easily thrust by the hand between the teeth, or allows of the convenient application of the required force by the mallet. When in place, the wedge is cut off at the nick. Referring again to the diagram. Fig. 81, another modification is 300 ORAL DISEASES AND SURGERY. Fig. 82. found in the relation of the lateral incisor of the right side to the central. As in the case of the central with its fellow, it is seen to override, but it differs from this first in possessing an impinging surface, continuing from the cutting edge to the neck. Teeth so related are to be separated, first, by the wedge introduced at the neck ; and, second, may have the space thus secured increased by the file, the cutting, however, to be so directed as to leave at the neck an unfiled portion which shall prevent the parts falling again together, after the removal of the wedge. To excavate and fill a cavity in such a situation would seem to be a very difficult matter, and, indeed, will be found so, unless the operator forces for himself space, and which in all instances is to be effected, wedges of wood or india-rul)ber and the file being used as found necessary. It is to be accepted as a rule that the file may be used where after-changes are not to bring the cut surfaces in contact. Still another modification is exhibited in Fig. 82. Here the gums are found somewhat receded, the necks of the teeth being exposed. In the proximal surface of each tooth near the gums is a cavity of decay. To get at such cavities, the space made by nature in the V-spaces seen in the diagram may be all- sufficient. If this should not be the case, then the wedge may be employed, being driven midway between the cavity of decay and the cutting edge. Such cavities being excavated and filled, the teeth are allowed to fall together. It must be seen that the mis- fortune of fillings so placed would lie in the absence of self-cleansing properties, compelling thus continual care for their preservation. To obviate such an objection, the use of the chisel has been advo- cated, scooping out a Y-space which is to extend from the neck to the cutting edge, treating such teeth, indeed, precisely as described with the uncomplicated cases, — a plan undoubtedly to be preferred where no lateral pressure exists to force the cut surfaces together. In Fig. 83, representing the six inferior anterior teeth, the same condition is ex- hibited as shown in Fig. 82. The plan of treatment would, of course, be the same. Other modifications connected with the anterior teeth will not unfrequently be en- countered, but with the general ideas here given the ingenious operator Fig LOCAL TREATMENT OF DENTAL GAR FES. 301 will find in his own skill, after a little experience, all the directions required. In deciding on a mode of separating teeth, the practitioner will find constant demand for the exercise of judgment. It may be laid down, however, as a rule that never more than two teeth should be undergoing the process in the same mouth at the same time. When the rubber is used, it is also to be accepted as a rule that plenty of time should be allowed for the operation, — from two to five days being about the time required ; that when soreness arises no increase in the thickness of the rubber is to be made until it has subsided. As a rule, young teeth endure displacement better than old ones ; indeed, it seems to be a conclusion of many, that separation of the teeth in persons over forty years of age may be made with safety alone by the file. In filling proximal cavities, occasion is often felt for the use of a very temporary matrix, — a form of instrument lath-shaped in blade, Fig. 84. ^ II which may be passed between the teeth, making a wall of suppoi't for the gold until convenience allows of its condensation. The flat blade No. 5 from the right, Fig. 84, represents such an instru- ment. It is a blade which will be felt to contribute very much to facility in filling such cavities. To use it, it is simply necessary to rest it flatwise against the neck-wall of the cavity, creating thus a fully-bounded hole into which the gold is worked. (See 3Iatrices.) Modifications of excavators are also exhibited in Fig.. 84, which will be found uiost valuable in excavating ; indeed, than the forms 1, 2, 3, 5, and 6, left side of diagram, none better may be found. 302 ORAL DISEASES AND SURGERY. They cannot be too highly commended, being recognized to apply to almost every form and position of cavity. Passing now to the bicuspid teeth, the diagram Fig. 78 ex- hibits approximal decay involving both teeth of the left side. Teeth presenting cavities to the grinding face, as here seen, will invariably be found scooped out, and overhung by unsupported enamel. To fully uncover such cavities, no instrument is better than the chisel, — the operator simply cutting away the operculum, directing, where possible, the greatest breadth of the cut inward ; such manner of cutting is expressed upon the opposite side of the diagram, where, as is seen, the cavities are fully exposed upon the sides of inclined planes, while the anterior faces of the teeth are not at all disturbed, the cavities being put into a position and aspect in which they may be esteemed as simple and without complication. Complications. — A first complication may be described as a proximal cavity associated with a second occupying the sulcus found on the grinding face of these teeth. Here a plan pursued by many consists in exposing the first cavity as just directed, and, this accomplished, preparing the second precisely as in any simple crown cavity. If both are found entirely separate, perfectly healthy dentine lying between them, they may be treated as distinct cavi- ties ; if, on the contrary, there is found to be the slightest associa- tion, they are joined together by cutting out the septum which re- lates them. A second complication is found in the existence of that extent of decay which has so weakened the front or back wall of the tooth as to make the removal of such wall necessary. Such a condition is unfortunate, as it renders the operation of filling more difficult, except, indeed, to the experienced, who are able to adopt the plan of making what is called a contour-filling, — that is, building up with metal the part lost. To prepare such a tooth for filling, the operator finds himself compelled to cut wherever the disease may lead him. This he does, using the chisel, — chipping away, little by little, the weak parts, desisting only when the evidences of disease are passed. Commonly,. teeth so decayed are found with the pulps exposed ; if this should not be the case in any particular instance, the question of how the required filling is to be retained becomes of all con- sideration in the cutting of the cavity, the answer mostly existing in the formation of retaining points. These are points or slots cut out of the dentine, allowing places of anchorage ; fillings in such teeth being made — when ffold is used — of that form known as LOCAL TREATMENT OF DENTAL CARIES. 303 the adhesive ; it being remembered that it was remarked of gold thus prepared that it could, with all facility, be built upon the sur- face of a metal dollar. Still another complication met with occasionally consists in cavities meeting in the middle from either proximal surface. Such cavi- ties are treated by cutting away with the chisel all the overlying grinding surface, thus making a common cavity, which occupies perhaps the whole body of the tooth. Thus exposed, this common cavity is excavated and cleansed precisely as though it were, what indeed it has become, a deep crown cavity. (See diatrices.) Such a cavity necessitates contouring. The most common form of decay found in the bicuspid teeth, excepting the proximal, is that running in the sulcus between the two cusps. Where this is simple, it is prepared for filling by ream- ing it out at either extremity with a delicate rose drill, and con- necting the two drill-holes by the employment of the excavator or chisel. A modification in this single groove is frequently seen in a middle point of division entirely healthy. If such septum is of any size, it maybe allowed to remain, and each cavity be reamed out separately. Fig. 8o. BIB ^aarfly ^^''' "'' 1"™"!'""'^ luMMiU MMmm Form of Files used in separating the Molar ieeth. When, however, the slightest doubt exists as to its integrity, it is much the safer plan to remove it, thus cutting the two cavities into one. We refer now again to the diagram. Fig. 18, and observe the relation of the proximal faces of the first and second molars as seen on the left side. These teeth, while presenting at the surface a healthy aspect, are yet found to have cavities midway of this face, and which, as thus situated, have only been discovered by the insinuated 304 ORAL DISEASES AND SURGERY. point of a delicate excavator, or, what is more likely, the passage of a silk thread. Referring now to the opposite side, these cavities are found exposed. This is accomplished either by the chisel, or otherwise by files purposely prepared to make such a cut so far back in the mouth without interfering with the lips. Fig. 85 represents such files. The cavities, before unseen, are now exhibited upon the sides of the inclined planes, and fillings placed in them are recognized to have surfaces that must be self-cleansing. Passing to the grinding surface of these same teeth, cavities of decay are seen running out over the lateral walls. The excavation of these consists simply in following the sulci wherever they may lead, bearing in mind the fact that the excavation is to be of such character as provides for the retention of the filling ; that is, that at all aspects it is to have a wall slightly concave. Sometimes, when much depth has been attained by that portion of the decay in the crown, and perhaps as well that upon the side, — the connecting sulcus being of slight signification, — it is good practice to scoop out this intervening portion, without regard to the shape of its walls, and carr}'' the adhesive gold, arch-like, into and over it from one plug to the other. Passing now to the proximal faces of the second and third molars, left side, attempt has been made by the artist to represent cavities in these teeth prepared for contour-fillings, — a plan of preparing all proximal cavities of any extent in the bicuspidati and molars grow- ing rapidly into general favor, and certainly productive of the ability to make beautiful operations. First, it is seen that a sepa- rating file, slightly V-shaped, has been passed between the teeth. Next, the cavities have been excavated, being cut directly down from the crown surface, and have been so shaped that in putting in the metal the operator works directly from this crown surface. These teeth are so excavated that when filled it is proposed to re- store fully the portion lost. The preparation of the teeth — molars or others — for contour-fill- ings must find direction in experience. It is to be recognized that the idea and intention are to repeat in metal what has decayed or been cut away. In proportion as the part removed has been extensive, so must it be recognized that proportionate difficulty will exist in securing fixedness for the filling. Contour-fillings, save in exceptional cases, should possess inclined surfaces. A filling which represents the surface of an inclined plane has been amply demon- strated by experience to be the better kind. LOCAL TREATMENT OF DENTAL CAEIES. 305 In excavating a cavity of any class, certain rules are to be observed and practiced : 1. A cavity must have such exposure as shall afford room to introduce the filling properly. 2. Walls are to be made as perpendicular as the case will admit of, and the margin of a cavity is to be at right angles with the sur- rounding surface. 3. The orifice of a cavity is to be without fissures or irregularities wherever these may be avoided; must have a firm decided margin, and must be supported solidly by the underlying dentine. Rough- ness or brittleness in the edges of a cavity is most objectionable. 4. In excavating a tooth, regard is to be had to the proximity of the pulp. A pulp is not unnecessarily or carelessly to be exposed, nor to be too closely approached ; for if the first, the case is immedi- ately changed from simple to complicated ; if the latter, the organ might eventually become chronically inflamed, and die, as a result of the thermal irritation arising from the presence of the filling. Neither is it permissil)le to file or chisel a tooth too freely, except where regard is had to the density of the organ. A tooth of very loose texture will not uufrequently have an inflammation of the dentine and pulp provoked by the removal of even a slight portion of its enamel, while, on the contrary, a tooth of very dense structure may commonly be cut with considerable impunity. 5. In cavities having radii running from a common centre, which radii may not with propriety, on account of their extent, be included in a single round hole, care is to be observed that each extremity be rounded, never being allowed to retain its natural sharpness or fissure-like aspect. Crown fillings fail more frequently from the non-observance of this rule than from perhaps any other cause. In the process of excavating the teeth, the practitioner will re- quire, besides the instruments mentioned, a syringe for washing away the debris, and a mouth-mirror, to be used either for casting additional rays of light, or showing him more conveniently the cavity at which he may be working. Of the two mirrors exhibited, the form represented in Fig. 86 is the most desirable. Syringes are of various construction. Fig. 88 represents one made with a hand bulb of rubber. It is to be commended for a simplicity of construction which does not allow it easilv to get out of order. 20 306 ' ORAL DISEASES AND SURGERY. Fig. 86. Fio. 87. Fig. Fig. 80. CHAPTER XIII. LOCAL TREATMENT OP DENTAL CARIES. INTRODUCTION OF THE FILLING. The instruments required for introducing a filling of gold will viu'y necessarily somewhat with the position of the cavity to be filled, and the character of the metal used, — whether adhesive or non-adhesive. A filling of non-adhesive gold is made on the principle of wedging. A filling of adhesive gold is made on the principle of interdigi- tation, or welding of the particles. To use the first form of gold, wedge points are employed. Such points, as for sale in the depots, are found of every variety of curve. A skillful hand, however, is best served in the forms represented in Fig. f'O. Fio. 91. Plain-pointed plii Serrated points. the diagram. Fig. 90, and in a single modification where the wedge is at right angles with the shaft. A wedge plugger may be slightly rough on its surface. To employ the adhesive gold, instruments with points more or less serrated are to be preferred. These serrations require to be kept very smooth on their planes, otherwise the metal is pulled away quite as rapidly as it is attached. Fig. 91 exhibits points of serra- tion magnified. The handle of a plugging instrument is to be round or octagonal, and so roughened that the hand shall hold it firmly, while the blade (307) 308 ORAL DISEASES AND SURGERY. is to be of a temper which allows of the employment of the neces- sary force without danger either of breaking or bending. These instruments have of late been brought to such perfection by the makers that the operator need not hesitate to receive them as sup- plied. The temper, at the point, is to be of straw color, and from this, u]) to where substance gives strength, it is to be purple. As dryness is essential to the integrity of a plug, we digress at this point to review the means equivalent to sucli end. Napkin)^. — Answering in all ordinary cases we have the napkin. A dental napkin is an oblong square of linen, varying in size to suit the idea of the operator; dimensions which will be found conve- nient are: length, twelve inches; breadth, three. In applying this napkin to the upper denture, it is folded upon it.self in part obliquely, until one end is brought to a point. Beginning with this point, the linen is laid delicately and smoothly between the gums and cheek, being carried backward or forward according as the initial end may have been placed, until turning into the mouth at a convenient dis- tance from the tooth to be operated upon, it is made thus to envelop the organ, being supported on either side of the arch by the fingers of the left hand. Applied to the lower denture, the napkin is first folded upon itself into a ribbon-shape of an inch in width ; second, the initial extremity is back-folded until a pad is made which shall correspond in length to its width, that is, being an inch each way. This pad is to be laid upon the floor of the mouth directly back of the incisor teeth, thus covering the orifices of the ducts of both the submaxillary and the sublingual glands : from this point it is carried around the arch into the vestibule as required. To hold the floor pad firmly in place, as is demanded, various plans are adopted. The most common one is, where the tooth to be filled is upon the right side of the jaw, for the operator himself to fix it by the thumb of the left hand while the index-finger is extended over the part occupying the vestibule. Where the tooth to be shielded is upon the left side, the index-finger of the right hand of the patient is employed, the three remaining fingers being doubled out of the way beneath the chin. As the encroachment of the saliva constitutes about the most trou- blesome oflense in dental operations, ingenuity has been exercised to its utmost for its control. Fig. 92 represents a tongue-holder devised by Dr. J. Foster Flagg. LOCAL TBEATMENT OF DENTAL CARIES. 309 Fig. 92. "It will be found that the use of this instrument will insure addi- tional facility to the operator, and maintain the tongue in position with perfect comfort to the patient, producing no fatigue, no un- pleasant sensations, and even removing all desire to resist constraint. After introducing a fold of napkin, or a small piece of muslin, under the tongue, and then covering that organ by l^ack-folding the napkin, or placing another small piece of muslin upon it, the holder should be put in position nearest to the side where it is proposed to operate, and the patient be requested to retain it thus by means of the inglit hand if the cavity be on the left side, and the left hand if the cavity be on the right side, the elbow resting upon the arm of the operating-chair." Another instrument, a modification on an ingenious invention of Dr. Hawes, is that which bears the name of Morrison's compressor. (See Fig. 93.) The diagram fully illustrates its working. The Fig. 93. Morrison's compressor. napkin, being put into place beneath the tongue, is held by the bars of the curve, the cup receiving the chin, the ratchet-work approxi- mating and holding the two parts in the required relation. A later 310 ORAL DISEASES AND SURGERY. instrument of this same character is one designed by P. T. Smith, Fig. 94. Siiliva-puiiip. D.D.S., the variation consisting in the sliding of the bar which supports the compress, and in an ability to change the position of the chin-rest. A still later, is a porcelain tongue thimble, which highly commends itself. The annexed cut represents " a saliva-pump and tongue-holder combined, the invention of Dr. Dibble. The object of this instru- ment is to facilitate the operation of filling teeth of the lower jaw by keeping the mouth free from saliva, and as a means of holding the tongue away from the teeth ; also a means of supporting the upper jaw, and so assisting the muscles which keep the mouth open, the application of which will be readily understood from the illus- tration. The instrument is com- posed of coin silver heavily plated with gold, and hard rubber. A designates the plate which keeps the tongue away from the teeth ; B, the arm which supports the jaw; C, the silver tube and base which fit over the jaw ; D, the opening where the saliva enters the tube ; E, the chamber that receives the saliva. A vacuum is made in the saliva chamber by the pressure of the bulb I, thereby causing the saliva to flow into the opening D ; H, the opening where the saliva is discharged ; Gr, the exhaust-valve. There are two mouth-pieces, one for the right side and one for the left side of the mouth. " The instrument is readily LOCAL TREATMENT OF DENTAL CARIES. 311 cleaned externally bv means of a brush, soap, and water; internallv, b}' drawing- soap and water through it. It must not be laid down on its side after using until emptied of saliva. The entire length of the instrument is fifteen inches." An instrument most happily serving as an adjunct to the man- aging of a napkin, holding in place pellets of spunk, bibulous paper, etc., is an extension-finger devised by Dr. J. H. McQuillen. This consists of a silver shield (see Fig. 95) (to be worn upon the index- finger) with a socket on the under surface, in whicli a steel finger B fits. A number of these fingers or bits bent at d liferent angles Fig. 05. McQuillen's extension-fingev. Taffs tliinil.Ie. accompany the shield, being adapted to meet the various require- ments. This instrument is also found of the greatest assistance in fixing mats of gold in position during the process of filling, doing away, in many instances, with the necessity for retaining points. A second form of instrument having a similar signification with that just described, known as Taft's thimble and extension, is repre- sented in Fig. 96. This thimble is to be used upon the index or middle finger of the left hand. It is also employed to aid in holding the napkin, paper, spunk, or whatever may be used to prevent the encroachment of saliva. The point of this instrument, like the first, can extend into the mouth where the finger, either on account of its size, or for want of length, cannot go. It may also be used to hold down a piece of gold until it is made fast in the proper position. It will likewise be found a convenience with which to reach over and draw the napkin up firmly against the lingual sides of the teeth. A form of compressor for the Stenonian duct, the invention of Dr. Rich, and figured on the following page, is thus described : " This forceps and spring professes to accomplish the closure of the duct more perfectly than any other appliance. The spring, with a pad of bibulous paper, or napkin, prevents all flow of saliva, while the tip is free to yield to every motion ; whereas with a wad of napkin in the cheek, the lip is tight, and very little motion frees the duct, allowing the saliva to flow. 312 ORAL DISEASES A.\W SURGERY. " In use, the recurved ends of the forceps fit in the recess of the spring, whicli closure of the handles will ex- pand. Then, having placed the pad in posi- tion, — exactly opposite the second upper mo- lar, — release the grasp on the handles, the spring will close and forceps be detached at once. An outer pad may be slipped under the spring afterwards, if desirable." An operative plan of controlling the pa- rotid secretions has been suggested, and perhaps to some ex- tent practiced, consist- ing in placing a tempo- rary ligature about the ducts. This is certainly to be opposed as an unsurgical proceeding, and one which might most readily eventuate in stricture. Of all the various appliances, however, aside from the napkin, designed for the con- trol of the salivary se- cretion, not one has seemed to meet with so universal an ap- proval as what is known as the coffer- dam of Barnura. This consists in a simple sheet of thin rubber, prepared for the purpose, LOCAL TREATMENT OF DENTAL CARIES. 313 into which one or more minute holes are to be punched for the passage of certain teeth associated with the proposed operation. When properly applied, even a lower tooth may be protected from the saliva for a period of four or five hours, should such time be a requirement. In applying this dam, the operator starts with the principle that a delicate round hole is to be made in a sheet of rubl)er ; this is to be stretched by passing the diseased tooth through it. The rubber thus tightly grasping the tooth is forced beyond the place of decay, putting the cavity in a water-tight dam. Applying this dam of Dr. Barnum to an isolated tooth, an oper- ator would be led to conclude that nothing was left to be desired ; passing, however, to one of complicated relation, he would err as far on the other side in inferring it to be without value. That the reader may be possessed of a proper appreciation of the capabilities of the appliance, attention is directed to the communication of a gentleman who seems to have had all necessary experience in this direction, J. F. P. Hodson, D.D.S., being an essay offered by him for the consideration of the First District Dental Society of New York. It will of course be found that others have expedients to meet the same indications varying markedly in character. These expedients come to suggest themselves to every person of reasonable ingenuity as experience widens, but, as a study, the suggestions in this paper cannot fail to afford many useful hints in the direction of the use of this dam. As a study simply, it is quoted. " Experience," says this gentleman, " only can enable one to judge as to just which cases to apply this dam. As an operator becomes more and more skillful through practice in manipulation with it, he will find the cases to which he cannot apply it becoming fewer, and in the course of time discovers that whether to apply the dam or not to any case — perhaps one in fifty excepted — becomes vierely a ques- tion of expediency. " I seldom," he continues, " use the dam for simple cavities in the grinding surface of superior molars, but lay a narrowly-folded napkin or bilmlous paper along the gum outside instead. I do use it, on the other hand, in almost every case, for the lower teeth, and nearly always for approximal cavities, wherever situated. " Two or three, or, in extraordinary cases, more teeth, should be embraced by the rubber, unless the tooth operated upon is standing isolated from the rest. The holes should be as round as possible — as a sharp angle in them is a tear suggested — and very small. 3U ORAL DISEASES AND SURGES Y. though varying with the resiliency of the rubber, — say the size of an ordinary pin's head for a bieuspis, and in this proportion for the other teeth. The distance which the holes should be apart must be a matter of judgment for each case. Where the teeth are near together, they may be within an eighth or three-sixteenths of an inch of each other. Where there is a wedged space and approximal cavity, it is a nicer matter to determine, as you must have sufficient rubber between the holes to allow for both teeth being embraced so snugly as not to admit of leakage, wliile an excess of rubber would puff up between the teeth, and hide that essentially important point, the cervical edge of the cavit}'. After the holes are cut, carry the rubber down between the teeth with waxed floss silk, being careful to place the silk as near as possible to the edge of the hole, otherwise the rubber will be torn. It is more convenient to com- mence with the tooth nearest the front of those which are to be embraced, and apply to each one back of it successively, till all are. encircled. The edge which now stands up against each tooth must be turned under, to prevent leakage. This may be accomplished by carrying the floss tightly again.st the approximal surface of each tooth, and down upon its neck; then, with a small burnisher, com- plete the circuit by turning the edge upon the buccal and lingual surfaces. This is all done when the rubber is applied, and does not, in practice, consume one-quarter of the time that it takes to write it. At the first and last spaces leave the floss, to prevent the slip- ping off of the rubber. " Incases of partially-developed teeth, or those whose crowns are of too conical a form to retain the rubber unassisted, special appliances will be required. Some operators suggest, for the lower teeth, tying a piece of twine or floss around the tooth over the rubber, attaching a small weight to the ends, and allowing it to hang down out of the mouth. This, to my mind, has many objections, chief and conclu- sive among which is the fact that when the tooth is sufficiently developed to apply this string-holder, I can entirely dispense with its use, and depend on leaving the floss between the tooth and gum, as I shall hereafter describe. " The following method I much prefer to the string and weight above mentioned. Take a piece of annealed iron wire, of medium size, and twist it tighlly around the tooth, and as near its neck as possible, leaving the ends half an inch long, and projecting from the buccal side of the tooth ; lift it off carefully, and, having applied the rubber, hold it on with one hand, while with the other you place the LOCAL TREATMENT OF DENTAL CARIES. 315 wire ill position over the rubber, holding that with your finger till, with a large plugger, you push it down on the tooth all around, getting it to catch at some point, if possible ; then, holding it down with the plugger on the lingual side, push the projecting ends or 'handle' down close to the gum; place finger or thumb upon it, and you are 'master of the situation.' "The foregoing applies especially to partially developed inferior molars. If, as is often the case, a thick lip of gum projects over the posterior part of the grinding surface, and is too stiff for the rubber to push back, I excise it and proceed as before. lu the great ma- jority of cases, however, with these teeth, there is no difficulty in causing the rubber to retain its place, by carrying floss silk, single, double, or triple, down between it and the posterior approximal surface of the tooth ; and if there be a tooth in front of it — Avhich in such cases should also be embraced by the rubber — passing the floss forward from each side, and making it l)ind around the tooth by crossing it between the two anterior to the one operated upon. " But when these teeth are so little developed as that the difficulty of retaining the dam upon them will not be obviated by either of the just-described methods, I employ the following : Fig. 98. 12 3 " (No. 7.) Form a wide clasp of thin gold, or other metal, to fit the tooth, rounding the ends somewhat, and letting them slip past each other; let it be a trifle flaring from its lateral centre to each -edge. The lower side is flared because that portion of the tooth which is below the gum line is larger than that above it, and the upper flare is to retain the rubber ; or, if preferred, the upper flare may be represented by a wire soldered around the edge. (No. 3.) Slip this clasp down upon the tooth as far as possible, letting it penetrate between the tooth and gum, and proceed to apply the dam to this clasp, after which pack the space between the tooth and clasp with spunk, for the purpose of damming out any moisture from that direction; when, with a finger upon the top of the clasp as a security for its retention, proceed to accomplish the now ren- 316 ORAL DISEASES AND SURGERY. dered simple operation of introducing the gold. And just here let nie say that this 'spunk' that we use is invaluable for stopping, under pressure, any leak — unless it be a very large one — which may occur during an operation from an inadvertent puncture of the rubber. I do not wish to omit mentioning, at this point, and for these opera- tions, a little instrument that I use very often. It is simply a broken excavator bent into the shape, or nearly so, of a very large but short-turned corkscrew plugger, the curve fitting the posterior surface of the tooth, and the part resting upon the gum, a*t that point filed to a flat surface. It is held in the left hand throughout the operation, and in the position indicated, there being one for each side of the mouth. It is very valuable in those cases where wo have the combined difficulties presented of a very unyielding gum and conical shape of the tooth's crown. "At least as difficult cases as these to control are those of gum cavities, whose edges are below the gum line, and for them I have several appliances, according to their position. We will consider, first, an inferior molar, with a gum cavity, large or small, upon its buccal surface. I have for such two or three clasjjS, of such con- struction as I shall immediately describe, with sufficient variation in their shapes to comprehend the more pronounced corners and angles of all molars. "(No. 6.) This appliance is an open clasp, formed from clasp-gold or steel, with the ends left wide and heavy on the lingual side of the tooth, which ends are to be turned outward at right angles to the clasp, for a length of say three-sixteenths of an inch, leaving a short space between the two. A hole is drilled through one of these pro- jecting ends for the easy play of a short and thick screw, and a thread cut in a corresponding hole in the other, to engage with the thread on the screw. This is, as is apparent, for the purpose of fitting the clasp tightly to the tooth. The upper edge of the clasp is to be cut away on the buccal side, leaving it the width of an eighth of an inch or less ; the upper side of this turned outwards, and the lower side, which is to engage with the neck of the tooth, finely serrated. On the upper side of this buccal portion is left standing a little ear- shaped piece with a dent in its centre, which is to be turned down to a horizontal position, and is for the purpose of carrying down this portion of the clasp, under the pressure of an instrument held in the left hand, with its point resting on the ear-piece. The whole clasp should be formed in such a manner as that, when in position, the lower edge of this buccal side shall dip slightly below the correspond- LOCAL TREATMENT OF DENTAL CARIES. 317 ing edge of the lingual In applying it, if the buccal contour of the tooth be irregular, the clasp should be fitted somewhat to these irregularities with the pliers before putting on the rubber; then apply the dam, put on the clasp, and, after stretching the rubber to the edge, hold it and the clasp in position while you turn the screw on the lingual surface and snugly fit the clasp. It will be found necessary, in most cases of this nature, to hold the clasp down, as before described, with an instrument, throughout the operation, though it may sometimes be dispensed with. This is more espe- cially adapted to gum cavities in those teeth whose buccal contour at the gum line is either very convex or very irregular. " (No. 5.) Where, however, the tooth presents aflat surface at this point, I have a clasp of thin steel, very wide, and going over the tooth from lingual to. buccal surface, with ver}'' delicate teeth cut on the extreme ends, which are turned in, as shortly as possible, to a right angle. Opposite the cavity the clasp is cut out, leaving the smallest possible rim ; the external edge of this is to be bent up towards the clasp till that portion which was next the gum is brought to a little above a right angle ; the inside edge of the rim is to be serrated, and is to engage with the tooth, below the edge of the cavity. On the outside of the rim, next the gum, is left a small ear, precisely similar to the one described on the last fixture, and for the accomplishment of the same end. (Xos. 5 and 4.) This style of clasp is equally applicable to labial or buccal gum cavities on all teeth, with, of course, the shape modified to suit such cases. " For the front teeth, and particularly the lower ones, there are some cases which this will not reach. For such I employ two or three patterns of the following. (No. 1 ) Cut from a piece of plate, of medium thickness, a form resembling the inverted letter V, with a square top, and of such length as that, when laid against the tooth with the ends pointing towards the gum, they shall reach nearly to it on each side ; to these ends solder a small but stiff rim, running in front of the tooth at a slight angle downwards to the main piece, the ends of the latter having been previously bent inward some- what, in order to freely expose to view the cavity between them. In the square top of the main piece are drilled two holes for the purpose of attachment to the tooth. The whole is applied by putting on the rubber, carrying down the approximal edges, as in all similar cases, drawing the rubber to the cervical edge and super- posing the holder upon it — after looping a piece of floss silk through the holes in the top, and passing the loop over the tooth, and tying firmly to place. 318 ORAL DISEASES AND SURGERY. " Where the cavity is an approximal one, and extends under the gum, the wire clasp before mentioned may be made useful for hold- ing the rubber and gum away from the cavity, by threading between the teeth, and twisting it on, after the rubber has been applied; or it may be put on before the rubber, leaving the twisted ends pro- jecting ; and, in carrying the rubber to place, pass through the hole which is to embrace this tooth both the tooth and ends of the wire, and bring the wire above the rubber with a small burnisher. "When teeth have been wedged apart for the purpose of filling approximal cavities, they are always more or less loose and tender, and it has always been ray practice in such cases to insert a thin wooden wedge at the necks, before commencing to operate, for the double purpose of keeping them firm and apart while operating. This wedge, when the dam comes to be applied, may be left in its position, and the dam superposed upon it, or it may be taken out and placed over the rubber. The great objection to the latter method has been, that the resiliency of the rubber, together with the movement of the teeth in operating, does not admit of a simple wedge's keeping its place. This difficulty has been remedied by a little device, suggested to me by Dr. Varney, of this city, and which consists in inserting between the wedge and rubber a T-shaped washer, of very thin metal, the long arm being of a width to pass readily between the teeth, and the inside of the short ones cut to fit the buccal corners of the teeth between which it passes. This appliance is also of great value for exposing all approximo-buccal cavities. " (No. 2.) When, however, the cervical edge of the cavit}' is so far beneath the gum, and the gum on either side of the approximal surface is so hard and unyielding as that this method shall prove insufficient to surmount the difficulty, recourse is found in the fol- lowing: cut a strip of clasp plate, of medium thickness, to a width approximating that of the lateral diameter of the tooth ; drill two small holes across and near the end ; then bend the strip just below the holes to an angle of foi'ty-five degrees or thereabouts, and of a sufficient length to reach across the space and to the cervical edge of the cavity. (In special cases, — for instance, if the crowus are long, — it is well to bend up at a slight angle this end for the one thirty-second of an inch, for the purpose of obtaining the essential requisite in the premises, viz., a flat surface pressing the rubber downward and at the same time springing against the neck of the tooth below the cavity, as, if these are not complied with, the teeth will not be held LOCAL TREATMENT OF DEXTAL CARIES. 319 firnil}' apart, or the rubber will be pressed awa\^ from the neck of the tooth, causing leakage.) This end is to be beveled to an edge, and slightly serrated, to prevent it slipping. Now apply the rubber, and after looping a piece of floss silk or fine wire through the holes, lay this part of the spring against the approximal surface of the adjoining tooth ; push the rubber down to the edge of the cavity ; superpose upon it the toothed end of the spring, and make fast by tying or wiring tightly around this adjoining tooth. As has been hinted, this appliance will, if properly made, hold the teeth firmly wedged apart while filling, — a very essential matter, and one that must in such cases always be accomplished in some manner, as the dam tends to add to their natural inclination to return to the position which they occupied before wedging. "The matter of turning under the edges that stand up against the teeth is so essential, that I would reiterate the necessity of its accomplishment in all cases and around each tooth ; otherwise there will be leakage at these points, the unturned edge being precisely analogous to an open valve and the turned edge to a closed one. " While upon the subject of gum cavities on the labial surfaces of the incisors, I omitted to mention the following: if the cervical edge is but a short distance beneath the edge of the gum, and still so far as that the dam, unassisted, will fail to keep its place, I employ an instrument — of which I have several shapes — held in the left hand, for the purpose, the essential part of which is simply a wide, flat blade, with the edge on its end hollowed out to correspond to the contour of the tooth's neck; this concave sharpened, and, if thought proper, finely serrated, it will be found more convenient to hold, if that side or end of the concavity which is farthest from the hand that holds it is left longer than the other. The particular shape which I find best adapted to all cases is that of an enlarged hatchet excavator. " In regard to the quality or thickness of rubber best fitted for our purpose, it is greatly a matter of taste The thinner qualities require more skill in their use than the heavy ones, as after the application of the former, if great care is not constantly exercised, particularly in cavities anywhere near the gum, it will be stretched away from the tooth, and the operation flooded. On the other hand, far more delicate presentations are effected through it than by the heavier; besides which, it passes more readily between teeth which are nearly approximated : indeed, it may be laid down as a rule, in this connection, that it will follow floss silk into any position. For 320 ORAL DISEASES AND SURGERY. general use, however, if the thinnest were numbered 1, and the thickest 4, my recommendation would be number 2. "Any sized piece may be used, but that which will be found best for most cases is, perhaps, four or five by six inches. And though it may often be applied in such a manner as that the patient may close the mouth and swallow, it Avill generally be found more con- venient for the operator, and to accord better with tlie taste of most patients, to spread a large napkin or towel over the shoulders, for the purpose of taking up the saliva as it leaves the mouth; or a double-valved saliva-pump may have its nozzle resting in the mouth, the rubber tube from which leads to the spittoon, when an occa- sional squeeze of the air-chamber will effectually keep the mouth free from saliva. " The ends of the dam may be held l)ack out of the way by -means of a little fixture, invented, I think, by Dr. Coggswell, which is simply an elastic band, with a slide-clasp on each end for seizing the end of the rubber, and a contrivance, in addition, on one end, for drawing the band tight, the latter passing around the head. Another method is, to catch the ruljber with small hooks, at the end of a piece of twine, on each side, and crossing the ends, to which are attached small weights, on the head-rest behind the head. "When one uses the dam very much, he will find that the con- stant pressure of the floss silk under the nail of the forefinger — which is the one most used in applying the dam — will keep it in a constantly sore and irritated condition. To obviate this, I cut off an ordinary thimble, so that it shall form a cap for the end of that finger, and then serrate it deeply over the whole end. It can be taken off as the fingers are required to apply the dam from tooth to tooth, by turning that finger to the centre of the hand, and reapplied in the same manner when the floss is taken up." In connection with this paper may be exhibited an appliance invented by Dr. Forbes, Fig. 99. Fig. 9U. "The use of this instrument is to force the rubber down be- tween back teeth, evenly to the necks, without tearing it; and also to pass the tying cord around molars more pleasantly than can LOCAL TREATMENT OF DENTAL CARIES. 3:21 be done with the fingers. When a very high strain is needed, fix the cord in position with half a turn around the button, and tighten it while pressing the points of the fork between thumb and finger." Operators whose experience with the I'ubber dam has been large, recognize that few cases will be found where the ligature of thread or silk cannot be made to fulfill all indications in the way of securing it in position. In the use the author has himself made of this means, he has certainly been able to accomplish his ends without exercise of the ingenuity exhibited in the paper quoted: as a study, how- ever, the suggestions must be found to have much value to the inexperienced. A cavity before prepared to receive a filling is to have a direct drying; that is, all the moisture it contains is to be absorbed. To this end, what is known as bibulous paper is commonly used. A means widely employed, and highly extolled, is the application of dry heat; this is to be effected by the use of an air syringe with heated bulb. Fig. 100, showing such an instrument, will explain the manner of its use at a glance. Fig. 100. Hot-air syriuge. In filling the proximal face of a tooth when the napkin is de- pended on to keep the part dry, attention is necessarily directed to the oozing from the mucous crypts immediately surrounding the neck. To control this, some operators depend exclusively on pads of absorbing-paper held as closely as possible to the part. A mode more convenient, however, and more reliable, consists in passing a wedge of soft wood between the cavity and the gum, allowing it to press hard against the latter. Still another excellent means is found in including the neck of the organ in a ligature of heavy silk or other thread, tying it as tightly as possible and thrusting it. closely against the gum out of the way of the operation. Another mode yet is found in the cauterization of the gum, a strong solution of iodine, nitrate of silver, or chloride of zinc being used. The me- chanical means suggested, however, will be found the most satis- 21 322 ORAL DISEASES AND SURGERY. factory to employ, as no ulterior ill consequences are to be appre- hended. The Filling. — Xon-adhesivo gold is used in four forms : in cylin- ders, in plates or mats, in ribbons, and in twists; these forms being also frequently conjoined in a single cavity. To make a cylinder, a sheet or portion of a sheet of foil is folded upon itself until a ribbon is obtained, which, iu width, is to be some- what greater than the depth of the cavity in which it is to be used. The ribbon is converted into the cylinder simply by rolling it around a common pin or brooch ; this is accomplished in a moment by laying the ribbon lengthwise along the index-finger of the left hand, and, with the thumb resting upon the pin, which is laid across the initial extremity, revolving it toward the palm. To make a plate or mat, first convert the sheet into a ribbon as before, of such varying width as may be required; next back-fold into the required length. To make a ribbon, proceed as has been directed. To make a twist or rope, first convert the sheet or portion of sheet into a very loose ribbon; twist this now upon itself cork-screw fashion. Referring now to individual cavities, which will serve as studies to direct the ingenious hand, attention may first be given to such simple forms as are represented by round holes, — cavities alluded to as being common to the crowns and sides of the molar teeth and to the posterior faces of the incisors. To fill cavities of this class, the cylinder naturally suggests itself. Selecting one of a size which may be carried readily to the bottom, it is, after being placed, to be laterally expanded by a wedge plugger carried through its centre, or otherwise may be condensed in mass against the wall of the cavity. The space thus made is to be filled by a second cylinder of convenient size, the wedging to be repeated, and the introduction of cylinders to follow, until no more space may be obtained. Plates are found, in the beginning of an operation, to conveni- ently replace the cylinder where crown cavities are large and of more or less irregularity in form. They are used precisely as the cylinder, being carried into position by means of the foil-carrier, and con- densed carefully and accurately against the immediately neighboring- wall. The plates following the first may either be arranged around the cavity, thus making as it were a gold cylinder into which cylinder after cylinder as before directed is wedged, or one plate may be condensed against its fellow until in this way the cavity is full. LOCAL TREATMENT OF DENTAL CARIES. 323 Filling a cavit}^ with the ribbon, although highly Fia extolled by many, is associated with much more trou- ble than the use either of cylinders or plates. To manipulate gold so prepared, the operator, after carrying the initial extremity to the bottom of the cavity and fixing it by any convenient means,: — generally by holding it with an instrument held in the left hand, or confiding the task to an assistant, — folds upon this, first, layer after layer, making the bend at such distance above the orifice of the cavity as considers the con- densation to which, later, it is to be subjected, and which, if properly done, is to afford a solid surface that shall not be sunk below the margin when the necessary filing and polishing shall have been com- pleted. Twists or ropes are used precisely as the ribbon, fold after fold being bent and carried into a cavity until no more may be received. It is more common to con- fine the use of the rope to small cavities, such as are found on the proximal faces of the anterior teeth, although operators are met with who employ gold in such form exclusively. A modification on the use of the ribbon and rope, as just described, consists in wedging the centre during the progress of the filling. The operator first gets his cavity loosely filled ; then, leaving the rope as related with the last fold, he wedges the gold against the parietes of the cavity. This secondaiy cavity is then filled by turning the rope into it, as in the first instance. Another study, which may serve as the demonstra- tion of a second class of fillings made of non-adhesive gold, are the cavities in the anterior teeth, proximal faces. As the filling of all such cavities is on a common principle, we will take the incisor. Fig. 78, right side, as seen prepared. To fill this tooth, — being made ready as under- stood, — the operator takes a leaf of gold, preparing with it, besides a rope, a number of plates. The plates he arranges upon his tray or table, having various sizes, which he has laid in such convenient rotation that, without search, he may be able to pick up such size as required. The rope may be cut into small pieces. The gold thus made ready, the next require- Foii^carner. 324 ORAL DISEASES AND SURGERY. ments are the necessary instruments. Fig. 102 exhibits a set of plug- gers, designed b}" Dr. W. G. Redman. Possessing these instruments, an operator will find himself able to introduce and pack cyJinders, plates, and ropes in the various cavities to which they are found adapted. " These cuts represent thirty of the most approved points. They can be made with handles to suit the purchaser. A half-inch ivory or ebony handle is recommended. Nos. 1 to 1 (serrated-foot instru- ments) are lateral condensers for all cavities. Nos. 8 to 11 (smooth- foot instruments) are used in the same cavities and in the same manner, but not until the cavities are nearly full. Nos. 12 to 24 are all approximal condensers. No. 25 is for anterior approxiraal cavities, molars and bicuspids. No. 26 is for posterior approximal cavities, molars and bicuspids. Nos. 27 and 28 are for crown cavi- FiG. 102. 10 11 12 13 14 15 16 i' ) n B"3 23 24 25 26 27 28 29 30 ties, upper molars and bicuspids. Nos. 29 and 30 are for crown cavities, lower molars and bicuspids." To fill the tooth selected, the operator would take up with his foil- LOCAL TREATMENT OF DENTAL CARIES. 325 carrier a plate of gold of a size suited to an easy introduction into the cavity. This plate it is designed to place firmly against the neck- surface of the cavity. To so direct and place it, any of the instru- ments, Nos. t, 11, 2Y, or 28, might be employed. The first piece in position, a second plate is to follow, being introduced in like man- ner and consolidated against the first. Sometimes, however, and particularly where the labial wall of the cavity is delicate, it is found best to lay this second plate against this surface, obtaining thus increased security against fracture. Plate after plate may now be added until the cavity is full, or, if preferred, the cut rope may be used, piece after piece being carried and wedged into place. Another plan of using the plates in cavities of this character con- sists in first lining with them the circumference and afterwards wedging the cut rope into the centre. Still another plan that is found at times convenient consists in placing one plate against the neck-wall, and a second in that portion of the cavity nearest the cutting edge of the tooth, wedging now the cut rope, or other plates, between these. Another plan still is found in using a twist or rope of gold, as directed in the case of crown cavities, turning into the cavity layer after layer, until no more can be entered. This formerly was the almost universal practice, being now, however, replaced by adhesive foil, a means shortly to be described. In operating on a cavity of such position as we now consider, the head of the patient is to be thrown back, the mouth looking upward. The operator stands at the right side of the chair, while the fingers of the left hand support the tooth, as may be found required for the comfort of the patient. The chair upon which a patient sits is to be of such height of seat that the head is brought on a level with the breast of the operator. For such purpose there is the greatest variety of construction. (See Catalogues.*) A head-rest, applicable to almost any chair, and which will be found of every desired convenience to the army sur- geon and to the practitioner who may not desire to purchase a costly chair, is an invention of Dr. 0. C.White. This rest "makes its * Catalogues containing illustrations of almost every instrument and appli- ance used in operations connected with tlie teeth are to be obtained, free of cost, by addressing any one of the prominent manufacturers of dental iroods. 326 ORAL DISEASES AND SURGERY. own fastening to almost any style of chair, sofa, lounge, or settee. It has full movement in ^^^ all directions, on a scale for a tall person Or for a child, and is securely fastened by turning a single thumb-screw." The accompanying cut represents the rest applied to a common of- fice-chair, with dotted lines showing its movements ; and the rest, on the same scale of size, folded up, to occupy but little space, either for transportation or to lay aside. Weight, 4| pounds. Upon the operating-tray should always be found pellets of bibulous paper and one or two twists of cot- ton. A small bottle of chloride of zinc, or of Monsel's solution of the persulphate of iron, should also be within convenient reach in case of slight hemorrhage from an accidental pricking of the gum. Twists of cotton are sometimes found of great service in slipping between the cavity and the gum when the napkin is used. The thumb and finger holding the tooth will also fix and retain the twist. It is to be held tightly against the gum. Even more convenient than the cotton will be found delicate strips of wash-leather. This latter in my own practice I have come to prefer ; it absorbs the moisture fully, and is more easily kept clear of the cavity, should this be near the gum. Passing to still another study, we may consider the anterior proxi- mal surfaces of the bicuspidati and molars. Referring to the dia- gram, Fig. 18, it will.be seen that such cavities, when properly ex- posed, are converted into those of very simple forms. To fill them it is only necessary to employ the mechanica-1 means given. Com- monly the operator commences with a plate which he fixes against the cervical wall, laying plate after plate against this first one, until the cavity is full. Where the cylinder is employed, the principle of White's Head-Rest LOCAL TREATMENT OF DENTAL CARIES. 327 introduction and consolidation will be seen to be precisely the same. In large cavities of this position, it will be found an excellent plan first to bound the cervical and lateral w^alls with plates, and after- wards wedge the cylinders or mats within this golden cavity. Posterior proximal faces are commonly much more difficult to fill thah the anterior. Such difficulty, however, is found most markedly' influenced by the preparation of the cavity and the state of the boundaries of the mouth to be operated in. A deep narrow arch with the labial orifice small and tense, and much buccal adipose tissue, and with the patient unable or unwilling to assist by keeping the mouth well open, will worry the most skillful and experienced. On the contrary, in the wide mouth of free and lax orifice, little more trouble is experienced than in the case of the anterior. Such cavities are filled with the non-adhesive gold precisely as are the anterior. The use of matrices in the construction of a temporary wall for the conversion of such cavities into simple holes has long been a favorite means employed by many persons. A very easy and always convenient way of making such matrices, and one which the auth'or has employed in hundreds of cases with satisfactory success, con? sists in breaking off a section of an ordinary separating file having a free or uncut surface, and, slipping it between the two teeth, wedging it in place. This, as must be seen, is not by any means a complete wall, but it will be found to answer a most excellent end, needing, indeed, to be seconded only by a reasonably skillful touch to fulfill sufficiently well the indications. Such matrices are most conve- niently used if the temper is first removed. Another mode of making a matrix to apply to an approximal in- clined plane consists in taking a delicate strip of silver, and after cutting and filing so that it shall half cover the cavity, being bulged, however, just over it, wedging it by means of splints of boxwood into place: this manipulation forms, as is seen, a limited last wall, but such wall is quite sufficient to answer the ends. A character of matrix invented by Dr. Louis Jack has attained most deserved popularity. A description of its use given by the inventor will be readily understood by reference to the cuts which accompany. When cavities are of such extent as to complicate very much the process of introducing and fixing the gold, these matrices, from what might be termed their permanent and full char- acter, will be found not only to spare the operator much fatigue, but to assist materially in giving form and solidity to a plug. 328 ORAL DISEASES AND SURGERY. "The difficulty," says Dv. Jack, "of correctly filling the proximal surfaces of bicuspids and molars is so universally acknowledged, that any means which may render this class of fillings more easy of performance, and which may promise more certain results than are usually secured, would bo regarded by every one as an important desideratum. It would also be desirable to reduce the weariness which is inseparable from difficult operations on the proximal sur- faces of the molars, with which all who endeavor to be faithful are familiar. My own experience in this class of cases has been excessive, and the constant repetition of extensive proximals has so repeatedly exhausted my nervous force as at times to fill me with despair. It is therefore a satisfaction to have made an improvement by which much of this difficulty is overcome; by which the introduction of the gold has been rendered much simpler, more certain, and so man- ageable that I must now let others have the full benefit of my expe- rience. " It will at once be granted, at least by those who have learned to appreciate the advantages gained by the use of the mallet, that if we had a fixed boundary or wall to the outer side of the cavity, having the form required to give a proper shape to the surface of the filling, and a sufficient opening to freely introduce the gold to every portion of it, the solid filling of the space would be easily attainable. " I have for some months been working up a method of introduc- ing proximal fillings by the use of what may be not inappropriately, called proximal matrices. It will be necessary first to describe the preparation of the cavity, including the modifications in its form required to adapt it to the application of the means to follow. 1 trust to be excused for entering at some parts into what may seem excessive detail. To be more clearly understood, and to limit the use of technical terms as much as possible, it will be assumed that considerable caries is found between the superior first molar and bicuspid, involving both teeth on their proximal surfaces, extending from beneath the gum to the masticating plate of enamel, but not involving the pulp. Everything herein written will apply to the treatment of these two cases, leaving the application to other posi- tions to be made by the reader. " The first step, in case the teeth are in close contact, is to separate them, either by pressure, or, as in so extensive caries as is under consideration, by a parallel-sided file ; and from this slight separation rapidly and freely open by cutting down the enamel at the middle of LOCAL TREATMENT OF DENTAL CARIES. 329 the spnce, afterwards increasing somewhat freely with the chisel the inner portion of the opening. Another plan I sometimes pursue, where no fracture of the masticating plate has occurred, is to pass a small five-sided drill until it fails to meet with resistance, increasing by a larger drill ; and from these two half-circles I cut in either direction with suitable chisels by carefully splitting down the ena- mel, — first the masticating portion, — and continuing until a free space is secured on the inner side ; then more carefully opening toward the buccal division, until a slight space is made at this point. The tile may be used at this stage to further open the space, and in bringing the surfaces into proper shape and smoothness. When the cavities are so large as is assumed above, there will usually be found so much disorganization of the enamel as to render necessary so much cutting to procure a healthy surface as will open a space abundantly large for the subsequent work. If more is needed, it is secured by wedging ; in any case a separation as large at the lower part as a No. 7 Froid file, and at the cervical part as a No. 3, is easily secured. The buccal space should be but slightly wedge- shaped, and somewhat smaller than the palatal, for reasons which will appear in the proper place. "After removing the softer caries, the walls of the cavity are prepared for the reception of the filling; the overhanging masti- cating plate being first cut away in a circular form on a line with the bottom or pulp wall, so that by direct approach every part of the cavity is accessible to slightly curved or even straight instru- ments. This opens the whole cavity to view. The instrument best adapted for this purpose is the gouge-shaped chisel, which cuts with exceeding keenness, and produces the form desired at this part. The removal of this portion of the enamel is an important and indis- pensable step in the improvement I am pursuing. It is practiced by the better operators to a somewhat less degree, and is in many cases an advantage to the organ. No other argument to defend this course need be used than that in these fillings, so difficult of execution, everything subservient to better performance must be fol- lowed out which is not injurious to the strength and preservation of the organ. It will often prove true here, as elsewhere in surgery, that something must be taken to save the remainder. " The cervical wall is now cut at a right angle to the proximal sur- face, taking care to remove from the surface of the tooth beneath the gum any half-decomposed enamel which may be present at this part. No retaining groove or pits are needed on this wall. 330 ORAL DISEASES AND SURGERY. "The buccal and palatal walls are next smoothly cut, and on the side of each, where they have sufficient strength, a shallow, round- bottomed groove is made the whole length, and terminating at the very surface of the masticating jdMc of enamel. The outer retain- ing groove should be near the margin, to avoid any approach to the pulp ; the inner one should be nearer the bottom of the cavity, that, in the subsequent cutting away of a portion of the palatal wall in the finishing process, the hold of the gold may not be obliterated. The instruments best adapted for this grooving are made by filing a straight point quite round and small, then bending at a suitable angle, and shaping so as to have the edge at the inner side of the curve. Instruments of this form are better adapted for cutting the hard dentine and enamel than any others, for the reasons that they may be made harder than usual without danger of breakage; they cut with more keenness, do not chatter, leave the surface without sharp lines, and in grooving each cut follows in the last with cer- tainty. They are directly reverse in form to the hoes and exca- vators in general use. " The pulp wall of the cavity is not altered in the form it presents after the removal of the caries. " The next and very important step is to remove the sharp corners of the mouth of the. cavity, and at every part well polish it with pumice-stone ; this facilitates the passage of the gold over the sur- face and the perfect contact of the foil with every part. This polish- ing is rapidly done by rotating a piece of boxwood armed with pulverized pumice. " Selection is now made of one of the appliances figured below, which are intended to give farm to the outer surface of the filling, and are called matrices for this reason. These little affairs are made of a variety of shapes, sizes, and thicknesses. They are formed of slightly wedge-shaped pieces of steel, and are, as the cut designates, hollowed out at their thicker edge, which depression terminates at the thinner edge. At the part of the depression designed to give shape to the buccal edge of the filling the cut is generally abrupt and deep; at the inner portion it is more shallow and more inclined. It will be observed that the depression widens as it passes toward the thinner edge to follow the usual form of proximal cavities.* The lower and thin * In Fig. 104 tho boundary of the right end of the depression should be similar to the other end. LOCAL TREATMENT OF DENTAL CABLES. 331 edge is rounded, to outline the curved margin of the cervical wall, and to effect pressure upon either the gum or the appliances used to stop the escape of mucus and blood from this tissue. " The plane parts of the face are file-cut or coarsely draw-filed. The reverse side, represented at Fig. 105, and which for convenience of description is divided into three sections, is in most cases plane and smooth, excepting at tbe section c, which is file-cut. It is often necessary " -e. character that it very frequently occurs that the mere closing of the handle will loosen the tooth. When, however, this does not occur, the tooth is to be rocked until the connection is felt to break. Ex- amining a tooth held in the grasp of this instrument, the points of THE EXTRACTION OF TEETH. 409 the blades will be found met in the interspace. Always, before applying the force, it is well to have the points thrust as deeply as possible below the free edge of the gum. When such precaution is not taken, and the sharp points do not reach the interspace, they are almost certain to produce fracture. This instrument is, of course, not applicable where caries has proceeded to such an extent as to have separated the roots. Figs. 156 and 157. These are the cow-horn forceps in pairs: the shape of the handles, and the curve for the rest of the little finger, add much to convenience of employment. Together, they make a very efficient set for lower molars. Fig. 158 is a forceps designed for the inferior molars; it is known as Wolverton's instrument. It is preferred by many as combining the advantages of the Maynard and Harris. Fig. 158. — Lower Molar, Either Side (Wolvekton'.s). Fig. 159. — Lower Molar (Hutchinson's). Fig. 159 is a lower molar forceps. In a deep mouth, and where the tooth to be extracted is much concealed by one anterior to it, the curve of the blade will be found to render it of great service. Admirers of the instrument commend it particularly for the shape of the fenestrum. Fig. 160 designates the forceps for wisdom-teeth of upper jaw, either side. As a rule, these teeth are found to have but a single 410 ORAL DISEASES AND SURGERY. root. This, in shape, is conoidal, with a curve which directs the apex toward the tuberosity of the bone. To remove these teeth with least effort and risk, this curve of the root is always to be con- sidered, requiring the extraction to be in the line of its axis. To accomplish such a requirement, the crown of the tooth, after being grasped in the beak of the instrument, is to be directed backward. This rolls it, as it were, wheel-fashion, from its socket. The forceps Fig. 145 will also be found well adapted for the removal of these teeth when they may be sn)all. Fig. IGO. — Upper Dknte.s Sapienti^, for Either Side, with or WITHOUT Hook. It happens, however, that in man}' instances the superior wisdom- teeth have three, or even more, bifurcating fangs: when this is the case, it is quickly to be recognized by the undue resistance offered to the employed force, and its direction. No rule may here be given outside of that which applies to the neighboring molars: the oper- ator, if the irregularity is very peculiar, feels his way by testing for the aspect of least resistance. Fig. 161. — Physick's Dextes Sapientke, Either Side. Fig. 161 represents a forceps designed by the late Prof. Physick for the extraction of wisdom-teeth. The instrument is seen to represent a double inclined plane, and, in consideration of the neces- sity for throwing these teeth backward, is designed to be applied between the tooth to be extracted and the one directly anterior to it. The closure of the handle is expected to throw the tooth from its socket. It sometimes occurs, however, that these teeth, as seen in the superior tooth in the drawing (Fig. 131), have more than a single THE EXTRACTION OF TEETH. 411 root ; and these roots, instead of being inclined in a common axis, are frequently spread out in various directions. In cases of this kind it is plain that the instrument would not apply. Another objection to its use lies in the injury apt to be inflicted on the anterior or ful- crum tooth; this not unfrequently having the enamel so crushed and broken as to expose the more susceptible dentine, and thus lead to caries. Still another objection lies in the contusion inflicted on the periodonteum, this membrane being occasionally so injured as to result in its severe inflammation. The ordinary key instrument, when lightly and delicately made, answers a very admirable purpose with this class of teeth. The roots being generally quite short, there is. little of the common danger of alveolar fracture, and being but lightly set in their sockets, and easily yielding, the application of but very trifling force is required. In using the key, the fulcrum should be placed on the inner face and well back upon the tooth, the claw being upon the opposite face and well in front ; this application allows of the proper direction of the force, and admits of the easy and natural removal of the organ. Still another instrument employed in the extraction of these teeth is the elevator. (Fig. 167.) To apply this instrument, the grooved face is laid against the antero-lateral aspect of the tooth, and, being carried down to the pro- cess, the hand is depressed so that the free edge of the blade alone impinges; the tooth is then pushed outward from its socket, and backward. When wisdom-teeth are but ordinarily adherent, this is an admirable instrument for their removal ; care, however, is neces- sary that it shall not slip from the tooth and inflict injury on the neighboring soft parts. Elevator No. 6 (see Fig. 161) is the one most commonly employed. Fig. 162 — Lower Dentes Sapiknti^, Either Side. Another instrument yet is Fig. 162: long of shank, and with blades curved at right angles with the handle, it answers a most admirable purpose in the case of the inferior wisdom-teeth. 412 ORAL DISEASES AND SURGERY. ♦ Fulcrum Forceps. — These instruments, of which seven consti- tute a set, act on the principle of the key and elevator. A glance at their construction will exhibit the mode of application. That when skillfully used they are capable of meeting many emergencies, Fig. 163. — Upper Incisors, Cuspids and Bicuspids, for Eithkr Side OF THE Mouth. Fio. 164. — Lower Incisors, Cuspids and Bicuspids. (Two pairs, one for tlie right and one for the left side of the mouth.) Fig. 165. — Lower Molar. (Two pairs, one for the right and one for the left side of the mouth.) may not be doubted. The forceps of this class here figured are the invention of Dr. E. M. Jones, of Richmond, Va. Another instru- ment of the same general character, which, in respect to the fulcrum, highly commends itself, is the invention of Dr. H. H. Perrine, of Marvland. THE EXTEACTION OF TEETH. 413 All instruments of this class are, however, but modifications of the key of Garengeot and of the elevator, and, in the deserved com- FiG 166. — ITppkr Molar. (Two pairs, one for the right and one for the left side of the mouth.' mendation they receive, serve to exhibit the virtue of the instruments they replace. The key, so long and so completely abandoned, should Fig. 167. — Elevators used in Extr.acting Roots. 414 ORAL DISEASES AND SURGERY. not be without its place in an instrument-case. With a variety of claws to fulfill the diversified indications, and with skill and care in the adjustment of the fulcrum, it is a most valuable addition. An advantage possessed, hov/ever, by the fulcrum forceps, is easier adaptation of the claw, together with a more direct oversight during the act of extraction. In applying either this forceps or the key, it is necessary to force the blade as deeply as possible along the root of the tooth, and so to arrange the pad that the pressure upon the soft parts shall be as little injurious as possible. Bruising and crushing the gums are the objections. Concerning the fulcrum forceps, much commendation has been received, — gentlemen of experience considering them an essential to a satisfactory success in this direction of practice. Extraction of Fractured Teeth and Roots of Teeth. — It not unfrequently happens that, in attempts to extract teeth, fractures re- sult ; and such fractures must, of course, present the greatest variety of aspect, and require various resources for the removal of the parts left. Teeth of the first, second, and third classes present the same com- mon features of fracture, and may claim a first attention. Fig. 168 represents the alveolar line, and the various relations held to this line, or free border, by fractured teeth or roots. Tig. 168. — Eelation of Fractured Eoots to Alteolar Line. 1 2 3 4 5 6 7 A fractured tooth, as represented by Subfig. I (the first root to the left), is placed in no worse condition for easy extraction than before the occurrence of the accident. The same forceps and the same manner of its application still apply to it. Subfig. 2 represents a slight modification of the same condition. The one forceps and the one application still, however, apply. It is advisable, if the tooth is at all brittle, to work the blades of the instrument well beneath the alveolus. This affords greater support and yields increased security. THE EXTRACTION OF TEETH. 415 Subfig. 3 may represent a bicuspid tooth with the crown half broken away. In such a case, if the remaining portion is not at all brittle, and if the process is soft and spongy, the forceps, as de- scribed, having well-sharpened blades, may again be tried, working them well beneath the process, and securing all the hold possible on the root. If fracture again occurs, which, indeed, is very likely, simulating Figures 4 and 5, the cutting forceps is to be employed. To use a cutting forceps, make, with a scalpel or other blade, an incision on either side of the root through the soft parts directly down to the process; these cuts must correspond with the exact centre line of the root. The forceps is now to be applied scissors- fashion, cutting directly through the bone. Being thus brought in contact with the root, and grasping it perhaps full half its length, the removal is, of course, a perfectly simple matter. Some operators prefer to precede the cutting forceps with the elevator, and this instrument, in many cases, certainly effects the end very well. In the application of the cutting forceps, it not unfrequently hap- pens that, from want of care, the blades, instead of coming directly . upon the root, slip to the back or front of it. In these cases the fang may generally be easily enough picked out with the ordinary root forceps. A form of cutting forceps used by many, consisting of a double curved blade, avoids this accident, but it is to be objected to on account of the wound it makes. Roots, represented in Fig. 168, Nos. 4, 5, 6, and T, are removed on a Fig. 169. — Inferior Combined Root Incising, Separating, and Ele- vating Forceps. (Dr. T. C. Stellwagen's Pattern.) common principle. The first attempt is to be made with the ele- vator: laying the groove of this instrument clo.sely against the root, its sharpened knifelike edge is insinuated between the fang and pro- 416 ORAL DISEASES AND SURGERY. cess, being worked down as far as possible. The handle is now carried obliquely to the line of the root, and thus, with a careful oscillatory motion, the piece is forced from its bed. It is very well known, however, that with a dense, heavy, alveolar process, this instrument cannot be made to operate so happil}^ it being next to Fig. 170. — Superior Combined Eoot Incising, Separating, and Ele- vating Forceps. (Dr. T. C. Stellwagen's Pattern.) impossible to insinuate it between the lione and tooth. Under these circumstances, another instrument, the screw (Fig. 171), may be brought into requisition. Fig. 171.— The Screw. The screw is designed to operate upon the tooth root as the spiral operates upon the cork. Well tempered, and very sharp, it is intro- duced into the pulp canal, and quietly and gently turned until it has taken a firm hold. A simple direct movement, and the root is brought away. It may happen, however, that no hold sufficiently firm for the extraction can be obtained with this instrument. When this is the case, it may be laid aside, and the always reliable cutting forceps brought into requisition. If preferred, however, the screw can be bored into the tooth until fracture is produced, and this will some- times enable us quite easily to pick away the splinters: particularly will this be found to be the case when the line of the fracture divides THE EXTBACTION OF TEETH. 417 the root in its length. The forceps known as Dubs' and HuUihen's represent the combination of the screw with the forceps. In the Hullihen instrument the screw is designed more especially to aflFord support, preventing the blades from crushing the root. In the Dubs' forceps the spring trigger corresponds with the two forces, affording thus not only support, but allowing the extracting force to be divided between the two means. In using these instruments (their employment being confined to the single-root teeth), the shank holding the screw is to be confined in the grasp of the blades, and, thus controlled, it is to be screwed into the pulp cavity : a proper hold secured, the blades are to be expanded, and thrust, as in the ordinary application, about the root, which is then extracted secundum artem. In many instances, however, the immediate employment of the screw is found impracticable, owing to the shape of the canal or the Fig. 172. — Dub.s' Screw Forceps. 1, conical screw with square ratcliet shaft; 2, beaks of forceps, grooved inside; 3, socket with square hole to receive shaft ; i, spring trigger by which the screw cau be detached at pleasure at any given point. Fig. 173. — Hullihen's Screw Forceps. density of the dentine : in these cases the fang is first to be reamed out, which manipulation is accomplished without effort by the use of drills. Roots of the molar and wisdom teeth, superior and inferior, are removed on a common principle. In the use of the elevator, a very happy result is not unfrequently secured by applying the blade to 27 418 ORAL DISEASES AND SURGERY. the inner face of the root, carrying the shank across the mouth, and making a fulcrum of some convenient opposite tooth. Where the roots of a molar tooth are so firmly fixed as to seem incapable of removal with the application of an ordinary amount of force, it is better to divide them. This is easily done with the cutting forceps, and after the separation each root may be picked out singly, and generally with comparative ease. Fig. 174. — XJpi'Er Front Root, Si'kaight. Fig. 175 — Upper and Loavkr PiOot, Hatf Curvi:t). Fig. 176 — Ldwkr Hoot, Full Cuuvkd. Fig. 177. — Upper Back Eoot (universal Forceps of delicate beak are much in favor for the extraction of roots- of teeth: indeed, it is a common practice to exhaust their capability before resorting to other means. Figs. 174 to 180 exhibit different forms of such forceps. Figs. 177 and 178 are to have the preference, — these being quite capable of performing the work of the others. THE EXTB ACTION OF TEETH. Fig. 178. — Bayonet-shape Eoot. 419 Fig. 179. — Half Curved, Long Beak, Alveolus. Fig. 180. — Lower Molar Eoot (with Croavns). I Deformed or Anomalous Teeth. — Understanding the principles on which teeth of ordinary character are extracted, the practitioner will need but little instruction so far as anomalies are concerned. In Fig. 181, Subfigures 1, 2, 3, 4, and 5, although so ill portrayed by the artist, sufficiently represent five anomalies, and these may very Fig. 181. well stand for the class. In removing such teeth from the mouth, the matter of greatest importance is to recognize them. Now, while this cannot in all cases be done so as to appreciate exactly the con- dition of the roots, yet we may always say that some impediment to the removal exists ; and this, after all, is the most important 420 ORAL DISEASES AND SURGERY. matter, as it influences the amount of force exhibited, which, too freely rendered, might result in fracture of the bone, or still greater injury to surrounding parts. A tooth, as represented in Subfig. 1 (the first to the left), will generally yield in its roots so as to pass the intermediate piece of process. If it does not so yield, then this wedge of bone will frac- ture and be brought away. Such fracture, however, results in no harm, and is to be deemed of little consequence. Subfig. 2, by the great curve in the root, is made incapable of passage, unless, after being loosened, it is carried outward in the direction of the axis of the curve. In this way it is easily removed. The character of the curve is recognized by the resistance ofl'ered when the tooth is carried in certain positions, and by the absence of such resistance when it is carried in the proper line. The attempt to remove such a tooth by simple force would result either in frac- ture at the curve, in lifting out a neighboring tooth, or in fracture more or less extensive of the alveolar process. Subfig. 3 represents exostosis of a root. A tooth fang so enlarged will not pass through the process unless the bone is very open in its structure. Such a tooth may be made quite loose, but, while it moves freely enough in its socket, it is felt to be held by something abnormal. To free such a tooth, it is only necessary to use the cutting forceps, or, what I prefer, to take the ordinary small surgical chisel and cut away sufiicient of the process to admit of the passage. This little operation is easy of accomplishment, and must prove adequate to the end. Subfig. 4 represents a form of twin teeth. The two must be extracted together, which may be difficult or the reverse, accord- ing to the character of the process. It is well, before making the effort to extract, to free the process from the teeth as thoroughly as possible: this is done'by a sharp and flat elevator or the chisel. Subfig. 5 represents a second form of twin growth, the result of original germ union. If the offshooting bulb is situated within and covered by the process, it is to be treated as if it were a case of exostosis of the fang. These germ unions are exceedingly rare, and one might not be met with in a lifetime. Among other curious examples of anomalous teeth to be seen in the Philadelphia Dental College are those exhibited on the succeed- ing page. Referring to the conjoined molars, the gentleman who presented the specimens remarks : " The practical feature in this case concerned the extraction. This I THE EXTRACTION OF TEETH. 421 was effected with less trouble than might be supposed. In the attempt to extract the second molar, it soon appeared that there was some- thing wrong, and the effort to remove it was suspended, and a Fig. 182. Fig. 183. thorough examination made. In the second attempt, the force was very cautiously applied, to find what direction the tooth would take. It yielded most to an inward motion, and by a continued effort in that direction the removal was effected with only a slight fracture of the lingual border of the alveolus." The second specimen is a union of three of the anterior teeth. CHAPTER XYII. GENERAL REMARKS ON EXTRACTION. The relationship of the teeth with the jaws is through the medium of a cellular process known as the alveolar. Each tooth is lodged in pits or alveoli corresponding to the number and character of its roots: thus, the central and lateral incisors, the cuspidati, and the bicuspidati, having each but one root, have each but one alveolus. The molar teeth of the superior jaw have three roots, conse- quently a threefold relation to the alveolar process. The molar teeth of the inferior jaw have two roots and two al- veoli. The wisdom-teeth, as a rule, have a single short curved and stumpy root, consequently a similar alveolus. The association of the teeth with their alveoli is through the medium of a fibro-cellular tissue ; this membrane is coarse and resist- ing about the free edge of the bone, loose and cellular as it gets deeper. A properly-shaped lancet may be made to excise the coarse fibres ; consequently, the operation of extraction should always be preceded by that of thorough lancing. In this way much of the strength of the relationship of the tooth with its socket is to be overcome. A tooth extracts with difBculty or with ease as influenced by the character of its periodonteum, and the loose or firm structure of its alveolus. A limited fracture of the alveolar process is generally not to be considered a matter of much consequence. If an extensive fracture should associate with an extraction, the tooth and bone may be laid carefully back in place, and treated as any common fracture; or, if this does not seem desirable, the fractured piece may be dissected from the soft parts, and the wound treated on general principles. Sometimes, when too much force is injudiciously used, a fracture may occur, including several teeth. In such accident, the circum- stances of each particular case must direct the practitioner ; they are ugly and generally unnecessary troubles, and not apt to occur where proper care is exercised. Meeting myself with such an accident, I (422) GENERAL REMARKS ON EXTRACTION. 423 should certainly make a first effort to reunite the parts ; failing in which, I would have, of course, no resource but to dissect away the piece, or otherwise wait on nature for a process of exfoliation. Laceration of the gums is an accident frequently associated with the careless extraction of teeth. Such laceration may be trifling or it may be serious, and is, perhaps, always to be guarded against by proper attention to lancing. A small piece of gum torn by a tooth as it comes away had better be removed ; left in the mouth, it is a source of annoyance, and reflects, in the mind of the patient, on the practitioner. Large strips are to be carefully laid back in place, and secured by one or more stitches, or other convenient means of retention. Hemorrhage. — Hemorrhage after extraction is influenced by two circumstances : the state of the parts, and the predisposition of the patient. An ordinary tooth extraction is followed by hemorrhage lasting but a very few minutes. In extraction for periodonteal trouble the bleeding is more profuse. Such hemorrhage, however, if at all reasonable, is not to be interfered with ; it expedites the cure of the case wonderfully, relieving the general congestion of the parts. . Undue hemorrhage of local signification is found to depend either on non-contractility in the foraminal and circumferential vessels, or on excessive vascularity in the alveolar walls. Where the bleeding is from an ai'tery, it will be more or less per saltern; where venous or capillary, it will be continuous. Hemorrhage of constitutional expression is associated with the defibrinating condition, or with hereditary predisposition. Anaemia as a cause is perhaps the most common of the systemic vices ; next to this may be ranked a typhoid state ; after this, purpura. Plethora conjoined with laxity of the tissues is another of the constitutional causes. Vicarious relation- ship is a condition sometimes met with. In cases where a hemorrhagic diathesis exists, alveolar hemor- rhage is not unfrequeutly of the most profuse character, making necessary the most judicious and energetic treatment for its arresta- tion. Two cases, occurring with the author in the persons of a father and son, may illustrate such direction of practice. Mr. B., aged 19, applied to his dentist for the removal of the second superior molar of the right side. The operation over, the bleeding seemed not excessive, and the patient was dismissed as usual. On the same day, in the latter part of the afternoon, bleed- ing recommenced ; Monsel's solution of the persulphate of iron was employed, and the patient again dismissed. During the night hem- 424 ORAL DISEASES AND SURGERY. orrhage again recurred, and the family physician was sent for ; the solution of iron was again employed, and a temporary arrest again secured. The next day it reappeared, and nitrate of silver was applied in the alveolus. This controlled the hemorrhage until the succeeding day, when it again appeared ; and so off and on over a period of eight days. At this time I first saw the case in consulta- tion, the patient being unable to swallow any other than liquid food, owing to the swelling of the fauces and oesophagus from the effects of an over-free use of the nitrate of silver. In examining the case, we first took from the cavity the half- coagulated clot it contained, and, washing the parts thoroughly, discovered that the bleeding came not alone from the socket of the tooth, but fi'om about the margins which had been ulcerated and degraded by the various applications. Hemorrhage was entirely capillary. In a treatment which resulted in the immediate control of this case, the following course was pursued. First, an impression in wax was taken of the roof of the mouth, inclusive of the bleeding part. From this impression a model was made, to which was struck a silver plate. This accomplished, which consumed about two hours, the bleeding cavity was packed with alum-saturated lint, the lint pro- jecting and overlying the ulcerated margin. Over and upon this was now placed the accurately fitting and compressing plate. Upon the plate, raised to the common level of the adjacent teeth, was laid a fold of linen : the lower jaw was next closed upon this compress and kept in position by a bandage. Tincture of Erigeron Canadensis was administered, and the feet of the patient were placed in hot water. Hemorrhage ceased entirely in the course of an hour, and did not recur. Mr. B., the father of this young gentleman, aged perhaps 50, suf- fered five days from hemorrhage, under the following circumstances : A wisdom-tooth of the left upper jaw troubling him because of its great looseness, he applied to his dentist for its removal. Not deeming it necessary or desirable to wound the gum, the practitioner extracted the tooth without the preliminary step of lancing, and in the act was so unfortunate as to tear away a small strip. Hemorrhage was immediate, and more or less continuous. MonsePs solution being prescribed by his physician, it was employed, but with somewhat the same result as in the son's case. On the evening of the fifth day I first saw this case. The patient was much weakened from the excessive discharge, and exceedingly frightened and nervous. Washing away the clots, I discovered the blood oozing from the 1 GENERAL REMARKS ON EXTRACTION. 425 torn gum, and not at all from the tooth-socket. I commenced imme- diately to give erigeron in drop doses, repeated every minute, and ligated against the wound a tuft of alum-saturated cotton. The hemorrhage ceased entirely within ten minutes, and did not recur. As an assurance, I prescribed the wine of iron, which the patient continued to take to the amount of four ounces. Tincture of Erigeron Canadensis, in cases of this character, seems to be a quite reliable haemostatic; not entirely so, however, as I have prescribed it where it certainly failed to exert the slightest influence. Hemorrhage dependent on the typhoid condition is to be treated with most success by conjoining with the local medication the internal administration of acids, than which none seems to answer so good and reliable a purpose as the dilute hydrochloric. Purpura, as a predisposition, demands its own peculiar class of remedies. Anaemia is best treated for immediate ends with the tincture of the chloride of iron. Vicarious hemorrhage requires an attention which shall dispose to the restoration of the lost harmony. What- ever the systemic vice, appreciation of the requirements and the meeting of the indications constitute a most important direction in the treatment. Depressing the action of the heart is, under almost all circum- stances, a most valuable means for the arrestation of hemorrhage. To this end the tincture of veratrum viride is alwaj^s to be given with satisfaction. Conjoined with this, and indeed in many instances quite capable of taking its place, is the hot foot-bath, — the impres- sion to be continued until the patient shall either grow faint or break out into profuse perspiration. Lead and opium prescribed in conjunction form a very reliable hemostatic ; two grains of the first to one of the latter may be given every two or four hours, according to the urgency of the case. Rest is one of the reliable means of cure. A patient is to be kept quiet, both as the body and the mind are concerned. The local treatment of dental hemorrhage has the threefold signifi- cation of mechanical, vital, and chemical. The first considers means which, through compression or clot, shall confine the blood to its vessels. Plugging the alveolus is a common practice in this direc- tion. A plug may be made of almost any convenient material ; common raw cotton, or shreds of lint made by scraping linen, answer commonly every purpose. When hemorrhage is per saltern, a splint of soft pine wood, shaved to a point corresponding with the apex of the alveolus, being carried and retained in place, will almost 426 ORAL DISEASES AND SURGERY. of a certainty control the hemorrhage. Plates of metal or gutta- percha, moulded so as accurately to close the cavity, thus favoring the formation of a clot, are frequently employed with success. Spider-web as a clot-holder is another means, the web being packed into the cavity and there retained. Compressed sponge is still another of the mechanical means. This, when thoroughly coated with wax and of delicate point, may be carried to the very apex of a cavity, and, when forced into itself dnd maintained in position l)y an overlying compress, constitutes one of the most reliable of this character of agents. Of the medicinal agents having the signification of forming a clot, preference is to be given to tannic acid. The persulphate of iron, a preparation much used in general practice, is to be denied applica- tion in the mouth. Without doubt a clot is to be formed more speedily and solidly with this agent than with the tannin, but the dianger from secondary hemorrhage overbalances all its virtues. A tannin clot is not soluble by the blood, and needs but support to possess all required virtues. Of the astringents and stimulants, acting by exciting responsive force in the tissues to which they are applied, and controlling hem- orrhage through contractility, we have alum, zinc, lead, capsicum, iodine, turpentine, and most of the mineral acids. Alum in full saturation with water is one of the most reliable of the haemostatics, and, when properly supported by a mechanical adjunct, it will seldom be found to fail. Of agents acting chemically to the control of hemorrhage, mention may be made of catechu and kino among the vegetables, and nitrate of silver among the metals; the latter, however, is an objectionable preparation, because of the destruction of tissue so common to its emplo3'ment, except when used in dilution. All ordinary means failing for the control of an alveolar hemor- rhage, the actual cautery may be applied. A control thus secured, however, is to be seconde'd by the anti-hemorrhagics of internal expression, as it is frequently found to be the case that the separation of the slough re-excites the original trouble. Compression made to a bleeding alveolus should be moderate, not severe ; and when made, and the hemorrhage has been con- trolled thereby, it should not be too hastily removed. Luxation of the Inferior Maxilla. — Occasionally, as the result of a sudden movement, or an abnormal laxity of the ligaments of the temporo-maxillary articulation, the condyloid process falls GENERAL REMARKS ON EXTRACTION. 427 forward over its glenoid boundary. The patient is thus rendered unable to close the mouth, and is said to labor under luxation. (See chapter on Luxaiion.) Local Anesthetics in the Extraction of Teeth. — The em- ployment of various local agents to secure exemption from pain in the operation of extraction has of late commanded so much atten- tion that no chapter treating of such operations would be complete without reference to the subject. The most simple and, we may say, elementary application in this direction consists in inclosing in a piece of bladder, or other conve- nient skin, a small portion of pounded ice and salt, and enveloping, for a few moments, the part to be operated on. To secure most conveniently the effect of such a process of refrigeration, various instruments have been devised, but none, so far as the application of the ice and salt is concerned, have been found to answer any better purpose than the bladder or skin inclosure. Such skins should consist of two little bags, one to rest upon the outer, the other upon the inner, side of the gum. To prevent pain from the application of the cold, the bags should be brought gradually in contact with the gums ; or, what will answer a similar purpose, the application may be preceded by ice-cold water held in the mouth for' a few moments. An apparatus designed and manufactured by Messrs. Home & Thornwaite, of London, is said to answer a very good purpose, and is thus described : "A required amount of water is cooled down, by means of ice and salt, to about zero, in a vessel called a refrigerator. To this vessel is attached another, called a graduator, containing warm water at about 100°, and so constructed as to allow the slow admixture of its contents with the chilled water in the refrigerator, and thus produce' a gradually diminishing temperature, for the purpose of preventing sudden shock and pain to the teeth, which a direct application of cold would inevitably cause. A tube conveys this graduated cur- rent into a terminal portion constructed of very fine membrane, which adapts itself to the form of the gums, and wholly surrounds the tooth to be extracted. The fluid then passes away through an exit tube. In this manner a constant current of cold, at a decreasing temperature, is made to pass over the part, abstracting therefrom all heat, and consequently all feeling." The concentrated tincture of aconite is a useful local anaesthetic, but one that should be used with a considerable degree of caution. 428 OBAL DISEASES AND SURGERY. If a portion of this tincture be applied to one-half the lip, sensibility will be so interfered with that a goblet placed to the parts will appear as if broken. A mixture of chloroform and laudanum in equal parts is much lauded by some. To apply this, it is only necessary to saturate a tuft of cotton and lay it against the tooth to be extracted. Another means, serving to attract the attention of the patient from the operation, consists in painting the gum heavily with tinc- ture of iodine. After such painting, people will often be found to say that the pain has been much ameliorated. Electro-galvanism claimed at one time a good share of attention. Its application consists in applying one pole of a battery to the for- ceps, while the other is held in the hand of the patient; a gentle current is then to be let on, during the passage of which the tooth is extracted. This mode of effecting local anaesthesia is still prac- ticed by very many; but I must say that, in my hands and in the hands of many experienced friends, it has proved a failure. Not that it is to be denied that in certain cases it does seem somewhat to obtund sensibility, but in the majority of instances it either does no good at all, or adds the discomfort of the current to the pain of the operation. The application of the spray of ether or of rhigolene is the latest, and perhaps the most worthy and reliable, of the local anaesthetics ; certainly one may say reliable when employed for operations of limited extent about the soft parts, but as to an equal availability in tooth extraction, my experience has not so well satisfied me. With these agents as thus locally applied I have performed many incisions, in the way of the removal of sebaceous and other super- ficial tumors, the opening of abscesses, carbuncles, and similar operations, and the result has been everything I could have desired ; but in their application to the teeth, the obtunding of the sensibility has not by any means been so marked ; and particularly has this been' the case where rhigolene was used. The process of freezing a part through the known refrigerant power of evaporating ether seems first to have suggested itself to Dr. Richardson, of London. An instrument invented by this gentle- man for the accomplishment of such an end is here exhibited, forms of bellows for both hand and foot being represented. For the spraying of any plain surface, the simple straight tube is all that is necessary. For the teeth, the double sprayer, as seen in the drawing, is used ; with this instrument a continuous vapor is GENERAL REMARKS ON EXTRACTION. 429 cast both upon the outer and the inner face of the gum, and congela- tion is rapidly induced. Fig. 184.— Spray Apparatus— Hand-Ikstrttment. In using this hand-instrument, the operator himself should not work the pump. A very few moments' compression of the ball renders the hand shaky and unmanageable. Upon this instrument of Dr. Richardson's many modifications have already been made. Of these, one by Messrs. Codman and Shurtlefif, of Boston, has perhaps attracted most attention. It cer- tainly seems to divide the ether more Infinitesimally, thus insuring a more complete vaporization ; but it has a weak point, in that the tube seems frequently to freeze or choke up, an accident that does not occur with Dr. Richardson's instrument. An objection urged to the use of extreme cold as thus induced is that injury is done to the soft parts, as it is thought will be mani- fested in inability to unite wounds happily and easily. That such objection is, however, not valid, I have satisfactorily proven; for, if anything, parts thus operated on have united better and with less inflammatory reaction than has obtained where the spray has not been used. 430 ORAL DISEASES AND SURGERY. Rhigolene or hydrocarbon, manufactured from coal-oil, and much vaunted by some, has not, in my hands, proven so satisfactory as Fig. 185.— Spray Apparatus— Foot-Instrument. ether. It certainly freezes a part more quickly than this latter agent, but this does not seem alone to be the object, as anaesthesia IS not nearly so complete. CHAPTER XV 1 11. GENERAL ANESTHESIA, " So long as pain is an evil and ease a good — so long, in other words, as man is man — must any means be prized that is capable of achieving the latter by the abolition of the former. As, then, the pain of surgical operations is certainly of the most terrible of its class, and it is no matter of doubt that agents exist which possess the power of abolishing this pain, what remains for consideration is not so much whether tliis means shall be hailed as a matchless and priceless discovery, and be cherished and adopted as a blessed thing, — this appreciation has been made, this adoption has been consecrated by almost universal practice: what remains for con- sideration is, whether the good is a pure good, or is counterbalanced by evil. " The obvious, open, palpable, glorious good of anaesthesia, and particularly ether anaesthesia, is to deliver the wretched victim of surgical disease from the additional torture of pain while seeking the goal of health through the portals of chirurgery. The evils that have been said to follow or accompany this good have, how- ever, been regarded by some as of so serious a character as not only to induce them to reject general anaesthesia in their own practice, but to denounce it publicly as a means that should not obtain with scientific and conscientious men. " We confess that we are surprised whenever we hear these expressions; and, strange as it may seem, there are even now enough to give expression to them. Of the hundreds and thousands — we might say hundreds of thousands — who have taken ether to insensibility, we have been unable to discover, after the most ex- tended inquiries, a single case which resulted in death, or left behind it consequences of serious importance that were certainly attributable to it. In a small proportion of cases there have, no doubt, been some unpleasant results, such as temporary depression of the vital powers ; headache, more or less considerable, for some hours, or even days ; hysterical excitement in women for a similar length of (431) 432 ORAL DISEASES AND SURGERY. time ; slight bronchial irritation, nausea, and sickness, and some other slight affections ; but the proportion of patients suffering, even in this slight manner, has been extremely small, — indeed, won- derfully small, when we consider the indiscriminate manner in which the practice has been had recourse to, with bad ether and bad manipulators. Indeed, that so very few and such trifling accidents have occurred in such a state of things, is most convincing proof of the general safety of the practice. For, in considering the entire incompetence of the many who are in daily, fearless employment of the agent, so far from these uniformly innocent results being antici- pated, one might very naturally look for others of a very different kind. We have ourselves been constantly looking for ill conse- quences, and we are still prepared to find them; but when thy arrive, if ever they now are to arrive, we shall have to consider well, before condemning the agent, whether the event was a neces- sary consequence of its use, or merely an accidental result from its abuse." The preceding very impartial and terse consideration of the gen- eral question of anaesthesia, as reference is had to its production by sulphuric ether, we find in a British monograph. The question, " To what are accidents (if accidents there are) attributable ?" is naturally suggested, and would excite in the mind a desire to enter on the consideration of a subject fraught with such importance, before taking up its use or joining in the cry of those who abuse. Such consideration I propose to make the subject of this chapter, and trust that not a little personal experience enjoyed will enable me to present it with some degree of clearness. We first consider sulphuric ether. An agent, refreshing in itself, may, in improper hands, become a source of ill : this truth applies to the whole Materia Medica. What is sulphuric ether ? "When equal weights of rectified spirits and oil of vitriol are mixed in a retort, the latter connected with a good condensing arrangement, and the liquid heated to ebullition, a colorless and highly-volatile liquid, long known under the name of ether, or sulphuric ether, distills over. The process must be stopped as soon as the contents of the retort blacken and froth, otherwise the product will be contaminated with other substances which then make their appearance. The ether obtained may be mixed with a little caustic potash, and redistilled by a very gentle heat. "Pure ether is a colorless, transparent, fragrant liquid, very thin GENERAL ANESTHESIA. 433 and mobile. Its specific gravity at 60° is about 120 ; it boils at 96° under the pressure of the atmosphere, and bears, without freezing, the severest cold. When dropped on the hand, it occasions a sharp sensation of cold, from its rapid volatilization. Ether is very com- bustible ; it burns with a white flame, generating water and carbonic acid. Although the substance is among the lightest of liquids, its vapor is very heavy, having a density of 2.586. Mixed with oxygen gas and fired by the electric spark, or otherwise, it explodes with the utmost violence. Preserved in an imperfectly-stopped vessel, ether absorbs oxygen and becomes acid, from the production of acetic acid. This attraction for oxygen is increased by elevation of temperature." {Fownes.) Dr. Jackson's formula for the preparation of ether for anaesthetic purposes is, we believe, as follows : procuring the strongest and purest rectified sulphuric ether, — that just described, — wash it well, to get clear of any acids ; then decant from the water, drying it with chloride of calcium, to free it of any water that might other- wise remain from the washing. This, however, is but a single formula. Different chemists arrive at the same ends through different processes. The surgeon should buy of a reliable druggist rather than attempt the preparation for himself. This, then, is ether, an agent which, as experience demonstrates, will produce insensibility when breathed into the lungs. To exhibit ether successfully, four essentials seem necessary: 1st. That the ether should be very pure. 2d. That the vehicle upon which, or with which, the agent is exhibited, should be of such character that full volume of atmo- spheric air is allowed to pass through the ether into the lungs. 3d. That the vapor of the ether be properly diluted, given for the first few inspirations comparatively weak, and increased in strength as the glottis, air-passages, and lungs can bear it. 4th. That insensibility be produced as quickly as the system will bear, as evinced by obvious signs. A cone-shaped, close sponge is the best means for administering ether. This possesses every advantage, except that of economy in the administration, without having any of the common faults. From two to five minutes will be found the average time necessary to pro- duce the full effect of perfect sleep; though cases will present them- selves where double this time will be required, and where, indeed, it may be necessary to combine with the ether the more powerful 28 434 ORAL DISEASES AND SURGERY. effect of chloroform, or even to employ the undiluted chloroform. From an article emanating from a gentleman of much experience in anaesthetic agents, we take the following suggestive remarks: "It is possible to inspire three, four, nay, ten times the quantity of ether capable of producing sleep, without this state being pro- duced, provided the vapor be taken in a too diluted form ; and we believe this over-dilution and its consequent protracted inhalation is a frequent cause of the excitement which supervenes in the practice of many persons, while it so rarely shows itself in that of others. In these cases the patient may be made drunk; drunk in the first degree, but not dead - drunk, the condition required for surgical purposes." It will be remarked, let it be noticed in passing, that one of the most common objections of the opponents of ether lies at this door, — this supervening state of excitement instead of the desired state of stupor; but does not the question again very pertinently apply, Is the fault with the agent, or with the operator? The idea is to be conveyed that the effects of sulphuric ether and of the common alcoholic beverages are the same. The effects of alco- holic liquids are too well known to require minute description. We have, first, the state of exhilaration, which gradually changes to com- plete stupefaction or narcotism : the last state, the result probably of a narcotized condition of the brain. Just so acts ether, yet passing through its various stages more quickly, the result of its being poured in a continuous and undiluted stream upon the heart and brain. The ether is no sooner absorbed than the blood charged with it passes to the left side of the heart, and immediately thereafter is cii'culated through the coronary vessels, the carotid and vertebral arteries, and thus pervades the tissue of all parts of the heart, as well as of every portion of the brain. A writer, in an influential dissertation, presents an example in this wise: " Suppose, to take an extreme illustration, that the blood M^as as capable of absorbing as much ether as water can combine with, or one-tenth its own weight. If, then, we suppose the blood in the lungs was impregnated to this extent, it would be applied in that state to the heart and brain ; whereas, if the blood in the stomachic vessels was impregnated to the same extent with ether, before reach- ing the liver it would have mingled with more than its own mass of pure blood from the splenic and mesenteric veins. The tenth would then become a twentieth, and, on the blood leaving the liver and joining the larger current of the inferior cava, the twentieth GENERAL ANESTHESIA. 435 would become a fiftieth or sixtieth; a further dilution would take place at the confluence with the superior cava, so that the blood, on reaching the heart and brain, instead of containing one-tenth part of absorbed ether, could not contain as much as one-hundredth. When, therefore, the same quantity of ether, or any absorbable substance, is taken up from the lungs and from the stomach, it must, in the former case, be applied to the tissue of the heart and brain in a state of concentration at least ten times greater than the latter, and will therefore act on these organs with more suddenness and energy." The evanescence of the effect of ether, as compared with that of alcohol, is explained by a momentary consideration of the different manner of absorption. During the inhalation of ether, as we have just seen, the charged blood is applied to the heart and brain, while the blood circulating in the lower parts of the body contains a much smaller proportion of it. Now, on stopping the inhalation, the blood in the heart and brain speedily passes off by the veins, and is suc- ceeded by the comparatively pure blood coming from the lower regions of the body, and so the narcotic symptoms disappear. "It is far otherwise when alcohol is absorbed from the stomach, for the whole mass of blood must be impregnated with it before a highly-charged blood can be applied to the heart and brain ; and then the effect continues for many hours, till the alcohol has been thrown out of the system by the lungs and skin. With respect to ether, it must not be supposed that on the subsidence of the nar- cotism it disappears from the body ; for it is merely weakened in its effects by being diffused over the whole mass of blood. This is obvious, from the smell of the breath for many hours, and from its frequently causing copious perspiration." Does not the question here suggest itself, If the effects of ether and of the common alcoholic beverages are so nearly alike, why the great dread of the one and the entire fearlessness with the other ? Would not the answer seem to be something of this kind? Men when etherized are as dead-drunk : our eyes are accustomed to seeing them only partly drunk. In this state they excite amuse- ment : in the state of profound drunkenness they have always aroused our fears for their recovery. Associations have great weight. The immediate and obvious effects of etherization on the individ- ual hardly require notice, as they must be familiar to all our readers, if not from a personal experience, certainly from observation upon others. " All the usual phenomena of the deepest sleep supervene, 436 ORAL DISEASES AND SURGERY. gliding often into the profoundness of sopor, and verging occasion- ally upon, if not actually lapsing into, coma. The voluntary mus- cles become suddenly relaxed, the jaw falls, the arms hang down, the eyes roll upward under the lid, the respiration becomes slow and labored, and the face becomes either very pale or morbidly flushed ; the aspect of things is truly such as can hardly be contemplated for the first time without alarm: the individual seeming, to the com- mon eye, to be sinking into the sleep of death." It is impossible, says another observer, to see a single case of ether- ization without being struck with its resemblance to asphyxia ; and experiments exhibit a real relation between the two. But in ordinary asphyxia the nervous system loses its power under the influence of black blood, or blood deprived of its oxygen. But in etherization it does so under the direction of this singular agent. This is really all the difference, for in both there is the same loss of sensation and voluntary motion, and the same at least temporary persistence of the respiratory movements. In one word, there is the same survival of the medulla oblongata over the spinalis. " Etherization exhibits to us the entire mechanism of asphyxia : we mean the successive deaths of the various nervous centres. It iso- lates, just as mechanical experiments do, the intellectual powers, the co-ordination of the movements, sensibility, motility, life. The isolation of life — this point, this vital knot of the nervous system — forms the most striking point of the experiments. " In an etherized animal one point alone survives, and while it does so, all others retain at least a latent life, and may resume their active life; this point once dying, all dies." Throwing out of immediate consideration the idiosyncrasies, let us for a few moments consider the question of the general safe ex- hibition of the agent. The safest agent may be made a source of ill : as the intruder on the physical laws of his organism must sutler the consequences of his ignorance or temerity, so may any agent, however good, be made an injury by its abuse. As the imbibition of alcoholic beverages may be carried to a point beyond which the life-principle reacts not, just so, and as the warmest supporters of the anaesthetics would have impressed, may ether be made an instrument of irreparable injury, blasting and destroying where it was designed to refresh and save. To lay down certain reliable rules, applicable in all cases, for the process of etherization, is an impossibility. The presentments of conditions in various individuals ditfer so materially, that it would I GENERAL ANESTHESIA. 437 be charlatanism to act upon any but rules resulting in a general knowledge of the agent and a comprehension of physiological laws and pathological alternations. One person, as Dr. Snow remarks, " shall become impassable as the subject on the dissecting-table ; another talks incoherently or mirthfully, replies to questions, or obeys directions; others utter exclamations of pain, which they afterward retain no reminiscence of having felt ; and others again declare that they have suifered pain but felt themse:lves powerless for its expression. Finally, in not a few, ungovernable violent or convulsive action takes place, quite adverse to the performance of any delicate surgical operation. With some an utter oblivion is induced ; while others, while undergoing all the apparent torture of a prolonged dissection, are reveling in the realms of memory and in the fields of imagination." M. Jobart and other observers have attempted to lay down three distinct stages in the effects of the agent, according to the prolongation of the etherization. 1. That of inco- herence, agitation, or delirium, as the case may be. 2. Acceleration of the pulse, with loss of sensibility and loss of power. 3. Exhaustion and coldness of the surface. As we have remarked, the matter cannot thus be methodically laid down, for it is quite certain that any of these conditions may be induced, in diflPerent individuals, by very various doses of ether; while others, again, are susceptible of only the first degrees, to appearances, and yet enjoy an immunity from suffering during operations. Even the quickened condition of the pulse and respiration, and that almost universally employed crite- rion, the stationary condition of the pupil, may deceive in the supposed impression produced. A number of the French Academicians some years back instituted a series of experiments upon animals, for the purpose of determining the mode and order in which the various portions of the cerebro- spinal system were influenced during inhalation. The following are some of the conclusions arrived at by the veteran vivisectdr. Baron Flourens : " The action of ether upon the nervous centres follows in a given course. It acts, first, upon the cerebral lobes, disturbing the intellect. It acts, secondly, upon the cerebellum, deranging the equilibrium of the movements of the animal. Thirdly, it acts upon the medulla spinalis, in which it extinguishes, successively, the sensory and motor principles; and, lastly, it acts upon the medulla oblongata, where arrived, life becomes extiact." To produce the best effects of sulphuric ether, it is of the first 438 ORAL DISEASES AND SURGERY. consequence that an entirely reliable article be employed. " For myself," says Dr. Robinson, of London, "I feel convinced that many of the failures that have occurred in its administration in some measure may be attributed to the imperfect preparation of the fluid. I have myself obtained ether of various specific qualities from dif- ferent chemists; and on one occasion, requiring an extra quality for a series of experiments, the gentleman supplying, being out of that quality he had generally furnished, sent some of a different kind which he had in his establishment, w^hich was administered in two cases. I found, however, I could only produce partial uncon- sciousness, not insensibility to pain, and therefore deferred the operations, which were upon the teeth. I afterward procured some of the first quality ether, and employed it in the same case with success." The effect of a bad article of ether is not only the inability on the part of the operator to produce more than a partial unconsciousness, but it is almost certain to produce nausea, giddiness, and prostra- tion. If a good article cannot be procured, better use none at all. The quantity of ether that may be given to any individual patient is a matter for the practitioner to decide upon in connection with each case. It is impossible to fix the dose of vapor that will be required to produce given effects upon any patient, neither is it always an easy matter to decide when just enough has been admin- istered. We cannot rely implicitly on the state of the pupil or pulse, or upon what is considered by so many as an exact indication, — namely, the insusceptibility of the eyelids to impressions made by striking the hairs. Perhaps the changes in the breathing are the most reliable signs: these certainly influence me most; so long as breathing continues easy and natural, little danger is to be antici- pated, but the moment it becomes labored, one is to proceed or recede cautiously. In etherizing a patient, let the operator watch the pulse, the expression, and the respiration. So long as these give no counter-indications, the exhibition may be carried forward to the end desired. As to the question of the continuance of a patient in the anaesthetic condition, I think it will be found the proper rule to make the time just as short as possible : that is to say, as the continuance of the exhibition of the agent is concerned. If an operation to be per- formed in the anaesthetic condition may be completed in five, ten, or fifteen minutes, it is not good policy to prolong it, and with it the continued administration of the ether, to a half or a full hour. That GENERAL ANESTHESIA. 439 there is, however, any imperative or absolute necessity to hurry through an ether case is not at all implied. I have known a patient kept continuously under ether for forty-two hours ; and in obstet- rical practice ten or twelve hours of anaesthesia is not at all unfre- quent. I only contend that it is neither necessary nor prudent to prolong, without object, the condition. Where, however, such a prolonged action is demanded, it is to be secured, not by keeping the saturated sponge constantly applied over the air-passages, but by applying it at such intervening periods as may be necessary to pre- serve the anaesthesia. The condition of the temperature, as might be inferred, has much to do with prolonging or shortening the time commonly considered necessary to place a patient in a state of sleep. Dr. Snow obtained, from experiments, the following results : One hundred cubic inches of air, saturated with the vapor of ether, at a temperature of 44° would contain 27 cubic inches of vapor. 54° " 24.3 64° " 43.3 Y4° " 53.6 84° " 66.6 Being doubled by a rise of only thirty degrees ; or, in other words, if at a temperature of 84° Fahrenheit we employ two or two and a half minutes in affecting a person to the state desired, at a tem- perature thirty degrees lower we would require from four and a half to six minutes to obtain the same result. Concerning the idiosyncrasies, I would speak my own experience by saying that I have never yet met with a person who I thought might not take ether, or ether in combination with chloroform. The London Medical Gazette considers its use inadmissible where there is a tendency to apoplexy or epilepsy, and also in plethoric individuals. Another intelligent source says that persons presenting the slightest signs of being cataleptic should be viewed as idiocratical. Persons under the influence of liquor, it is generally considered, should be viewed for the time as not fit subjects. In a conversation with Dr. J. B. F. Flagg, had several years back, that experienced man told me that he believed in no idiosyncra- sies, except it might be a very high, nervous temperament; that he had administered ether to the infant of thirty-six hours and to persons in extreme old age ; had given it to the robust and the weak, the plethoric and the consumptive; had used it in all stages 440 ORAL DISEASES AND SURGERY. of pregnancy, except that stage known as quickening : would also exhibit it here, but would feel called on to exercise more than ordi- nary care. Seeming idiosyncrasies might generally, he thought, be explained by an examination of the operator's ignorance of the agent. The faith of this gentleman in the perfect safety of the use of ether was so great that he remarked he would not hesitate to use it where there had been, or was, aneurism of the aorta. The opinion of Dr. Flagg concerning the non-existence of idiosyncrasies is to be taken before that of most persons, either of this country or Europe. His opportunities for observation were not surpassed by those of any other person, and perhaps equaled by few. A work published by him in 1854, long before his retirement from practice, has not, up to the present day, been advanced on, and is an heirloom to be valued by those to whom his industry has left it. CHAPTER XIX. GENERAL ANESTHESIA. From the consideration of sulphuric ether we may pass to an investigation of the character and merits of the perchloride of formyle, or chloroform. This agent is, without doubt, the most powerful and reliable of the anaesthetics; but, unfortunately, it pos- sesses qualities which render it not unfrequently fatal to life, and therefore make it of less value than the one we have just been con- sidering. No person should employ chloroform who is not prepared to meet many emergencies. To procure chloroform, the chemist takes of chlorinated lime say (to take a common formula), lb. iv; rectified spirits, Oss; water, Ox; chloride of calcium, broken in pieces, 5j- Put the lime, first mixed with water, into a retort, and add the spirits, so that the mixture may fill only the third part of the retort. Then heat them in a sand- bath, and as soon as ebullition begins withdraw the heat as quickly as possible, lest the retort should be broken by the sudden increase of heat. Let the liquor distill into the receiver so long as there is nothing which subsides, the heat being reapplied if necessary. To the distilled liquid add a quarter of the water, and shake them all well together. Carefully separate the heavier portion, which sub- sides, and add the chloride to it, and frequently shake them for an hour. Lastly, let the liquid distill again from a glass retort into a glass receiver. In appearance, chloroform resembles the freshest water of the mountain-spring. To the taste it is hot and very sweet; to the nostril it has much the odor of the common strawberry. When dropped upon linen it evaporates very quickly, leaving, if pure, no stain or sign behind. In weight it is quite one-half heavier than water, and, as its vapor is concerned, is four times heavier than atmospheric air. The smell of chloroform, says Dr. Snow, should be esteemed one of the best tests of its purity and identity. When dropped on the (441) 442 ORAL DISEASES AND SURGERY. hand it should quickly evaporate, leaving not the least smell or moisture behind. If a disagreeable odor remains on the hand after the evaporation, the chloroform has probably been made from impure spirits, or even from wood or acetone, and is therefore unfit for me- dicinal purposes. When chloroform becomes decomposed from any cause, it acquires a greenish-yellow color, and gives off chlorine and h^^drochloric acid, so that the alteration is at once apparent. When chloroform is pure, it has no reaction on test-paper, but is quite neutral. The best way, according to Dr. Snow, to detect a small quantity of hydrochloric acid in it, is to moisten a slip of blue litmus paper with distilled water, and hold it just within the neck of the bottle exposed to the vapor. If sulphuric acid be present, it may be discovered by agitating the chloroform with distilled water and adding nitrate of baryta. Chloroform may be degraded by admixture with alcohol, and this can be done without making any perceptible change in its appear- ance : its specific gravity, however, is thereby lowered ; and, accord- ing to M. Mialbe, the foreign presence is most easily detected by adding to the suspected fluid a small quantity of water, when a milky opacity results. Chloroform, as the heart's action is concerned, is a powerful seda- tive. In nearly if not quite all the fatal cases resulting from the administration of this agent, cardiac syncope has been the cause of death ; and in a very small minority of the cases indeed has there been any evident interference with the process of respiration. This fact is always to be held in strictest remembrance when exhibiting the agent. In oral surgery, where it is desirable to produce the profoundest and most prolonged primary impression, chloroform, if it were without danger, is the anaesthetic most indicated and required. In- deed, in my own practice I find many cases where I do not seem to be able to get along without it, using it either alone or in associa- tion with the ether. Therefore, because its use is so frequently necessary, the oral surgeon should make himself as familiar as pos- sible with all that concerns its defects as well as its virtues. Experiments have demonstrated that eighteen minims of chloro- form is the average quantity necessary to put an adult in a con- dition of insensibility to surgical operations, — that is to say, that this amount should be absorbed and carried to the nerve-centres. It has also been shown " that chloroform vapor has the effect of suddenly arresting the action of the heart, when it is mixed with GENERAL ANAESTHESIA. 443 the respired air to the extent of eight or ten per cent, or upward." With these two lessons appreciated, it is seen that the manner and character of the exhibition of the agent have much to do with the result. Not everything, however, as it is undeniable that fatal accidents have occurred in the best and most skillful hands, although in these latter cases the inference is to be drawn that the deaths occurred from idiosyncrasies. Eighteen minims, according to Dr. Snow, are to be absorbed from thirty-six breathed ; allowing thus that one-half is lost in expiration. But temperature, as in the case of the ether, has much to do with the taking up of such a quantity. The following table comprises the experiments of Dr. Snow in this direction. At a temperature of 40° Fahrenheit, one hundred cubic inches of air will take up but seven cubic inches of the vapor. At 45° 8 cubic inches. At 70° 24 cubic inches. 50° 9 " t5° 29 55° 11 " 80° 36 60° 14 " 85° 44 65° 19 " 90° 55 This table readily exhibits the fact that anaesthesia by the use of chloroform must come on at varying periods, and that therefore no judgment of its proper exhibition is to be derived in this direction. Again, outside of these atmospheric associations, the manner of the exhibition would have much to do with the minims inspired : where, for example, it is exhibited poured over a single layer of linen (as upon a handkerchief laid over the face), quite as much would be lost in the surrounding atmosphere as would be inhaled into the lungs. Considering the danger as arising from the direction of cardiac syncope, advantage is to be taken of all conditions antagonistic to such depression. In bloodletting, it is known that such a condition is much the most readily brought about when the operation is per- formed on the patient standing, and when the primary impression is made most marked through a large exit for the blood. In states of depression, arising from whatever cause, either of physical or mental disturbance, such tendency is increased. A surgeon always hesitates to bleed a depressed patient; or, if such bleeding seems a necessity, supporting means are employed and continued in con- junction with the bloodletting. Advantage is taken also of all col- lateral indications, as, for example, position, the patient lying down, 444 ORAL DISEASES AND SURGERY. the head perhaps being placed on a lower plane than the body, the orifice of exit being made very small, intermissions in the flow of the blood, stimulants, as the pre-exhibition of brandy or wine, kind and encouraging assurances, etc. The depressing effect of fear on the heart's action is never to be lost sight of in the administration of chloroform. How many patients faint even while preliminary arrangements in anticipation of an operation are going forward I and, indeed, how many are the cases on record of death from such fright! It would seem, then, that one would never be justified in administering chloroform to a patient laboring under any marked depression ; at least such is my own conviction, and upon such con- viction I have always acted. All persons, or nearly all, approach an operation with a certain amount of trepidation ; but such fear may, in the majority of cases, be dispelled ; or if this is impossible, then a preliminary artificial courage may be given by the use of brandy, or cerebral consciousness may be disturbed by the inhalation of a few drachms of ether. The objection that chloroform should not be administered to a patient in a sitting position does not, however, seem to hold entirely good. In oral surgery this is nearly always the necessar}'^ position ; and I have thus administered it, in perhaps hundreds of cases, with- out ever having had any ill result. A difference in the character of cardiac syncope is here to be recognized. The paralysis may arise from two sources, and exhibit, as the state of the heart is con- cerned, quite different appearances; that is, there is a syncope of anaemia and a syncope of narcotism. Now, while there is between these two conditions much relationship, as the que.stion of a vital propulsive force is concerned, yet there are also certain differences, of which, as surgeons, we may take advantage. Paralysis of the heart occurs when, from any reason, the organ is deprived of the effect of its natural stimulus, the blood: this is the syncope or paral- ysis of anaemia. It occurs again when, through the action of a common or specific narcotic, its muscular fibres are relaxed and deadened. The two causes may exist and act in conjunction. Chloroform is a specific narcotic, as the heart is concerned ; at least this would seem to be the deduction from post-mortems made in the fatal cases of its exhibition. In anaemia, syncope is partly a me- chanical production ; the patient, in a standing position, faints, as the result of gravity countei'balancing the natural distribution of the blood. In narcotic syncope, position is, perhaps, of little con- sequence, at least as the action of the producing cause is, of itself. GENERAL ANESTHESIA. 445 concerned. The question, then, of sitting or lying, as the exhi- bition is concerned, resolves itself into a consideration of the state of the general health of a patient : if there is deficiency either in quality or amount of the vital fluid, then the erect or even serai- erect position should never obtain. If, on the contrary, a patient does not present such conditions, then it would seem there is no special danger in such position. Prefatory stimulation, if not contra-indicated, is happily employed in conjunction with chloroform. A tablespoonful or more of brandy given to a patient some five or ten minutes before the exhibition of chloroform, will frequently support the natural action of the heart through a prolonged operation, and thus dismiss the common source of alarm. In my own practice I never like to use chloroform but in conjunc- tion with ether ; not mixing them, as in the common chloric ether, but alternating, as the case seems to require or allow. Thus, employing the cone of sponge, I commence the process by pouring within it a quantity of ether, when it is gradually, and yet as rapidly as possible, brought to cover the mouth and nostrils. If now I find the pulse rapidly increasing, or even remaining fixed and steady, and par- ticularly if undue cerebral excitability manifests itself, I drop into the cone ten or twenty drops of chloroform. This will generally be found to quiet the patient almost instantly. From this point I pro- ceed, using principally the chloroform or ether, according to the result to be secured. If an operation is one of simple character and of quick performance, as the extraction of teeth, or the making of some simple puncture or incision, then I think we had better not risk anything with chloroform. If, on the contrary, it is some difiS- cult and tedious case about the mouth, where, after commencing, the surgeon cannot well stop to readminister the anaesthetic, then I take the risk of the excess of chloroform for the prolonged effect it yields and the greater profundity of the impression it secures. The manner of the exhibition of the agent would have, as one would infer, much influence, as the result is concerned. Thus, of the various apparatuses that have from time to time been devised to assist in the use of chloroform, many are deserving of no better name than life-traps; and in this connection one naturally finds himself wondering at the character of contrivances which, particu- larly in the earlier history of chloroform, were employed, even by the ablest men, in experiments directed to the testing of the general safety and results of the agent. I can never read of the white mice. 446 ORAL DISEASES AND SURGERY. and guinea-pigs, and cats, and bell-jars of these pioneers, without wondering that it should never have occurred to the experimenters that animals might as readily die from lack of proper respirable air as from the effects of chloroform. In using pure chloroform, it is most desirable that there should be the fullest admixture with air; with this intention we use the sponge, first softening it with warm water, which water is to be well squeezed away. The respiration should be easy and natural, and the patient fully e7i rappoi't with the operator. He should be given to understand that anaesthesia is but a gentle and harmless sleep, and that one should enter upon such a condition as he enters upon natural slumber. If such confidence can be secured, there will not be found much trouble in producing narcotism. Another plan of using the agent, and one which has many advocates, is to let fall drop after drop upon a napkin, laid loosely over the air-passages. However employed, the principal indication is to have the agent in proper dilution and combination with atmospheric air: this secured, any mode of inhalation must be a proper one. Insensibility, as re- marked by Dr. Snow, is not caused so much by giving a dose as by performing a process. Nature, continues this gentleman, supplies but one mixture of diluted oxygen, from which each creature draws as much as it requires; and so, in causing narcotism by inhalation, if a proper mixture of vapor and air is supplied, each patient will gradually inhale the requisite quantity of the former to cause in- sensibility, according to his size and strength. It is desirable to vary the proportions of vapor and air, but rather according to the purpose one has in view, whether medicinal, obstetric, or surgical, than on account of the age or strength of the patient; for the respira- tory process bears such a relation to the latter circumstances as to cause each person to draw his own proper dose from a similar at- mosphere in a suitable time. The induction of insensibility varies with the individual, or rather, I may say, with classes of individuals. One class will breathe quietly and slowly, until unconsciousness supervenes as if by a natural sleep : persons of this class are of the lymphatic temperament. The nervo-sanguine or bilious class are apt to become restive and frightened, and require a great amount of care and attention, being the most difficult to impress. The true and full nervous class, while timid and frightened, are apt to be impressed by a very few inhala- tions. There is one question that here arises in regard to the exhi- bition of timidity. When a patient becomes restive and excited, GENERAL ANESTHESIA. 447 shall the chloroformization go on ? Yes, I would answer, if such exhibition is associated with mental disturbance produced by the chloroform ; for here it is not as the condition previously named, but is rather an hallucination. These patients should be forced rapidly beyond such states of excitement ; and here is the point in which the production of anaesthesia demands the greatest skill, courage, and judgment. I have over and over seen incompetent operators worry a poor creature into a most wretched condition simply by fearing to pass this Rubicon of excitement. If assured that all is right (and such assurance is to be derived from the general aspect of the patient rather than from any special signs), we are to get over this intermediate excitable stage as quickly as possible, and get over it by concentrating the chloroform. Patients laboring under this excita- bility will, often enough, assure you that they feel that another inha- lation will kill them ; that it is impossible to breathe; that the heart is laboring under a wonderful depression; with many complaints of like character. Such speeches are mostly to be taken cum grano salts : the practitioner must judge for himself. Before an operation of any magnitude is commenced, it behooves the surgeon to assure himself that his patient is in the proper anaes- thetic condition. Entire paralysis of the muscles of animal life is commonly received as indicative of such a state, — this being mani- fested in the lifeless falling of an arm when raised. But this is not strictly reliable, as to obtund sensation we are aware the posterior root of the spinal cord is to be affected, while loss of motion implies only anaesthesia of the anterior root. So quickly, however, does the action of the agent pass from the one to the other, that this sign is found to be one most convenient of acceptance. Dr. Snow, so far as I am aware, was the first to call attention to indications afforded by the eyelashes: this test I have depended on for years, and usually find it reliable. Just after unconsciousuess is induced, remarks this observer, the eyelashes are often closed very strongly when their margins are touched, especially in females, and there seems to be a positive hypertesthesia ; this, however, is only apparent, and arises from the control of the will being removed while sensibility remains. By continuing the chloroform the sensibility of the edges of the eye- lids diminishes, until, at last, the}'' may be touched without causing winking. Under these circumstances, the most severe operation may, in almost every case, be commenced without pain. Upon this indica- tion of the eyelids, Dr. Snow thinks we may so entirely depend, as ordinary cases are concerned, as to accept from them information as 448 ORAL DISEASES AND SURGERY. to the exact extent of anassthesia existing. When, for instance, he says, touching the margins of the lids causes very slight and lan- guid winking, the patient will commonly flinch a little if the knife is used, but only in a manner that can be easily restrained and that will not interfere with the majority of operations. Three degrees of narcotism are described. " The first degree in- cludes all the effects of chloroform that exist while a patient retains a perfect consciousness of where he is and what is occurring. In the second degree there is no longer correct consciousness. The mental functions are impaired, but not necessarily suspended. In the third degree there are no longer any voluntary motions." The circumstances which influence or modify the effects of chloro- form are thus considered by Dr. Snow, than whom, perhaps, there is no one whose observations have been of a more extended or thorough nature; although it is not to be overlooked that he was so enthusiastic in this direction that perhaps, in some instances at least, his prejudices may have influenced somewhat his judgment. " I arrived at the conclusion," says he, " after much careful obser- vation, that chloroform might be given with safety and advantage in every case in which the patient requires, and is in a condition to undergo, a surgical operation. And having acted on this conclusion for several years, I have found no reason to change it. It is de- sirable, however, to pay attention to every circumstance connected with the health and constitution of the patient before exhibiting chloroform, as many of these circumstances influence its effects." Age. — " The age of a patient has considerable influence in modi- fying the effects of chloroform. It acts very favorably on children. They sometimes oppose the inhalation of it as long as they are con- scious, but it does not occasion the rigidity and struggling, after loss of unconsciousness, which are sometimes met with in the adult. Anaesthesia is generally induced with a less amount of narcotism of the nervous centres in children than in grown persons. " The effects of chloroform are more quickly produced, and also subside more quickly, in children than in adults, owing, no doubt, to the quicker breathing and circulation. It often happens, however, that when the insensibility has been kept up for some time, say twenty minutes or half an hour, in a child, it is followed by a natu- ral sleep of a few hours' duration, provided there is no painful wound or other cause to prevent the sleep. I have given chloroform, in a few cases, as early as the age of eight or ten days, and in a con- GENERAL ANESTHESIA. 449 siderable number of cases before the age of two months. And I own memoranda of hundreds of cases under a year old to whom I have administered this agent. There has been no ill effect from it either in these cases or in those of children more advanced in life ; and it is worthy of remark that none of the accidents from chloro- form which have been recorded have occurred to young children." There is nothing peculiar in the effect of chloroform upon people advanced in years, except that its influence subsides rather slowly, on account of the slower breathing and circulation. I have given chloroform to many patients over seventy-five years of age, and to one as old as ninety years. Strength or Debility. — " The comparative strength or debility of the patient has considerable influence on the way in which chloro- form acts. Usually the more feeble the patient is, whether from ill- ness or any other cause, the more quietly does he become insensible ; while if he is strong and robust, there is very likely to be mental excitement in the second degree, and rigidity of the muscles, and probably struggling, in the third degree of narcotism. Patients in a state of debility resemble children, not only in coming quietly and easily under the influence of chloroform, but also in the circumstance that the common sensibility is suspended with less narcotism of the nervous centres than is generally required in robust persons. Chil- dren, and persons in a state of debility, have usually an acute sen- sibility, which causes them to sutfer pain from very slight injuries, but this sensibility is more easily suspended by chloroform than the less acute sensibility of robust persons." Hysteria. — " Patients who are subject to hysteria sometimes have symptoms of the complaint, such as sobbing, crying, or laugh- ing, as soon as consciousness is suspended, or even impaired, by the chloroform ; but these symptoms can always be subdued by pro- ceedino- with the inhalation.* * Chloroform in hysteria is, I think, one of the most valuable medicines of the Materia Medica, while, on the contrary, sulphuric ether is, so far as my experience goes, most decidedly objectionable to such patients. I have treated females afflicted in this way where ether had been used by the pound with no other effect seemingly than increasing, intensifying, and prolonging the par- oxysm ; yet with a very few inhalations of cliloroform I have had the pleas- ure of seeing these persons fall into the most natural slumber, and after rest- ing quietly for hours, the slumber prolonged, perhaps, as sometimes has seemed indicated, by occasional repetition of the inhalation, I have seen them, again and again, awake perfectly recovered. 29 450 ORAL DISEASES AND SURGERY. " In some persons who are subject to hysteria the breathing be- comes excessively deep and rapid while inhaling chloroform.* This usually occurs just as the patient is becoming unconscious, but in a few cases even earlier, and the patient is aware of the impulse to breathe in this manner. After this kind of hysterical breathing has lasted a minute, the patient generally rests nearly a minute without breathing at all, after which the respiration becomes generally very natural. Chloroform is to be given very sparingly during the vio- lent breathing, or else withdrawn altogether for a minute or two." Pregnancy. — It is not generally thought that there is anything in this condition objectionable to the use of chloroform. The Menstrual Period. — This period is certainly not to be pre- ferred or selected as an occasion of chloroform exhibition. Yet there is nothing at all in the condition adverse to such exhibition. The controlling effect of the agent over hysterical symptoms has just been remarked, and such irritability of the system is the only pecu- liarity of this state. Indeed, it is very common that the hysterically inclined female is compelled to resort to chloroform, particularly in conditions of dysraenorrhcea. Diseases of the Lungs. — "Affections of the lungs sometimes cause a little difiQculty and delay in the administration of chloroform, as the vapor is liable to excite coughing when the mucous membrane of the air-passages is irritable. The inconvenience is, however, con- fined to the time of inhalation, for the cough is generally relieved afterward. f " I have given," says Dr. Snow, " chloroform for surgical purposes in many cases where phthisis was present, and in several patients who had suffered from haemoptysis, and have not seen any ill effects from its use in these cases. Chloroform has, indeed, often been inhaled with advantage to relieve the cough in consumption. The * Dr. Snow, in his paragraph, remarks the supervening of this condition after the first few inhahitions, but, according to my own experience, it is as uncommon when chloroform is used as it is common in the employment of ether. When, in administering ether, I see the slightest signs of hysteria, either in male or female, I always expect at once to control them by replacing the ether with chloroform.' f This difiiculty, as observed not only by Dr. Snow, but also by nearly all writers on anaesthesia, I have found to be almost, if indeed not entirely, obviated by preceding the exhibition with a tablespoonful of thick mucilage of gum acacia, the patient allowing it gradually to lose itself over the mucous surfaces. GENERAL ANESTHESIA. 451 cases of chronic bronchitis in which chloroform is administered and for surgical operations are still more numerous." Disease of the Heart. — " There is a very general impression that the use of chloroform is unsafe when disease of the heart exists, more particularly fatty degeneration of that organ. This belief has been encouraged by the circumstance that this affection has been present in a few of both the real and alleged deaths from chloroform, and also by the fact that, in the accidents that have been really due to chloroform, the heart has been the organ on which it has exerted its fatal influence. When we come to investigate these cases, however, we shall find reason to conclude that the heart has probably been diseased in quite as great a proportion of the patients who have taken chloroform without ill effects as of those who have succumbed under its influence. As regards my own practice," says Dr. Snow, "the only case in which death could in any degree be attributed to the chloroform, was one in which there was extreme fatty degeneration of the heart ; but, on the other hand, I have given chloroform in numerous cases without ill effect where the symptoms of this, as well as of other affections of the heart, were present in a marked degree. Indeed, I have never declined to give chloroform to a patient requiring a surgical operation, whatever might be his condition, as I early arrived at the conclusion that this agent, when carefully administered, causes less disturbance of the heart and circulation than does severe pain. Wherever," continues Dr. Snow, " I have had an opportunity of seeing an operation per- formed without chloroform, I have carefully examined the pulse, and although none of these operations have been of a very severe nature, 1 have found the circulation to be much more disturbed than it would have been by chloroform carefully administered. The pulse, in most of these cases, has been exceedingly frequent during the operation, and in some instances it has intermitted to an unusual extent. " In one instance I had an opportunity of witnessing a similar operation on the same patient, first without chloroform, and after- ward under the influence of the agent. In the operation, which was lithotrity, at the first operation I began to feel the pulse just when the patient saw the lithotrite about to be introduced. It was 120 in the minute. As soon as the instrument was introduced the pulse increased to 144, and immediately afterward it became uneven, irreg- ular, and intermitting. I could not count more than three or four beats at a time ; and occasionally, when the pain seemed greatest, 452 ORAL DISEASES AND SURGERY. and the man was straining and holding his breath, the pulse was altogether absent for four or five seconds. In order to ascertain whether the absence of the pulse at the wrist might not depend on the pressure of the muscles of the arms, caused bj grasping the table, I applied my ear to the chest, and found that there was no sound whatever to be heard during the intervals when the pulse was imperceptible. It was evident that the patient held his breath till the right cavities of the heart became so distended as to stop the action of the organ till the respiration returned. The man did not complain or cry out during the operation. "A week afterward the lithotrity was repeated, but on this occa- sion I administered chloroform. The pulse was 120 in the minute when the patient began to inhale the chloroform, but it became slower as he was made unconscious, and it was regular during the operation. It was only toward the end of the operation, when the effect of the agent was allowed to diminish, and when the man began to strain a little, though not yet conscious, that the pulse in- termitted slightly, passing over a single beat occasionally. There were none of the long intermissions of the pulse observed on the former occasion. " It is very evident that if the above-mentioned patient had been the subject of any affection of the heart which weakened or embar- rassed its action, he would have run a much greater risk from the pain of the first operation than from the inhalation of the chloroform in the second one. "In a few of the patients having the arcus senilis of the cornea, a weak, intermitting, or irregular pulse, and other signs of fatty degeneration of the heart, there have been a feeling of faintness and a tendency to syncope as the effects of the chloroform were sub- siding, especially when the operation had been performed in the sit- ting position; but these symptoms have soon subsided, in all cases I have met with, on placing the patient horizontally, with, or with- out, the help of a little ammonia to the nostrils." Cerebral Diseases. — "Affections of the head offer no obstacle to the administration of chloroform. I have given it to several patients who had suffered previously from an attack of apoplexy; some of them still retained the paralysis resulting from the attack, but the chloroform has not been attended or followed by ill effects in any of these cases." The following interesting and most instructive case is mentioned in this direction : GENERAL ANESTHESIA. 453 " The 31st of October was a day appointed by Mr Fergusson to perform lithotrity on a gentleman seventy-eight years of age, who had a phosphatic calculus in his bladder. He was a patient of Mr. Propert, and Mr. Fergusson had removed a similar calculus by litho- trity, and I had given him chloroform at each of the operations, and it was arranged that he should have chloroform on the present occa- sion. Mr. Propert informed Mr. Fergusson and myself on our arrival that his patient had, the night before, an attack resembling apoplexy ; he had been insensible ; the breathing had been stertorous, the pupils dilated, and the face very red and congested. Mr. Propert had caused him to be cupped to fourteen ounces, and had given him twenty grains of calomel in the course of the night, and in the morning he was as usual, and remained so at the time of our visit. We considered the case with Mr. Propert, and, as there were reasons for not postponing the operation, it was determined that he should inhale the chloroform rather than be subjected to the pain. The vapor acted very favorably : he recovered his consciousness a few minutes after the operation, and expressed himself as feeling quite well." Insanity. — Chloroform acts on insane patients just as it does on others : when the effects subside they are in the same state of mind as before. Mr. Snow remarks the suspiciousness of the insane, but gives his experience where teeth have been extracted and other operations performed which it would have been impossible to ac- complish in the same individual without resorting to inhalation. The employment of chloroform in the delirium of mania a potu has, through the experiments of Dr. Ely McClellan, of the United States Army, lately been revived, and commanded much attention, the successes of this gentleman having been sufficiently verified by practitioners in every part of the country: given in drachm doses, pro re naia, it seems completely to break the paroxysm, causing the patient to fall into profound sleep, from which, after eight or ten hours, he commonly awakes entirely relieved. In delirium, however, the chloroform is to be taken into the stomach, and not breathed. I may close this consideration of chloroform by again remarking, as alluded to in the commencement of the chapter, that the agent, if one feels justified in using it, is far to be preferred in oral surgery to the ether; a profound impression created through chloroform will not unfrequently continue through quite a prolonged operation ; or, if it be necessary to renew the inhalation, the desired impression 454 ORAL DISEASES AND SURGERY. is generally made with great rapidity. Operations about the mouth, unlike most other surgical services, require to be executed with great rapidity ; therefore is it a necessity to be as little interfered with as possible: an impression, apparently very profound, made with ether, is apt to be broken in the very first shock of an oral operation. This first step may be of a character starting, in some instances, frightful hemorrhage, and which can be combated only at the completion of the operation ; to have a patient pass from con- trol at such a moment, and under such circumstances, is sometimes a matter of serious concern. If one has not used chloroform up to this time, and the article is at all convenient, it is very apt to be given to the patient in a quite free manner. I certainly do desire heartily to recommend it, but prefer, as my own practice is con- cerned, to combine it in varying proportions with sulphuric ether. I have in this chapter used in many instances the strong authori- tative experiences of Dr. Snow. I am convinced of the truth of all that he maintains; his experience with the agent has certainly been of the most extensive nature: personally, however, I am still afraid to use chloroform except in conjunction with ether ; and while such fear may not be well grounded, yet, as it exists, I cannot do other- wise than give expression to it. At this day it were certainly idle to attempt to deny that many deaths have resulted from the use of chloroform ; and a large proportion of these accidents have occurred in the hands of eminent and skillful men, and where every possible scientific precaution had been taken. Again, the accidents have seldom or never been traceable to an overdose of the agent; the deaths have never occurred from narco- tism, but from direct, immediate, and unforeseeable paralysis of the heart. I have not overlooked the fact that fatal results happening while chloroform was being used might not be owing to this agent. Certainly there are cases enough on record justifying such a conclu- sion, — cases with which every surgeon must be familiar; but, on the other hand, there are instances of such doubt, or perhaps I should rather say, of such certainty, that one may incline to err on the side of discretion. NITROUS OXIDE GAS. Except as its use in such speedily-performed operations as the extraction of teeth is concerned, it would not seem that nitrous oxide will ever be found applicable to oral operations (at least, as GENERAL ANESTHESIA. . 455 at present we know how to get the effects of the agent). In this opinion, I am aware, others may not feel disposed to agree with me, and it may very well be that I am wrong, as I have had little ex- perience with the agent. Be this as it may, however, ether and chloroform appear so satisfactory, and every way reliable, and at the same time are so convenient of use as compared with the gas, that I imagine they will continue to hold the supremacy. Should it be felt by any experienced in such matters that the pro- toxide of nitrogen as an anaesthetic possesses advantages over ether and the chloric-ether, they will hail with satisfaction the lately per- fected attempt to furnish the substance in liquid form. A convenience called the " Surgeon's Case" is now to be procured, in which in a cylinder one foot long by three inches in diameter are stored by compression one hundred gallons of the gas. This cylinder is refilled at the depot as may be required. The other contents of the case are the constituents of the required inhaling apparatus, — the rubber bag, tubing, and mouth-piece. The whole weight of the case and contents is fifteen pounds.* It is a neat arrangement, and highly recommends itself. *The subject of nitrous oxide will be found considered with a fullness which may be said to be exhaustive, in several elaborate essays, written respectively by Drs, George J. Ziegler, Geo. T, Barker, and F. R, Thomas, of Philadelphia. CHAPTER XX. ARTIFICIAL DENTURES. PIVOT TEETH. Passing to the consideration of a mouth in which certain teeth, or it may be the whole denture, have l)een lost, the surgeon, having the assistance of a mechanical dentist, finds it in his province to consider the replacement of the lost organs. Lost natural teeth are replaced, either through the pivoting of crowns upon healthy roots which may remain, or by adjusting the substitutes to plates of various kinds. Pivot Teeth. — The pivoting of a crown to a root (Fig. 186) is an operation which has its commendation or condemnation in the 'features of each particular case. It is to be ac- cepted as a cardinal principle that only the perfectly- vital healthy root is able to support an artificial crown. Pivot teeth are found most useful and satisfactory when confined to the six anterior roots, superior or inferior, — the incisors, central and lateral, and the cus- pidati ; although, except where bifurcation or great flat- ness may exist very near the neck, they are frequently attached to the roots of the bicuspidati. The incisor Crown pivoted ^ howcvcr, are those to which these crowns are pre- to root. ' ' * eminently adapted, and to which it may prove as well to confine them as closely as circumstances shall permit. Pivot teeth are always to be considered as promising most useful- ness and stability when possessed of lateral support by the presence of contiguous natural teeth : hence it is that while one or two of such teeth having an alternate relation with intervening natural organs will be found — cseteris paribus — to answer excellent ends, where three or four are required contiguously, experience demon- strates that it is better to employ a plate. Satisfied of the desirability of using a pivot tooth, and of the (456) ARTIFICIAL DENTURES. 457 ability of a root to support a crown,* the first steps In an operation consist In such cutting and filing manipulation as pertains to a jointure between the two parts, and In a reaming out of the pulp canal for the reception of the pivot. A case presenting Itself as a pivoting operation will commonly be found in the condition of a half-destroyed crown with a pulp dead, or, it may be, only serai-devitalized. The latter condition of the pulp existing, a first step will reside in its destruction. To accomplish this, as little disturbance as possible is to be provoked. If such pulp be exposed, the very best plan to pursue is to prick into it, with any convenient needle-pointed instrument, arsenic and atropia, equal parts of which have been rubbed up in creasote. From a tooth in my own mouth I have had such a semi-devitalized pulp removed in the space of fifteen minutes. It is done without pain, and is a simple opera- tion which may be repeated by any person who possesses sufficient delicacy of touch. A pulp so treated limits irritation to the closest confines. When the pricking instrument is felt to strike against the foramen of the root and sensibility is lost, It is only necessary to introduce a barbed broach, and, by a few turns in the canal, the mangled pulp is caught and withdrawn. In a broken tooth where a cavity of decay does not expose the pulp, such exposure may be made by delicate manipulation with the drill or excavator, or otherwise it is to be treated by the introduc- tion of the arsenical preparation into the existing cavity, and the sealing up of the same for a period varying from twelve to twenty- four hours, according to the density of the tooth. A piece the size of an ordinary pin-head will be found sufficient to destroy a pulp. The pulp thus destroyed, the crown of the tooth may be cut off", as now to be described. A previous mention, however, is to be made of those accidents, not uncommon, which have caused the fracture of a perfectly healthy tooth. If in such cases, as is most likely, the shock has excited pulpitis, and, it may be, periodontitis, a first attention is to be directed to the resolution of such conditions. No immediate attempt is to be made to destroy the pulp, unless indeed it be exposed, when it is to be pricked as before described ; but a local vigorous antiphlogistic treatment is to be instituted and con- tinued until the practitioner is satisfied that resolution is not to be effected. Quiet secured, the broken tooth is allowed to remain strictly at rest until all irritability has subsided, when a spear drill * It is not to be understood that an attempt is not to be made to restore an unhealthy root to the healthy state. 458 ORAL DISEASES AND SURGERY. is to be used for the production of a receiving cavity into M^hich the arsenious paste is to be applied as before directed. Another way to eruploy the paste with such broken teeth is to build about the edges of the fracture a ring of gutta-percha, to be accomplished by trailing a solution which has been made by covering parings of gutta-percha with chloroform ; the chloroform, quickly evaporating, leaves the gutta-percha firmly adherent to the parts upon which it has been laid. Within the ring thus secured, the paste is to be laid and covered in with the same solution. Teeth from the accident of fracture are sometimes made so sensitive as to render it impossible to use the drill. The means just suggested will meet the indication. If the gutta-percha should be found not to adhere with sufficient tenacity by this method, it will be necessary to excavate a groove in the face of the denture, and, after thoroughly drying the parts, build on piece by piece the ring of " Hill Stopping," or red gutta- percha, when the paste may be placed in position and covered with a portion of the same material. Sometimes it is found also to happen that nodules of secondary dentine exist in the pulp, interfering with the absorption of the arsenic; in such cases it will be necessary to repeat the application a number of times, or else expose the organ and prick it. Resistance to arsenical applications is quite diagnostic of the presence of pulp nodules. (See chapter on Odontalgia.) To cut the crown from a root, the first instrument required is the excising forceps. This is used in anticipation of the file, the crown Fig. 187. — Upper Excising Forceps. being cut away little by little until the neck is uncovered. This extent of excision being accomplished, it is prudent to give the part a rest of a day or two ; it is a safe plan, although certainly not in all cases, or indeed even in the majority, a necessity. In place of the forceps some operators prefer the saw for excising a crown ; it will not, as a rule, be found so convenient of employ- ment, and is more apt to provoke inflammatory response. It is not amiss, however, to have such an instrument, as occasionally it will be found quite useful. ARTIFICIAL DENTURES. Fig. 188. — Saw for Excising Crown. 459 Fig. 189.— Pivot Filks. Following the excising forceps is the pivot file. This instrument, being half round, cuts a concave face on the neck of the root, which aspect of face is seen to correspond with the accommodation required by the neck face of the artificial crown, which, as it comes from the labor- atory, and is used, is convex. In filing down the natural root, the most judicious gentleness is to be combined with the necessary dispatch. The file used at first should be sharp, so as to accomplish the required amount of work with the least irritation, and should be used until the gum is fairly touched ; the sharp file is then to be exchanged for a comparatively dull one, with which the now concave face of the root should be smoothed until a marked bleeding from the gum occurs all around the root. The object of this is to insure an accurate covering of the joint between root and pivot tooth by the healed gum. It is sometimes, though very rarely, the case that with previously irritated roots this preparatory opera- tion should be divided into several sittings, mean- while pursuing antiphlogistic treatment ; but the cutting with the dull file which is to take off the root below the gum is to be the step immediately preceding the attachment of the new crown-, other- wise the gum will be found to fall over the root and thus partially cover its surface. During the process of cutting down the natural crown, or, to make a rule, we may say at that stage which is to employ the dull file, the preparation of the canal is to claim attention. To effect the re- quirements here demanded, rose or bur drills of various sizes may be employed, commencing with one received into the natural canal, and increasing seriatim until a sufficient diameter is secured, — such diameter being in correspondence with the size of the pivot used. The depth to which a canal may be reamed, and also the diameter, depend upon 460 ORAL DISEASES AND SURGERY. the size and density of the root ; a rule applicable to all cases can- not be given : it is to be deemed necessary, however, that sufficient circumference and depth be secured to insure the retention of the pivot; half the length of a root may commonly be reamed with impunity. The process of reaming completed, a delicate spear drill is to be passed into the continuation of the canal, and the parts cleansed to the apex. This secondary canal is then to be filled with gold (see Filling Pulp Canal) ; this accomplished, the root is ready for the crown. The selection of a crown for the root considers — first, the shade or color, which is to correspond with that of the neighboring teeth ; second, the shape and adaptability of the crown. By having in one's possession a few hundred artificial crowns, it is quite pos- sible to find among them many of such perfect match as to render the slightest alteration unnecessary. Third, it is requisite to have the pivot canal in the crown and that in the root so correspond that when the jointure is made the crown occupies its right position. To be satisfied of such proper relation of parts, the crown and root may be put together for the moment with a pivot of round match- stick. It is suggested, and practiced by some, that when there is lack of natural correspondence in the canal of the root, the required direction shall be given by the drill: this, however, is to be con- demned as bad practice ; it is much better to seek a new crown. To have an accurate adaptation of the crown to the root is most desirable : this may require some grinding of the crown ; and to know just where to grind makes it necessary that the touching points be recognized. Such information may be secured by coating the surface with a film of wax ; putting the parts now together, the wax over- Pjq J9Q lying the points implicated will, of course, be found indented and dis- placed. A plan even better than that just described is, immediately upon having the root prepared, to take an impression of it and the contiguous teeth in wax (see Taking Impres- sions), and, having made a model of plaster of Paris, fit the crown to the Hand-Lathe. modpl To grind a tooth, a stick of corundum is used by many. Such sticks are to be procured at the furnishing depots for a few cents. ARTIFICIAL DENTURES. 461 Fig. 191. A better means is found, however, in the employment of a lathe; of these instruments the greatest variety is offered. The smallest hand-lathe, however, is commonly found sufficient to meet all the requirements. Fig. 190 represents such a lathe: it may be attached temporarily to any stand conveniently at hand. This lathe is entirely noiseless. Having neither cog-wheels nor belt, it is free from oil, dirt, and thef trouble of adjustment. The motive power is commu- nicated by friction gained by covering the small wheel, or pulley, with a rubber ring which comes in contact with the inner surface of the driving-wheel. The driving-wheel is six and a half inches in diameter; the small wheel, two inches in diameter; and the weight of the lathe is two and three-quarter pounds. A form of lathe which, being worked by the foot, leaves both hands at liberty, is repre- sented in Fig. 191. Such a lathe is in many respects preferable to the first: it is certainly more convenient to the operator. This lathe has a movable column and table, and is capable of being elevated eight inches: it is made to accommodate the operator in either a sitting or a standing posture. As the grinding instrument, wheels of corun- dum are used on these lathes ; the surgeon should provide himself with five or six of these wheels, of varying sizes. Crown and root prepared, the pivot is the next consideration. A pivot is made either of wood or metal. A wood pivot is only to be made of thor- Foot-Lathe. oughly-seasoned and firmly-compressed hick cry: a box of such pivot sticks, which maybe purchased at a depot at a cost of twenty-five cents, will set hundreds of teeth ; it is best thus to provide one's self. To use the wood pivot, the operator commences by securing the exact length required: this he learns with least trouble from his temporary pivot of match-stick. One end of this pivot is now fitted into the crown, the other being of a size corre- sponding with the canal in the root. Everything being thus pre- pared, it only remains to put the two together, and the operation is completed. It will occasionally, however, be found to happen that, in defiance of the nicest care which may have been exercised, there is slight 462 ORAL DISEASES AND SURGERY. fault in the articulation of the cutting edge of the new crown with the corresponding teeth of the lower jaw: this is commonly most easily remedied by filing away the impinging point on the natural tooth, or with the corundum stick it may be taken from the artificial crown. A second and much more serious complication is periodonteal in- flammation, the root becoming sore and painful. When such inflam- mation supervenes, it is to receive at once the required attention. (See Periodontitis.) Metal pivots are variously used. A common plan is to make a delicate tube of gold of such size as will permit its introduction into the drilled opening of the root (which in these cases should be made somewhat larger than is required for wooden pin pivoting, and should be bell-mouthed), leaving suflBcient space around it to fill solidly with foil. A wire fitting this tube should be inserted into it to prevent its compression, and it should then be filled into posi- tion. The wire is then withdrawn, the tube filled either with wood or gutta-percha to prevent its injury, and the face of gold filed con- cave as though it were tooth structure ; tliis leaves only a ring of cementum exposed, thus efl'ecting, from the exceeding durability of this substance, a very permanent and desirable result. An impres- sion is now taken in wax, a plaster cast is made, and from this, metal dies. A thin plate of gold is now struck between these dies, fitting accurately the face of the root, being filed to the exact shape of the face and outlines of circumference. Next, the plate of gold — the cap having a hole drilled through its centre corresponding with the tube in the canal — being laid in place, a piece of gold pivot- wire is passed through it into its place in the tube, and secured with a small piece of adhesive wax. Cap and pin are now removed, invested in plaster of Paris, and the two soldered firmly together. The tooth here to be used is what is known as a plate tooth, — a tooth having pins of platina in its back. Selecting a tooth of this class to suit the case, the cap and pivot are slipped into place, and the crown, held in the exact position required, is fixed by a particle of wax. The whole piece thus joined together is now removed from the mouth : this is accomplished by inserting the blade of an exca- vator beneath the plate, and thus lifting it. The tooth is backed by a plate of gold having holes punched for the passage of the pins ; backing, tooth, and cap are now soldered together, and the fixture is completed, requiring only to be cleaned and introduced into the tube. If all is as desired, the gold pivot should then be tapped later- ARTIFICIAL DENTURES. 463 ally very gently with a pivoting hammer, when it will be found, upon introduction, to remain with all necessary firmness. In a case such as just described it is not necessary that the surgeon do the mechanical work of swaging plates and soldering; — all this is indeed more in the province of the mechanical dentist, and to him it would seem proper and desirable to intrust it ; that he accomplish it satisfactorily it is only necessary to furnish him with the wax impression and the crown selected. Indeed, as we go on it will be seen that the accomplished mechanical dentist is as necessary to the oral surgeon as is the mechanician to a general practitioner. An improvement, as it is thought by some, on the plan just de- scribed, consists in the replacing of the root tube by a hollow screw, a screw-tap being used to cut the thread on its inner wall ; this screw, fixed in its place, is to be leveled with the face of the root and the operation completed as already described. In roots having canals not in correspondence with the position demanded for the new crown, the mode of using caps for the attach- ment of the new crown seems to afford all that can be desired, inas- much as when teeth are thus pivoted a correspondence between the canals of root and crown is of no imj^ortance. A condition indorsing most fully the employment of the tube is found in such roots as are somewhat decayed. Here, the tube being in place, after excavation of the part, as in any case of caries, it is solidly built in situ by a plug of adhesive gold. It is not the case, however, as is often affirmed, that this is the only mode of pivoting that may here be employed, since Dr. J. D. White, the eminent dentist, has fully and practically shown that to use the common wood pivot it is only necessary to ream a first canal of a size which takes in this decay and removes it, and from such first circumference to make a second of the ordinary character. Of course the pivot has a double diameter to correspond. A plan of pivoting which is to be considered a combination of the plans just described, consists in passing through the centre of a wood pivot, which has been drilled out for the purpose, a second pivot of gold wire ; such wire is found materially to strengthen the wood, and is thought by many to be the most desirable pivot that can be employed. Still another plan is the employment of what is known as the vulcanized pivot. This process is as follows. The root being pre- pared as previously described, by tubing, a wire of length sufficient 464 OBAL DISEASES AND SURGERY. to protrude one-eighth of an inch or so beyond this tubing is flat- tened at one end and inserted into the tube; a tooth (usually a " vulcanite tooth") is adapted and placed in position ; the wire and tooth are next joined together with adhesive wax, and while yet warm are placed again accurately into position ; the wax pressed against the root face is cooled by jetting a stream of cold water upon it from a mouth-syringe, and the tooth, wax, and pin are carefully withdrawn. Moulds are then made of plaster as for vulcanite work, the wax is removed, vulcanizable rubber is introduced in its place, and the pin and tooth are secured firmly together by the vulcanizing process; the rubber is then filed and polished. This is a very neat, easy, and altogether, as thought by many, desirable operation. A hieans of setting a pivot tooth founded on the ease with which the Mack screws may be worked, and applicable particularly to bicuspid and even molar teeth, consists in inserting into the pre- pared face three or more of the screws, and, having a tooth prepared for the purpose, of a box-like character, the chamber is filled with cement plombe, or any of the oxychloride preparations, and while the material is soft the tooth is put into place, being retained by the fingers until the cement hardens about the pins. A box tooth may easily be made by soldering a metal chamber to the pins of an ordi- nary plate tooth. Another plan, pertaining, however, only to the treatment of the root where this has been weakened by decay, consists in first making proper excavation of the diseased dentine and replacing it with oxychloride or amalgam. The material used having set, a pivot canal is reamed in its centre, and the operation completed by the use of the wood or wire-wooded pivot. Such mode of treating a decayed root is not, however, to be commended, as it takes but very little experience to demonstrate. A pivot inserted in osteo- dentine so exposed could have no permanency; while a periosteal degeneration — indeed, a necrosis of the root, quite as adverse — is almost certain to associate itself with the use of the amalgam. A method of setting a plate tooth on a root, and giving an addi- tional support by a rim of gold, which certainly has the merit of originality, is thus described by H. E. Dennet, of Massachusetts : "First cut the crown ofif; then tunnel out the root, by enlarging the pulp cavity, making it very large at the orifice, and smaller as it goes in, making retaining points at proper places. " Solder a platina point to a suitable plate tooth, the point being large where it is soldered, and a gradual taper bringing it nearly to ARTIFICIAL DENTURES. 465 a point; then make it barbed or rough, so that it will not pull out after the tooth is set. "Having prepared the root and the tooth, put on the rubber dam ; fill the root to the point where the end of the pivot will meet it; put on the tooth, and fill around the pivot (turning the tooth in and out, and laterally, as convenience requires, the pivot being easily bent without danger of breaking); build out to the natural form of the tooth, using first soft gold, then that which is partially adhesive, then adhesive." "The writer of the above," ssvys Dr. J. H. McQuillen, "placed in my hands the root of a tooth, with a plate tooth attached in the manner described. The operation was very skillfully performed, and the plan proposed is certainly preferable to building out a golden crown, which, however perfectly executed, cannot be said to add a charm to the smile of beauty, although it may prove useful in mas- tication." The restoration of partly-fractured crowns is an operation which, as belonging to the front teeth, would seem to be worthy of more attention than it has heretofore received. As an example in such direction of what may be accomplished, the following case from the practice of Chas. J. Essig, D.D.S., is well worthy of being quoted: "The patient, a student of the Philadelphia Dental College, had the misfortune, ten years back, to break off, by a fall, about two- thirds of his right central incisor; in such condition he applied for relief from his deformity. " The idea," says the gentleman whose practice is quoted, " of restoring its shape by what is known as ' contour-filling' was abandoned as soon as thought of, as was also that of the usual method of pivoting, for the following reasons: First, we would be obliged to cut away, and consequently lose, the substantial body of the tooth, with its enamel covering, and depend upon the frailer por- tion, the root. Secondly, the difficulty of matching in general ap- pearance the adjoining teeth, they being somewhat peculiar. And lastly, the knowledge that the period of usefulness of pivoted teeth is, under the most favorable circumstances, a short one. So, as neither of these methods afforded the two important desiderata of permanency and natural appearance, I decided to splice the broken tooth with a piece of porcelain. This was done, and the contour perfectly restored. " The method of proceeding was as follows. The vitality of the tooth had been destroyed by the accident, and some years after the 30 4^6 ORAL DISEASES AND SUBGERY. pulp canal had been filled with gold. The fractured portion pre- sented an uneven edge and surface, which extended diagonally in- ward and upward toward the adjoining central. The first step was to remove the irregularities and obtain a perfect edge and a level surface, by means of a flat file. I then drilled up, following the pulp canal, to the depth of one-quarter of an inch, with a No. 16 drill of Palmer's set, following and slightly enlarging with a flat bur-drill. A small square gold box was next constructed, placed in the canal, and the four sides carefully and firmly filled around with gold. Into this box a pin made of platina gold fits accurately, the pin being split fully two-thirds of its length. At this point an impression was obtained of the broken tooth and the adjoining central and lateral ones. The pin, which had been left long enough to project three- sixteenths of an inch from the box, indicated in the impression the inclination of the canal. "A cross-pin plain plate tooth was next selected to exactly match in color the natural one ; it was ground away equally from the cut- ting edge and neck, so as to leave the pins as nearl}' as possible in the centre of the porcelain ; it was then fitted accurately to the tooth, and the cutting edge ground to imitate that of the adjoining central. " The piece was at this point found to nearly cover the mouth of the box, being almost as thick as the tooth itself. This difficulty was readily obviated by cutting off all that projected of the gold pivot and upon its end soldering a small plate, which fitted accurately upon the plane mentioned above as having been leveled with the file. A gold backing was then fastened upon the piece, and a slight concavity ground in the porcelain to receive the little plate. Before, however, finally soldering the piece to this plate, it was temporarily fastened with cement and tried in the mouth, as the plaster cast is liable to undergo some change in handling. It was then removed, after some little extra adjustment, invested iu sand and plaster, and the backing and plate united by solder. " The piece can be removed and replaced with every facility, and the flat surface cleansed and polished whenever deemed necessary. "When in position, the line of union is almost imperceptible, and is really not observed unless attention is specially directed to it, and a very close examination made. " It has now been worn and thoroughly tested for several weeks, and its appearance is unchanged." ARTIFICIAL DENTURES. 467 AETIFICIAL DENTURES— THE IMPRESSION. Plate Teeth. — The proper preparation of a mouth for the recep- tion of a plate implies that the operator consider in the relations of each case the hygienic, mechanical, and artistic considerations there- with necessarily associated: one mouth, the lips being long; the process full, the arch markedly concave, and of some depth ; the gums solid and resisting ; the submucous structure neither deficient nor excessive ; the teeth all absent, or such as may remain having harmonious relation ; temperament lymphatic ; such a mouth the merest tyro will accommodate. On the contrary, lips short ; process absorbed to a line; arch flat; gums irregularly flaccid and hard; teeth all gone, or, where some remain, inharmonious to a common articular relation ; temperament nervous ; such a mouth the most refined skill will scarcely serve to satisfy. A mouth before prepared to receive a denture, full or partial, is to be free from all roots which may have association with the parts to be occupied ; teeth irregular to the arch, and thus the source of de- ficient symmetry, or such as may interfere with a successful fitting of the artificial piece, or such as may be diseased and lacking in promise, these are to elicit attention and judgment. As a rule, a plate is not to rest upon a root, healthy or unhealthy. The retention of an isolated tooth in the dental arch (all the others having been lost), however healthy and symmetrical, except it be in a position where a plate is not to go back of it, will be apt to antag- onize the merits of any denture, however perfect its construction. Soft teeth are not to be clasped. A cachectic mucous membrane is to be covered alone with a gold plate which has been alloyed with platinum, the baser materials being irritative. A turgid congested membrane is not capable of affording an impression which will allow a denture to be useful. Scorbutus, ptyalism, all unhealthy condi- tions are to be corrected before an impression is taken. Clasp teeth are to be freed from tartar, and (except when the denture is to be temporary) alveoli are to be absorbed. The Impression. — The first step in the construction of an artificial denture is the taking of an impression, or measurement. This is in the province of the surgeon, and consists simply in filling a tray (of which every size and variety are supplied at the depots) with soft- ened wax, plaster, or other impression material, and pressing it over the parts to be modeled. 468 ORAL DISEASES AND SURGERY. Trays are of two general forms, the one being- designed for the superior arch, the other for the inferior. Fig. 192. — Tray for Superior Jaw. Fig. 193. — Tray for Inferior Jaw. In selecting a tray for use in any special case, regard is to be had to the requirements of the case. First, such a tray is to be employed as shall admit of easy passage through the labial commis- sure. If an arch be deep in its palatine aspect, the tray used will demand to have marked convexity, or otherwise a common tray may be made to answer equally well for deep or shallow arches by having a false bottom. For application to the lower arch, a deep or narrow rim will be found demanded, as the process may be promi- nent or the reverse. In many mouths the site of the original alveo- lar process will be found to have entirely disappeared, leaving a perfectly flat surface, requiring a tray without the slightest flange. A tray is to be large enough to embrace the alveolar arch, leaving a space between the process and rim of about a quarter of an inch : it is to be deep enough to include the tubers of the upper jaw, or to touch the rami of the lower. If teeth long and prominent stand in either jaw, particularly the anterior of the lower, as is very com- mon, it may be found more convenient to use one so cut as to admit of such teeth passing through it. (Fig. 194.) This, however, is not a necessity, and not always even a convenience. Modifications on these common trays ai'e numerous; few practi- tioners, however, recognize sufficient merit in them to feel their con- sequence, finding rather in a skill the result of practice that which meets the various requirements. One of the very best impressions I have ever seen was taken with a piece of shingle, whittled for the ARTIFICIAL DENTURES. 469 occasion, — but the hand that secured the cast was skillful and experi- enced. I have never in my own practice employed other than the character of trays here shown, and take it for granted that my trouble in getting satisfactory impressions has been about of a common experi- PiG. 194.— Tray for Passage of Teeth. ence with others. As suggested, however, I employ for the palatine arch the tray with a false bottom. Any one can make such false bottoms for himself by replacing, with pieces of tin or other metal bent into shape, the centre which is to be cut from the tray as shown in Fig. 192. Having a number of these bottoms (which should be somewhat larger than the piece removed), an operator finds himself requiring very few trays: half a dozen, or certainly a dozen, will be sufficient. The materials used for taking impressions are wax, plaster of Paris, and gutta-percha, either being used alone or in combinations. The inexperienced should begin with wax, as this is most simple and easy of manipulation, and at the same time quite capable of meeting all indications. Wax. — Two kinds of wax are used, the white and the yellow: of these, the white is, on some accounts, to be preferred. It will take a sharper impression, and has not its shape so readily deranged. An objection, however, is its want of plasticity as compared with the yellow, much more time and trouble being required to prepare it for the tray, while corresponding increase in pressure is demanded to force it into place, — the latter being a matter of importance where there is excess of the submucous cellular tissue. 470 ORAL DISEASES AND SURGERY. Yellow wax, when pure, will, under all ordinary circumstances, afford a satisfactory impression. To soften it to a required consist- ency, which should be about that of dough, it is only necessary to work it at the fire, or over a spirit-lamp. Having selected a tray and observed the requirements of the special case, that is, the matter of depth of mouth, position of remaining teeth, and character of mu- cous membrane, whether hard or soft, yielding or unyielding, the wax is piled into the tray, being heaped in the middle if the mouth is deep, smoothed and flattened if shallow ; the wax to be very soft if the membrane be flaccid, of greater consistence if it be firm. The operator, if to take an impression of the upper jaw, stands behind, leaning over the head of the patient ; if of the lower, a position is assumed in front and to the right. The tray and wax being in the mouth, observa- tion is demanded to see if such correspondence of relation exists as will allow of the tray being carried into place. If care be not exer- cised in this direction, it will frequently be found that the cup is not far enough in the mouth, or perhaps is too far in, or too much to one or the other of the sides, so that, in carrying it into place, the sharp edge of some portion of the ridge comes down upon the gum, producing thus not only much pain, but rendering the impression good for nothing. A proper correspondence existing, it only remains to press the tray gently and steadily upon the arch, throwing the lip off should it interfere; a manipulation easily accompli.-5hed by running a finger between the lip and wax. A tray is never to be rocked into place, but rather carried with all steadiness until it is felt to be fixed and firm. Such a bearing obtained, the finger of the operator is to press the wax around the external face of the alveolar process, and where the false bottom has been used this is to be forced into the roof of the mouth. If the impression is of the lower jaw, then it is to be pushed with the finger against the internal face of the process as well as against the external. Before removing an impression of wax from the mouth, it should be allowed to remain a few minutes to harden. If, in the withdrawal, suction is recog- nized, the impression will almost certainly be found to prove a good one. A tray is held most steadily in the mouth by being supported on either side. Some operators, skillful in the use of wax as an impression mate- rial, find it necessary to employ a strand of silk or thread run through the wax just before introducing it into the mouth, that after securing the cast they may get it away by letting in air through the withdrawal of the string; the accuracy of the fit they obtain result- ARTIFICIAL DENTURES. 471 ing in a suction which makes it otherwise difficult to get away the tray without a derangement of the impression. Before taking an impression, a mouth is to be cleared of saliva and mucus. This is most conveniently accomplished through rinsing with water and cologne, a teaspoonful of the latter to half a goblet of the former, or, if more convenient, the cologne may be replaced with alcohol. It is occasionally found recommended that immediately upon the withdrawal of a wax impression from the mouth it be plunged into ice-water, or otherwise that it be laid upon ice. This is a practice scarcely to be indorsed, the varying thickness of the wax resulting in unequal contraction. Unless hurry exists, it is much better to leave the cast to the existing state of the atmosphere. Sulphate of Lime — Plaster of Paris. — Plaster of Paris mixed with water into a paste is very widely employed as an agent in the taking of impressions. Plaster to be useful for such purpose must be of the very best quality; this implies that it has been well cal- cined and thoroughly pulverized. To employ it, the operator selects a tray, and filling it with the plaster, which has been semi-liquefied into a self-sustaining paste or batter, it is passed into the mouth in such manner that bubbles of air shall not be caught in the depth of the arch; that is, the pressure which carries the mass into place is to be exerted gradually from the front backward. For plaster (employing it with the upper arch), cups or trays, as portrayed in Fig. 192, are commonly used. A plan, however, ])re- ferred by many, consists in first taking an impression in wax, pre- cisely as has been directed. This secured, the surface of impression is indifferently cut away, simply with the view of securing what might be termed a fairly-fitting wax tray. Into this is now poured the plaster batter, and the whole is reintroduced into the mouth. Employing plaster for the lower arch, the tray as shown in Fig. 193 is found entirely applicable. The requisites of a tray holding tlie plaster batter are, depth of flange sufficient to invest the alveolar face to an extent required to be covered by the paste, and that re- lation of arch which shall insure the plaster reaching every position of tUe part to be modeled. To take an impression in plaster, a patient is to be seated upon a low chair, and the head is to be inclined forward at an angle sufficient to prevent the falling of particles of the batter back into the fauces. The batter is to be of that consistency which neither allows it to run 472 ORAL DISEASES AND SURGERY. from the tray, nor on the other hand so stiff and hard that it may not take the desired impression. The time required for setting is about three minutes; it may be shorter or it may be longer, — this depending on the character of the plaster used. The proper time for the removal from the mouth of a plaster impression is designated by the sharp, abrupt break to be seen by fracturing any inconsiderable and unimportant fragment, or by testing such portion as may be left in the mixing vessel. The matter of the time for removal is of very marked importance ; should the batter not have set, the cast is of course good for nothing. Should it, on the contrary, have become too solid, it might bring a portion of the mucous membrane with it, particularly in the case of the superior arch. Plaster that is slow in setting finds the defect removed by the addition of a small portion of common table salt, or, what is thought by some to be better, the sulphate of potash. Plaster of Paris as an agent for impressions finds its most conve- nient aj)plication to edentalous arches ; that it is used, however, with all success for partial sets of teeth is daily demonstrated. To take a partial impression it is found more convenient to have a tray with a false flange. After the batter has set, this flange is to be with- drawn, the bottom part of the tray being separated from the mass by means of the point of the knife-blade. Next, the impression is broken into pieces, each fragment being removed and preserved with all care. When all are away, each piece is coaptated with its fellow, thus restoring the cast. A second mode of taking a partial impression is found in the use of the wax cast : the plai)th the supe- rior and the inferior maxilla, exhibits decided preference for the latter, attacking it, as the author would be led to infer from the ex- perience of his own practice, in twenty cases to five of the former. The disease presents a twofold primary expression. It may com- mence as a general ostitis : stasis of the circulation quickly antag- * "As soon as that peculiar mutual dependence and reciprocation of parts has ceased in the human bodj', which emanates from their genetic unity, and which we call life, it encounters the same conditions of the outer world as do the inorganic bodies : that is to say, the only force which tends to maintain it in its form is cohesion. This, however, owing to the extraordinary abun- dance of water, is very limited, and hence immediately after the occurrence of death the decay of the body begins, which takes place at first slowly, then, however, continually more and more rapidly, and finally leads to its complete dissolution. As long, moreover, as the outer form is in any measure retained, we call the body dead, understanding by this term that a body, although still exhibiting organic structure, is no longer the seat of organic function. "At the death of the entire organism, medical skill, as it is known, ceases. We might, therefore, spare ourselves the trouble of studying the changes which the death of the tissues occasions, were there not also a partial death, or death of individual parts of the organism, which we call necrosis, morti- fication, gangrene. "The anatomical changes which follow the occurrence of partial death are not the same in every case. The very various causes producing necrosis, as well as the natural situation and constitution of the dead parts, condition widely-separated varieties, especially as to the amount of blood and water contained, which give occasion to the production of a dry or a moist gan- grene." For a series of the most widely-suggestive and practical annotations bear- ing upon the general subject of necrosis, the reader is directed to Professor Kindfleisch's Text-Book of Pathological Histology, pages 21 to 70. (f)66) NECROSIS. 567 onizing nutrition, thus killing the bone outright ; or, as more com- monly witnessed, it is a result of periosteal disease, the membrane affected being the periosteum proper, or, as recognized in a great majority of instances in which the condition is met with, the alveole- dental tissue, — periodonteum. In such primary membraneous as- sociations, either the tissue, as it reacts upon the bone life, is found dead, or it is seen separated from the bone by a degener- ating plastic exudate.* In such inflammations and separations, it would be inferred that the layer of bone immediately adjacent to the membrane would be the first to be affected ; this is so truly the case that timely incisions and combating of the inflammation are most influential in the limitation of the disease, — this being most markedly exhibited in periodonteal inflammation. The superior jaw, however, is much more liable to take on a general inflammation than the inferior; but the higher vascularity and resistive force of this part seem to enable it to resist the destructive action and to limit the part overwhelmed. Inflammation of the jaws, whether osteal or periosteal, is pri- marily to be treated on general principles. If acute in character, we may first try the effect of the hot pediluvia and saline cathartics. These failing, the parts may be well scarified, or leeches may be applied, or blood taken from the arm. Diaphoresis may be employed. In short, antiphlogistics of any and every nature, promising con- trol of the excitement, may be pressed into service. If all, however, fail, and pus forms, vent cannot too soon be given it. When, on the contrary, an inflammation is chronic and asthenic in character, as marked in the puffy, debased character of the parts exhibited in the dyscrasic, with the necessity for free scarification will exist a demand for local stimulating douches and the administration of tonics. Of the supporting medicines applicable to these cases, the very best, I think, will be found in the union of sulphate of quinia with the muriated tincture of iron. A combination very frequently employed is as follows : R. — Tincturte ferri chloridi, 3} ; Quinise sulphatis, 5j- M. Sig. — 15 drops in water four times a day for an adult. * In necrosis confined to part of a bone, the increase in the vascuhirity of the parts, as shown by the curious cases exhibited by Mr. Paget, — see his lec- tures on Nutrition, — may give rise, especially in young persons, to hyper- trophy of the remainder. 568 ORAL DISEASES AND SURGERY. Ostitis, as a primary expression, exhibits its most intractable cases in the periods connected with dentition, whether first or second; the irritability being increased and kept up by the excitability associated with this psocess. Hence the great amount of care necessary to guard against any increase in the A'ascularity natural to such age. The trouble aroused, nothing can be done, however, beyond such treatment as applies to ordinary cases ; except, indeed, it will be found that there exists a greater necessity for the use of sedative medicaments. In directing treatment to a condition of ostitis or periostitis, as relation is had with necrosis, an indication of principal signification lies in the discovery^ and removal when possible, of the exciting cause or causes. That such causes may have proper and definite signification, we proceed to the division and study of the subject as clinically it presents its diversified phases and aspects. In the order of frequency in which maxillary necrosis is met with, the following table may be accepted and studied : 1. Dental necrosis. 2. Alveolar necrosis. 3. From lack of room for eruption of wisdom-tooth. 4. Syphilitic necrosis. 5. Mercurial necrosis. 6. Necrosis from injuries.* 7. Exantheniatous necrosis. 8. Phosphor-necrosis. * " The complete cessation of nutrition within a certain mostlj'^ circum- scrihod portion of bone is followed hy a series of inflammatory processes in the neighborhood, whose final result is the loosening and separation of the dead from the living parts. The course of these changes is mostly determined by the particular cause of the necrosis. In traumatic necrosis, under certain circumstances, the loosening of the dead portion from the living is already eflfected (comminuted fracture), but the concealed situation makes a rapid extrusion impossible for the time being. In injuries, also, a purulent peri- ostitis is mostly tlie force bringing about the necrosis, as it is present, as the first and only cause, in by far the most cases of necrosis. The purulent peri- ostitis culminates, as has been mentioned, in a collection of pus between the periosteum and bone. A preformed cavity, capable of dilatation, does not exist here, but probably the cambian layer of bone (M. Schultze), especially in youthful, still-growing bones, is so soft that comparatively slight resistance is ottered to its loosening. Only the vessels which pass tolerably numerous from the periosteum to the cortex of the bone, must be ruptured, and it NECROSIS. 569 Dental IsTecrosis. — Dental necrosis — death of the teeth — may claim a first attention as being the most common of all the troubles of the ossa corporis. depends on the intensity of the inflammation — that is, on the quantity of the pus — to what extent this is accomplished. This laceration of the vessels is not incorrectly looked upon as a principal cause of the frequency of peripheral necrosis after purulent periostitis. It is, in fact, very obvious to designate the direct interruption of the supply of blood to the outer third of the com- pact substance, which properly belongs to the periosteum, as the cause of the complete cessation of vital processes in just this third. Nevertheless, although necrosis does not follow upon purulent periostitis by any means in all cases, this must not determine us to reject, without more ado, this so evident etiological agent, but invite us to seek the causes of the exception in peculiar relations ; for example, in a substitution, still possible, at the right time, of the cortical circulation of the vessels of the medulla. Only the pus itself is to be regarded from the beginning as something excreted from the organic unity, in this sense dead. Its presence excites a sequestering inflammation, as well in the periosteum as in the bone. The periosteum is very soon converted into a pyogenic membrane, which protects and excludes the organism against its own secretory products. In the bone there develops a rarefying ostitis, whose office it is to exclude the organisms from this side also by a layer of granulation tissue from the dead part. This rarefying ostitis is nourished from the medulla, and reaches as far into the compact substance as its vascular tracks have re- mained open and in circulation. There are cases where it develops upon the upper surface, when the Haversian canals dilate and the tissue of granulation springs up in numberless vascular villosities and unites into a continuous layer, which then connects with the elevated periosteum into an abscess membrane inclosed all around. More frequently, it is true, the outer layers of the com- pact substance have been too long deprived of circulation and the exchange of material for their revitalization to be possible by the medulla, and their own rarefying ostitis appears as a sequestering inflammation, which separates the lamellae that have perished, and ends in pus, which fills the abscess cavity. The dead bone is called sequestrum ; the rarefying ostitis which sepai-ates it, demarkation. The demarkation may occupy months and years. During this time the suppuration continues uninterruptedly ; the elevated periosteum, however, again returns to its ossifying capacity, and forms under the pyogenic surface a layer of new osseous tissue, which in time may attain a very con- siderable thickness. A bony capsule, called coffin (Todtenlade), which is thus produced, lodges the more or less loosened sequestrum in its interior. The adjacent, not elevated, periosteum, also participates by ossifying periostitis. For a distance upward and downward osteophytes and exostosis arise in vary- ing form and number. All these phenomena of inflammation, extending to some distance, disappear as soon as the sequestrum is successfully removed. Even the bony capsule diminishes, and by the obliteration of the cavity of the abscess it again applies to the surface of the bone, the exostosis disappears, and the bone again assumes its normal form." — Rixdfleisch. 570 ORAL DISEASES AND SURGERY. A tooth has a twofold source of vitality, — an internal or tubular circulation, secured from its pulp; and an external or membranous. . The destruction of this internal circulation, through the killing of the pulp and filling the root-canal with metal, is so common an occurrence as to be familiar to almost every one. By the majority of teeth, if properly treated, such destruction seems to be sustained without much apparent inconvenience. This treatment consists, as we have learned, in extracting from the cavity every particle of the dead pulp, and so filling the chamber with gold or other material as to prevent the introduction of more irritating matter. Where teeth, however, are not properly treated, or where there is great susceptibility in the system to inflammatory action, the destruction of the pulp results in an extension of the destructive action to the periodonteal membrane, yielding the trouble known as periodontitis; this, if not aborted or resolved, terminates in the death of the tooth. A dead tooth is not, however, fortunately, treated in all cases by the system, or even in the majority of cases, in so summary a man- ner as a piece of dead bone. As a rule, there exists a wonderful forbearance on the part of nature to its presence, and the organ may be retained in its cavity and made to serve useful purpose for a long time. True, it is discolored, and, provided there is no decomposing pulp in the canal, in proportion to this discoloration may the degree of death — if I may so speak — be judged. A tooth lowers in the scale of vitality in various degrees. It may be dete- riorated as the death of part of its pulp is concerned, or as the death of all of it is implied, — as regards the whole or any part of its en- veloping membrane. When both pulp and membrane are dead, the tooth, of necessity, must be dead with them ; and in proportion to their destruction, so is its destruction. Some systems are so irritable that all skill might not make the mouth retain a tooth in which simph^ the pulp is dead. Others, on the contrary, are so unimpressible that half the teeth in the arch might be utterly necrosed, and yet no complaint be made. The author once, as an experiment, replaced in the mouth a central incisor tooth which had been extracted twelve hours before, and although it had been carried in the pocket, enveloped in the usual collection of dust, tobacco, keys, knife, etc., the whole intervening time, it was kept in its socket until the parts became reconciled. Many years have since passed, and it seemed, when last seen, about as useful as in its palmiest days. The repetition of this experiment is now common. NECROSIS. 671 The irritation, inflammation, and death of a tooth are generally the result of caries exposing its pulp. The first stage in the destruc- tive process is the death of this part ;* here it may end, the pulp sloughing off at the foramen, and the periodonteum assuming the full duties of nutrition. If this is not the case, this membrane be- comes involved; if it too should die, the root is left as if scraped : the tooth is then dead. A dead or partly dead tooth is recognized by its loss of translucency, the opacity varying from the slightest discoloration to complete blackness. A dead tooth is not, however, necessarily associated wnth caries. Inflammation, resulting in its destruction, may be induced by at- mospheric changes, blows, etc. This should be recognized, so that by reason of the absence of decay a diagnosis may not be obscured. A dead tooth is thrown off in two ways : either by chronic or acute action. When by acute means, violent inflammation is set up in all the surrounding parts, the tooth is elongated and loosened, much pus is discharged, and eventually the tooth drops from its socket ; this accomplished, the trouble commonly subsides. In chronic exfoliation, the parts indurate, one or more sinuses form as in ordinary abscess, all the parts about the tooth are thickened and rough, as if some ugly disease was in process of development, and the tooth generally grows dark, perhaps black. It does not get loose, but is apt to frighten into its removal. If such extraction be not resorted to, the disease involves the bone, and tooth and alveolus become eventually cast off as a common sequestrum. Another, and more common chronic form, consists in the gradual absorption from about the roots of a dead tooth of its alveolar process. This is most common to old persons, although not by any means so con- fined. This form of exfoliation is usually very slow in its progress, extending over a period sometimes of several years. Cases, how- ever, frequently present — confined to young persons — where several teeth are cast off in this manner within eight or nine months. Teeth sometimes die as the result of general structural consolida- tion. This never occurs but in what are commonly recognized as very dense teeth, and is seldom found associated with caries. Such teeth loosen day by day, and finally-^it may be after a period of years — drop from their cavities. The condition is seen alone in old persons, or in those beyond middle age. To arrest this trouble *The pulp of a tooth is composed of most delicate connective tissue, in which ramify the vessels and nerve. (See diagram.) 572 ORAL DISEASES AND SURGERY. seems impossible. I know of no treatment that has ever seemed to have the least effect. Alveolar Necrosis. — The membrane enveloping the root of a tooth is associated, as a nutritional vehicle, with its alveolus ; hence it is commonly termed the " alveolo-dental periosteum." As the result of such relationship of structure, an inflammation originating in a tooth extends to the surrounding bone, and, according to its severity, affects the parts involved ; hence portions of alveolus, overwhelmed, as it were, by the force of the attack, sometimes die and sequester. This form of necrosis, while very common, would perhaps with proper treatment seldom occur. The dentist, for the purpose of destroying the pulps of teeth, applies the arsenical mixture. This is placed in a cavity of decay, and covered with cotton or wax. It happens, however, occasion- ally, that from an improper application, or some difficulty of retain- ing it in place, the paste oozes down around the neck of the tooth, and thus acts upon parts not intended in its application, inflaming them. In this way alveolar necrosis is sometimes induced ; the portion destroyed is seldom, however, very considerable, and gen- erally exfoliates in from two to four weeks. The local application of the sesquioxide of iron has been thought by some to exert a happy efifect, applied immediately on the discovery of the accident. Re- peated syringings are not to be neglected. A case, occurring in the person of a physician, has, at this date of writing, been treated by the author, where arsenic had been sealed in a tooth-canal having a drill-hole through it communicating with the alveolus. As a result, all the bone forming the envelope of the antrum was destroyed and came away. Alveolar necrosis is sometimes induced by the application of chloride of zinc, used as an obtunder of dentinal sensibility, and also for the purpose of controlling the slight hemorrhages caused by the slipping of instruments in the operation of filling. The first effect is of course upon the gum, inflaming and engorging it, the effect upon the bone being secondary. Nothing better than the ordinary antiphlogistic applications can be employed. The action here is much more tardy than in the destruction induced by arsenic ; the sequestrum, however, is seldom very considerable, the alveolus per- haps of a single tooth. The action of nature in the separation should always be awaited. Cases which, for want of a better name, might be termed anom- alous, sometimes occur. A single instance may illustrate. I. B., an NECROSIS. 573 Irish laborer, consulted for pain in the two inferior incisor teeth. No caries, no periosteal inflammation, nothing indicating disease, was observable. The pain increased day by day, until at the end of the second week the two teeth and their alveoli were found detached, and were dissected from the gum. This case is one of a very few of the kind that have been met with, and which may well be termed anomalies. The pulps are not found dead if examined at such time, as under ordinary circumstances one would expect to find them. There is no soreness of the teeth on pressure, and, strangest of all, there are none of the common phenomena of inflammation. The practitioner in these cases must be guided by such indications as he may be able to seize upon. The condition is, in every sense of the word, strange. Necrosis from Lack of Room for Eruption of Wisdom-Tooth. — This is found most commonly associated with the lower jaw. The close relationship of the second molar with the ramus frequently makes the egress of the advancing wisdom-tooth an impossibility ; hence an irritation resulting in inflammation. The serious extension of the trouble to the bone is alwaj^s, however, preceded by more or less trismus and difficulty in deglutition: thus every chance is given for an anticipating surgical relief. This form of necrosis is to be looked for between the seventeenth and twenty-fifth years. The extraction of the second molar allows the wisdom-tooth to fall for- ward ; thus the irritation is removed and a cure effected. These cases are, if rightly treated, as simple and harmless as they are severe and prostrating if left to chance or improperly managed. Extract the second molar tooth, and do not attempt the removal of the offending one, — that is, if such extraction threatens difficulty.* * " The advent of the wisdom-teeth is very often accompanied by painful and distressing symptoms, that may be protracted through many months, or it may be even years, unless relieved by surgical interference. These circum- stances arise from the position occupied by the wisdom-teeth, so close to the joint of the lower jaw, where the mucous membrane is reflected from the gum to the cheek and fauces, combined with the very common condition that the jaw is not sufficiently elongated backward to allow the dentes sapientise to range in the horizontal series with the other teeth. This mechanical diffi- culty not only prevents the proper evolution of the wisdom-teeth, holding them back in their bony bed, but it often perverts their direction of growth and dislocates them. Annoying and very painful as are often the symptoms attendant on difficult cutting and misplacement of the upper wisdum-teeth, they are trivial in comparison with those which occur in similar conditions of the lower. 574 ORAL DISEASES AND SURGERY. Exfoliations of laminae of bone are very common after the opera- tion of extraction of teeth. Such scales vary in size from that of the finger-nail to a pin's head. They seldom require any particular attention, coming away generally without pain or trouble of them- selves. " The ordinary misplacement of the upper wisdom-teeth is either backward or outward, or in both directions combined. When the teeth point back- ward, every time the mouth is closed its crown comes in contact with the mucous membrane, passing up on the base of the covonoid process. When the direction is outward, which is more common, the tooth projects into the cheek, and when the jaws are brouglit together, a portion of the mucous membrane in this region is nipped and pinched. This is a very painful affair; the surface becomes ulcerated and extremely tender; there is partial cicatrization, and the structure becomes stiff and hard as well as painful. "The difficulty which most commonly occurs with the inferior dens sapi- entiiB is attributable to insufficient room in the jaw. The tootli grows nor- mally in direction and in position as regards its neighbor in front, but, from an imperfect lengthening of the horizontal ramus of the jaw, the birtli of the crown is only partial and incomplete. The tooth is upright, but only its front cusps emerge, while the hinder cusps are still covered in with gum (see, for lesions, page 200), or the wall of the bony loculus in which it was formed. This produces a terrible pinching of the mucous membrane every time the jaws are brought together. Before, however, the enamel eminences of the tooth's crown make their appearance, the soft structures behind the second molar become much inflamed, and often suppurate. The inflammation to which the impaction and pressure give rise extends to surrounding tissues ; the cheek becomes stiff' and painful, and deglutition is difficult, and attended with sore- throat. " Next in frequency to the foregoing malposition is that in which the wisdom- tooth is developed horizontally forward, more or less. It is attended often with serious consequences. This direction is sometimes combined with an inward leaning, and very rarely the crown of the tooth points outward. This latter dislocation is very unusual, but the most severe case of suffering from displacement of the lower wisdom-tooth which I have ever seen was of this variety. "The most distressing result, however, that occurs in these cases is the suppuration which sometimes attends the difficult eruption of the tooth. In slight cases, even where there is no misplacement or want of room, but simply a restrained progress from an unusually dense or cartilaginous over- lying gum, pus will be occasionally formed. In severer cases, the pus bur- rows among the areolar tissue, around the periosteum of the jaw ; the neigh- boring soft structures become infiltrated with Ij-mph, and the integument is glued irregularh' to the bone ; pus points at different spots, often remote from its original source; and the whole cheek may be undermined with sinuses." — S. James A. Salter — Holmes. NECROSIS. 575 Syphilitic Necrosis. — The hard palate seems particularly liable to suffer from attacks of this specific disease, the venereal ulcer of the overlying soft parts and that of the soft palate being observed as among the most common of the constitutional affections. That these ulcers are, however, strictly venereal, one may be oftentimes led to doubt ; certain it is that they appear and exist with greatest virulence where mercury has been used with unnecessary freedom. Yenereal ulcers of the mouth are of two kinds : the superficial, and the ordinary ulcer of necrosis; either of them being represented in general appearance by the non-indurated chancre. The superficial ulcer may be found both upon the hard and soft palates, but is much more common to the latter. These ulcers — as the chancres — vary in size and character, being sometimes very amenable to treatment, at others resisting and phagedenic, even to the destruction of the parts. Their treatment is to be conducted on general principles. Few surgical conditions require nicer general judgment or more attentive care ; it is, really, to blow hot to-day and cold to-morrow, and vice ver'sa. As a rule, such ulcers are oblong in form, from an eighth of an inch to an inch or more in length ; more or less exca- vated, the cavity being filled with a dirty-white semi-solid paste. The truest practical comprehension of these cases is found, as the experience of the author leads him to infer, in looking at them as one looks at scorbutus. Touching locally with the acid nitrate of mercury, with the nitrate of silver, or with a mixture of equal parts of iodine and creasote, not unfrequently causes them speedily to assume healthy action. A case will seldom be met with in which the internal exhibition of a mineral acid does not seem to be in some degree useful; and par- ticularly is this found to be the case where a phagedenic tendency exists. Whatever remedies, however, be employed, the venereal basis of the trouble is always to be kept in mind. Syrup of the pyrophosphate of iron, conjoined with minute doses of corrosive sublimate and iodide of potassium, will, under certain conditions, compel such ulcers to disappear as if by magic; or a combination which may be employed commonly with a happy effect is as fol- lows : R. — Hydrargyri chloridi corrosivi, gr. ij ; Potassii iodidi, 5'j ; Syrupi hypophosphitis, ^iij ; Syrupl sarsaparillse compositae, §iij. M. Sig. — Tablespoonful three times a day. 576 OJiAL DISEASES AND SURGERY. The ulcer of necrosis, looking like the preceding, differs from it in having the pasty mass, which constitutes the apparent bottom, associated with dead or dying bone beneath. The ulcer in this case is not the trouble to be cured, — indeed, could not be cured while the underlying disease exists. Ulcers of this class, being an attendant condition, are always, of course, situated over the bones, generally about the maxillaiy and palate sutures. They are always preceded by an engorged and tumid state of the parts in which they are situated, indicative of the osseous trouble beneath. The character of this tumidity is a matter of much concern, as in proportion to its solidity will generally be found the extent of destruction in the soft parts; the variability of such destruction is seldom, however, in proportion to the disease below. The author has seen the whole palatine process die while the indicative ulcer lias not been larger than the eighth of an inch in circumference ; on the contrary, the smallest sequestrum will sometimes be found attended with the largest ulceration. Incision into and through this. tumid engorgement will always be found satisfactory practice. The cuts, however, are to be made, not carelessly, but with judgment ; always taking into consideration the vitality of the part. Such incisions, if made through the peri- osteum, will frequently be found to exercise quite a controlling influ- ence on the ostitis, just as in cases of ordinary inflammation, while the effect upon the soft parts is always for good. The treatment which should succeed the incisions is only to be determined by the circum.stances of each particular case ; not unfrequently it will be found amply suflBcient to keep the parts well cleansed, and await the coming away of the sequestrum ; never, however, forgetting to meet the constitutional indication. In other cases, as when, for example, the phagedenic type is assumed, the most vigorous and well-directed local treatment is necessitated; when cases are first seen in the open ulcerated condition, semi-indolent, as is frequently the case, no treat- ment seems superior to packing the ulcer with cotton saturated with creasote and iodine. Cases have come to the writer for treatment where the bone would be found exposed to the size of a silver three- cent piece, and where all the consequences of a large opening into the nares were to be apprehended, yet, by such an application, re- peated ever}^ other day, allowing the cotton to remain in the ulcer the intervening time, in the course of two weeks the denuded bone has entirely granulated over, and the parts have remained perma- nently cured. NECROSIS. 577 Breaks occurring in the hard palate, associating the oral cavity with the nares, are easily remedied by a covering of gold or silver plate. An impression of the full roof of the mouth is taken in wax ; into this is poured plaster in a cream form ; to the cast thus pro- cured is fitted the plate of metal, supported by the teeth, or by atmospheric pressure, precisely as in the case of a plate for the attachment of teeth. Any reasonably ingenious mechanical dentist can meet the indications. (See Obturators.) In breaks of the soft palate a simple wad of cotton may be tem- porarily^ used with a considerable degree of satisfaction. Astonishing results in the way of diminishing or closing these breaks, both in the hard and soft palates, may not unfrequentl}^ be secured by freshening the edges and touching every second or third day with iodine, zinc, dilute sulphuric acid, or the compound tincture of capsicum. Great care is, however, to be exercised in this practice not to over-stimulate the parts, very troublesome degenerating inflammations being some- times the result of an over-excitement. An ugly feature in the syphilitic ulcer is its tendency to recur: a palate, looking healthy to-day, will assume to-morrow an indo- lent relaxed type, becoming semi-yellowish; some point or other will take on a fatty look, and in a few hours break down into an ulcer. This may recur a dozen times ; the explanation is to be looked for in the systemic condition. Such recurrence of the ulceration may extend over a period of six or eight months, in defiance of the most careful attention. The author has certainly found it so in his own practice, and believes it to be a common experience. The salt-bath will be found in these cases invaluable, affording, as it does, increased vitality.* * To Professor Sigmund, of Vienna, are we indebted for an appreciation of syphilitic manifestations occurring where there is associated with the disease nothing of the ordinary history. Syphilis of the mucous membrane of the mouth and jaws ( Wiener Med. Wochenschrift) is recognized as a second- ary or tertiary form of the disease commencing in the genitals or region of the anus. Those cases, on the other hand, are rare in which syphilis most undoubtedly, or with a probability amounting almost to certainty, occurs as a primitive affection of the oral mucous membrane, especially the lips, and thence extends to the general system. Professor Sigmund, in 1865, called attention to the inci-easing frequency of affections of the lips of primitive syphilitic forms, — indurations, papulise, ulceration, — and this opinion has been confirmed by subsequent experience in his own private hospital practice. This observation has, in addition to its importance with regard to pathology 3t 578 ORAL DISEASES AND STJBGERY. Mercurial Necrosis. — Ostitis, and exfoliation from the undue use of the mercurials, are so common as to have come under the notice of almost every physician. These cases have generally a history regular and distinctive in progress. First is observed by the patient, while the medicine is being taken, a coppery or metallic taste; quickly associated with this is an enlargement of the tongue, recognized through the indentations made by the teeth as the organ encroaches on these bodies. The next stage is a puflBness observed about the necks of the teeth, commencing generally with the inferior incisors; the congestion of the oral mucous membrane, which soon extends over the entire cavity, produces a sense of dryness, and not unfrequcntly burning ; the tumefaction, which has now become gen- eral about the necks of the teeth, assumes a livid color, and presents a grayish, cedematous surface, which extends more or less widely throughout the mouth ; the inflammation, attended with its cacoplas- tic exudate, next intrudes on the alveolo-dental membrane, and the teeth soon become so loose as readily to be lli"ted from their cavities, and when so thrown off are found covered with the sticky, grayish lymph in abundance. and treatment, a deep social significance. From 18G1 to 1867 seventy-three cases of these primary aft'octions of the lips came under the notice of Profes- sor Sigmund. Of these, thirty-two were presented at the hospital, and forty- one in private practice. These seventy-three cases of syphilitic affections of the lips occurred out of 5551 patients. The disease was ohserved much more frequently in the upper than in the lower lip. The most frequent explanations as to the cause of its having been contracted were, in males, smoking, and the use of certain tools, and in women, the rubbing of a spoon against the upper lip, and also the habit of holding between tlie lips thin, sharp, and pointed instruments, such as are used in sewing, arranging flowers, drawing, painting, working in cardboard, and similar occupations. It is worthy of remark that these affections of the lips occur in all ranks of society. Professor Sig- mund passes over the special etiological i-eports appertaining to these affec- tions, as they are in many cases doubtful, and, moreover, savor of .scandal. Labio-genital coitus could be clearly proved in some cases, and in others contagion by means of paint-brushes, tobacco-pipes, drinking-vessels, etc., was made out. The syphilitic affections of special importance to the practi- tioner are those produced through kis.sing. Any method of transferring syphilis to a he^iUhy individual from one previously affected at an earlier or later period, but evidently, and to a superficial observer, cured of the disease, is of the greatest importance; and even these methods have, according to Sigmund's experience, occurred with great frequency, and form a very note- worthy, but often neglected, mode of origin of the affection. Interesting cases of specific inoculation by kissing are recorded in con- siderable number in American medical publications. NE CEOS IS. 579 TJncom bated, the effect of the metal passes rapidly to the alveo- lar processes, this tissue seeming to undergo a process of liquefac- tion and absorption. Necrosis, when it ensues, may be partial or complete. Many interesting cases of such condition have come under the notice of the author, some of which will be found alluded to in other parts of this volume. Children, during the dentitional period, are found most in danger of mercurial necrosis, the parts seeming preternaturally susceptible : the result, without doubt, of the excitement related with dental genesis. When the mercurial poisoning is conjoined with the scrofulous condition, the ravages are found most marked. The writer has known a single two-grain dose of calomel in a child of this cachexia to kill half the lower jaw. The inflammation accompanying mercurial necrosis is apt, from its slough- ing tendency, so to destroy the neighboring soft parts that not unfrequently the mouth is permanently closed, requiring for relief plastic operations of the most difficult and complicated character ; and, unfortunately, even these proceedings are not alwaj^s able to restore to the patient the lost offices of the parts. (See 02yerations on the Lips and Cheeks.) The state of salivation, so characteristic of the mercurial poison- ing, comes on at varying periods, the susceptibility being influenced by different conditions : the increase of saliva varies, also, from that which may scarcely elicit attention, to a secretion which shall keep the mouth of a patient constantly over a vessel. Persons occasionally are to be met with who will be salivated by the simple smell of a mercurial ; there are others, on the contrary, who appear in this expression, at least, entirely unirapressible. It would seem to be a just experience that the mercurials, as a rule, should not be given to teething children, or to scrofulous subjects, and assuredly it can never be productive of good to push the medicine, let little or much be demanded, beyond that point at which its effects are observed upon the festoons of the gums. In the treatment of mercurial ulitis (which see) attention has been called to a practice by free scarification and the local use of iodine. Many cases of threatened necrosis have by these means been aborted ; but very great care is to be exercised, that the low vital force be not still further depressed. The treatment that applies to ulitis applies also to ostitis. In the special treatment of the mercurial, as of any other seques- trum, it is to be looked upon as a matter of much importance that the dead piece be detached by nature alone, assisted by the surgeon 580 ORAL DISEASES AND SURGERY. only as in other paragraphs described. Particularly does this seem important in the young jaw, as thus it may happen that we shall not disturb, unnecessarily, the germs of developing teeth. Much stress has been laid by some practitioners on the preserva- tion of such teeth as are associated with the sequestrum, and advice given that incisions be made through the soft parts that shall allow the bone to be drawn away from the loosened teeth. Such treat- ment can certainly only apply to very few and peculiar cases. As a rule of practice, the author is confident it must be found of little signification. The ill odor and putrescence associated with mercurial necrosis are to be antagonized by the free use of antiseptic injections. Necrosis from Injuries. — Accidental injuries received by the jaws are not infrequent causes of necrosis. Having such origin, the recognition and comprehension of the condition are the appre- hension of the common pathological expression. Traumatic influ- ences capable of provoking an ostitis or periostitis, which may result in necrosis, may be independent of external wound, depending entirely on concussion.* The treatment of such cases is the treat- * " As a result of injury there are extravasations into the cellular structure of the bone ; also, perhaps, into tlie compact substance, and occasionally under the periosteum. If these ruptures of the vessels be so extensive that their results cannot be removed by collateral circulation, which is of difficult estab- lishment in bone, part of the bone will no longer contain any blood ; this will die, and, according to circumstances, we may have central, superficial, or total necrosis. The portion of dead bone remains in the organism as a foreign body, but still continues in continuity with the healthy bone. What becomes of bone so destroyed? Dead bune may be dissolved and consumed by granulations. Hence we should expect that the elimination of the sequestrum would not require any aid. From my observations, I have no doubt that small sequestra may be completely consumed by proliferating granulations. Granulations that are being destroyed or undergoing cheesy degeneration have no power of dissolving bone. We have already stated, when speaking of caries, that partial necrosis occurs so readily in atonic, suppurative, or caseous ostitis, just because the inflammatory neoplasia, which so quickly breaks down again, does not dissolve the bone, but leaves it to be macerated in the body. But the reabsorption of the sequestrum has its limits: first, of course, it ceases when the bone is uncovered, for here the granulations have no effect ; it also ceases as soon as they secrete pus on their surface : hence a sequestrum resulting from acute periostitis is not usually absorbed at the point where the perios- teum suppurates, and where pus forms during the whole process, because it does not come in contact with the granulations; but at all points where the sequestrum must be loosened, reabsorption commences from the interstitial NECROSIS. 581 ment of inflammation anywhere. Death of the bone, in whole or in part, resulting, the case has the common history of necrosis. ExANTHEMATOus NECROSIS. — As a result of the exanthemata, it occasionally, though fortunately quite infrequently, happens that a subacute inflammation of the jaw Qpcurs, resulting in limited or, it may be, extensive necrosis of the part affected. To this form of disease, as the recognition of its associations is concerned, atten- tion seems first to have been directed by S. James A. Salter, of Guy's Hospital, who records twenty-three cases as being met with in the associated population of that institution. The author in his own practice has now met with four cases, all of them being the sequel to measles ; and, unlike the condition as it seems most com- monly met with, the disease extensively involving the bone, — the lower jaw in three cases, the upper in one. The accompanying cut is froiii a photograph of pieces, constituting the full half of the lower jaw, removed from the mouth of a German boy six years of age. The earlier history of this case could only be procured to the extent of learning that some time after an attack granulation masses forming on the bone. Lastly, after the sequestrum is de- tached, if these granuhitions also produce pus, reabsorption ceases here also, and the sequestrum, bathed in pus, ceases to decrease ; the granulations of the pus cavity, growing from all sides toward the sequestrum, in the course of time undergo chemical change, — they become very gelatinous, mucous, and ..often undergo fatty degeneration. " But the sequestrum must finally come out. Can it do so unaided? This does occur. Whence the power that pushes it out? Let us suppose a central necrosis : a sequestrum becomes detached from all sides ; then it is consider- ably smaller than the cavity in which it lies. The piece of bone is now quite loose ; granulations grow towaixl it from all sides except from the one where the pus cavity opens externally. Here there is no resistance ; if the opening be large enough, the constantly-increasing granulations push out the seques- trum. But for this to occur, there must be certain mechanical conditions which are rarely fulfilled. Small sequestra are thrown off" spontaneously; large ones, which cannot pass the existing openings, must be removed arti- ficially. "The treatment of necrosis consists at first, simply, in keeping the fistula clean. Chemical solution of the sequestruna is not to be thought of. If you were daily to pour muriatic acid into the fistulous opening, it would affect the newly-formed osseous tissue as much as, if not more than, it would the seques- trum, which would be very unfortunate, as it must replace the latter. Hence the mechanical removal of the sequestrum is the only thing; this should not he attempted before comjylete detachment. This is a very important rule." — Billroth. 582 ORAL DISEASES AND SUBGERY. of measles the child commenced to complain of a sore mouth, the gums swelling as in an attack of periodontitis, the swelling after a few weeks being followed by the continuous Fig. 2^7. discharge of pus, which the parents stated had beeq, troubling him for several months; could not say whether it might be two or four. When first presented at the clinical service, the child was so emaciated that little hope ,, „ , was entertained of saving its life ; but, after Sequestrum after Measles. ° ' ' having been placed upon vigorous tonic med- ication for two weeks, taking iron and quinine, drinking beer, using salt-baths, and having the parts almost hourly syringed, thus washing away the offensive semi-putrid pus in place of allowing it as before to pass to the stomach, and at the same time using local means of a stimulating nature, the reaction was of the most prom- ising character, and invited and indorsed the attempt to remove the sequestrum. Making at a second clinic thorough examination, it was evident that the body of the bone in mass was dead, and that not the slightest attempt had been made toward the formation of any new osseous structure. In this instance, all proper attempt was made to excite the production of new bone, the necrosed structure only being removed when to leave it longer in its bed would have been to risk the life of the child. The removal of the bone in this case resulted in a considerable I* immediate deformity, but which after two years had so completely disappeared as to be scarcely observed, while the natural motions of the jaw seemed quite as good as in other children. , In a second case, the disease attacked the upper jaw, resulting in a repetition of small inflammatory sequestra, together with the crowns of the undeveloped bicuspidati of the side affected ; the dis- ease continuing, in defiance of treatment, for over a year, and yielding finally only to a summer spent upon the mountains. In the treatment of these cases, nothing special seems demanded, unless it might be that we should be able to recognize and admin- ister the specific for the peculiar poison. Lacking such knowledge, the case is to be conducted on general principles: great cleanliness, conjoined with stimulating and antiseptic injection, constitutes the principal local demand ; while systemically, the patient is to be supported under the drain which, to a greater or less extent, always attends the process of exfoliation. NECROSIS. 583 In cases of slight signification, such as are referred to among others in the foot-note from Holmes, where the exfoliated part maj involve but the edge of the alveolar process, so little attention might be demanded as to deny the surgeon even the opportunity to see such states of the condition.* * " I believe that the necrosis and exfoliation of the alveolar process and portions of the jaws in children, consequent upon the eruptive fevers, is essentially the same as the maxillary necrosis in the victims of phosphorus fumes, and that it is the result of the local application of a specific poison to the vascular parts of the teeth. There is this difterence, however, that in the case we are now considering the poison is generated within the individual, but with affinities for certain structures and tendencies to action upon certain organs, which give its morbid consequences an equally local character. "What- ever opinions may be entertained as to the homological relations of the several tissues of the teeth to those of the general integument, there can be no ques- tion as to their being members of the dermal system, and as such we should, a -priori, expect that they would share the consequences which attend those particular diseases which spend their chief force on the skin. There is one circumstance, however, that modifies such an anticipation : it is the low state of vitality of the teeth, and the extremely slight nutritional changes which occur in them when once they are formed, and which must conse- quently remove them to a great extent from those transient, though potent, influences which would destroy or morbidly afiTect vascular or growing tis- sues. But such a qualification does not apply to the conditions of the teeth during their development. From the time of birth until the eighth or ninth year, the jaw-bones are the seat of intense developmental nutrition in the formation of the teeth, and are among the most vascular parts of the body. About the middle of the period named, five years of age, the maxillae con- tain no less than forty-eight developing teeth and developing tooth-germs. It is about this time that the poison of the exanthematous fevers appears to exert its most deadlj^ influence on the dental system. "The form of necrosis aftecting the alveolar edges of the maxilla, and accompanied by the shedding of the teeth, which we are now considering, was, I believe, first recognized by myself (Transactions London Pathological Society, vol. xi. pp. 209 to 215) as one of the sequelae of the exantliemuta, and dependent necessarily on their previous occurrence. Many isolated cases of the aflection have been described, and our museums contain specimens of the sequestra ; but the supposed relation of cause and effect has not, so far as I know, been expressed before. (The earliest recorded cases are mentioned by Fox in his ' History and Treatment of the Diseases of the Teeth,' p. 112, London, 1801. These cases, two in number, occurred after smallpox.) "This aft'ection is by no means common, considering the almost universal occurrence of the eruptive fevers. The very large population tributary to Guy's Hospital has onlj' furnished me with twenty-three or twentv-four cases during the last nine years; and I have reason to think that even in this I have been disproportionately favored. If** 584 • ORAL DISEASES AND SURGERY. Phosphor-Necrosis. — This is a term applied to that necrosis of the maxillary bones dependent on phosphorus-poisoning, being a disease peculiar to workmen in match-factories, and confined here almost exclusively to such as are engaged in the processes of dip- ping and packing. How phosphorus affects the maxillary bones, whether from a systemic or a purely local relation, continues to excite discussion. That persons possessed of carious teeth are alone af- " The cases are all .singularly alike. A little child has just recovered from one of the eruptive fevers, most p.rohably scarlatina ; the case has been in no way unusual as to its severity or its course. Within six weeks or two months of the passing off of the acute symptoms, tenderness of the mouth is com- plained of, and the mother notices fetor of the breath. Upon inspecting the mouth, the gum is seen to be peeling from the edge of the jaw around the neck or necks of some temporary tooth or teeth, pus is discharging, and more or less dead bone is exposed. The denudation of the bone, progresses rather quickly in depth, but usually not after the first in lateral extent. The tem- porary teeth at the affected part become loose, and often fall out. There is no swelling, and no ossifying callus is formed in the region of the necrosed bone. In a few weeks from the first of these symjitoms the sequestrum be- comes loose, and is easily removed, leaving a large gap and a raw, granulating surface, which rapidly heals. The necrosis almost always includes the bone which constitutes the loculi containing the developing permanent teeth, as well as the alveoli of the temporary ; but it does not go further, and in the lower jaw the base of the bone is very rarely affected, — note clinic case recorded. I have never seen such an occurreijce. The disease is frequently symuietrical. When attacking the bone about the temporary molars on one side of the jaw (its most common situation), it often manifests itself immedi- ately after on the opposite side, and sometimes in tl\e same regions of the other jaw. The same sj-mmctry is observed in front of the mouth. "As far as I am aware, this affection only occurs after the eruptive fevers, and scarlatina is its most potent cause. In the instances which .have been under my own care, two were after smallpox, five or six after measles, and fifteen or sixteen after scarlatina. There is, however, nothing in the condition of the mouth to indicate which has been the precursor. The age at which this affec- tion occurs is usually about five years : from three to eight are the extreme limits I have known. " The issue of these cases is simply comprised in the loss of a certain amount of bone with the contained teeth, and the consequent disfigurement. As the permanent teeth are lost with the temporary, the disfigurement is very great when it affects the incisors ; but when the temporary molars, and their suc- cessors, the bicuspids, suffer, the damage is comparatively slight. " The treatment of these cases involves little beyond patience-and cleanli- ness. No operative interference is indicated ; the extent of the necrosis asserts itself from the first, and cannot be curtailed. When the sequestrum becomes loose it is to be taken awav." — S. J. A. Salter — Holmes. NECROSIS. 585 fectecl, seems sufficiently verified ; while, on the other hand, as shown first by Dr. Letheby, of London, phosphorus has a systemic relation, as exhibited by its detection in excess in the urine of the poisoned patients. Yon Bibra and Geist, holding to the theory of a local contamination, direct attention to the fact that "toothache invaria- bhqDrecedes the more severe affection," that a carious state of some tooth or teeth is a "sine qua 7ion,^' and that "so long as the teeth remain good the affection does not show itself." Lorinser, who was the first to describe the phosphorus-disease, holds to the analogy of the affection with the mercurial poisoning, — a view which the experience of the author of this volume leads him markedly to sympathize with, although it is not to be denied that such view is markedly in opposition to that which at the present time is generally held : this common view being that phosphorous oxide, in a low form, finds a way to the periosteum through the dental pulp canal, producing, as a result, this peculiar and specific inflam- mation.*' A jaw, however, fretted and vascularly excited by teeth in a state of disease, would naturally be expected to be in a more susceptible condition than one strictly healthy: hence it might very well be that such special susceptibility could explain the attack, the natural resistive force of the part being to such extent lowered. Such supposition certainly tends to add force to the views of Dr. Lorin- ser, "that the fumes act by infecting the blood, laying the primary foundation for a disease which remains dormant until an exciting cause fixes the spot for the outbreak." In proof of his inference, attention is directed IJy Dr. Lorinser to the peculiar dirty sallow, combined with a dull, expression, together with the gastric derange- ments, which are prodromous to the local affection ; expressions which the author has observed as characterizing his own patients. In certain Nuremberg patients, however, mentioned by Yon Bibra and Geist, these prodroma were not only lacking, but, on the contrary, the majority were seen to be of healthy, florid complexions, which some retained to the last stage of the disease. Let the true expression of the case be as it may, a prophylaxis always to be commended to workers in phosphorus is found in that continuous attention to the mouth and teeth which insures the most perfect cleanliness, combined with the immediate filling of every tooth, which becomes carious, thus preventing exposure of the pulp. A * For arguments, see Clinical Lecture by Mr. Simon, Lancet, 1850. 586 ORAL DISEASES AND SURGERY. second prophylaxis is one suggested by Mr. Salter (see Holmes), who expresses the belief that by keeping the atmosphere of the factories ammoniuretted, and thus neutralizing the acid vapor, few, if any, cases of the disease would ever occur. Still another means having general commendation is found in the employment of a respirator, of which perhaps the best is that de- vised by Mr. Graham for persons exposed to carbonic acid vapor. This consists of the mixture, in equal bulk, of fresh-slacked lime and sulphate of soda, worked into a cushion, through which it shall be eas}'- to breathe. Carbonate of magnesia, used in teaspoonful doses twice each day, and applied with all freedom locally, will be found of great service in antagonizing the acid. Outside of the association of the patient with phosphorus, there is nothing which, to an ordinary observer, would distinguish the incipient condition of this loathsome disease from a case of severe periodontitis. The first sign of a commencing phosphor-necrosis is found com- monly in one or more teeth becoming sore to the touch, feeling, on occlusion, as if raised in their sockets ; in a short time the sur- rounding gum begins to swell : in the character of this swelling is the first distinctive sign. It is not the acute, firm, inflammatory swelling of periodontitis, or of traumatic ostitis, but from the begin ning has a puffy, debased, and degenerating look. One feels as if he might hesitate in adopting any very decided antiphlogistic treatment, or, indeed, in employing any other than an expectant one. (See case from Von Bibra and Geist.) Phosphorus acts both on the upper and the lower jaw-bone, but seems to have a decided predilection for the lower ; as twelve to nine, perhaps.* The history of a case of phosphor-necrosis might be epitomized as follows: a degenerative inflammation commences in the alveolo- dental membrane, or in the substance of the bone ; the author in- clines most strongly to the belief of its commencement in the latter. The degeneration of this bone progresses until its enveloping peri- osteum — which remains unafi'ected as its vitality is concerned — separates from it. The bone dies in bulk, or in part. In the lower * Of twenty-two cases reported by Dr. Loi'enser, nine were of the upper jaw, twelve of the lower, and one in which both were affected. Of fifteen cases occurring in Nuremberg, five were in the upper, nine in the lower, and one in both. Of eight cases recorded by Dr. Neumann, three were of the upper jaw, four of the lower, and one of both. NECROSIS. 587 jaw, the body alone commonly dies, the rami remaining unaffected. In the upper, one cannot well infer where the demarkation will occur. During this process of death, the periosteum, particularly in the lower jaw, is most active in the reproduction of new bone, osteo- phytes, so called ; this new material exhibiting markedly its endeavors to envelop and- replace the old. The separation of the dead from the living bone, in the lower jaw, when the dead part is at all exten- sive, will be' found most likely to occupy a period of from seven to nine months, and is apt to be attended with the formation of many sinuses, both in the mouth and about the neck, being very ex- haustive to the patient, both on account of the great suppurative drain and the nauseating character of the discharge. All the soft parts associated with the affected jaw, the periosteum perhaps excepted, synipathize warmlyduring the process of the dying and separation, looking, indeed, as if very badly affected with scurvy. At the period above alluded to, the separation being completed, the surgeon may remove, with little effort, the sequestrum ; the sinuses then heal, and the parts may recover with as little deformity as attends the extraction of the teeth and the ordinary absorption of the alveolar process. This, I think, will be found a common history of the disease. The author has seen and treated many cases, and it is thus that it has presented itself to his observation. It might perhaps be added that the teeth, influenced by the advancing disease, loosen one by one, so as to make necessary their removal long before the bone is ready to come away. In phosphor-necrosis the death of the bone seems to be a result of morbid porosity, the loosening and expansion of the structure proving antagonistic to its nutrition; as vitality diminishes, so, as the result of a cacoplastic exudate, the periosteum is found to separate itself, such secretion explaining, in its degeneration, the character- istic abundance of fetid pus. Indeed, it is to be seen almost from the earliest affection of the bone that the periosteum is aroused to efforts for self-protection; so marked is this in many instances that attempts at the formation of new bone separating the periosteum from the dead tissue result in numberless osteophytes, if indeed a perfect wall is not secured. The writer has seen not unfi'equently the whole floor of the mouth, back to the base of the tongue, occu- pied by such new bone. As is to be readily recognized, however, the tendency of this 588 ORAL DISEASES AND SURGERY. exudate to degeneration is marked: thus, the osteophytes are found in inverse proportion to the quantity of pus. These osteophytes, in characteristics, are seen also to be greatly influenced by a treat- ment employed in a case : in the beginning they are, it is to be inferred, uniform ; from such uniformity we see them as slender shreds, in masses, and indeed in every irregularity of form and feature ; decidedly disposed also are they to break down and disap- pear, and this particularly where extreme cleanliness is not observed or the s^'stem at large is left without the support of tonic medica- tion. It is, indeed, simply the common history of lymph degenera- tion, — an inability on the part of the plasm to the maintenance of a self-supporting organization. A dull, dirty-yellow complexion, as has been remarked, is almost universally associated with phosphor-necrosis: this has been variously attributed to dyscrasia, to the pain, the impeded ingestion, and to the immense drain made on the system in the progress of the ex- foliative process. The most reasonable hypothesis is that all these causes are alike implicated : certain it is, that to get a patient clear of such a complexion, all require to be considered in the treat- ment. The tendency to the burrowing of pus in acute phosphor- necrosis is remarkable, and to a marked extent will such burrowing occur in defiance of treatment : if the lower jaw is the seat of the disease, the sinuses will riddle the neck ; if the upper, the antrum tends to receive the pus, while in grave cases it not unfrcquently finds its way to the ear and the mastoid process of the temporal bone. Salivation is another of the marked characteristics of the condi- tion : the author has had patients who were compelled to have a handkerchief constantly at the mouth to receive the drainage. Another source of discomfort resides in vomiting: particularly does this tend to occur in the morning, the result of the pus swal- lowed during the night. Fever, diminution of appetite, and de- rangement of the bowels follow the progress of the disease, and, if not vigorously combated, are apt to end in an inanition fatal to the patient. The sequestra of phosphor-necrosis in the lower jaw look some- what like pieces of rotten sponge, being almost as light and porous; this arises from the suppuration and discharge of the primary exudate which was the cause of the original enlarijement : the NECROSIS. 589 organic material being all discharged, nothing remains but the cell- riddled, inorganic structure, hence the brittleness. Treatment. — The treatment pursued in phosphor-necrosis is to consist in the employment of means which shall circumscribe as much as possible the disease, which shall hasten the process of limited death and the accruing separation, and which shall support the patient undeir the drain to which he is necessarily subjected. When a case presents in its incipiency, that is, simulating a de- veloping periodontitis, we commence the local treatment just as we would that of the periodontitis. If the inflammation has about it anything of a healthy acuteuess, we limit as much as possible all ex- ternal irritation, by softening in the gas-flame or by the stove a piece of gutta-percha, and moulding it over some opposite tooth, or tooth farthest removed from the seat of trouble ; a mouthful of cold water hardens this cap, and thus occlusion against the sore tooth or teeth is prevented. A dose of Epsom salts or other saline cathartic is ordered, and a sinapism is applied to the back of the neck. A hot pediluvium is found sometimes to act very happily as a derivative; or a diaphoretic, such as the spirits of Mindererus, may serve a very good end. Depletion by leeches, however, has never seemed to the author to be an indication : the affection has its very origin in asthenia. If we first see the case — and this is most apt to occur — when a discharge has made passage for itself by opening through the gum at the neck of a certain tooth or teeth, we immediately make a free incision through the soft parts down upon the bone, and s^a-inge the parts thoroughly with some medicated water, stimulating or antisep- tic, or both, as indicated. Having the parts well cleansed, we stuft" the wound which has been made, with cotton or sponge. This is repeated the next day and the next, until, particularly as the syring- ing is concerned, it may be absolutely necessary to repeat it a dozen or twenty times per diem, the progress of the disease being so marked by discharge and offensiveness. As day by day the cotton or sponge stuflfing is renewed, it is insinuated gently between the separating periosteum and bone. This manipulation will be found to hasten the separation wonderfully, and expedite the cure of the case. It might here be asked, perhaps, by some one, " Is not this pro- cess of working off the periosteum an unsurgical proceeding, com- pelling an extension of the disease beyond that which would have been the result if left to itself?" The author can only answer from 590 OBAL DISEASES AND SURGERY. his own experience in different modes of treatment, and say that he is perfectly satisfied that this is not the case, and that the result is for the good of the patient in every way: the portion of bone destined to die has the destruction markedly hastened ; the sooner the death, the sooner the separation; the sooner the separation and exfoliation of the sequestrum, the less exhaustion to the system. The compound tincture of capsicum, with an excess of myrrh and an addition of the permanganate of potash, is an excellent wash for the mouth in these cases. Cold water, with a little salt and mag- nesia dissolved in it, can be used ad lihiium. The sinuses which are so apt to form upon the neck, in defiance of all treatment, and which greatly annoy by their discharge, are most comfortably treated with dressings of patent lint. Once formed, it is a waste of time to attempt the healing of them : they will only get well when the source of offense in the dead bone is removed. It has been remarked that the death is limited in the lower jaw to the body of the bone, the horizontal portion, the demarkation oc- curring at the angle. This, in the majority of instances, will be seen to be the case, particularly if the treatment has been properly directed. Seven months has been found, in the practice of the writer, the minimum required for the course of the disease, nine months the more common time, and fifteen the maximum, although this latter does not accord with German experience, cases being reported of two years and a half standing. The drain during most of this time is immense, the patient requiring the most generous tonics and sub- stantial fare. Attention to the repair of this wear and tear is, per- haps, of greater consequence than any local treatment; certainly, if one could not have both, his chances would be best with the former. Both are to be esteemed as of vital consequence. To commence, however, with the ordinary medicinal tonics, is ill advised. One cannot well keep on with them, and by employing them in the begin- ning of the disease we lose their powerful assistance at a time when every help is found weak enough at the best. Good underdone roast beef is quite enough for the first two or three months ; then an addition may be made of generous malt liquors, together with the salt-bath. The latter portion of the time will demand iron, quinine, brandy. The hemorrhages, sometimes so profuse, are held very well in check by the exhibition, once or twice weekly, of five- drop doses of tincture of Erigeron Canadense. The period at which a sequestrum is i-eady to be taken away can NECBOSIS. 591 only be known by repeated examination, the proper treatment being to wait always until the separation is complete, be such time longer or shorter. Nothing, the author is satisfied, is gained by expediting the removal through operative proceedings, as by breaking away the bone, using the chain-saw, etc., while the risk to life is very considerable. To wait patiently, keeping the system equal to the demand on it, is the surgeon's highest duty; to do more is to do harm. The removal of the bone is always to be effected from the inside ; it does not seem that an outside incision would ever be found neces- sary. If the opening along the gum, obtained in the treatment, be not great enough, it is easily enlarged to an extent desired. A step preliminary to the removal of the body of the lower jaw is its divi-sion at the symphysis. This is most easily accomplished by means of the straight-cutting forceps. It is better to cut little by little, from above downward, than to crush through the bone with a single cut ; it does not hurt or shock nearly so much. The opera- tion is not a severe one, seldom demanding the patient to be ether- ized, yet it is generally enough to be borne at one sitting. To take away the bone, no instrument is found better than the ordinary tooth forceps, such as is in common use for the extraction of the inferior incisors and bicuspidati. With such forceps, com- plete control of the part is secured, and the removal, as a general thing, easily effected. A trouble frequently encountered,, and one which, undistinguished, would prove confusing and deceptive, consists in the grasping of the sequestrum, when extensive, by the lateral overlying tissues, — not by the new bone, but by the indurated soft parts. The writer recalls a case which he once had under treatment, where, the dead bone being thus held, the practitioner bad been waiting for the separation a period of over two years, being deceived entirely as to the condition of the part. To satisfy one's self as to the condition, pass a small hook under the bone, and lift : if the bone yields springy, it is only thus held, and may with safety be pulled through ; if, on the contrary, it is firm and unyielding, it is to be left alone, — separation has not yet taken place. In the reproduction of the new bone, which, at the period for the removal of the old, should be found to have obtained such character as to keep up perfectly the shape of the parts, the observer will be struck with the excess deposited along the middle line of the mouth : it seems, oftentimes, as if the floor was a mass of bone, — which, 592 ORAL DISEASES AND SURGERY. indeed, it really is. It will not be found necessary, however, to do anything with this excess, nature taking all proper care of it. Phosphor-necrosis attacking the upper jaw seems not so much to be dreaded as that associated with the lower. It is seldom so for- midable in its nature or so destructive in its progress, the disease in these parts having been seen to run its whole course with an entire absence of acute action. A portion of bone dies, and the surround- ing soft parts seem utterly indifferent. One would scarcely know anything abnormal was going on, were it not for the indication given in the loosening of the teeth ; these drop out somewhat as they would out of the dried skull, while the soft parts eventually present the appearance of shrinking away from the bone, which structure becomes fully exposed, — as dry and lifeless, apparently, as that of any dead skull. This, however, is, of course, not the common his- tor}'. The inflammatory action is of the same type as that associ- ated with the disease in the lower jaw, but more limited in extent and consequence, and nmch more susceptible to remedial measures. A bad feature consists in a niarked tendency to recurrence of the trouble ; but this, perhaps, will mostly be found within the control of the surgeon. The removal of a sequestrum here is a trifling matter, comparatively little dissection letting the piece pass. If the bone seems grasped by the contracting soft tissue, the easiest plan of removal will be found in the introduction between the parts of pellets of cotton : these quickly swell, and thus effect loosening. At a Medical Congress in Zurich, Switzerland, Professor Billroth, in citing his experience with phosphor-necrosis, remarked that in attacking the upper jaw it seemed to act with greater and more destructive force, and was more unmanageable. The author does not know how to reconcile these differences in clinical observation, unless an explanation may be found in the im- plied greater tendency to return which exists on the part of the dis- ease when situated in the upper jaw. In the lower jaw, the full part that is to die seems impressed from the beginning, — that is to say, a certain portion seems predestined, and it dies in defiance of all you may do. Not that the evidence of the disease is general over all the involved part from the beginning : on the contrary, the incipient stage is markedly localized; but then, day by day, and week by week, the trouble extends over the apparently predeter- mined or preimpressed part. When the death occurs, it is a single death ; and when the piece is cast off, there is not apt to be any NECROSIS. 593 Fig. 228. — Appearance of Patient WITH Phosphor-Necrosis. renewal of the trouble. The sequestrum of the upper jaw, on the contrary, is generally small, some portion, most likely, of the alve- olar process ; but unless the treatment is of the most supporting and speciSc kind, it is apt to repeat itself, again and again; but your treatment will be responded to here, and thus, with care and atten- tion, you have the amount of destruction comparatively under con- trol. If it is found more unmanageable in Zurich, then the means would not seem to be so well adapted to the end as those here em- ployed, or otherwise the circumstances must be different. Again, at the same Congress frequent resections are commended. To be so commended, they must, of course, have been found to answer a good purpose. The patients who have their jaws resected for phosphor-necrosis disease in this country gener- ally die, or, if happily they escape death, they do not find their disease cured without an inflammatory sequestrum at last. This case (Fig. 228), taken from life, represents a patient as he appeared with the disease five months in progress. At the end of eight months the writer removed the jaw at the articulation : the loss was very fully repaired at the date of operation, the parts having excellent motion. An important objection to the operation of resection, even were the question of life not involved, is the great resulting deformity. Let nature take her course, and of this there may be little or none. A late patient was a gentleman for whom the author removed — or rather from whose mouth nature cast out — the whole body of the inferior maxilla, and no one might tell whether it had been a case of necrosis or of simple extraction of all the inferior teeth, with the con- sequent alveolar absorption, so perfect has been the repair in accord- ance with the destruction. The objection that this new bone keeps up the trouble, by becoming involved in the diseased action, is not according to the experience of the author. If it becomes involved, it would seem to imply that it has not been properly cared for. Care- ful and properly repeated syringings with water medicated with 38 594 ORAL DISEASES AND SURGERY. iodine and creasote will protect it. This experience does not, how- ever, include the isolated osteophytes ; these do without doubt incline to degeneration and decomposition, but by care the many may be stimulated to a self-supporting combination to which the periosteum becomes what it was to the bone exfoliated. It is certainly most unfortunate that in the case of the upper jaw no osseous repair seems attempted, but it is not the experience of the author that the horrible deformities mentioned by various writers are at all common. Local and systemic stimulation combined with a tonic treatment insures more or less attempt at supporting the surrounding parts by an exudate which assumes a fibro-carti- laginous aspect, and which will assume the duties of the structure lost, to very good purpose. In loss of structure in the lower jaw the most vigorous efforts are seen to exist on the part of the periosteum almost from the be- ginning to reproduce the impressed part, disproving to such extent, as it would seem, the deduction of Dr. Geist, that the phosphor- ostitis is secondary to periostitis, for assuredly is it the case that under no circumstances of excitation does this tissue exhibit higher vitality. That this secondary deposit differs from the original bone, in possessing an excess of organic structure, implies perhaps only that the deficiency in inorganic substance has its explanation in the presence of the corroding acid of the disease. That the capsule of new bone is so frequently found to atrophy may have similar explanation with the primary osteophytic degenerations, requiring, if not a local, yet a constitutional care. A suggestion made by Mr. Salter that the new bone be supplied with function by using it as soon as possible as a base for artificial teeth may be found to have in it much practical import.* * As a study, having associated with it a post-mortem, and which must indorse the hints furnished in the body of this paper, attention is directed to the following, taken from Von Bibra and Geist. The reader, however, should be impressed with the inadvisability of any treatment by depletion. "Barbara Keim, aged twenty-two, a well-made, under-sized brunette; of healthy constitution; menses regular, no morbid predisposition, nut scrofu- lous; had been engaged for four years in a lucifer manufactory in counting the matches, which at that time was done in the .drying-room. "During the first three and a half years she remained perfectly healthy; during the last half year she had occasionally suffered from toothache on the light side of the lower jaw, but to this she paid little attention, as she had ■ formerly been subject to toothache, and had lost several teeth by caries. As the pain only occurred periodically, she was not induced to quit her occupa- NECROSIS. 595 tion. At the beginning of February, 1843, the toothache on the right side of the lower jaw became more severe, it ceased to be limited to the carious teeth, and extended through the whole jaw, over the cheek, and even to the temporal region and the neck. At the same time considerable febrile dis- turbance, with occasional rigors, supervened, accompanied by swelling of gums and cheek, with erysipelatous redness of the latter. February 4, she was admitted into the hospital. The examination showed the right cheek much swollen, and very tense towards the eye, the mouth, the chin, and neck; the tension most considerable in the vicinity of the lower jaw. Pain deep- seated, throbbing, piercing, concentrated at the angle of the jaw, and radiat- ing thence over the adjacent soft parts. Extreme tenderness on pressure. The gums of the diseased side of the jaw much swollen, tense, darkened, and tender ; the mucous membrane of the cheek equally so ; between the angle of the jaw and the first molar, thick, fetid pus of a phlegmonous character oozed out on pressure. " The first and fourth molars on the right side of the lower jaw were carious ; the other molars deficient, incisors and canine sound. Tongue furred, bitter taste, pain in forehead, oppression at epigastrium, ructus, nau- sea, constipation, inflammatory fever. "Ordered, an emetic, fifteen leeches at angle of jaw, a laxative to follow, and a gargle of oxymel and aq. flor. sambuci. " Evacuation of a large quantity of acid and acrid saburra. Relief of general sjmptoms ; gradual progress of local affection. The swelling of gums increased, became more tense, extended to the soft palate; dysphagia and salivation supervened ; and the jaw became almost immovable. Sup- puration increased, pus laudable, but fetid. Ordered eight leeches to angle of jaw. Ung. hydr. with ol. hyosc, to be rubbed in, nitre mixture, iodine externally and internally. Poultices. " During the second week, the four incisors and one molar became loosened, suppuration ichorous and rusty, gums softened and livid, formation of sinuses on the external and internal surface, through which the probe reached the bone, which appeared in part rough, in part smooth. Pain lessened, extreme exhaustion. Commencement of cough and hectic symptoms. In the pro- gress of the disease, increased retraction of gums from the alveolar surface, fresh abscesses, increased discoloration, and burrowing sinuses, so that the entire side of the jaw was exposed to the probe, both externally and internally. The bone appeared almost entirely detached from the soft parts, floating in an excessively fetid sanious fluid. The first and fourth molar and the four incisors either fell out or were taken away by the fingers. The swelling of the cheek, over which there was a frequent livid flush, remained undiminished, but it yielded more to pressure, apparent fluctuation at one or two points, but no pointing of abscess externally. The lips and ej-elids became oedema- tous ; and during the latter weeks of the patient's existence, the left cheek also became painful and swollen. The affection had thus reached the stage of gangrenous destruction of the soft parts ; the pain ceased almost entirely ; but there was a gradual increase of the hectic symptoms; and in spite of tonic and antiseptic treatment, the patient died on the seventy-third day of the illness, worn out by hectic. 596 ORAL DISEASES AND SURGERY. "Post-mortem, eight hours after death. " Extreme emaciation, right cheek swollen, soft, livid. On being detached from the edge of the lower jaw, a rusty, grumous, highly offensive, and greasy fluid exuded. Neither gums, periosteum, nor muscles of the cheek were distinguishable. All those soft parts appeared to be dissolved in the grumous fluid, which was inclosed in the integument of the cheek as in a pouch. The right half of the inferior maxilla perfectly denuded, and void of all connection with the soft parts in this grumous mass, so that after divi- sion of the capsular ligament it was extracted without the least difl[iculty. In the lungs, tubercular deposition ; but neither softening nor suppuration, which accorded with the previous symptoms, as nothing had indicated the second and third stages of pulmonary phthisis. No tubercles in the mesen- teric glands. Anaemic and flabby state of the chief organs, the heart, liver, spleen, and kidneys; the' blood in the large veins very thin and blackish. "Descri-ption of inferior maxilla. — On the external and internal surface of the ramus of the right side, there is a deposition of new osseous matter, partly accumulated in large masses, partly in small isolated portions round the neck of the articulating process, without affecting the glenoid surface, extending along the external and internal surfaces of the condyle and the coronoid pro- cess to the angle of the jaw. The deposit is extremely delicate at the neck, and where it forms the detached portions, increasing in compactness and size as it descends, so as to present a thickness of from a line to a line and a half at the angle of the jaw, where the deposits of the two sides join, without at all points being in actual contact with the bone of the jaw. On the inner sur- faces of the maxilla the deposit extends almost to the chin. At the alveolar processes of the incisors, there are three larger insular deposits. On the ex- ternal surface this new formation reaches to the fourth molar, and there are smaller deposits on the alveolar process of the right carious tooth. There are also two delicate deposits on the left side in the region of the first and second molar. " The new deposit is everywhere but loosely attached to the subjacent bone, has no organic connection with it; the thinner portions may be easily removed by the nail, and the surface of the exposed bone appears perfecth' smooth. Some parts of the former decay, and separate spontaneously, which, however, is not the case in the more compact mass attached to the angle of the jaw. The more delicate portions of the deposit present a porous structure, resem- bling a fine sponge, an appearance due to the innumerable vascular orifices. In proportion as the deposit descends, and becomes more compact, the spongi- ness diminishes, and at the angle of the jaw the surface is much smoother, and the vascular orifices less numerous. The new deposit is partly of a dingy gray color, partly having a yellowish or a brownish or reddish tinge. The alveolar process, at the right and left last molar, is perforated, and looks cor- roded. The alveoli, which are open, present nothing abnormal. The bone of the maxilla itself presents throughout a smooth surface, even under the new formation, and must be considered, so far as external signs serve as an indication, as a perfectly sound bone." As a clinical case, having in it a valuable lesson, the author may add the following from his own practice. On a date forgotten, a father presented for NECROSIS. 597 treatment a daughter with the communication that she had a very sore tooth, and that her wedding being appointed for the third following day, it was hoped she might be cured by that time. Examining the mouth of the patient, a periosteally diseased tooth was at once recognized, but the gum about it was so debased and puffy as to imply almost to a certainty more extensive disease and to suggest phosphor-poisoning, the fact of which poisoning the information that the girl worked in a match-factory at once verified. To tell this patient that her wedding must be deferred for a year, and to explain the long tedious treatment necessary for her cure, was to provoke a fainting-fit and quite a disagreeable scene. These people, both father and daughter, were quite intelligent, and much trouble was taken to explain the principles of treatment and cure, and par- ticularly to make understood the great demand necessarily to be made on their patience and endurance. Seven months this case was under care, being seen every third day, and treated precisely as suggested in the body of this chapter. At the end of this period the body of the bone was found loose in its new envelope, excepting that the ramus of one side had not quite separated. This objection to an immediate removal was explained, and directions enjoined to continue treat- ment for another month, when in every probability the whole jaw would be capable of being lifted away without trouble or pain ; while at the same time the preservation of the contour of the face would be secured by the new jaw which was being formed. Ill advised, the girl, losing faith in a treat- ment which necessarily seemed to be going from bad to worse, discontinued her visits. When next heard from, she had invited the operation of expe- diting the removal of the sequestrum by a saw-cut at the line of demarkation, and which resulted in death within a week. CHAPTER XXIX. WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. Wounds of the mouth and associate parts have, of course, the signification of wounds in general. Thus, some are of an incised character, being slits or incisions made accidentally or purposely by sharp-edged instruments. Some are lacerated, contused, or torn, being made by dull and blunted instruments ; some are punctured, being made by pointed but not sharp instruments ; some are pene- trating, as when the offending agent passes through the lip or cheek into the oral cavity. A wound may be of a compound or compli- cated nature, as, for example, in the case of blows or falls, which, while they cut and contuse the lip or cheek, break, at the same time, the teeth or fracture the jaw; gunshot injuries, lacerating or simply puncturing the soft parts, comminuting the hard ; bites of rabid animals, introducing a virus ; syphilitic inoculations, etc. Compli- cations may also be considered as embracing hemorrhage and shock as primary associations ; inflammation, with its varied phenomena, erysipelas, pyaemia, tetanus, etc., as secondary associations. Every wound presents a first indication. If an individual receives a hurt which covers the injured part with earth or other foreign substance, such substance is to be washed or taken away as the primary step. If hemorrhage is the feature, arteries are to be ligated, or other necessary means taken to control such bleeding. If shock be present, this is the most immediate feature, and is first to be combated. If a rabid or poisonous animal has inflicted the wound, the destruction of the virus is a first indication. Foreign Particles. — To remove earth or similar foreign parti- cles, no better means can be employed than the simple sponge and water. Holding the injured part over a basin, squeeze water upon it from the sponge ; if the particles are not washed away with the sponge closely applied, let it be lifted away, and the water allowed to fall from a distance. It is not, as a rule, at all necessary to permit the sponge to come directly in contact with a wound. Bodies which may not be washed away, no matter what their character, — (598) WOUNDS OF MOUTH AND ASSOCIATE PARTS. 599 splinters, shot, balls, particles of powder, spiculae of bone, etc., — are to be removed with forceps, scoop, or other convenient means, the rule being to allow nothing to remain that may interfere with the process of repair. Hemorrhage. — A first matter to consider in hemorrhage is its character. Is it arterial, venous, or capillary? An arterial hemor- rhage is known by its scarlet color, and by issuing from the wound in jets. Hemorrhage from a vein is dark, and has a gradual and regular flow. Capillary hemorrhage is an oozing. Arterial hemor- rhage may require that the bleeding vessel shall be ligated. To do this, it is only necessary to sponge away the blood until the vessel can be plainly seen ; it is then to be taken hold of by the forceps, or caught in the tenaculum, and a strand of waxed silk thrown around it. In tying this silk,, one must be careful that he shall not break his strand at either side of the knot ; also that the tightening shall be sufficient to cut the middle and inner coats. To prevent tearing the vessel from its bed by the breaking of the ligature, the rule of holding the thumbs upon the strands close to either side of the artery is always to be observed. After llgating a vessel, one end of the ligature may be cut off and the other brought out from between the edges of the wound ; this allows of an easy future removal of the knot. Torsion of a bleeding artery is a favorite mode of treatment with many surgeons. The end of the vessel is to be caught by the for- ceps and twisted. The author of the mode suggests that the torsion be continued until the end is twisted off. Acupressure is another and a very common method of treatment. A steel or gold needle is passed beneath the vessel in such manner as to tightly compress it against the neighboring parts. Pressure by pad and bandage, when a hemorrhage about the face will not yield to simpler means, is a very satisfactory way of treat- ment, and one entirely reliable. AH the vessels of this region rest upon a bony floor, and all of them, at certain points, are sufficiently superficial for the purpose, — the facial, at the notch in the inferior maxillary, in front of its angle; the temporal, just in front of the ear above the zygomatic process ; the supraorbital, at the notch in the orbit; the infraorbital, at the foramen below the border. A bandage of common application for any of these vessels is the crossed or knotted circular. A glance at the drawing (Fig. 229) will exhibit the manner of its employment. It is, however, very seldom that any of these operations are 600 ORAL DISEASES AND SURGERY. necessary for the arrestation of hemorrhage about the face or mouth. Cold water thrown over the bleeding part from a sponge will fre- quently cause such a contraction, both of vessels and tissues, as to control it quickly enough. If water alone will not answer the pur- pose, let alum be added, as much as the water will dissolve. If even this should not answer the end, use a syringe, throwing a jet from Fig. 229. — Crossed or a distance directly upon the part bleeding ; Knotted Bandage. this last will seldom disappoint. Monsel's solutions, so warmly lauded for their styp- tic qualities, have exhibited to me more ill results than I have ever met with from any dozen other articles. If used at all, I think the bleeding points should be alone touched ; but of one thing any one using them may be assured : if the application does not control the hemorrhage instantly and permanently, he will have increased his trouble manifold. A hemorrhage that is venous or capillary will seldom require more than an application of cold water. If this or the alum-water should fail, astringent medicines may be administered internally. Of the anti-hemorrhagic medicaments, none has ever stood me in better purpose than a tincture of the Erigeron Canadense ; one drop to be given in a teaspoonful of water each minute. This dose seems like a very small one, but a larger administration has always ap- peared to me to do harm rather than good. Opium and lead I have used with much satisfaction, one grain of the former to two of the latter ; three or four of such pills may be administered at intervals of from one to two hours each, if found necessary. (See Hemor- rhage, p. 423.) SHOCK. Depression generally attends, to a greater or less extent, the recep- tion of all wounds. Surgeons divide shock into primary and sec- ondary, or that which is immediate upon the reception of the injury, and that which does not exhibit itself until some later period. Shock is prostration : this may be simply of a nervous nature, implying functional disturbance; or it may be organic, implying injury of some vital part; it may, again, have the twofold relation. In my own experience I have found few things more important to observe than the differences between real and apparent shock. One WOUNDS OF MOUTH AND ASSOCIATE PARTS. 601 person, heavy and lymphatic in temperament, shall receive an in- jury mortal in its character, and yet, as the immediate or primary shock is concerned, afford less evidence of such injury than another of nervous temperament who may suddenly be called to look upon his wound. Mistakes, in such conditions, have very frequently re- sulted fatally to the persons most concerned. An article in the val- uable work* of Prof H. H. Smith, of the University of Pennsyl- vania, so tersely considers this important matter that I am sure no language could give it better expression. f * Principles and Practice of Surgery, by Henry H. Smith, M.D., etc. f " In the normal or healthy condition of the body," says Professor Smith, " each function is so well and accurately performed as to pass unnoticed by an ordinary observer. The moment attention is called by marked inconve- nience, to any part, that moment its healthy action is changed, the duration of the disordered action varying greatly. When only interrupted for a lim- ited period, the function may be again performed without any appreciable alteration ; but when the interruption is of some hours' duration, the pre- servative action of life may be so impaired as to result more or less quickly in death. " When any injury of a part is of sufficient' magnitude to produce a marked derangement in the function of the local nerves, reflex action may induce such a depression of the general powers of life as will result in the state tech- nically designated as Prosiration or Collapse. This depressed condition is especially noticeable in the disturbance of the ganglionic system and its effects on the circulatory apparatus, and is shown either immediately or some hours or even days after the receipt of the injury. When apparent within a short time after the injurj', the condition is designated as />wmec?ja^e or Primary Shock; but when not developed until several hours or days subsequently, it is known as Insidious or Secondary Shock. In both there is a common feature of depression, the degree of which depends on the violence and extent of the injury, or the character and position of the part injured. " In the lighter forms of primary shock the patient trembles, is pale, faint, and with an anxious countenance ; and much the same symptoms are said by Longmore* ' to be witnessed in the horse, mortally hit, no less than in his rider ; the graver the injury, the graver and more persistent is the shock.' In marked cases the pulse is small and feeble or fluttering ; the respiration some- what oppressed and sighing ; the skin pale and moist, with cold perspiration ; while nausea, vomiting, and hiccough are also seen, and in some cases there are often well-marked convulsions. The disorder of the nervous system varies greatly, and is sometimes rather the result of mental than of corporeal action, as in a pistol-shot in an extremity not involving important parts, but in which the patient's mind, having been impressed with the danger to which he was exposed, continues for some time subsequently to influence his corporeal func- * On Gunshot Wounds, Phila. edit., p. 45. 602 ORAL DISEASES AND SURGERY. Virus. — If a rabid dog, or other animal, bite the part we are con- sidering, or any part, — if a poisonous serpent strike its fang, or even tions. The violence of the symptoms of primary shock, in connection with moderate injuries, will depend often on the temperament of the patient, and his mental condition at the time. If excited by passion, quite severe injuries will often pass unnoticed, while in cool blood the very idea of a simple opera- tion will suffice, in some persons, to produce nervous prostration of a marked character, so much so as readily to induce syncope. In gunshot wounds of the lower extremities, and in severe railroad-injuries, and extensive burns, the symptoms of shock are usually most marked. In these cases the patient sometimes loses his consciousness entirely, and becomes faint, exhibiting great mental disquietude, with absence of thought, and giving foolish answers, or incoherent mutterings. The skin is covered by a cold sweat, and is pale and flabb}' ; the muscles are all relaxed ; the arm, if raised, drops as if paralyzed ; the sphincters of the bladder and anus permit the escape of urine and feces, and of this the patient is unconscious. Kespiration is much disordered, and barely perceptible ; the pulse hardly to be felt ; the action of the heart feeble, or sometimes so faint as only to be heard by applying the ear to the chest ; the eyes have a vacant expression ; the eyelids when raised remain open from want of action in the orbicularis palpebrarum; the jaw drops, and the hear- ing is temporarily lost, or is stimulated only by loud noises — the patient re- maining in this semi-dead condition for a period which varies greatly, as from a few minutes to hours, according to the extent of the shock. In the milder forms, with sufficient consciousness remaining, there is only a mental commotion, so as to permit easj' reassurance; but in the more marked degree this is often difficult, death sometimes supervening without reaction, though most frequently a certain amount of reaction is established and consciousness returns, or prostration again supervenes and the patient dies. When a limb is shot or torn away, or the body badly scalded, the local paralysis induced by the injury apparently prevents its immediate perception by the brain, and in numerous instances the patient has been ignorant of the loss of a limb until his attention was called to it. But as soon as the brain becomes cognizant of the injury, and the stage of depression or shock sets in, these apparently dis- tant local injuries are attended by the symptoms just enumerated, though they are seen less quicltly than when the injury involves the trunk or head. "When the symptoms of shock are marked, serious internal injury may be diagnosed even though not apparent at the moment. In most cases of marked shock the power of deglutition is more or less impaired for the time, while even in the milder instances the patient experiences such difficulty in swal- lowing as will cause, when the-attempt is made, the sudden spasmodic effort designated as a 'gulp,' or the portion partially swallowed is ejected with symptoms of strangulation, often evidently of a hysterical character. When consciousness is not so much impaired, the patient may be able to control the pharyngeal muscles, yet those of the extremities will be so imperfectly regu- lated as to cause the limbs to tremble as if with fright, or as if exhausted by violent exercise. WOUNDS OF MOUTH AND ASSOCIATE PARTS. 603 if the loose kiss of the chancrous lip inoculate, — a first indication is to get clear of the poison. How? It is now very generally ac- " Duration. — The duration of the primary shock is very varied. In mild cases it disappears rapidly, the patient quickly recovering ; the depression or the disposition to syncope passing away and leaving him feeble in his cir- culation as well as in his general strength. But in more marked cases, as in the crushing of a limb by a railroad-train, or by machinery, or a round shot, the collapse lasts for several hours, when, the powers of life rallying, 7-eaction occurs, and there is a renewal of the ordinary functions of the nervous system, noted in the circulation, which now tends to excessive action as much above the healthy standard as the depression was below it. " This reaction after the shock of injury, if not regulated by appropriate treatment, frequently creates a hyper semia or congestion of the blood-vessels, and soon develops inflammation and traumatic fever. To prevent this, and keep the reaction from exceeding its proper bounds, and yet raise the flagging powers of life, is the important indication to be accomplished in the treat- ment. "Treatment of Primary Shock. — In mild cases of shock, a few encour- aging words, a mouthful of water, or wine and water, with judicious expla- nations of the limited extent of the injury, will often suffice ; but in marked cases, when the patient's consciousness is impaired, and his powers of deglu- tition are temporarily paralyzed or much weakened, our means of reviving the action of the system must at first be limited to such remedies as can be ap- plied without being introduced into the mouth. The best plan of treatment is, therefore, to dash cold water on the head and face ; to excite artificial respiration by gently and quickly compressing the costal cartilages, or by the ' Eeady Method' of Marshall Hall ; by applying stimulating vapors, as strong ammonia, to the nostrils ; by exciting the nerves of the skin by sinapisms applied especially to the epigastric and cardiac regions, and to the extremi- ties; by applying heat to the surface of the body through hot bricks, bottles of hot water, etc., and by rousing the dormant action of the sympathetic nerves, through the bowels, by administering stimulating enemata, as oleum terebinthinse, infusion of capsicum, etc., sufficiently diluted with water or mucilage to prevent the development of rectal infiammation. About gij of ol. terebinthinffi in a pint of soap-suds or salt water usually suffices. "When by the continued use of these remedies the patient regains suffi- cient consciousness to be able to swallow, or when the depression has not gone so far as that just alluded to, stimulants may be cautiously introduced into the stomach. Of these, such should be selected as are not likely to induce congestion of the cerebral vessels ; hence ten or fifteen drops of the aromatic spirits of ammonia in a little water, repeated every ten or twenty minutes, answers better than alcoholic liquors, unless the latter are given in moderate quantities, and their intoxicating tendency oarefully guarded against. "As the pulse begins to respond to these measures, the use of both external and internal stimulants should be omitted, the natural tendency being to a reaction that must be restricted to proper limits. Should the pulse become 604 ORAL DISEASES AND SURGERY. cepted that the immediate application of solid nitrate of silver to the parts wounded will neutralize these poisons, or that, at any rate, it full, hard, and frequent, so as to indicate febrile reaction, cold drinks, cold sponging, saline cathartics, and arterial sedatives, such as five drops of the tincture of veratrum viride every hour, may be necessary, — the powerful action of the latter remedy requiring its cautious administration, so as to repress but not depress too much the action of the circulation. The strong tincture of aconite root, in doses of two drops, or of tincture of digitalis, in the dose of ten drops every two hours, for a few hours, may also be advanta- geously used, if carefully watched and omitted as soon as the force and fre- quency of the pulse indicate their sedative action. By judicious attention to the proper action of the circulation in these cases, carefully stimulating the patient when in the collapsed or depressed condition, and inducing sedation when the reaction becomes excessive, patients may be rallied from the shock of injury and subsequently treated as demanded by the peculiar nature of the case. In that mild degree of shock, sometimes seen in patients who have been shot by a bullet in the extremities, or struck on the testicles or in the pit of the stomach, which is characterized by faintness, trembling, and men- tal anxiety, a little cold water, or wine and water, with a few wqrds of hope as to the result of the injury, often suffices. " In many severe injuries, and especially in those which involve the main trunks of large nerves, or the spinal cord, or a great extent of the surface of the body, there is sometimes noted, at varying periods after the reception of the injury, a train of symptoms of a marked character, that are very justly spoken of as those of the secondary or insidious shock of injury. ^^ Symptoms. — The symptoms of insidious shock are often so masked as to escape the attention of an inexperienced observer until they are so far devel- oped as to render it difficult to rally the forces of the patient. Thus, when a limb has been torn off by a cannon-ball, or in a rolling-mill or a thrashing- machine, or by a railroad-train, the patient not unfrequently appears to be almost unconscious of the severity of his injury, the local paralysis being so perfect as to prevent the excruciating suffering that such an injury would otherwise create. In the case of a railroad-accident, by the collision of opposing trains on one of our railroads, I saw a young man who had his arm cut off near the shoulder-joint, with so little suffering as to be unaware of the extent of the injury till his clothing was removed. By great care he subse- quently recovered. " In numerous instances in the experience of all surgeons, such patients have presented the following symptoms: immediately after the injury they are remarkablj' cool, self-possessed, and as if endowed with indomitable fortitude ; the pulse is often barely accelerated ; the respiration quiet and natural ; the skin pleasantly warm ; the mind clear, though perhaps a little torpid, but apparently with perfect consciousness. In some cases patients have been known to walk or ride some distance, evidently unconscious of injury, till suddenly faintness supervenes, and they fall to the ground, and die in the course of an hour, more or less. In other cases, where the external wound WOUNDS OF MOUTH AND ASSOCIATE PARTS. 605 will so alter the condition of the wounded part as to slough off the offending agent and prevent its absorption. If an escharotic is not or injurj' is more evident, they will give directions for their removal, arrange their bed, business, etc., reply to questions rationally, and with great compo- sure ; yet, as has been well described by the late Dr. George McClellan,* they will present a countenance that is altogether unnatural, having 'an in- quiring, anxious look about the forehead, eyes, and upper portions of the face, while all about the mouth is smiling and composed.' In addition to which, ' they look with a stare of alarm and suspicion at the surgeon when his atten- tion is called to them.' " After this period of treacherous calmness has existed from three to eighteen hours, the expression suddenly changes ; the lips become livid or deadly pale; the blood leaves the surface of the body ; the pulse flutters and becomes too rapid to count; the respiration is short and panting ; a great sense of oppres- sion distresses the patient, and he sinks slowly, as if suffocated, or dies as if struck by lightning. In these cases the foundations of life are undermined, and the paralysis, which was at first limited to the part injured, suddenly extends to the nervous centres, and life is arrested by the want of proper nervous force. ^^ Prognosis. — The prognosis in cases of severe injury, in which the patient is thus unconscious of suff"ering, cannot be too guarded, the patient not being out of danger from insidious shock until after the lapse of forty-eight hours of perfect tranquillity. In the majority of such cases, when secondary shock supervenes, death ensues. " Treatment. — The treatment of secondary or insidious shock should be chiefly prophylactic, special attention being given to the preservation of the powers of the nervous system by the administration of food and stimulants, while all muscular action on the part of the patient should be carefully guarded against. " In many cases it will be useful to give milk-punch, beef-tea, quinine, car- bonate of ammonia, chalybeates, etc., as often as possible, until some evidence is shown of their effect upon the circulation. Then, while the patient is strictly confined to the recumbent position, stimulating frictions should be made along the spine, cold applied to the head if it becomes hot, pediluvia or hot bottles applied to the feet if cold, and access given to a sufl&cient amount of fresh air in the chamber to favor active respiration, while the patient is at the same time kept warmly covered up in bed. By such means the occurrence of secondary shock may be prevented ; but should it supervene, nothing but powerful stimulants to the spine, or the administration of ether, brandy, cap- sicum, etc., with the free use of beef-essence, atfords a hope of checking the rapid prostration that, if not watched, will carry off" the patient. In every case of serious laceration of a limb, opening a large joint, tearing nerves, etc., cautious watching of the pulse can alone guard against the development of insidious shock. If the patient is disposed to sleep, let the pulse be noted, and * Principles and Practice of Surgery, p. IS. Phila., 1848. Edited by Dr. Jno. II. B. McClellan. 606 ORAL DISEASES AND SURGERY. at hand (and this, at the moment, would be not unlikely), such a wound may be cut away. Suction is also an admirable prophylactic (not as the chancre inoculation is concerned: there would be here no immediate hurry) for most poisonous introductions. The danger to the person sucking such a wound would be very trifling; any danger at all depending on a casual abrasion that might at the time be present about the mouth or lips. Excision of bitten parts is frequently practiced. I recall an occasion, several years ago, where an enraged rattlesnake escaped from an experimenter, strik- ing its fangs into a colored assistant standing by. Without a moment's hesitation, the gentleman excised the part: no harm ever came of the matter. Tiding a patient over the depression of rattle- snake-poison by the stimulus and speciiic effects of whisky has let him be awakened every hour to take nourishment, if the pulse begins to flag. As the symptoms of shock are usually the result of serious and extended injury, the question of the propriety of operating for the relief of the injured part will often arise. Unless in the case of the laceration of blood-vessels from which the blood oozes, the opinion of most surgeons is adverse to the propriety of operating until reaction is fully established ; and since uncon- sciousness can be readily induced by the use of anesthetics, the supposed ad- vantages derivable from amputating a limb while the patient was unconscious of the injury are generally regarded as evidence of a want of judgment on the part of the operator. How soon after a reaction an amputation should be performed, will depend on circumstances, and be again alluded to -when speak- ing of the advantages of primary over secondary amputations. " Occasionally it happens that, after reaction is established and traumatic fever supervenes, the patient becomes delirious, or traumatic delirium or wandering, without fever, is met with. If this delirium is an attendant on the febrile condition, sedatives, cooling applications, and the judicious use of opiates, with antiphlogistic remedies, as antimony, arterial sedatives, and such others as are adapted to inflammatory fever, will be required ; in other cases opiates are mainly sufficient. Should delirium tremens supervene, the usual treatment, as described in treatises on the practice of medicine, with great attention to the seat of injury, will be requisite. Among high livers or in the intemperate, a comparatively slight injury will often induce an attack of delirium tremens, requiring opiates and stimulants to counteract it, or, if the pulse is exceedingly frequent without prostration, the administration of large doses of the tincture of digitalis or vcratrum viride. In delirium tremens supervening on pistol' wounds, in many of our volunteer soldiers in camp for the first time and deprived of their habitual drams, I have seen marked benefit derived from the administration of half an ounce of the tinc- ture of digitalis every four hours until three doses are taken, this apparently heroic treatment sometimes inducing a perfect cure in thirty-six hours. As the dose advised is very large, the pulse should be cautiously watched before it is repeated." WOUNDS OF MOUTH AND ASSOCIATE PABTS. 607 received so many confirmations as to have become a matter of common knowledge. In my own practice I have had on several occasions to excise poison wounds, and all have been successful. Without exception, however, the wounds excised had been received through some intervening substance, and such substances may have prevented the introduction of any poison. Healing Wounds. — Primary indications met, the second ques- tion is the healing of a wound. Every wound heals by granulation. The difiFerence between a healing by first intention, as it is termed, and a healing by second intention is only a difference in degree. An incised wound, delicately and accurately approximated, heals with so little new inter-tissue that Mr. Paget mentions cases where no line of difference was discernible even under the microscope. A healing by second intention, so called, may require so much material to fill up a gap that the new or cicatricial tissue is observable at a great distance, as is frequently witnessed in scars from burns. An indication, then, of the utmost importance to be met in wounds about the face, is the avoidance of a necessity for new tissue. To accomplish this, every wound is to have its parts as nearly and as neatly approximated as possible, and the associated vascularity controlled. How wounds are best approximated is a matter which is always eliciting discussion. The common methods are by stitches, plasters, and compresses. An incised wound, of limited extent, about the cheek, seldom needs more than that a strip of adhesive plaster shall be thrown across it. If such a wound occupies the position of the lips, and shall have made a complete separation, adhesive plaster will not, perhaps, be found sufficient for the purpose. To insure the least scar, a stitch may be used to approximate the free edges, and increased support given by placing' two lateral compresses at the sides of the wound, approximating these with a turn of the circular bandage ; or it may be found that, after the stitch, the adhesive strips will answer the purpose. Pins, with a figure-of-8 turn about them, make a very nice, reliable, and accurate adaptation, and, if not kept in too long, leave very little scar. A mode of approximation, which will be found very satisfactory, consists in using a suture of silver wire, and bringing the edges of the wound together, as directed in cleft palate. An objection, how- ever, it must be admitted, to all pins and stitches, lies in the fact of new wounds being made, — an irritation being begotten by the pres- ence of the foreign body, which is very apt to provoke more or less 608 ORAL DISEASES AND SURGERY. suppuration, thus making other scars, as is witnessed so frequently in operations performed for hare-lip ; therefore it may be set forth as the best practice, that any means which breaks the flesh should be avoided, if any other may be made to answer. Silver or lead wire is preferred to the waxed silk only from the fact that these metallic agents seem to irritate less, and are, therefore, not so likely to make points of suppuration, and consequently scars. When pins or stitches are used, they are to be left in place only so long as is absolutely necessary. This time will, of course, depend very much on circumstances. If an incised wound does as well as it may, twenty to seventy hours will usually be found sufficient for the union, while instances enough exist where, in this time, the pro- cess of repair seems scarcely to have commenced. A very good way to obtain information is to sponge off the wound, and to be instructed by the line of approximation : if this continues to show its incised nature, the pins are not to be disturbed ; if, on the contrary, it is a fleshy line of comparative solidity, the pins may be removed, — the parts will hold. The withdrawal of a pin or ligature is a matter demanding delicacy of manipulation. It is frequently, and indeed generally, the case, that more or less blood-rust collects upon a pin, making the removal a matter of such difficulty that, unless the precaution be taken to scrape away such rust before making the attempt, a disturbance of the cicatrix is almost inevitable. In the withdrawal of a pin, an important matter is the rotation of it ; such rotation facilitates the removal wonderfully. Metallic ligatures are generally disturb- ing ; the proper plan to take them away is to cut the wire at the side of the spot or knot opposite to that on which it seems desirable to withdraw it ; the end is then to be carefully straightened, so as to place it on a line with the part in the wound ; support is to be given the cicatrix by a finger applied on either side, when, with a rotatory movement, the wire is to be drawn away. In the use of the pin and figure-of-8, a very excellent plan is, on the removal of the pin, to allow the blood-matted silk to remain glued to the wound ; it serves to hold the parts together, and is entirely void of any offense as a source of irritation. When plasters are used, it is a necessity to have all hairs shaved away and the parts perfectly dry. The ordinary adhesive kept on sale by every druggist, composed of resin and lead plaster, is per- haps open to as little objection as any. It is to be applied in strips of convenient length and breadth, and rendered adhesive by holding, WOUNDS OF MOUTH AND ASSOCIATE FARTS 609 for a moment, the back of the strip over a vessel of hot water. There are skins, however, which this plaster irritates and inflames ; when cases of the kind are encountered, it is well to employ the isinglass plaster. An objection to this plaster is its tendency to curl and roll up. It is applied by moistening the glazed surface with water. In the use of plasters, it is a good rule to allow a space between each strip: this not only keeps the wound exposed to observation, but permits of easy drainage. The only exception to this rule is found in small cuts where it is thought desirable to use collodion. This mixture of gun-cotton and ether is applied either directly over a cut — first nicely approximating the edges, and holding the parts together until the ether has evaporated — or indirectly through the agency of saturated slips of gauze or other convenient material. Tbe removal of a plaster is to be effected by drawing the strip from either side toward the wound ; such a removal being accom- plished without any strain upon the cicatrix, the line of union being, of course, supported by the thumb and forefinger of the other hand. If a wound seems to be doing well under plaster, there need be no special haste in its removal. It is usually the case, however, that such a dressing will not continue to do service longer than two or three days. In simple incised injuries, this is generally all that is required, but in lacerated wounds, dressings are demanded an in- definite length of time, and require continued renewal. In reapply- ing a dressing of adhesive strips, a good plan is to displace and replace one at a time. Complicated Wounds. — The history of a few cases may, perhaps, best serve to illustrate practice in this direction. Case I. — Little girl, of remarkably perfect temperament, — tem- peramentless, it might be said, — about four years of age, brought into the office with quite a gash in the lower lip, and the six anterior teeth knocked directly back; considerable hemorrhage. Treatment. — Checked the hemorrhage, and cleaned the parts by the free use of cold water applied through the syringe ; pushed the teeth back into their unfractured alveoli, and retained them in place by laying a delicate roller over them, fixing it beneath the chin. A single stitch of waxed silk was placed in the wound of the lip. The case was dismissed for the day, with directions to keep the parts refrigerated through a continuous application of cold water. Second day. Same treatment continued, the band over the teeth being replaced by a fresh one. Third day. Wound in the lip healed sufficiently to remove the 39 610 ORAL DISEASES AND SURGERY. ligature. Teeth somewhat tightened ; very little inflammation ; continued the bandage, but left off the application of the water. Fourth day. Removed the bandage. Teeth very sore, but doing well, and quite fast. Eighth day. Patient dismissed ; some soreness still in the teeth, but needing only time to bring them to full health. This case was seen three months after the accident ; there was no discoloration of the teeth, and not the slightest evidence that any harm had been done them. Case II. — Child six years of age. Four front inferior teeth knocked loose by a blow from a ball ; some contusion of the lip, but no break in the continuity ; very little bleeding. Treatvient. — Removed the injured teeth ; absorption having pro- gressed to a considerable extent, applied to the lips dressing of cold water ; case well enough to dismiss next day. Ca.se III. — Little boy, five years of age, fell upon a curbstone, fractuting the superior alveolar process. Examination revealed six teeth movable in mass, the fracture extending from tuberosity of right side to canine fossa of left. The accident occurred nine hours bel'ore recourse to treatment. Condition. — Child feverish and restless; pulse much excited; soft parts about the seat of fracture considerably swollen, and so tender as to cause the little patient to scream when the parts were touched. Treatment. — A Seidlitz powder; hot pediluvia; the mouth syringed with cold water ; iced lemonade ad lib.; spts. Mindereri, 3'j, j'g S^- acetate of morphia. This was the treatment on the after- noon and night of accident. Second day. Hot pediluvia; iced lemonade, made of crushed ice; mustard poultice at back of neck. Third day. Swelling of gums very much abated. Fed the child freely with spoon food, then brought the fractured part to its place by reducing to proper articulation with lower teeth, and retaining in position by means of the yard strip modification of the Barton band- age ; a fairly comfortable day was passed. In the evening the band- age was loosened, the child again fed, the bandage tightened, patient put to bed ; a comfortable night was passed. Fourth day. Doing very well. On loosening the bandage there was very little tendency in the fractured part to move of itself; child fed with soup food ; mouth well syringed with cold water ; bandage reapplied. Patient played about the room most of the day, taking WOUNDS OF MOUTH AND ASSOCIATE PARTS. 611 lemonade and rice-gruel very frequently, by placing the fluid within the lips and sucking it between the teeth. From fifth to tenth day did little more than continue the treatment of the fourth. Eleventh day. Removed the bandage. Fracture fairly solid ; able to hold of itself; liquid food continued; no other treatment. Fifteenth day. Patient began to eat solid food ; passing on, with- out further treatment, to a good cure. Case IV. — Little girl, three years of age, markedly scrofulous; lip cut through ; fracture of process of central, lateral incisor, and cuspid teeth of left side inferior maxilla ; cutting edges of teeth thrown backward. Treatment. — The wound in the lip being quite extensive, a hare- lip pin was inserted, and the parts pushed together and held with a figure-of-8. The fractured process was restored to position, and retained by tying the one end of a strand of waxed floss silk around the last molar tooth of the injured side, bringing it forward, passing it between the first molar and cuspis of the fractured part, back of the three teeth of the broken process, then out between the central incisors, and back to the first molar, where it was tied. This liga- ture supported the part in its place very well. The ferrated elixir of bark, in doses of twenty-five drops, directed three times a day. Second day. Wound in the lip doing tolerably well ; seat of frac- ture looking puffy and asthenic. Yery weak solution of compound tincture of capsicum ordered to be thrown, ter die, over the part. Third day. Looking worse ; ligatures cutting into the gums ; patient refusing solid or soft food ; took away the ligature ; tempted the appetite with ice-cream and jellies ; scarified the puffy gum. Fourth day. Matter oozing from about seat of fracture ; etherized the child ; dissected down to the fractured piece, and removed it. Sixth day. Very much improved; wound healing fairly; con- tinued to syringe with the dilute capsicum comp. Eighth day. Case well enough to be dismissed. The pin in the lip had been removed on the third day. The wound gaped some little ; but the removal was a necessity, on account of irritation produced by its presence ; support was given by an adhesive strip, after the taking away of the pin, and the part stimulated with capsicum, under which it healed very rapidly. Case V. — M. L., an iceman, aged perhaps thirty-five, brought into the office immediately after having been kicked on the mouth by a vicious mule. Patient very pale and faint. Examination revealed 612 ORAL DISEASES AND SURGERY. comminuted fractures of the alveolar process of both jaws, with the teeth knocked into every position. Treatment. — First, stimulation with a little brandy. The patient revived. Incisions on either side of the teeth were made down to the bone, and some eight pieces removed, with the teeth associated. No hemorrhage of consequence attended the operation, and in the course of three or four days the man was going about his business, — no treatment, outside of the free use of cold water, having been indicated or employed. Case VI. — C. H., struck over the angle of the jaw by a minie- ball, which plowed across the face, completely dividing the cheek, and grooving the right nasal ala. A first treatment employed on the field, where the injury was received, consisted in associating the severed parts with a series of interrupted sutures, and the application of a poorly adapted bandage. In this condition the patient was sent several days' journey, to a hospital in which I happened at the time to be employed. My first observation of the case exhibited an im- mense wound, stitches all torn out ; superior maxillary bone exposed, with groove cut into it ; suppuration most profuse ; patient ex- hausted, irritable, and feverish. Treatment. — The weather being oppressively hot, a large basin of water was brought, in which the head and face were thoroughly, yet tenderly, washed. The matted hair was combed out and arranged. This refreshed him very much. Examination of the wound was commenced. On the groove in the bone was found no splinter, nor other indication adverse to the direct and immediate overlying of it by the soft parts. Attention to the line of wound in the soft part exhibited that the slough, which must necessarily have ensued from the passage of the ball, had been completed, and that a process of repair was attempting to inaugurate itself. Indications thus being rendered very plain, the whole of the cut and suppurating surface was slightly stimulated by an application of dilute tincture of iodine, and then carefully moulded into place and approximated. The main- tenance of this apposition was accomplished by fitting a compress to the cheek, and also below the wound, and with a bandage, carefully lifting and supporting it; no stitches, pins, or plasters being em- ployed. The success was perfect, the whole line of the wound being exposed, permitting the fullest and most frequent examination. In ten weeks the parts had united so firmly as to allow of the removal of the compress and bandage. The only medication employed con- sisted in the administration of an occasional Seidlitz powder, and a WOUNDS OF MOUTH AND ASSOCIATE PARTS. 613 daily glass of porter, with repeated applications to the wound of the dilute iodine, one part of the officinal tincture to four parts water. Case VII. — Little girl fell over the shafts of a wagon, cutting, in some unappreciated way, her tongue directly in twain, for the dis- tance of an inch down the middle. Hemorrhage was very profuse, requiring the ligature of a vessel. This wound was united by two stitches of the interrupted suture passed deep in the substance of the organ ; cold water directed to be held in the mouth quite continu- ously, for the first day ; patient fed on ice-cream and jelly. Third day, ■ stitches removed, union complete, ligature loosened, and was pulled away on the seventh day. Case VIII. — Brigadier-General D., standing upon an outlook, was struck by a sharpshooter, the ball passing through the right ramus of the lower jaw, shattering the bone, passing forward across and through the tongue, emerging from and splintering the body of the bone on the left side. The treatment pursued upon the field had been to check an alarming hemorrhage from the region of entrance of the ball, by stuffing the wound with charpie saturated with Monsel's solution of iron, throwing a bandage over it, and hurrying the patient to the hospital. Condition on enti^ayice. — Patient arrived, and was put under my care about eleven o'clock at night; complained, by writing on a slate, of great thirst, with entire inability to swallow, and of the painful eflfort it required to breathe ; had not been able to drink since the accident, which happened two days before. Treatment. — Examination revealed marked displacement of the middle piece of the fractured bone. This, with the tongue being pulled backward by the hyoid attachment of the genio-hyoglossal muscles, sufficed to explain part of the difficulty in respiration and deglutition. The tongue itself, however, was much swollen, and had a ball wound through its base. Two primary indications thus presented : to keep the body of the bone and tongue in position, and to reduce the swelling in the tongue. The external wounds were for secondary consideration : the patient had to breathe and had to be nourished. The mouth was first well syringed with cold water, which was found most refreshing ; the bone was then brought forward, the inferior teeth in front of the superior ; the jaws were closed, and held together by a delicate bandage, the middle fragment being thus retained even in front of its natural position, and pulling the tongue forward with it. This accomplished, the patient was propped up in an arm-chair, and his feet immersed in hot water, the 614 ORAL DISEASES AND SURGERY. application being continued until every vein and capillary was en- gorged. A local abstraction of blood was not thought desirable, as he had already lost as much as he could well spare. The result of such a primary treatment was, that in half an hour the patient was able to swallow spoonfuls of lemonade. This drink, cold as it could be made, was continued during most of the night, serving by its refreshment to give much comfort, and by its refrigeration to abate the vascular excitement. About four o'clock in the morning the patient fell into a disturbed sleep, which continued until eight. At nine o'clock the tongue was examined by separating the lips and looking at it through spaces which existed between the teeth ; the swelling and turgidity had very much diminished. The feet were again placed in hot water, and the blood held in the parts until a sense of faintness was experienced. This gave increased relief The patient thus being over the immediate danger, attention was directed to the state of the external injuries, and the line of passage of the ball. The wound at the external angle of the jaw was found to occupy quite a space in the parotid fossa, the ball having evidently been received as the general had turned his head to address some one behind him. It was stuffed with charpie, looking now a black and blood-infiltrated mass, and which evidently had been thrust hard and solidly into the wound, and now had swelled to double its former size, displacing the parts to a very marked extent. This plug being found firmly fixed, it was left to be removed or not, as circumstances should seem to direct, at a future time. The wound of exit was larger than might have been expected, spiculae of bone having considerably torn the parts ; from it were removed several small splinters. The probe, passed into this opening, revealed the line of the wound running through the base of the tongue obliquely across the mouth. The treatment consisted in the free use of permanganate of potash and water. The patient passed the day in a fair degree of comfort. A sudden secondary hemorrhage being the next thing to fear, it was determined on the third day to remove the plug ; this was ac- complished only after a full hour of labor, the charpie having wedged itself into every imaginable space, the removal being effected by the very free use of milk-warm water and the most gentle of traction with the. forceps and scalpel handle. The removal was attended with considerable pain, but without the loss of a single drop of blood. The relief from the sense of pressure afforded was so very great as to change the whole appearance of the patient, he now breathing and taking his beef-essence with the greatest freedom. The appear- WOUNDS OF MOUTH AND ASSOCIATE PARTS. 615 ance of the wound was really very promising, attempts at granula- tion being quite evident, while nothing especially threatening was to be observed. The day after this dressing, the patient, in opposi- tion to all advice or commands, insisted on being passed to his family in Washington. All the dangers of secondary hemorrhage were exposed and explained to him, but he seemed to be possessed of the single idea of getting to his home. At five o'clock in the afternoon he was driven to the steamer plying between Fortress Monroe and Baltimore, continued in charge of a surgeon who had been sent with him from the field. At midnight, while on the Chesapeake, the most profuse secondary hemorrhage came on, which was controlled, as best it might be, by masses of ice held continuously to the wound. The patient died during the next day at a hospital on the wharf in Baltimore, under what exact circumstances I could not learn ; most likely, however, from exhaustion. Case IX. — J. B., middle-aged man, gash, from a blow, lacerating the cheek, opening the duct of Steno. Treatment. — With a heavy-eyed needle, carried a loop from the bottom of the wound to the inside of the cheek: the silk, which was very loose, conducted the saliva into the mouth. Brought the external wound together by strips of resin plaster ; no other treat- ment required, save an occasional dressing. In a week the loop had sloughed through into the mouth, preserving completely the track for the secretion, and the process of granulation had ad- vanced almost to the stage of cure in the external wound. No after- trouble. Case X. — C. A., young gentleman, twenty years of age, deep punctured cut in the floor of the mouth just to left of middle line, made by the slipping of an elevator in the attempt to remove root of upper canine tooth. No hemorrhage, or immediate ba,d sign of any kind; patient very much frightened. Accident had occurred two days before my seeing the case ; part very sore and tender; inflam- mation limited. Treatment. — Directed arnica-water for relief of the soreness ; nothing else indicated or required ; the wound healing rapidly and kindly. Case XI. — Cut received by young lady, exposing and incising mylo-hyoid artery of left side in the groove; hemorrhage very great and persistent. Treatment. — Upright position; tinct. Erigeron as directed; strong alum solution held to the part on tufts of cotton, afterward thrown 616 ORAL DISEASES AND SURGERY. with the syringe ; ice to the part, etc. No result on the bleeding. The patient becoming affected from loss of blood, enlarged the wound, picked out the vessel with the Liston forceps, and tied it. This, of course, controlled the hemorrhage. Patient recovered. Case XII. — Mr. C. Performed operation on the cheek for a pecu- liar erectile growth ; cut well into the sub-tissue, making quite a deep wound, just as if the part had been scooped out. Treatment. — Cold-water dressing; waiting on nature to fill up wound with granulations; nothing else required, nothing done; the case progressed to a satisfactory cure, excepting a raised scar. Case XIII. — Young man, shot through the cheek ; the mouth being, at the time, fortunately open, the ball passed out, doing no further damage; no hemorrhage. Treatment. — Applied cloths wrung out of cold water, for the pur- pose of controlling vascular reaction ; nothing else done ; wound suppurated until the compressed and devitalized tissues were sloughed ; then kindly granulated, the patient being entirely well in a month. Case XIV. — Patient, young lady. In an attempt to extract the first molar tooth of right upper jaw, a flap of gum had been torn, extending around the mouth to the left second bicuspid ; this flap had been hanging loose some three hours before the patient pre- sented herself Treatment. — Cut it off, and depended on granulations from the wounded surface for the filling up ; patient comfortable next day ; entirely well in a week ; no other treatment of any kind re- quired. Case XV. — Boy, twelve years of age ; playing with powder con- tained in a bottle, it unfortunately exploded, throwing the glass and powder into his face. When first seen, an hour after the accident, the patient was in the greatest distress; the eyes were completely closed, lashes entirely destroyed, hair singed, face raw and bleeding, pulse rapid, aud very irritable. Treatment. — First, Seidlitz powder, with half-grain of opium ; second, removal of such pieces of glass as could be readily picked away with the forceps; third, cold-water dressing. In an hour the patient was fairly comfortable; at the end of which time a second half-grain of opium was administered. Second day. Face very sore, but no burning pain ; picked away several small pieces of glass and a number of powder-grains. Con- tinued cold-water dressinar. WOUNDS OF MOUTH AND ASSOCIATE PARTS. 617 Third day. Reactive inflammation evidently aborted ; water dressings dispensed with; used in place R. — Olei lini, Aquae calcis, aa q. s. With this the surface was protected from the atmosphere until it cicatrized, — a period of two weeks. During the time of cure some little attention was given to the diet, the patient for the 6rst day craving principally ice-cream, which answered very well, and served to allay a slight tendency to irritative fever which existed; the latter four days of the first week stimulating articles of food were interdicted ; after this he ate what he best liked. Case XVI. — Patient, young gentleman. Struck, while on a gunning excursion, by a buckshot, which passed through the lower lip, burying itself in the bone. Patient not seen until the next day; lip too much swollen to permit of examination. Treatment. — Cold-water dressing to the lip. Mag. sulph. ^ss internally. Third day. No diminution in swelling; slight erysipelatous blush; brushed the parts with the following combination: B. — Tineturae ferri chloridi, J'j ; Quinije sulphatis, gr. xxx ; Tineturae cinchonae, 5j. M. In one hour the blush disappeared. Fourth day. Inflammation, with the swelling, disappearing very rapidly. Sixth day. Probed the wound ; discovered the shot lying near the root of the first bicuspid tooth ; dissected away the gum from the inside, and with a very small curved gouge picked the lead away. Seventh day. Inflammation back again, confined, however, rather to the inside of the mouth; reapplied the cold-water dressing, and directed a Seidlitz powder. Eighth day. Better ; inflammation rapidly yielding ; a little pus escaping from the shot track in the bone. Tenth to thirteenth day. Track of wound in the bone suppu- rating considerably ; tinct. iodine injected. Fourteenth day. Discharge diminishing; iodine still continued. ■ Sixteenth day . Discharge entirely ceased ; patient dismissed. Case XVII. — Patrick T., laborer. While engaged in blasting 618 ORAL DISEASES AND SUBGERY. rocks, the patient was struck with great force, just below the orbit, by a flying fragment, lacerating, in a frightful manner, the soft parts of the face, breaking and knocking into the naris the left nasal bone, and severely concussing the maxillary. No hemorrhage ; heavy shock. Treatment. — The patient being a strong, plethoric man, reaction was allowed to establish itself, which it did completely only after the lapse of several hours. Cold-water dressings were, however, at once applied to the parts, every deduction being in favor of the inference of sevei'e inflammation. The accident occurred in the morning. At seven in the evening, a pine stick, whittled, to make its introduction easy, was coated over the end by dipping it in melted wax, and with this, insinuated into the nostril beneath the depressed nasal bone, it was thrust out into place, position being maintained by a tuft of wax-coated cotton, having attached to it a string for its withdrawal, being pushed up beneath the fracture. . Examination of the injured face and maxillary bone revealed con- tusion and injury to such an extent as to make it evident that the process of cure must be that of exfoliation, sloughing, and repair by granulation ; the only treatment was then the expectant, and this was met by a simple water dressing. Second day. Most decided reaction. Mag. sulph. ^ss adminis- tered in half a glass of water; water dressing, medicated with lead and laudanum. R. — Plumbi acetatis, 5'j ; Tincturse opii, ^ij ; Aquae, ^xxx. M. Cloths wet with this lotion kept constantly upon the cheek. TJiird day. Inflammation abating, but patient complaining of feeling hot and generally miserable. Lemonade ordered as a febri- fuge, to be made by expressing the juice of an ordinary lemon into a goblet, sweetening, and filling up the glass with ice broken into a coarse powder. To be allowed ad libitum. Fifth day. Wound suppurating; fever all gone; dressing changed to simple water ; waxed cotton changed in nostril, — the replacement giving much pain. From fifth to tenth day. Water dressing continued ; portion of external plate of the bone apparently dying ; periosteum evidently destroyed. WOUNDS OF MOUTH AND ASSOCIATE PARTS. 619 Eleventh day. Stimulation commenced ; parts wet three or four times a clay with the following: R. — Aluminis pulveris, 5"j J Tincturae capsici compositae, ^ss; Aquae, 5xvj. M. Fifteenth day. Granulations being thrown out from around the edges of the wound ; parts brought as closely together as possible, and retained with adhesive strips ; nasal fractux'e doing very well. Twenty-fiflh day. Wound of face entirely healed, with the ex- ception of a small place in the centre, which, when examined with the probe, discovered a sinus leading to diseased bone. Thirty-fourth day. Piece of bone presenting at the sinus ; en- larged the opening, and withdrew a sequestrum rather larger than an ordinary finger-nail. Examination with the probe, after the removal, gave the fleshy feel indicative of repair. Case dismissed on the thirty-sixth day. Case XVIII. — Young man, struck on the side of the face, in a street-brawl, with a slung-shot; face severely cut and contused; outer boundary of the antrum driven backward into the cavity, not fractured apparently, but simply bent inward. Treatment. — Cold-water dressing, — no other application for the first three days. After this, the patient being compelled to go out to his work, adhesive strips were employed; repair progressed rapidly, without a single adverse manifestation. The depressed plate of the sinus gave no trouble, soon accommodating itself to its new position ; all sense of soreness leaving it by the end of the second week. External wound cicatrized in twenty days. Case XIX. — A young man slipped while standing on a stall in a market-house ; falling forward and downward upon one of the hooks, it entered his mouth, breaking off three of his upper teeth, perfo- rated his hard palate, and passed by its point into the right nostril. Treatment. — Seen first one hour after the accident. Pain in the broken teeth unbearably severe. Examination discovered the en- gorged pulps entirely uncapped and bulging from their cavities. The probe introduced through the wound in the palate passed readily into the nares, giving little or no pain. No fracture of the bone, save a few trifling spicule about the circumference of the puncture. The roots of the broken teeth were at once extracted, and the case, for the time, left to nature. 620 ORAL DISEASES AND SURGERY. Second day. No necessity for any interference ; some soreness, but no actual pain. Tfiird day. Nothing required to be done. Fourth day. Three trifling pieces of bone discharged into the mouth. Seventh day. Wound granulating very satisfactorily. Fifteenth day. Nature unable, evidently, to quite fill up the open- ing; assisted by scarifying the circumference of the wound, and touching with tincture of iodine. Seventeenth, tiventieth, and twenty-second days. Scarified, and touched with iodine. Twenty-fourth day. Opening completely closed. Case dismissed. Case XX. — Gentleman. While striking the iron handle of a chisel in the act of opening a box, a small piece flew off from the hammer, burying itself in the malar process of superior maxillary bone. Treatment. — With probe, searched in the wound for the foreign body; found it in position as described, with very oblique track through soft parts. Introduced a sharp steel instrument, and, after some trouble, succeeded in working the pjece loose; could not, how- ever, get hold of it with forceps without such manipulation as would evidently enough contuse the parts. Introduced a director down to the body, and cut to it; removed it in this way without effort. Wound closed with two delicate sutures, and the cold-water dress- ing applied ; in three or four days the parts were entirely well, with- out the slightest suppuration having occurred, — no noticeable scar being left. Case XXI. — A little boy, Harry H., while playing with a wooden paddle which had been made for use in rendering lard, slipped, while having one end of it in the mouth, the weight of his body carrying the stick through the soft palate, making a complete separation between the veil and hard parts. This patient was first seen three days after the injury. No inflammation of consequence existing. Treatment. — Etherizing the patient, the parts were stitched to- gether with interrupted sutures of silver wire, the approximation being maintained by perforated shots clamped over the wire. Only a very limited union, however, was secured, the two most important stitches sloughing out. Oq the fourth day from the introduction of the first stitches, those which had been lost were replaced, which last, by the eighth day, also sloughed out, yielding no increase in extent of the union, but happily being associated with such extent WOUNDS OF MOUTH AND ASSOCIATE PARTS. 621 of granular face to the wound that, when the veil was pressed up- ward, it met the part from which it had been torn. An impression of the mouth was now taken in very soft wax. From this a nTodel was secured, to which model was struck a silver plate. This plate enveloped the back teeth of the upper jaw, but was cut to fit the palatine faces of the anterior. Impressions were next taken of the inferior teeth, and caps made to fit the molars. Putting next the plate and caps in place, they were attached by means of wax, and the apparatus thus associated lifted carefully from the mouth, the piece being completed by soldering the parts together. Thus pre- pared, the apparatus was put in the mouth, and the two jaws held in place by means of the Garretson bandage. In two weeks union was sufficiently firm to permit the removal of the splint. Case XXII. — Stout Irish lad, twelve years of age, shot in the face by a playmate. In this case the pistol was in the hands of a smaller boy, the muzzle being directed obliquely upward. The ball, which was a good-sized minie, struck the centre of the nose, and, as it passed upward on the line of its projection, was deflected at an angle of about eighty degrees, by an influence exerted by the nasal bones, against which it struck. This boy was first seen on the second day after the accident. No inflammation, no evidence of shock, indeed, no anything that would lead to the inference of an accident of gravity ; even the wound of entrance was scabbed over, and looked like any insignificant sore. Treatment. — Breaking away the scab, search was made for the course of the ball by means of the ordinary silver probe. As the instrument reached the nasal bones, the condition of reflection was recognized. Examining next the mouth of the patient, a solid pro- jection was observed at the line of union of the palatine plates of the maxilla and palate bones. Inferring this to be the ball, an in- cision was made through the soft parts ; this exposed, however, not the ball, but a fractured portion of bone. Eemoving this, the ball, much flattened, was found immediately above it, being wedged in the site from which it had forced the bone. The boy seemed to re- quire no treatment, and therefore received none. In no way had he a bad symptom. Case XXIII. — Michael M., car-driver. Separation from its max- illary attachment of left nasal bone. Deformity very marked; the whole nose looking as if it had been thrust upon one side of the face. Treatment. — The parts being very much inflamed, application of the lotion of lead-water and laudanum was ordered, and continued 622 ORAL DISEASES AND SURGERY. until the condition was fully combated ; two days being required to secure such a desired result. Using now the handle of an ordi- nary scalpel, the displaced bone was lifted into position, and was retained by making a flattened roll of the common adhesive plaster, — the unspread side out; this, being dipped in olive oil, was directed into place, and retained for a week by a ligature, which kept it welL in position by passing over each ear. At the end of this period the roll was withdrawn and the parts left to nature. A perfect cure resulted. Case XXIV. — From Langenbeck. Head of patient was caught between a locomotive and its tender. The eyelids were torn away from the orbit, and a deep wound ran dow^u from the inner canthus to the upper lip. A probe could be passed into the antrum: not a trace of the eyeball could be found; while in the orbit was a bluish- black pulsating mass. The nasal bones comminuted. Patient con- scious, but sleepy; pulse slow; violent pain on right side of head. A week afterward,' as head symptoms disappeared, and the extrava- sated blood had been somewhat absorbed, a closer scrutiny could be made. The eyeball was discovered to have escaped into the antrum from the orbit by a hole in the orbital margin of the upper jaw, big enough to admit the finger easily, — the axis of the eye standing vertical, the cornea downward. The fragments of bone were adjusted as well as possible, and the eyeball replaced in the orbit. It was uninjured, and vision was perfect. About ten weeks after, by two blepharoplastic operations, the eyelids were brought into tolerably good condition. They could be closed, and usually so remained, but could be opened enough to ex- pose the cornea and permit sight. The globe was, however, per- fectly immovable. About five months after the injury, ulceration and suppuration of the cornea occurred, and the globe atrophied. CHAPTER XXX. / FRACTURES OF THE MAXILLARY BONES, Fractures of the niaxillarj bones may be divided into two classes, simple and complicated. The first applies to such cases as are with- out external or associate injury, implying^a simple break in the con- tinuity of the bone. The second applies to cases associated with comminution of the bone, to external lesions, injury to vessels, to teeth, — in short, any condition which alters the fracture from one of a simple to one of a compound character. The inferior maxilla, from the exposure of its position, from its shape, and from its office, is much more liable to the accident of fracture than the superior, — the accident being commonly the result of blows, falls, kicks, etc. These fractures will, in the majority of cases, outside of gunshot injuries, be found associated with the body of the bone, the rami escaping, from the fact that a force brought to bear upon them slips the articulation more easily than it may break the bone. The weakest part of a bone would most naturally be the part to yield in a diffused blow. In most inferior maxillae this weakest point is found to be the line of the roots of the canine teetb ; hence the most frequent seat of fracture in the bone is in this line, either to the right or left, as influenced by the direction of the force. This, however, as would be inferred, applies to an unbroken dental arch: when teeth have been lost, and the process removed, the situation of this weakest part is materially altered. In gunshot injuries, acci- dents from the passage of a wheel over the jaw, or similar applica- tions of force, fractures occur, of course, at the seat of such appli- cations, and follow no rule. In the work of Prof. Hamilton on Fractures, in twenty-four recorded cases of breaks in the inferior maxillary bone, one was perpendicular through the symphysis, twelve were through the body, five through the angle. Of the twenty-four, eleven were of a double or triple character, the direction of the frac- ture being mostly oblique, both as direction aoid the face of the break are concerned. (623) 624 ORAL DISEASES AND SURGERY. It is singularly the case that most fractures of the body of the lower jaw are compound, the opening existing on the lingual aspect : this seems to be the result of the easy lacerability of the gum tissue, combined with the quick displacement inward of the fractured part. This exposure of the bone seems, in many mouths, to be of no very material consequence. In others, however, it is quite the reverse, the saliva thus allowed to come in contact with the bone degener- ating and deteriorating the tissue. Fractures from blows of the fist, or similar concentrated forces, are apt to be single ; from falls, they are apt to be multiple ; from kicks of animals, comminuted. A common cause of fracture, familiar to every dentist, is found in the extraction of teeth having large and bifurcating roots: luckily, however, such fractures are not of a seri- ous nature, generally being confined to the alveolar process, although cases are on record where such accidents have been so extensive and severe as to cost the life of the patient. Complete division in the continuity is, however, rare, very few cases having occurred. The symptoms denotive of a fracture are seldom or never obscure. There are, first, the mobility at the break, and the crepitation ; second, when the break exists in the body, there is the loss of harmony in the line of the teeth, the short fragment being pulled upward. If the fracture be multiple, irregularities will be produced in the line of the arch, and in the articulation. If the freed portion be the anterior or chin part, it will be dragged downward and backward by the action of the genio-hyoid, hyoglossus, and digastric muscles. If it be at the line of the cuspid tooth and at the upper portion of the ramus, the fragment will be displaced inward by the action of the mylo-hyoideus, upward by the action of the masseteric, and forward by the action of the pterygoidei. If the fracture be single, and beneath the attach- ment of the masseter, crepitation will be present, but little displace- ment. If the neck of the bone is broken, the body is dragged for- ward by the action of the pterygoid, crepitation and mobility will be very apparent, and much pain will attend the movements of the jaw, produced by the displacing action of the temporalis. Pain, soreness, inability to masticate, inflammatory phenomena, impediment to speaking or swallowing, associate with and charac- terize the accident. In short, the history of a fractured jaw is the history of a fracture anywhere else, allowing for difi'erences in office. Fractures of the superior maxilla are quite infrequent, and when they occur, except from extraordinary causes, demand little attention outside of that which pertains to the injury as a contusion. Of such FRACTURES OF THE MAXILLARY BONES. 625 fractures I have treated a number which surprises me, considering the rarity of the accident ; but in no instance, outside of the alveolar fractures, have I met with a displacement which required apparatus for its cure. Indeed, the cellular character of these bones, and the existence of the antra, permit of such yielding that depression of the substance of the bone commonly forms the displacement : hence the associated frequency of caries with such accidents, the vitality of the part being low^ered or destroyed. It is not, however, to be un- derstood that displacements do not occur ; the force of an injury may be great enough, as cases are on record to show, to displace the bones in mass. In Mr. Heath's work is the record of a case taken from the Chirurgical Treatise of Richard Wiseman, which is a marked example of such displacement. The patient was a lad eight years old, who had received a blow on the middle of the face so severe that he appeared at first to be dead, and afterward lay in prolonged coma. "When," says Mr. Wiseman, "I first saw the boy, he presented a strange aspect, having his face driven in, his lower jaw projecting forward. I knew not where to find any purchase, or how to make any extension. But after a time he became sensible, and was persuaded to open his mouth. I saw then that the bones of the palate were driven so far back that it was impossible to pass my fingers behind them, as I had intended; and the extension could be made in no other way. I extemporized an instrument curved at its extremity, which I engaged behind the palate, and, having car- ried it a little upward, used it to draw the bone forward, which I did without any difficulty ; but I had hardly withdrawn the instrument when the fractured portions went back again. I theu contented my- self with dressing the face with an astringent cerate. I likewise prescribed bleeding, and some hours afterward I had an instrument better constructed to reduce the large mass of displaced bone to its proper position. I had it held by the child's hand, by that of its mother or of an assistant, each for a certain time. Nothing else was done. Thus, by our united attention, the tonicity of the parts was maintained, the callus was developed, and in proportion as it became solidified the parts became stronger, the face assumed a good appear- ance, — certainly better than could have been hoped for after such marked displacement, — and the child was entirely cured." A cast in the Westminster Hospital, of a frightful deformity pro- duced by the passage of a wagon-wheel over the face of a man who fell in the street, is also alluded to. " Here the bones were com- pletely shattered, and the maxillae were torn from one another, and 40 k 626 ORAL DISEASES AND SURGEBY. death was instantaneous." A case is also recorded admitted into the same hospital in 1860, resulting from the overturning of a cab upon the face of its occupant, who at the moment was leaning out of the window to direct the driver. Here, in addition to a fracture of the lower jaw, a little to the left of the median line, the nasal bones were broken, both malars w^ere loose and separated from their attach- ments, and the left bone was fractured, as also the external angular process of the frontal bone. Though not positively ascertained, the vomer was no doubt fractured, and probably the vertical plate of the ethmoid too. The case is reported by Dr. Fyfes, in the Lancet, July 18, 1860. "It was remarkable," says this gentleman, "to observe how movable the bones of the face were. On watching the profile of the patient while he was in the act of swallowing food, the whole of the bones of the face were observed to move up and down upon the fixed part of the skull, as the different parts were brought into motion. It appeared as if the integuments only retained them in their position. It was a curious feature in the case, that notwith- standing the very extensive injury done, and the violent character of the force which caused them, not a single tooth was fractured or misplaced." This patient is reported as having made a perfect recovery. Of gunshot injuries I have had an opportunity to see some marked examples. In comminuted fractures it has been my practice to pick away such pieces as were completely detached, but to leave and mould, when feasible, all others in place. I never met with trouble from uncontrollable hemorrhage, and generally found the reparative energy sufficient to unite the comminuted parts. In Circular No. YI. of the Surgeon-General's Department, however, secondary hemorrhage is noted as the principal source of fatality in the reported cases : 1579 cases of fractures of the facial bones are reported ; and of these 891 recovered, HI died, — the terminations of 517 cases being left still unaccounted for. The following extract, copied from Mr. Heath's Essay, is from the Official Medical and Surgical History of the British Army in the Crimea: "Wounds of the face," says the report, "though pre- senting often a frightful amount of deformity, are not generally of so serious a nature as their first appearance might lead the uninitiated to expect. The reason for this, apart from the fact that the face contains no vital organ, seems obviously to be the very free supply of blood the part receives. From this cause, the fleshy structures FRACTUBES OF THE MAXILLARY BONES. 627 readily heal, and even the bones are so supplied that extensive necrosis rarely happens. The bony tissues, also, are softer than the long bones of the extremities ; and we therefore here but seldom meet v^^ith long fissures and extensive necrosis as a result of concus- sion of bone so often seen in them. This leads us to the very im- portant practical inference, not in this situation, as a rule, to remove bony fragments unless the comminution be great, or the fragments completely detached from the soft parts. Even partially detached teeth will often be found not to have lost their vitality, and, if care- fully readjusted, will become useful. There is, indeed, no great object, beyond perhaps the present comfort of the patient, to be attained in removing either fragments of bone or loosened teeth in the great majority of instances. If they die they become loose, and are readily lifted away, without trouble to the surgeon and but little pain to the patient. This observation is especially applicable to fractures of the lower jaw. Surgeons in this war have seen so many cases of badly-fractured instances of this kind unite, and that with a very small amount of deformity, that men of experience are now excessively chary of removing any portion of this boue unless it has become dead, or the fragment is so situated as to interfere consider- ably with the adjustment of the remainder, or the bone so much comminuted as to give no probable hope of its becoming consolid- ated, or so sharply angular as to threaten further injury to the soft parts or to interfere materially with their adjustment and retention in situ. In these fractures of the lower jaw, much less support and adjustment than we are in the habit of thinking advantageous in ordinary cases of fracture of it will frequently be found necessary, or even admissible. A complicated apparatus cannot be borne at first, on account of the condition of the soft parts, and a slight sup- port by a gutta-percha or Startin's wire splint, and a split bandage, is all that can be done. Any attempt at ligaturing the teeth is very generally not only useless, but injurious ; and it is surprising how the parts often, as it were, adjust themselves, with but little aid from the surgeon." The treatment of a fractured jaw involves the indications to be met, and the mode or modes of meeting them. These indications and modes must of course vary with almost every individual case. For a simple fracture of the inferior maxillary, or, indeed, as well for compound fractures, the common pasteboard or gutta-percha splint will generally be found sufiBcient and reasonably satisfactory. 628 ORAL DISEASES AND SURGERY. To make this splint, take a piece of binder's board, or gutta-percha, and cut it as designated in Fig. 230. The board thus cut is soaked in hot water until it becomes suf- ficiently softened. The fracture is then set, and the splint moulded into shape and position. To do this, it is only necessary to lay the centre of the board beneath the chin, one-half projecting; the wings are now brought up and moulded to the cheeks ; next take the pro- jecting portion and mould it around the chin and sides of the face. This makes a complete cap, accurately fitting the parts, and, when dry, is uniform and unyielding. To hold it in position, a bandage must be applied. The most simple is a modification of Barton's, which suggested itself to the author some five or six years back, and which has since been used with much satisfaction. The Barton Fig. 230. — Barton's Bandage. A. Shape of the piece of gtltta-percha for the chin. B. Tlie same moulded to the part, — the ends, 1, 1, beiog turned upward, and the sides, 2, 2, turned from before backward. bandage, so generally employed in fractures of the lower jaw, con- sists of a roller eight yards in length and from one and a half to two inches in width, — following in this latter respect the taste and idea of the operator. To apply this bandage, place the initial extremity behind the left ear ; carry it around the side of the head, over the right parietal bone ; cross to the right over the neighborhood of the fronto-parietal suture ; carry down beneath the chin ; carry up on the opposite side ; cross on the forehead ; carry around the left parietal bone, and meet the beginning of the roller at the occipital promi- nence, or a little below it ; continue the turns until the bandage is exhausted. FRACTURES OF THE MAXILLARY BONES. 629 Gibson's bandage, used in the same and similar fractures, mostly employed when the break occurs at the jij^ 231. Gibson's Band- angle, consists of three distinct turns. age. First. Place the initial extremity in front of the ear ; carry down beneath the chin ; pass up on opposite side, and meet the initial by passing over the fronto-parietal region far enough back to prevent slip- ping; repeat this turn three times. Second. Reverse in front of and a little above the ear, and make three turns around the cir- cumference of the vault. Third. End the third of these last turns at the occiput, and carry three times around the occipito-mental circumference. This is also an eight-yard roller. The modification of the Barton bandage, which I find to answer every purpose in my own practice, and which possesses the virtues of ease in application, removal, loosening and tightening, is applied as follows: Take a strip of roller material, one and one-half or two inches wide, one and one-half yards in length. Standing behind the patient, rest the chin on the centre of this strip; carry the ends up, cross on the forehead, carry around the sides of the cranium, cross again at the occiput ; carry now forward, and tie, or otherwise fix, in front of the chin. In the application of this dressing or strip, if the parts about the jaws are tender, it is better to make the termination somewhere on the side of the cranium. To effect this, it is only necessary to place the chin, when first resting the strip, nearer to one or the other of its ends. The character of this bandage is shown in Fig. 231. A second method of dressing a simple fracture, one which allows the mouth to be partially open, consists in making two plates, one to fit the upper teeth, in part, and the roof of the mouth, the other to cap a certain convenient number of the lower teeth. After setting the fracture, these plates are put in position, and attached to each other by means of a piece of wax; the attached plates are now re- moved from the mouth and soldered together. This done, the piece is replaced, and the teeth are closed into the metal sockets ; the strip bandage is next applied, and the dressing is completed. This mode of treating a fracture of the lower jaw I thought original with my- self, but have found it employed by Mr. Listen, of England, some twenty years or more back, a splint entirely similar having been 630 ORAL DISEASES AND SURGERY. constructed by Mr. Nasmyth at least five years before the idea sug- gested itself to my mind. Fig. 232. — The Author's Bandage. In ally ordinary fracture of the lower jaw, the mode of dressing described will be found to meet all indications. In coniplicated in- juries, it has been the common experience that rules are of little or no consequence ; the surgeon will find himself governed and directed by the peculiarities of each case, and will be thrown entirely upon his own judgment and ingenuity. Perhaps no better exemplification of this fact exists than was exhibited in the practice of Dr. T. B. Gunning, of New York, in the case of Secretary Seward. The ideas of Dr. Gunning are multitudinous in this direction ; and while his professional sense has prompted him to the fullest exhibit of every means he has employed, yet I am well satisfied, from what I know of the profession at large, that the arrangements are too complex to come into general use. The monograph published by this gentle- man should, however, be in the hands of every surgeon. I know of few who seem to have studied the subject with more care or who have brought to it more enthusiasm and judgment. Fig. 233 represents the inner surface of a very simple splint used by Dr. Gunning, which incloses all the teeth and part of the gum of the lower jaw. This splint, as will be seen, would be very applicable where there were teeth on either side of the fracture, where there was little tendency to vertical displacement, and where there was an absence of swelling and undue tenderness. The holes marked A are for purposes of cleanliness, being large enough to receive the point of a syringe-nozzle. When in position, the jaws are to be closed, FBAGTURES OF THE MAXILLABY BONES. 631 the plate simply resting against the upper jaw or teeth ; the strip bandage, as described, may be thrown around the jaw and head. Dr. Gunning uses this splint without fastenings, but not unfrequently finds it necessary to secure it in place by ligatures, and in some instances by screws, which are made to pass into or between the teeth. In cases of much tendency to displacement, Dr. Gunning uses a splint very similar to the one which had previously suggested itself to Mr. Nasmyth and afterward to myself, — not so good or convenient, however, I am compelled to think, as it unnecessarily covers too many teeth, and is thus made cumbersome. This second splint is shown in Fig. 234. Fig. 233. — One of Dr. Gunning's Splints. Fig. 234.— Dr. Gunning's Second Splint. To secure this splint in place, screws are used. C represents an opening left between the conjoined splints, for food, speech, etc. ; D, a channel for the saliva from the parotid gland to enter the mouth. E is a screw used in the retention of the piece. The third modification of Dr. Gunning (Fig. 235) consists in the attachment to his splint of wings of steel. This is used in cases where the teeth have been lost in either jaw. F, upper wing; G, lower wing ; H, mental band, to hold the jaw up in the splint ; I, neck-strap, to keep the band back ; K, balance-strap, to hold the cap in place. Fig. 236 is a splint devised by Dr. Gunning to answer general cases. He suggests, first, the moulding of six or eight sizes, to be kept ready for use, from which one is to be selected suitable for any particular case presenting. The wings are of malleable iron, tinned to prevent rusting, and for more ready soldering. These sizes, he thinks, would be sufficient to select from. The splint should have a handle in front, that it may be used as a cup to take the impression 632 ORAL DISEASES AND SURGERY. of the jaw, the holes being useful to allow a small probe to be passed through the wax down to the teeth, thus allowing air to enter to facilitate the removal of the impression, and, when in use as a splint, Fig. 235.— Dr. Gunning's Third Splint. Fig. 236.— Dr. Gunning's Fourth Splint. giving entrance to warm water, thrown from a syringe, to keep the parts clean. The splint should be made to fit well by bending, cutting off the edges, and rounding them off smooth. When a tooth projects so as to keep the splint from fitting, a hole may be cut to let it through, if the metal cannot be hammered out. This should all be done before taking the impression, as a well-fitted cup assists greatly in this important matter. A splint devised by Dr. Bean, of Georgia, used with decided success during the war of the rebellion, among the Confederate troops, is in its character similar in principle to that of Dr. Gunning. The interdental portion is almost precisely the same. A modifica- tion consists in the use of a mental compress. This is simply a "piece of light wood, four and a half inches in length, three-six- teenths of an inch in thickness, and one inch and a half in width in the middle, tapering to seven-eighths of an inch, and round at the ends, to each of which is attached a metallic side piece four or five inches in length and from three-quarters to one inch in width, also a shallow cup, fitting the apex of the chin. Incasing these side pieces are temporal straps, made of stout cloth, and secured by a strong cord at the base of each piece. FBACTUBES OF THE MAXILLARY BONES. 63^ " A bandage, occipito-frontal, is composed of a band passing around the head from the forehead to the occipital protuberance, and secured by a buckle, one inch to the right of the median line behind, of another strap secured to the band in front and behind, and a third, extending from the temporal buckles on either side and secured to the middle strap at the point of crossing." It is sometimes the case that from comminution, or other causes, fractures of the inferior maxilla, like fractures of other bones, fail to unite. Necrosis intervening frequently prevents such union. In treating these cases the practitioner will find each to have its special indications. If necrosis exists, the exfoliation of the sequestrum must be awaited. In the few cases where the vital forces seem at fault, they are to be stimulated and elevated. If it occurs that the ends of the fragments have become rounded, and perhaps tipped with cartilage, operative means must of necessity be resorted to, — such means varying with the circumstances. One plan, much ap- proved, is to pass through the parts a seton, composed of several strands of wire, to be removed strand by strand, as inflammation is to be modified. Or, in place of the wire, other material may be used, as silk, thread, tape, etc. Another operation consists in boring one or more holes through each of the fragments, and tying them together with sutures of wire. Resecting the ends is still another means successfully employed by many. Irritating the ends, and thus provoking the desired inflammatory action, by rubbing the fragments together, is still another plan. Attention to the circumstances of a patient suffering from ununited fracture is important. A case exhibited several years back, at the clinic of the University of Pennsylvania, by Professor Henry H. Smith, was plainly enough due to the individual having confined himself exclusively to a diet of potatoes, such diet, in this case at least, being insufficient to accomplish the repair. The case of Mr. Seward comes, in many respects, within the category of the ununiting fractures, the means to overcome which constituted the skill em- ployed, the causes here being necrosis and non-fixedness. Complications, whatever their character, are to be treated on general principles. It is impossible to direct any special course, because of such conditions being constant to no rule. Hemor- rhages, so frequently alluded to, I have never met with of any par- ticular moment. When they do occur, however, they are nearly always secondary in character, and it may be well, where possible, 634 ORAL DISEASES AND SURGERY. to treat tbera ia anticipation : for example, an injury which has lacerated the facial arterj would perhaps yield little or no hemor- rhage at the time of accident ; yet, as the process of sloughing should expose the sound part of the vessel, hemorrhage might be profuse and alarming enough. In these and corresponding cases circumstances might, in special instances, justify one in searching for the ends of the vessels and ligating them. Injuries to the teeth are to receive due attention : it is not by any means every loosened tooth that is to be removed, or every displaced one that is to be looked on as lost to usefulness. Fractures occurring about the neck of the inferior jaw are to have the displacements corrected by the application of such compresses as are found to answer the purpose, no matter how closely such applications follow any special rules, or how far they depart from them. I do not remember in the course of my professional life ever having treated two fractures precisely alike. In fractures of the superior jaw, complications are still more anomalous. Thus, I remember being compelled in one case to re- move the whole alveolar process of both superior maxillse, the result of a kick received from a mule. In this case the patient was a man broken down by drink and dissipation. I anticipated by compulsion a process which I felt sure would have resulted, but which, to have been accomplished per vias naturales, would have cost the patient weeks of suffering, and, not unlikely, life. I have seen a case of fracture of the right upper maxilla, where the alveolar process (the fractured part) hung at least a quarter of an inch below the common level. In this case the part was moulded back into its place and supported by a simple strip passing across the jaw and fixed a little beyond the fronto-parietal suture. In three days the part became self-supporting, and in two weeks the patient was eating comparatively solid food. Gunshot injuries of the face and jaw are of every conceivable variety. The surgeon does primarily, in such cases, all that he can, and rests his hopes on nature. With Hamilton, we have to remark that it is " impossible to dis- cuss in detail all the varieties of accidents to which the complicated structures of the face are exposed from balls or other missiles." Certain general rules are, however, to be observed. For instance, as suggested by this surgeon, " Missiles entering and lodging in the face ought to be extracted as speedily as possible ; and, whenever it is practicable, they should be removed through the mouth. If per- FRACTUBES OF THE MAXILLABY BONES. 635 mitted to remain, they expose to the danger of secondary hemor- rhage, and increase the chance of subsequent disfigurement. " Loose fragments of bone should be speedily replaced, unless very much detached from the flesh and periosteum, experience having proven that they unite in most cases with facility. " No piece of skin which is torn up should ever be removed unless it is absolutely dead; but it should be laid back carefully in place, and retained either by a hw delicate sutures, or by some other gentle means of support. Tight ligatures and firm straps of adhesive plaster are apt to bind the tissues and destroy their little remaining vitality. The best means of supporting a fragment of skin in place, in many cases, is to lay upon it a thin piece of lint smeared with cerate, and over this a pledget of cotton-batting, securing the whole with adhesive plaster or a roller. "As soon as the inflammation and consequent induration have completely disappeared, and not before, it will be proper to make the final anaplastic operations." An addendum to these suggestions of Dr. Hamilton is to be made by directing attention to the necessity of controlling and combating inflammation. To this end cold water is to be freely used locally, saturated cloths being renewed as the temperature is elevated ; or the water may have to be medicated, acetate of lead and laudanum generally being added. A very admirable antiphlogistic applica- tion is prepared by adding to ^xvj of water 5ij of the former and ^ij of the latter. If a patient should be robust and plethoric, it will in most cases be advisable to assist the local treatment by cathartics, — sulphate of magnesia or the ordinary Seidlitz powder being employed. Imperfectly treated fractures not unfrequently induce so much discomfort as to warrant secondary fracture. As an illustration, the following case may be cited : T. H., an employe on the Camden and Amboy Railroad, received a double fracture of the inferior jaw, by being in some way jammed between two cars while in the dis- charge of his duties, — one break being on the line separating the second and third molar teeth, the other, the line of the cuspis root of same side. A treatment resorted to failed to retain the intermediate part in place, so that in uniting the teeth lay flatwise, presenting the buccal face as an articulating surface. Deciding upon the propriety of an attempted correction, the bone was rebroken through the unsolidified callus, and the depressed por- tion, being raised into position, was retained by a silver splint, — 636 ORAL DISEASES AND SURGERY. this splint being made and applied exactly as described on page 621. As a consequence of the injury inflicted, several pieces of the callus necrosed and came away ; but the daily injection of the parts with a much-diluted compound tincture of capsicum resulted, in the course of six weeks, in such solidification of the parts in their new position as to permit the disuse of the splints, — terminating in a cure most satisfactory to all concerned. CHAPTEH XXXL DISLOCATION OF THE INFERIOR MAXILLA, The frequency of this accident, the terror which it excites, and the harm resulting when not properly cared for, give to it an impor- tance which renders a careful appreciation of it a matter of much concern. There are four forms of submaxillary displacement: complete dis- location, incomplete, bilateral, and unilateral. In the first of these, one or both condyloid processes have slipped fully out of the glen- oid fossae and rest entirely in front of the articulating eminence, as exhibited in the view, Fig. 237.— Complete Dislocation of Jaw. In the second, the condyle rests upon the interarticular fibro* cartil&ge, directly over the articulating eminence, and will remain fixed, or may fall backward or forward as directed by accident, not being retained in its position, as is frequently thought, by the coronoid process being hooked under the malar bones, but resting, as it were, upon a point, with complete balance in the muscular structures. A bilateral luxation is a displacement of both condyles, and is of somewhat more frequent occurrence than the unilateral, or displace- ment of one side. (637) 638 ORAL DISEASES AND SURGERY. The diagnosis of a luxation is an exceedingly simple matter. An open mouth, with inability to close it, the lower jaw thrust forward in a straight line, or otherwise turned to the right or left, according to the accident, indicates a luxation of bilateral or unilateral character. The exciting ca'uses of dislocation are various : yawning, vomiting, putting large bodies into the mouth, blows received upon the chin from above downward, or in front, while the mouth is open ; the extracting of teeth, or extending the jaws widely for the convenient filling of them. The first case I ever met with occurred in a middle- aged man while laughing immoderately. The predisposing cause of the accident resides in a general or special laxity of the articular connections: thus, all are acquainted with persons who without effort will dislocate a finger or a toe. I have met with instances where the operation of removing a tooth was always attended with unilateral luxation unless a mento-occi- pital sling was used. What is the condition of the parts in luxation ? By placing the finger immediately in front of the tragus of the ear when the mouth is closed, and carrying it forward along the zygoma, the surface is found to be a plane. If the finger is kept on the surface, and the mouth opened, it is felt to drop into a fossa. This fossa is the glen- oid ; the concave rim above is the border of the cavity ; the rounded prominence below is the condyle of the lower jaw. Placing the jaw of the cadaver in this position, and dissecting down to the articulation, the condyle is found slipped forward, resting upon the interarticular fibro-cartilage ; the fossa has been partially vacated, and the bone rests against the articulating eminence. If now the condyle is dragged downward and forward over the eminence, the glenoid cavity will be found completely vacated, and, unless by manipulation, the condyle cannot be restored ; laying back now the soft parts, the cavity in front of the tragus will be found greatly increased, the finger falling into the unoccupied fossa. (An added diagnostic sign is then found to be increased depth and size of the fossa in front of the ear: this it is desirable to remember, as a fracture of the neck might simulate a luxation.) Returning to the examination, we find that to reduce the dislocation it is necessary to depress the head of the bone below the level of the articulating eminence, which, now being back of the condyle, serves to fix it in its abnormal position, as originally it was the means of its retention in place. But we pass to the con- sideration of the associate parts : the capsular ligament we do not find torn, as a rule, but stretched and elongated ; the lateral liga- DISLOCATION OF THE INFERIOR MAXILLA. 639 ments do not seem particularly interfered with, and impress us as having little influence in the matter, one way or another ; the tem- poral muscle shows itself stretched and dragged forward, but is seldom torn ; the pterygoid and masseter are relaxed. Dislocation is of more frequent occurrence in women than in men, is uncommon in children, and rare in the robust. When a disloca- tion has existed for a long time, there seems a tendency on the part of nature to make some compromise with the condition ; the jaw will gradually recover considerable of the lost motion, and I have seen cases where the patient seemed to be able to masticate his food without the least trouble. The original contour of the face I have never, however, seen entirely restored. A luxation of the lower jaw, like the luxation of any other bone, if left unreduced, even for a very few days, will be found difficult to replace ; the muscles become contracted, the condyle settles itself in its new position, lymph is effused and coagulates, and the general aspect and relations of the joint are changed. A patient, however, so situated, is not to be left unassisted, or to the relief afforded by nature. A satisfactory practice in cases of this kind, where a luxation may not be immediately reduced, is found in wedging corks between the teeth, forcing the back part of the jaws as far asunder as possible, and then with a properly directed compress and band- age approximating the anterior teeth, and at the same time forcing the lower jaw backward. This manipulation, assisted by the employ- ment of sorbefacieuts, not unfrequeutly results in the absorption of the semi-organized lymph and a consequent ability in the bone to reoccupy its original cavity. Reduction of a luxated jaw has been accomplished as long as ninety-eight days after the occurrence of the accident. Subluxations are of very common occurrence, particularly among weak women of easy means and luxurious lives. In England, at- tention was first directed to the condition by Sir Astley Cooper ; in this country it certainly has needed no particular one to discover it, — a proof, perhaps, of the physical superiority of English over Amer- ican ladies. This condition depends, evidently enough, upon a laxity of the ligaments, and perhaps more particularly on the weakness of the muscles of the part. In yawning, or not unfrequently in ordi- nary mastication, the condyle will slip forward on the articulating eminence, and, for a moment, the mouth cannot be closed, requiring, in many cases, the assistance of the hand to effect it. Depending on weakness, a permanent cure is only to be looked for as a higher and 640 ORAL DISEASES AND SURGERY. stauncher vitality is secured. Tlius, such a tendency and condition are to be treated by cold bathing, tonic medication, exercise, etc. In the case of a lady liable to such luxation, and who was made very nervous by its occurrence, the accident was entirely guarded against by the patient wearing the occipito-mental caps and bands. I was once consulted by a lady who was awakened almost every night by the peculiar and unbearable pain attendant on such slipping of the condyle during the relaxation of sleep. Dislocations associated with fracture are, happily, of very rare oc- currence. I myself have never seen a case, unless, indeed, it existed in association with certain gunshot wounds, when an appreciation of the condition, if existing, would have been of very little moment. Delamotte records a case where, in the person of a girl, double lux- ation existed with fracture of the body of the bone. Another is recorded by Roberts, where the body was broken in front of the right ramus, and the condyle dislocated outward. A third case (Heath) is reported in the Dublin Medical Gazette, and " occurred in a boy of ■ eight, who suffered a fracture at the symphysis, with dislocation of the left condyle upward and backward. There was bleeding from the ear, and the chin was much retracted and turned to the left; the mouth was open, but could be closed, and it was then observed that the lower molars overlapped the upper, but that the lower incisors were at least one inch behind the upper. Reduction was easily effected, and the case did well." Luxations are sometimes congenital. The first case of this kind was noticed by Mr. Robert Smith, of Dublin, who gives with mi- nuteness the results of his dissection. The patient, an idiot from infancy, died at the age of thirty -eight. The luxation existed on the right side, which was remarkably deformed, having a singularly hol- low appearance, which strikingly contrasted with that of the sound one, which was unusually full and plump. The extremity of the finger could be readily pressed between the posterior margin of the jaw and the auditory canal, owing, as was found on dissection, to the absence of the condyle of the bone, which was, in fact, greatly atrophied nearly as far forward as the symphysis. There was no interarticular cartilage or distinct capsular ligament, and the mas- seter, pterygoid, and temporal muscles were much wasted. The temporal, malar, superior maxillary, and sphenoid bones were im- perfectly developed, and the glenoid cavity existed merely in a rudi- mentary state. Treatment of Luxation. — By referring back to Fig. 237, it will be DISLOCATION OF THE INFERIOR MAXILLA. 641 plainly evident that the reduction of a disarticulated condyle con- sists in getting it back of the eniineutia articularis. How best to do this is the question. 1st. Wrap the thumb in delicate napkins, seat the patient on a strong chair, and, standing behind him, rest his head against your person ; place now the protected thumbs upon his inferior molar teeth, and with main strength force the jaw directly downward and a little backward : the moment you have depressed the articulating face of the condyle, it will be felt to be dragged into place. The amount of force required to depress the condyle depends entirely upon the muscular tone of the individual. In some cases the reduc- tion is effected almost before you are aware of having exerted any pressure ; in others it cannot be secured without the assistance of mechanical appliances. Fig. 238. 2d. Failing to reduce a luxation standing behind a patient, reverse the position, resting the head against an assistant. 3d. Take corks, one or two, according as the luxation is single or double, force them between the wisdom-teeth of the upper and the lower jaw as firmly and fixedly as possible ; now gradually force the chin forward and upward, using either the hands, or a tourniquet applied around the head. 4th. Take a piece of wood about a foot in length, place one end upon the molar teeth of the luxated side, make a fulcrum of the molar teeth of the upper jaw of the opposite side, and elevate the end held in the hand. If the luxation is double, reduce one side at a time. In the use of this lever, I have secured the result more easily 41 642 ORAL DISEASES AND SURGERY. Fui. 239. by resting the centre of the piece of wood upon the molar teeth of the side to be reduced, carrying the end downward. I think it will be found the most satisfactory application of the power. The forceps invented by Stromeyer yields a powerful leverage. This consists of two blades so expanded at thfe extremities as to fit, as Avell as may be, the dental arches, these blades being covered with leather ; a spring between the handles throws them apart, thus closing the blades. Reduction is attempted in two ways. Intro- ducing the padded blades so that each shall rest upon its proper tooth or teeth, — the third and second molars, — the handles are grasped in the hands of the operator and gradually brought together; when the blades have thus been so far separated that it is inferred that the face of the condyle is below the level of the obstructing eminence, the jaw is to be pushed forcibly backward into its place by an assistant. Another method of using this instrument is the employment of a screw and nut which passes between the blades : a delicate wrench fits this nut, and through its instrumentality the handles are gradually screwed together, sepa- rating of course the blades. The manipulation of pushing back the jaw, Stromeyer suggests, should be efi'ected at the same moment as the sudden closing of the blades. Even better, however, than the Stro- me^'er forceps is the instrument figured on page 207. With this it is easy to secure the required de- pression, when the condyle, not unlikely, is found to slip into place of its own accord. 5th. Still another method is that known as Xelaton's. To practice this, the patient is seated upon a common chair, and the surgeon, standing behind, fixes his thumbs upon the nape of the neck, while with his fingers he pushes the jaw forward and downward by pressure exerted upon the coronoid prominences. 6th. Anaesthesia. — In recent cases the anaesthetic agents may not A'ertico-JIeulHl Sling or CiiiJ. DISLOCATION OF THE INFEBIOR MAXILLA. 643 be required, although there is seldom objection to their employment. In cases, however, of any standing, or in muscular persons, it often happens that it is impossible to succeed in the reduction without the aid of relaxing agents; while, again, the formation of adhe- sions will be found to make attempts at reduction both painful and formidable. A luxation having been reduced, it becomes necessary to give support to the parts, and insure for a time against the possibility of the mouth being too widely opened. This is most conveniently in- sured through the use of a vertico-mental sling made with elastic straps. CHAPTER XXXII. OZ^NA. The term ozsena, like the term epulis, is a somewhat indefinite one, and is to be first considered in the width of its signification. Ozsena is from the Greek 6!^rj, signifying " stench," and the term is, therefore, in reality, applicable to any ill-smelling condition. By universal consent, however, it has been restricted in its application to foul conditions about the nares and associate parts, accompanied with offensive discharge. The study of ozsena, then, it will be seen, is the study of various conditions, and may be considered under the following heads: 1. Accumulation and degeneration of the common antral secretion. 2. Degenerated pus from tooth-abscess discharging into the antrum. 3. Ulceration of mucous membrane of the antrum. 4. Deteriorated secretions from constitutional causes. 5. Caries of the osseous walls of the antrum. 6. Ulceration of the mucous membrane of the nares. 1. Caries and necrosis of the osseous boundaries of the nares. 8. Lodgment and retention of foreign bodies. 1. The first of these conditions is most frequently observed in con- nection with the ordinary cold in the head. The outlet of the antrum, it will be remembered, is by an opening about the size of a goose-quill into the middle meatus, which opening is circumscribed by mucous membrane, and which membrane, as the result of congestion, can very readily occlude this outlet ; the parts being in this condition, it may happen that the pent-up mucus degenerates and decomposes, so that, on the subsidence of the swelling, the escaping discharges present this ofi'ensive odor. To diagnose this character of ozaena, it is only necessary to connect it with the preceding inflammation, with the absence of specific conditions, and with the readiness with which it yields to- simple treatment. Of course there would have been a preliminary feeling of the sense of congestion on the part of the patient; he would have had, to express it most simply, a cold in the (6i4) OZMNA. 645 head, and this cold, with its sense of dryness and consti'iction, would have grown worse, until, with the appearance of the discharge, he would have experienced a sense of relief, — the discharge implying the passing away of the congestion and the restoration of the normal circulation and secretion. To cure this form of oztena requires very little treatment, — indeed, in most eases no treatment at all. I am in the habit, when the discharge continues longer than two or three days, of directing the sniffing up the nostril of the affected side some such combination as the following: B. — JEtheris sulphatis, ^j ; Tincturae iodinii, ^ij ; Olei juniperi, 5j- M, If this fails to check the discharge, I then employ such constitu- tional treatment as seems indicated. Patients in whom such dis- charge exists belong to one of two classes, the plethoric or the aoEemic. With the first, the treatment demanded is depletory; a dose or two of sulphate of magnesia will generally be all that is demanded ; although in a few instances I have found it necessary to deplete from the veins. With the second class — and this is by far the more numerous — we have the mucous membrane of the part falling into a condition analogous to the urethritis of chronic gonor- rhoea ; in these cases tonics are at once to be resorted to, and the common combination of iron and quinia is perhaps the best that can be prescribed : R. — Tincturas ferri chloridi, §j ; Quiniae sulphatis, 5j- M. Sig. — Fifteen drops in water every three hours. 2. Fetid discharges depending on tooth-abscesses — abscesses which discharge into the antrum — find their cure, as a rule, imme- diately on the extraction of the diseased tooth. If this should not, however, prove to be the case, then injections are to be made through the tooth alveolus. Iodine is an admirable base for all such injections. My own practice would be first to control the odor with the permanganate of potash. B. — Potassae permanganatis, 5ss — j ; . - Aquae, oviij. M. Inject as occasion requires. 646 ORAL DISEASES AND SURGERY. It would most likely be quite sufficient to use this injection three times a day. After it the following should be thrown in : B. — Tincturae iodinii, 3j ; Glycerinse, 3] ; Acidi tauuici, 5ss ; Aquae Coloniae, 5j ; Aquae destillatae, ^iij. M. Or, Or, Or, B. — Tincturae capsici compositae, ^ss; Aquae rosae, ^viij. M. B. — Argenti nitratis, gr. xxx; Aquae, o^j- ^I- B. — Vini opii, 5j ; Yinl aroniatici, 3j ; Aquae, ^\g. M. Indeed, any stimulant preparation may be resorted to ; although I incline to believe that iodine acts the most happily. 3. Ozaena from ulceration of the mucous membrane of the antrum is not, so far as my experience allows me to judge, a condition of fre- quent occurrence ; without doubt this is the case where no specific disease, as syphilis, scrofula, or scurv}', exists, so that, meeting with such ozaena, we naturally at once revert to the constitutional condition. To discover an ulcer within the antrum is a matter for diagnosis by exclusion, and thus to discover it is not at all a difficult matter. If there are no diseased teeth or teeth-roots, no nasal ulceration, no antral dropsy, no acute preliminary conditions; if the fetid matter flows most freely when the suspected antrum overlies its nasal outlet, then we ^vill generally be right in inferring an ulcer of the antrum ; but an ulcer in the antrum is not necessarily a cause of ozaena. To give this fetid odor, it must be an unhealthy ulcer, by which is meant that it teuds to degenerate its granulations, rather than to organize them. An ulcer, says Mr. Cooper, may be defined to be " a granulating surface, secreting matter;" and this is certainly true of most ulcers, particularly if we replace the term se- creting with the term making; for the matter given off is, I imagine, nothing but degenerated lymph-corpuscles, to which the parts lacked strength to give force of organization. A healthy ulcer may be seen in any accidental sore tending to rapid self-cure : there is here OZ^NA. 647 little or perhaps no matter, for the reason that every particle of the exuded lymph of repair has in it vitality sufficient for its organiza- tion. An unhealthy ulcer, on the contrary, — and by such an ulcer we mean an adynamic one, — gives oif more or less pus ; it throws out its reparative lymph just as does the healthy one, but the via- bility of such lymph diff'ers materially from the exudation of the former ulcer. Thus, according to the nature and character of such degeneration, we have the produced pus : ichorous, a thin, watery, acrid discharge; scrofulous, a cheesy, curdlike pus; sanious, a thin, sizy dischai'ge ; glutinous and viscid, as in sordes, etc. Now, whether any or all of these kinds of ulcers should give us the fetor of ozaena, would depend on circumstances; not the least im- portant of which would be the state of the atmosphere, and the cleanliness preserved. Laudable pus, issuing from a healthy wound, w']]\, in hot weather, become quite offensive in a very short time, as is, unfortunately, too freely illustrated in hospital practice. Certain ulcers are, however, in themselves ofiTensive. Every one has had occasion to observe, at some time or other, the disgusting odor arising from the saliva of particular persons, — constitutional ozaena it may with most propriety be termed. I recall, even to this day, a certain schoolmaster, the odor of whose spittle, employed to rub sums from my slate, always made me sick. This kind of Siiliva, and this odorous ulcer, belong to the alkaline class of people. Give such persons acid ; they always need it ; I never knew an exception. A simple ulcer of the sinus — that is, one not associated with osseous diseases^is to be treated in the twofold direction of its con- stitutional and its local requirements. To treat an ulcer justly, calls for an understanding of the conditions on which ulcers depend ; and as ulcers of various signification so frequently present themselves about the mouth and throat, it may not be a digression to make a hasty review of so enlarged and important a subject. Ulceration is the absorption or the breaking down of some con- stituent part of the body. Its great cause is inflammation. Inflam- mation is always preceded and excited by irritation. The term irri- tation is a comprehensive one, and covers every source of offense to the human body. Thus, one man has an ulcer, the result of an in- flammation excited and perhaps kept up by the presence of some foreign body, as, for example, a ball, a splinter of wood, a particle of dust, etc. An ulcer, says Richerand, is from a cause inherent in the economy, and differs from a wound, which is always idiopathic, in being symptomatic. A second man has an ulcer, the result of 648 OBAL DISEASES AND SURGERY. a localized inflammation, predisposed by the presence within his system of some specific taint. These ulcers, a glance would exhibit, must vary widely in their character, and even more so in the treat- ment demanded for their cure. Thus it is that we speak of, and think about, ulcers in the way of their signification. We have simple purulent ulcers, venereal ulcers, scrofulous ulcers, scorbutic, varicose, and cancerous ulcers; the character of each being expressed by its adjectival prefix. A simple purulent ulcer is a sore, the result of some local accident, and is, most likely, self-curing; a venereal ulcer is one excited and kept alive by the presence in the system of the venereal poison; the scrofulous, scorbutic, and cancerous alike de- pend on dyscrasic conditions; the varicose on certain obstructions in the venous system, etc. To secure a cure in the first of these classes of ulcers, nothing more is necessary than to protect them from adverse influences. A varicose ulcer, to be cured, must be converted into a simple one by treatment directed to the trouble in the circulation; a cancerous, scorbutic, or scrofulous ulcer is only to be permanently cured by obliterating the cachexia. There is nothing obscure in the appreciation of these facts; the difficulty is in meeting the indications. Ulcers, it is true, are presented under a great variety of names ; but these variations have reference only to varieties in expression. Thus, the carious ulcer implies that the condition is dependent on the presence of dead or dying bone; a callous ulcer is one having an indurated circumference; a fungous ulcer is oue where the granulations of repair are in excess ; a sinuous ulcer is one constituting the orifice of a canal leading to a deeper than the manifested disease ; an irritable ulcer is one that, from in- ternal or external causes, has become tender and excited; a phage- denic ulcer is one that tends to take on gangrenous action ; a sordid ulcer is one discharging a dirty-looking glutinous matter; and so on, each of the many appellations being simply an expression of some distinctive peculiarity. Now, one man, having syphilis, gets a rheumatism in his joints; another gets an ulcer on his tibia. In these two cases the important features of treatment are, how- ever, to be precisely alike : both patients must have an antisyphilitic medication; the local applications are simply adjuncts. An ulcer simple in its character, situated over or upon some part in frequent motion, is apt to assume the irritable aspect ; an ulcer the result of an idiopathic influence, if occurring on a person of weak and typhoid condition, is almost certain to assume the chronic or indolent form; an ulcer engrafted by external cause on a depraved constitution is OZJENA. 649 always more or less influenced by the vice, and such vice must be considered in its treatment ; and so, whatever may be the extent of the review, this wide collateral relationship keeps itself in the fore- ground. To return, then, to ulcers in the antrum. We are prepared to recognize that such ulcers may be of various signification, and may, for their cure, demand a various character of treatment. So far as the odor, however, is concerned, all will benefit by the common pri- mary treatment of cleanliness and antiseptic injections. To correct the fetor in a chronic case, it generally becomes a necessity either to trephine through the canine fossa, or to extract one of the underlying teeth and get into the cavity through its alveolus: the latter mode is decidedly to be preferred. A plan, however, that may be tried, consists in keeping a tuft of cotton or fine sponge in the nostril, and frequently saturating it by the sniflSng into it of an antiseptic. The entrance into this cavity, however, through the alveolus of a tooth is one of the simplest procedures in surgery, demanding only that the operator shall recognize the position of the cavity as influenced by the shape of the jaw. Any spear-shaped instrument will answer to make the opening: to keep it patulous, it is only necessary to introduce, after each operation or injection, a tent of cotton or sponge. As an injection, the following combination may be employed : B. — Acidi carbolici, gtt. xx; Glycerin as, 5ss ; Acidi tannici, gr. v ; Aquffi, |vj. M. Or, R. — Spiritus vini, ^j ; Creasoti, gtt. x; Aquae, |vj. M. Or, as suggested on page 645, the permanganate of potash in the proportion of from two to ten grains to the ounce of water, as indi- cated. Phenate of soda, combining as it does antiseptic and alterative virtues, is one of the very best injections that may be employed in these cases. Associated with such antiseptic treatment, and which we use in every case of ozsena, whatever may be its origin, we connect the specific or peculiar treatment demanded by each special case, — the 650 ORAL DISEASES AND SURGERY. understanding of which treatment presupposes and necessitates the understanding of disease in general, and can conform to no special rules. It is true that for certain diseases we have certain medicaments which we have come, perhaps unadvisedly, to consider too much in the light of specifics. Thus, in syphilis, the mercurials are much depended on ; so that, having an ulcer of such origin to treat, a con- stitutional medicine might be prescribed, as follows : R. — Syrupi ferri pyrophosphatis, §vj ; Hydrargyri chloridi corrosivi, gr. iv. M. Sig. — A teaspoonful three times a day. Or, R. — Hydrargyri iodidi, gr. ij ; Potassii iodidi, 5ij ; Syrupi sarsaparillae compositae, §viij. M. Sig. — A tablespoonful three times a day. Mercury is to be considered as an active force, striking at the parasite of syphilis, destroying it; and while it is very well thus to kill such a parasite, it is quite as well to remember that the harm of the agent employed must be constantly met and counterbalanced. This we do by keeping up and supporting the system, so that I think it will commonly be found that syphilitic ulcers require, quite as much as a specific medication, wholesome food, fresh air, proper exercise, judicious bathing, — in short, the employment of every means that tends to the maintenance of the general health. In the mercurial ulcer of the antrum — which is far more common than the syphilitic, granting the true syphilitic to exist — the general and local use of the chlorate of potash is found to act very well. The medicine, dissolved in water, may be given in doses of ten grains, repeated four or five times a day; the injection should not be less in strength than a saturated solution. The character of a mercurial ulcer is discovered by associating the local lesion with the existing dyscrasia. Scrofulous ulcers are judged by the appearance of the sore, the nature of the discharge, and the existence of depression in the patient at large. A scrofulous subject, while not always bearing the clearest general evidences of the disease, usually has some one or more features that will allow us to distinguish the condition. General features associated with scrofula may be enumerated as OZMNA. 651 follows : the first manifestation occurs generally, not always, at the period of first dentition, the symptoms being irregular appetite, an ill-smelling, inspissated mucus, and swelling of the superficial glands of the neck. Continued manifestations advance with age, presenting subcutaneous h^mph effusion, particularly about the calves of the legs and the outside of the thighs ; various eruptions, inflammation, and suppuration of joints, especially the hip, knee, and thumb-joints ; a flaccid, enlarged condition of the tonsil glands, susceptibility to atmospheric changes, inability to endure physical fatigue, impover- ishment of the blood, general asthenia. Scrofulous subjects are generally languid in their movements, and without impressibility ; not always, however, for it is a well-known fact that many of the most precocious and bright persons end their effulgence in phthisis. In short, the history of scrofula may be viewed as the history of phthisis : it matters little, so far as a general efi"ect upon an individual is concerned, whether tubercle deposits itself in the lung or in the ganglia, or whether there is deficiency in the developing force. Scrofulous ulcers are always unhealthy in appearance, being covered with a dirty-yellowish aplastic matter, irregular about their edges, generally bluish or purple, more or less undermined, and dis- charging an ichorous, flaky pus. Local stimulation meets with little or no response, and, for the reason of the general deficiency in vitality, the parts around are usually indurated from interstitial deposits, chronically congested, and looking altogether indolent and ill conditioned. The treatment of scrofulous as well as of the true tuberculous ulceration is (in our present knowledge of the disease) simply a treatment of building up. Unacquainted with any special materia peccans, we direct our aim so to lift up the life-forces that a sufii- cient inherent vitality may be developed to throw off or overmaster the depressing influence. Exercise, tonic medicaments, cold bathing, salt and mountain air, rare or raw meats, generous liquors, — all are useful means to such an end. Iodide of potassium has long had a reputation in this condition ; also barium, iodide of iron, syrup of the phosphates, cod-liver oil, phosphoric acid, etc. My own individual experience is, that wrapping one's self in a wet sheet on getting out of bed, and securing vigorous reaction by a good hand-rubbing, and, after such operation, drinking the yelk of a fresh egg drowned in good brandy or whisky, is better than any medicine proper yet prescribed. Cei'tain I am that I have seen this treat- 652 OBAL DISEASES AND SURGERY. ment do such good as warrants the commendation these remarks would give it.* We always, however, do something for a local disease, from mere force of habit, if for no other reason. We can use with these ulcers any of the applications referred to a few pages back, and any one of them is about as good as any other, or we may use them one after another. Syphilitic ozsena from ulceration of the antral mucous membrane must be, as we have remarked, an exceedingly infrequent affection. Not so, however, with ulceration from such cause in the naris ; such a condition is quite common. When j'ou have a case in which dirty clotty scabs are constantly being received into the handkerchief, and much offensive sanies is discharged from the nose, you may feel well satisfied that you have a case of syphilitic ulceration, and particu- larly may you rest satisfied in j'our diagnosis if any evidences of the disease exist in other parts of the body. Syphilitic ulceration of the nose has frequently been confounded with a commencing polypus ; but the conditions are so dissimilar that only the most culpable care- lessness could fail to distinguish them. In the first condition there are the fetid discharge, and the association with the anterior train of accidents ; a scab soon conies away, and a temporary cessation of the obstruction ensues. In the latter disease the obstruction is apt to be gradual and continuous; there are no fetid clots, and no anterior accidents of association ; blowing the nose, in the one case, most likely relieves for the moment ; in the second, it throws for- ward the polypus so that we can see and feel it. Syphilitic ulcers within the nose attack equally any location, and possess the most unfortunate tendency to enlarge and burrow, so that, if not successfully combated, in a very short time the bony framework is involved, thus producing the deformities so common. A patient with a syphilitic ulcer developing in his nose com- plains first of a feeling of congestion. We come to our conclusions because we observe certain secondarv indications. A few days, more or less, pass, and he is troubled with a discharge ; this, at first, is very slightly or perhaps not at all offensive. Very soon, however, he remarks the odor, and the discharge, which continues to increase, frequently becomes so profuse that twent}^ or thirty pocket-handker- * The author, for convenience, here combines the conditions of scrofulosis and tuberculosis, as at present we have but a common treatment for them, and thus nothing practical would be gained in separating them. OZJENA. 653 chiefs are necessary for his daily use. Occasionally, and sometimes very frequently, dirty, gluey clots or scabs come away, and the ulcer, if seen, is noticed to present a I'easonably healthy look, — something, for example, as a chancre would look when only half destroyed and casting off its slough. If uncombated and uncon- quered, the ulcer eats deeper and deeper, until the bone is reached, which, in its turn, succumbs, giving us caries, or, much more likely, necrosis. Arrived at this stage, we have indeed a most formidable condition, and it is not at all unlikely that, in defiance of every effort, more or less deformity will result. An ulcer situated in the anterior part of the naris is indicated by the forced expirations of the patient. Situated well back, he relieves himself by forced inspirations; occasionally, however, from the very beginning the pituitary membrane becomes so thickened and en- gorged that the passage of air through the tube is almost shut off: in these cases the trouble is indicated by excessive restlessness. It is not by any means always the case that nasal ostitis is sec- ondary to ulceration : on the contrary, the cases are frequent enough where the bone becomes primarily diseased and where the ulcer is simply the associated lesion. Syphilitic ostitis very frequently ends in necrosis, and more particularly is this the case where the turbi- nated bones are the ones affected. The vomer, however, is the bone most frequently necrosed in syphilis, — that is to say, the most fre- quently attacked ; and this is brought about in three ways : first, from a primary ulceration of its mucous covering; secondly, by the deposition of submucous tubercles ; thirdly, by the direct affection of the bone. When ostitis attacks the vomer or any other bone, our best efforts are to be directed to the resolution of the inflammation. To secure this end we resort to such local means as seem indicated by the peculiar features of the case. The treatment would be that applicable to inflammation anywhere ; it could be influenced by the temperament of the patient and the stage of the disease. Locally we have at this time nothing to do with its specific character: we have simply to treat a perverted condition of the circulation of the part. Constitutionally, however, its origin is to attract our closest scrutiny; and, in connection with the local remedies employed, anti- venereals must be depended upon as our strongest supports. The diagnosis of inflammation of the nasal boundaries is not diffi- cult to make out. When the vomer is the bone attacked, the patient suffers from sharp pains, referred to the root of the nose ; he has headache, always increased by the recumbent position. If the in- 654 ORAL DISEASES AND SURGERY. flammation exists in the anterior part, pressure on the cartilage increases the pain. The nasal bones, when affected, exhibit an overlying congested skin ; pressure on the bridge is responded to by much pain ; the lachrymal secretions are affected, and not unfrequently, because of the congestion in the ductus ad nasum, run over the cheek. The turbinated bones, when they are the seat of the inflammation, yield a soreness to the lateral aspects of the canal, and respond quickly to pressure exerted thereon. Whichever of these bones may be affected, its history, so far as ozaena is concerned, is the same in signification. If the inflamma- tion is not arrested, necrosis or caries, partial or complete, results. Soon a discharge makes its appearance, disgustingly foul if the case is one of necrosis, and more or less offensive, and mixed with osseous particles, if it is caries. Anti-venereal treatment is a treatment of building up. You cannot hope to arrest syphilis in any other wa}^ when it has passed to its tertiary manifestations. Limit and circumscribe the local inflamma- tion as much as you can ; and to do this you will generally find that stimulants act a better part than depressants. An excellent medica- ment is a combination of iron, iodine, quinine, and glycerine: R. — Tincturse ferri chloridi, 5j ; Quiniae sulphatis, gr. xxv ; Tincturae iodinii, Glyceringe, aa ^j ; Aquas, siv. M. Sig. — Inject, or brush over and about the parts, three times a day Give iron and quinia internally. It is scarcely probable that a patient having syphilitic necrosis needs a mercurial course ; indeed, it is much more likelj^that he has already been so over-drugged with this medicine that his trouble is mercurio-syphilitic, rather than syphilitic alone. Iodide of potassium is recommended and freely prescribed in these tertiary conditions; it may be given in doses of from ten to twenty grains dissolved in water or in the fluid extract of sarsaparilla. But good rare roast beef, poultry, a daily glass of malt liquor, boat-rowing, wrestling, horseback-riding, systematic bathing, these are the reliable means, and may elevate the vital forces to an ability ^^er vias naturales to throw off the disease. It is confessedly hard to cure syphilis when it has fully taken hold of the system ; and when it inflames a bone, particularly a small one, OZ^NA. 655 the patient is lucky if he escape without the complete destruction of the part. Necrosis, partial or complete, implies, of course, the existence of a sequestrum ; and the getting away of this dead part implies very generally the cure of the ozsena. Particularly is this the case when the death is limited to the single bone or piece. To get away this piece is, then, one of the most important features in the treatment. How is it to be done ? Simply wait until the probe reveals that it is loose ; if it may not be taken away through the orifice of the sinus it has itself created, we have only to enlarge in any convenient man- ner such sinus, and then lift the piece away. If, after the removal of such dead bone, we find the discharge continuing, but modified as to character and odor, we infer the necessity for stimulation, and use iodine, or iodine and iron, or the combination with tannin and glycerine, as seems to be indicated. It may be, however, that neither the discharge nor the odor decreases ; in such cases we are seldom wrong in inferring that more dead or dying bone is in the wound, and the treatment first employed is to be renewed. When tertiary syphilis has associated with it severe nocturnal pains, great relief is frequently secured from the administration of the iodide of potassium, particularly if combined with minute doses of phosphorus, — say five drops of the diluted phosphoric acid as a dose ; it is to be remembered, however, that, because of the relationship of the potash with the mucous membranes, in many persons even very small doses will excite much irritability in the air-passages, thus seeming to in- crease instead of allaying the trouble. With such patients we must diminish the dose of the iodide j)ro re nata. Bromide of potassiurn is now frequently employed to procure rest and tranquillity. It is commonly prescribed in doses of ten grains ; but forty or fifty will be found the better dose. It is best given in a little water just as the patient is about to get into bed. Lodgment and Retention of Foreign Bodies. — In the use of cotton or sponge about the uares, care is to be taken that the pellets do not escape attention and remain lodged in the passages. Some of the most offensive and resisting discharges occasionally have their cause in this direction. Rhinolites — calculi varying in size from that of a pea to that of a pigeon's Q^g — sometimes form in the canals, and, by inducing ulceration and collecting detritus, become the source of ozsena. Peas, rags, buttons, and sundry other articles are not unfrequently found in the nares, thrust there by children of experimental procliv- ities : any of which may, of course, become a source of offense. 656 ORAL DISEASES AND SURGERY. The removal of foreign bodies from the nares is always to be ef- fected as speedily and with as little injury to the parts as possible. A plan that may first be tried is to place the patient in a strong light and search the parts with very delicate forceps : if the body can be seen, it may thus generally be removed. Another plan consists in giving a pinch of snuff and compressing the unobstructed nostril; the effort of sneezing will not unfrequently throw the body a con- siderable distance. Still another plan is to compress the unobstructed nostril and blow into the mouth, thus forcing it out. An annealed wire, bent into the form of a loop and passed over the body, is very frequently employed with satisfactory success ; a flexible, blunt, double hook is also used with advantage. The syringe is sometimes found beneficial, the obstruction being washed back into the throat. The convenience of the douche bath in ozasna is found very great. Thudichura's apparatus* highly commends itself in such direction. Another instrument of great service is the rubber bulb atomizer : this is used by the patient without effort or trouble of any kind, and carries the spray to every part of the nostril. This little instru- ment may be charged with a solution of permanganate of potash or with chlorine-water, and kept about the person ready for use at any required moment. In cases which emit much fetor, its employment will avoid many moments of mortification. Syphilitic coryzain infants, characterized by snuffling and difficulty in holding the breast, is not unfrequently associated with offensive discharge. Here the excessive delicacy of the affected membrane is not to be overlooked. While it is a necessity to keep the parts well cleansed, it is not permissible to employ any but the gentlest means. Borax-water associated with a little glycerine is a nice preparation, or a weak solution of the phenate of soda may most satisfactorily be used. Fissures of the membrane may be touched with dilute chloride of zinc, or with iodine ointment made very weak. *"Some j'ears ago it was discovered by Professor "Weber, of Halle, that when one side of the nasal cavity is entirely filled through one nostril with fluid by hydrostatic pressure, while the patient is breathing through the mouth, the soft palate completely closes the choana;, and does not permit any fluid to pass into the pharynx, while the fluid easily passes into the other cavity, mostly round and over the posterior edge of the septum narium, and escapes from the other open nostril, after having touched every part of the first half of the cavity of the nose, and a great part — certainly the lower and median canals — of the second half." — Thudichum : Polypus in the Nose, and Ozxna. OZ^NA. 657 The employment of the rhinoscope iu rhinorrhoea or oz^na is to be commended as of great value in making a diagnosis. Ante- rior rhinoscopy is performed most simply by using two delicate ivory spatulas and placing the patient in the full sunlight. Or, placing his back to a bright gas-flame, a stream of light is thrown up the nostril by means of a reflector. A mode of anterior illumi- nation frequently employed by the author consists in extending the ala, and passing the light through a silvered speculum. The nasal speculum of Metz differs from the ivory blades in being made of highly-polished metal. A speculum known as Duplay's anterior is the analogue of the common bivalve vaginal instrument, the valves being separated by means of a screw. Posterior rhinoscopy is not so easy and simple of accomplishment : indeed, in many cases it is impossible to reap any benefit from it. An instrument devised by Dr. Limrock is highly lauded by many for its capability in this direction, being provided with a movable spatula, which governs the movements of the uvula. A modifica- tion of the instrument by Duplay is also before the profession. This consists of a glass and delicate hook attached to associated shanks, the two separating as do the blades of a pair of scissors. The author frequently practices posterior rhinoscopy by placing the patient, with widely-opened mouth, in the direct rays of the sun, using the square glass, and controlling the uvula with a scalpel-handle.* * A most instructive clinical lecture on Rhinoscopy, by Dr. Harrison Allen, will be found published in the Philadelphia Medical Titnes for August, 1872, to which the reader is referred. 42 CHAPTER XXXIII. THE ANTRUM OF HIGHMORE, AND ITS DISEASES. Many years spent in a practice which should have afforded every opportunity for observation, as well as a scope of view which necessarily offers to one who is a frequent visitor at hospitals and clinics, combine to impress me with the truthfulness and propriety of the conclusion, that the diseases of the antrum are, for the most part, simple in character, easy of diagnosis, and, as a rule, not at all difficult of treatment. Indeed, I have not unfrequently thought that, for the "purpose of general study, one would not be entirely without justification in asserting that there are but two sources of trouble to be found in this cavity : the first, and prominent, being lesions secondary to the diseases of the teeth ; the second, the troubles common to mucous membranes, wherever situated. Certain I am, at any rate, that, without fear of successful contra- diction, I may assert that the gr.eat majority emanate from the first of these directions ; while the atonic conditions, represented by the dropsies, the puruloid secretions, the mucous ejigorgements, and the ulcerations, are in no wise different from the ordinary mucoid affec- tions, except as modifications may be made by situation, the last being conclusively proven, I think, by the fact that what is the cure of the one is the cure of the other. While thus asserting, however, that in these two directions lie the chief sources of trouble, I would not by any means be understood as implying that the subject is unworthy of investigation outside of such considerations : on the contrary, I am bound to confess that I find recorded more than one description of diseases of the cavity, which to me, at least, are as anomalous in principle as they are in description, and which I can only explain either on the ungenerous supposition that the authors must have drawn somewhat on their descriptive powers, or else that the antrum has some of the strangest anomalies. Again, as a class coming between these uncommon and the common affections, it follows, not at all indirectly, that there exist (658) ANTRUM OF HIGHMOKE, AND ITS DISEASES. 659 sequelae of certain of the exanthemata which have a special and peculiar affinity for this cavity ; while, in syphilis, I have seen the very first event in the secondary train exhibiting itself in a dis- turbance of this sinus. That this latter, however, is rare, I well know from observation extending ^ver a great number of cases ; indeed, syphilitic troubles of the antrum are so infrequent even in the tertiary stage of that affection, that observation will lead to the inference that the cavity never takes on the disease unless when, from continuity of structure, it has the trouble absolutely forced upon it, as it were, either from its relationship with the hard palate in the oral direction, or with the turbinated bones in the nasal ; for, while the practitioner will surely hear complaints, yet, if he investigates the cause of trouble, he will find, as I so often have found, that mer- curial inflammation of periodonteal membranes is the source of offense, rather than the specific condition. Clumsily performed surgical operations are also the occasional causes of morbid conditions being set up in the cavity, which, when existing, would of course be so evident as to force the consideration of them upon the attention, — the most common of these being the breaking of the fangs of teeth in attempts to extract these organs. With these preliminary remarks, we pass to a consideration of the premised principal cause of antral trouble, — diseased teeth. In the chapter treating on " Anomalies of Dentition," attention w^as directed to the. close relationship of the fangs of several of the teeth with the floor of the antrum, and to the fact that it was not unfrequent to find these fangs — particularly the palatine of the second molar — penetrating the sinus, thus associating their mem- branes, and furnishing a continuity of structure. In the same chapter attention was also called to such diseases and conditions of the alveolar border as were apt secondarily to affect the antrum ; means of diagnosis and treatment being sug- ge.sted. The reader who may feel sufficient interest in the subject will do well to review the chapter alluded to, ])efore proceeding to the consideration of the clinical cases presented, and which, I think, will sufficiently illustrate this department of diseases of the antrum. Case I. — Indolent Tumor on the Bight Cheek. — A woman had an indolent tumor on the right cheek, about the size of a pigeon's eg^, occasioning much disfigurement, but altering the color of the skin very slightly. The patient had often suffered violent tooth- 660 ORAL DISEASES AND SURGERY. ache on this side, aad, though young, had few teeth now remaining, and these all carious ; otherwise she was in very good health. The tumor was prominent toward the cheek, palate, and nostril, yielded on pressure, and gave a slight noise as it returned to its position. These symptoms caused the practitioner to suspect the existence of some fluid, which it was necessary to evacuate and follow with suitable injections. For this purpose, the cheek was drawn aside, and an incision made into the bone above the gum, with a bistoury, enlarging it before and backward, till a sufficient opening was ob- tained, from which escaped an inodorous mucous fluid. The bone was at no point denuded of its periosteum. The wound was dressed with a pledget of lint saturated with spirits of wine, and the next day the patient was better. On the third day she was feverish, the sinus was swollen and painful, and the discharge acrid and fetid. These symptoms were controlled by proper remedies, and, after twenty-four days, the walls of the sinus were nearly restored to their normal condition. The canine tooth of this side being very obliquely situated, it was thought proper to extract it, and thereupon followed an escape, through its socket, of fluid contained in the sinus, though the tooth itself seemed perfectly sound. Through this orifice injections were made. The opening made in the external wall healed promptly, without any exfoliation ; in six months the tumor entirely disap- peared, and the patient was cured. (From Baron Haller's " Collec- tion of Medico-Chirurgical Theses.") The translator of the above case, in commenting upon the treat- ment, pointedly remarks, " One cannot fail to see the uncertainty, not to say obscurity, of the treatment here adopted. Though all the teeth were carious, and their extraction was plainly indicated, an incision in the external wall of the antrum, or, more correctly, its destruction, was determined upon. Tlie result we see in the symp- toms which supervened on the third day, which were, perhaps, hastened by the spirits of wine. We have here a canine tooth quite displaced and involved in the tumor; yet it was long before the idea of its extraction occurred, though the subsequent discharge, through its socket, proved how advisable it would have been at the com- mencement of the treatment. In this way the time of cure might have been shortened by half." Case II. — Distention ivith Softening of the External Walls of the Sinus. — "In ," says this same surgeon, "I was consulted in ANTRUM OF HIGHMORE, AND ITS DISEASES. 661 the case of a large tumor of the right cheek. The external wall was much distended and softened, and yielded to pressure, upon the removal of which it gave a sound resembling the crushing of an egg-shell. The nose was turned to one side, — the nostril was obstructed, — yet the patient suffered no pain, and the skin, though distended, preserved its natural color. On examination of the mouth, I found that the crowns of the bicuspidati and molars were destroyed by caries, which induced me to advise the extraction of their persistent fangs ; the patient consenting, this was immedi- ately done. The shock occasioned by the extraction of each of the fangs, caused a portion of fluid to escape from the sinus through the natural opening: it was thin, reddish, saline, and inodorous, and, in all, about three spoonfuls. The tumor could now be made to dis- appear b}' pressure, but would again return to its full size. Pressure caused no escape of fluid through the nasal, and but slight through the alveolar, opening, which was at the bottom of the first molar socket, and large enough to admit the finger. " The interna] membrane of the sinus was entire, except at the alveolar opening : through this I made injections of warm water, strengthened with a little alcoholic vulnerary fluid. The next day I injected the sinus repeatedly with a decoction of agrimony* and honey of roses, meanwhile not neglecting external compres.sion. In fifteen days the parts returned to their natural condition, all crepita- tion of the bone ceased, and the discharge was very slight. I now had recourse to stimulating solutions. On the second day the dis- charge had ceased, and the alveolar opening was reduced to a mere fissure, and in a month from the extraction of the teeth the patient was fully restored." Case III. — Periodonteal Abscess affecting the Antrum. — A patient was brought to me who, for more than three months, had suffered with a tumor like the above, on the right side. The maxillary cavity was distended to a level with the orbital margin ; the nose was turned to one side, and the vault of the palate was remarkably prominent. I removed the fangs of the first two molars, the crowns of which had been destroyed by caries, and which I believed to be the immediate cause of the disease. I then enlarged the opening at * A mild tonic and astringent. An injection of more character would be as follows: R- — Grlycerina3, 5J ; Tincturffi opii camphorataj, 5ij ; Aquae Colonise, ,^iv. M. 662 ORAL DISEASES AND SURGERY. the bottom of one of the sockets, through which escaped a large quantity of a serous inodorous fluid. Pressure upon the palate and external wall caused its escape through both the alveolar and the nasal opening: this compression, together with suitable injections, soon terminated the disease. The teeth on the left side being in a similar condition, their re- moval was urged ; but to this the patient would not consent. In three months she came to me with a precisely similar swelling of this side, which, having the same cause, I cured in the same manner. Case IV. — Abscess of the Antrum caused by a Tooth. — The fol- lowing very interesting and instructive case is from the practice of Dr. J. D. White, and was reported for the Dental Cosmos by his son, Horace Meredith White, M.D. : "Mr. S., aged twenty years, light complexion, peculiar whiteness of the skin, — a characteristic of the family, — had been complaining for some time of a fetid discharge from the right nostril ; of heat, and a sense of tension, in the right superior maxilla. " He applied to his physician, who gave him a wash, with the belief that the parts would speedily return to their normal condition, he supposing the affection to be merely an increased discharge de- pending on a slight local hyperemia, the result, perhaps, of the bad state of the weather at the time. The parts, however, did not re- cover; the discharge became much more fetid, and evidently was principally composed of unhealthy pus, though it was not as copious as it had been previously ; the pain was not severe, but the heat of the parts more elevated, and the sense of tension increased. The patient was irritable and pale ; the heat of the body was rather above the average temperature. This was the condition of tlie patient when he came under the care of Dr. W. " Upon examining the anterior naris, nothing could be discovered to account for the discharge ; tlie mucous membrane being a little inflamed, but not sufficient to occasion it. A diseased state of the antrum was suspected, and the mouth was examined to ascertain if a diseased tooth could be the cause. The second molar, upper jaw, right side, was unsound. . Part of the crown was decayed away ; the bulbous portion of the nerve, and the filaments of the buccal roots, were dead, but that part in tlie palatine root was living, and occa- sioned the patient pain. A little arsenical paste was applied to de- stroy it. No sign of alveolar abscess was present in it ov any other tooth. The next day the nerve in the palatine fang was removed ANTRUM OF HIGHMORE, AND ITS DISEASES. 663 without trouble ; a careful inspection was now made, and important information was received. Upon examining the right nostril with a speculum, a little pus was seen in the middle meatus. The patient was requested to incline the head toward the left side ; he did so, and, upon looking at the parts again, a large amount of pus was found. This, together with the facts stated already in this paper, and that there was no other assignable cause of the discharge, was deemed sufficient to establish the diagnosis, — abscess of the antrum, caused probably by the unsound second molar tooth. " Extraction was advised and submitted to. Upon the removal of the tooth no pus escaped. A probe was introduced into the alve- olus previously occupied by one of the buccal roots, and readily passed on into the antrum ; pus now followed the withdrawal of the instrument. "The cure was completed on general principles." Dr. White concludes the description of his case by remarking a coincidence which it will not be at all amiss to repeat here, — a coin- cidence which must have been very alarming to the patient. The gentleman had repeatedly visited a horse belonging to his father, which had a profuse discharge from the nose, thought to be glanders. The date of the horse's malady was prior to that of the patient, and, of course, the inference as to infection was a very natural one. Dropay of the Antrum. — This, which is only another name for mucous engorgement, is not uufrequently, as I have had occasion to observe, the result of a reflected chronic periodonteal inflammation. In such cases, we have the analogue of similar inflammation in the cavity of the mouth : the membrane becomes puffy and thickened, the mucous secretions become inspissated, and the natural opening of the sinus (simply through this thickening of the mucous membranes, the folds of which are the natural outlet of the cavity) becomes ob- literated. All egress being closed, the result is not difficult to sur- mise : if there should not occur atresia of the occluding membranes, and no correct surgical assistance is afforded, there must, of course, result either the gradual attenuation of the weakest portion of the parietes of the cavity, or the setting up of active and severe inflam- mation. If, on the contrary, the natural outlet has a partial restora- tion, it is not at all unlikely that a troublesome and, if misunder- stood, tedious and unmanageable puruloid discharge will ensue: this being the result of a continuance of the cause of trouble. Recalling illustrative examples from my own practice, I remember 664 ORAL DISEASES AND SURGERY. particularly the case of a child who, previously to coming under care, had been treated nearl}' two years for the occasional discharge of muco-purulent matter from the left nostril ; the child was of bad temperament, being a cross of the bilio-lymphatic. This patient I had the satisfaction of relieving in a single week, the treatment being wholly directed to the dental arch, if I may except a course of salt sheet-baths, — continued long after the local cure, and which had been directed in consideration of the relaxed condition of her general system. The relation of temperament and conditions is to be closely con- sidered in connection with these diseases of the antrum : it is, of course, far from being every one who is troubled with a bad tooth, the fangs of which penetrate the cavity, who has secondary disease as the result. I have just now under treatment a patient suffering from necrosis of the whole roof of the mouth, the result of a syphi- litic cachexia, the exciting cause of the local trouble being an incisor tooth anomalously developed. This tooth, the extreme point of which presented just back of the incisive foramen, had been mistaken by a practitioner for the point of a sequestrum, and, being worked, and cut at, periostitis had developed ; and when the dead bone, which is the result, is ready to come away, I am sure I shall find both antra exposed.* Without such predisposing cause, it is evident, this extensive dis- ease would never have been excited. It is the same as in every other direction of surgical practice: one man receives a wound, a cut perhaps on the face, and it troubles him so little that he scarcely stops for a moment to examine the injury ; another receives pre- cisely the same kind of a wound, and in a week is dead from erysipelas. A purulent condition of the secretions of the antrum may be viewed as one would view a gonorrhoea ; indeed, Mr. Bell, the English author, describes the conditions as being similar, " both diseases," he says, " consisting equally of an altered secretion, — in the one, of the pituitary membrane, and in the other, of the muscular lining of the urethra, which in neither instance possesses any of the characteristics of abscegs, though the matter in both is purulent." Certainly, if we allow for some differences, as influenced by cause and location, the description of the one would very well answer as * This proved to be the case, the lost process being now replaced by an obturator. For the making of such an instrument, see " Palatine Defects.'' ANTRUM OF HIGHMORE, AND ITS DISEASES. 665 the description of the other. In both we have the same perverted secretion, the same molecular change, the same sthenic and asthenic modifications. As a gonorrhoeal discharge is always preceded by certain inflam- matory conditions, and as, after the subsidence of the acute attack, the discharge may long continue profuse, or, on the contrary, may decline to a scarcely perceptible minimum, so, in antral puijulency, must we have the associated inflammation, and may have the pro- fuse or limited secretion. In antral diseases, however, as may be readily inferred, very much depends on the nature and associations of the secretion. A profuse' discharge, with closure of the orifice of the cavity, must necessarily entail the most untoward consequences : the walls of the cavity will attenuate until (unless surgically relieved) the weakest point will give way, the rupture being most apt to occur either within the orljit or the mouth. Xot unfrequently, however, this weakest por- tion seems to be the canine fossa; the opening has also occurred at the tuberosity. My own experience would lead to the inference that the hard palate is by far the most common point at which the matter seeks egress. You will see a tumor bulging out from one side of the mesial line, and which advances more or less rapidly, until fluctuation becomes very distinct. A sign diagnostic of this class of tumors is, that its internal boundary is apt to be quite abrupt, and does not pass the line midway to the mesial division. The establishment of a fistula relieves it at once of the sense of distention, and, if it has formed in a convenient place, as within the mouth, the patient may feel disposed to congratulate himself on having come to a sufficient cure. Unfortunately, however, in the majority of cases, this satisfaction is of short continuance ; for, inde- pendently of the fact that the disease at once takes on the chronic form, making the sufferer an object of disgust to those with whom he is brought into immediate contact, — the fetor of the discharge, under some circumstances, being really unbearable, — the undue re- tention of the secretion within the cavity is a source of such irrita- tion to the parts that not unfrequently the most serious lesions result. In some instances — happily, rare — all the bones of the face are destroyed. The causes influencing retention of these secretions are twofold : First, the external wound is apt to heal, and to continue impervious until an increase of the secretion induces sufficient pressure to cause 666 ORAL DISEASES AND SURGERY. its absorption, as in any case of abscess. In tlie second place, the passage is blocked up by flocculi within the cavity. Puruloid secretion in the antrum may, from the onset, be of so limited a character that, like secretions in certain of the ovarian cysts, years may pass before marked inconvenience results. I am acquainted with a case, that of Mr. C, late an eminent merchant of this city, in whom, after five years of great mental and physical suffering, a disease of the antrum, supposed to be malignant, was found to be nothing but simple muco-puruloid engorgement depend- ino- upon a dead tooth. In this case the trouble had commenced with a feeling of heaviness and oppression in the body of the jaw ; the parts had gradually enlarged until finally there was distention of the cheek to the size of a large fist, the eye being thrown entirely out of position from the rising of the roof of the antrum. Much treatment had been given the case, without the slightest benefit accruing. Xo attention, however, had been directed to the dental arch, — the teeth, although the patient was sixty years of age, being apparently ia the most perfect condition. The result of this case was the diagnosis, on the part of a surgeon to whom he finally applied, of a dead nerve in one of the bicuspid teeth. The organ, although as healthy-looking as any of its fellows, responded to the stroke of an instrument in the manner described in the chapter on alveolar abscess; this tooth was extracted, and in six months the health of the patient was perfectly restored. A circumstance connected with the extraction of the tooth in this case offers an example of practice of which it is well not to lose sight. The practitioner who related to me the circumstance, informed me that he fexpected to find associated with the tooth-fang a pyo- genic membrane, and to have the extraction followed by a gush of pus, in both of which expectations, however, he was disappointed. The fang was clean, and the blood which followed the operation had nothing peculiar about it. Xot to be thus balked, he passed a probe up the alveolus of the extracted tooth, which, meeting a resisting yet yielding body, he punctured in the direction of the antrum ; the withdrawal was followed by a profuse purulent dis- charge. This resisting body may be simply flocculi, as alluded to, or it may be the mucous membrane proper to the parts: most likely it would be found the latter, for we are to remember that it is not alveolar or antral abscess with which, in these cases, we are deal- ing, but simply what might be termed a mucitis, and, of course, a break in the continuity of the membrane is not necessarily to be ANTRUM OF HIGH MORE, AND ITS DISEASES. 667 looked for. The practitioner, in this case, only approximated to the exact condition ; he thought, evidently, that the trouble was tooth- abscess discharging itself into the sinus, whereas (while the treat- ment was perfectly adapted to the requirements) the case was one of simple mucous or muco-puruloid engorgement, the result of re- flected irritation. The diagnosis of mucoid and puruloid engorgement of the antrum is, as a rule, not difficult to make out. At first there is inflamma- tion, and this, as suggested, is found most likely to have origin about the teeth. As the trouble advances, the patient begins to complain of a sense of heaviness about the body of the cheek. If the secretion is active, there will be much pain, sometimes shai'p in character, but more frequently heavy and unbearably dull. In all chronic periodonteal inflammation we have this same dull pain, but then it differs from the pain of engorgement in being confined to the alveolar arch ; in this latter trouble the greatest pain is found, I think, associated with the floor of the orbit, which, as will be remem- bered, makes the roof of tlje antrum. At length, as the secretions accumulate, the parietes of the cavity begin to attenuate and expand. The tumor now forming may be distinguished from others, — first, by the history of the case ; second, by dryness of the uaris of the affected side, the result of the closure of the orifice of the antrum ; third, by the gradual and regular enlargement ; fourth, by the non- association of the integuments of the cheek; and, fifth, by the fluc- tuation which it will finally yield. V/ To treat successfully such a trouble, we have only to search out the source of offense, and, where it is possible, remove it. If this should prove to be a tooth, we may, if necessary, secondarily treat the antrum through the alveolus. Where the trouble is thus of strictly local origin, we shall find that we need to do very little more than employ daily some stimulating injection, such as diluted tincture of iodine. Where the acrid character of the retained secre- tion has provoked degenerating ulcers, I have obtained the very happiest effects from weak injections of chloride of zinc. If, on the contrary, such bad conditions of the antrum be associ- ated with constitutional causes, I need not suggest that such causes must have our attention. In these latter cases, however, where the cure promises to be tardy, we may give to a patient complete relief, locally, by making an opening into the cavity, and keeping it patu- lous by means of a cotton teut; this, combined with the daily em- 668 ORAL DISEASES AND SURGERY. ployment of such injections as may seem indicated, will be found to yield decided benefit. Concerning abscess proper of the antrum, I think it may be set down as the rarest of rare diseases. Bell and Bordenhave each mention a case. Abscesses, described so frequently as occurring in this cavity, will, I think, commonly be found to have their origin in the alveolar border, and if treated like any ordinary case of alveolar abscess, will generally at once succumb. (See Alveolar Abscess, and Anomalies of Dentition.) "While," says Dr. Richardson, "we cannot trace out the nature of that condition of the blood which gives rise to purulent forma- tions, wc are informed by observation of the external conditions which foster it. We learn that the pus-producing disposition is an indication of deterioration of blood. We see that when the system is enfeebled, whether by diathesis hereditarily supplied, ns by the strumous diathesis, — whether by epidemic influences, or whether by deprivation of nitrogenous food, or the inhalation of had air, — that under these circumstances the tendency to purulent formations in local structures is marked, and that, in extreme instances of the kind named, the act of suppuration may take its absolute origin from blood thus depressed. " Hence we have reduced almost to a principle in medicine the saying that suppurative tendency is a sign of an impaired or vitiated nutrition. Hence, also, we reason in speculative argument, that pus is blood transformed into a lower form of organization, and we adduce, in evidence of this view, that the purulent fluid is incapable .of organic construction, and that in animals in which the respiration, the circulation, and the animal temperature are more than ordinarily active, the formation of pus, even in an open wound, is an occur- rence almost unknown." These remarks, from the lectures of Dr. Richardson, cannot fail to be suggestive; they have indeed much meaning; but I must be permitted to remind the student reader, at least, that their sig- nification is limited. Puruloid conditions are, without doubt, and as the rule, perhaps, indications of asthenia; but it would be very wrong indeed to jump from such data to the conclusion that every puruloid disease requires treatment from the constitutional stand- point; and particularly will this hold good as the diseases of the antrum are coucerned. All diseases should be treated on principle. M. Ricord, as many ANTBUM OF HIGHMORE, AND ITS DISEASES. 669 of my readers will remember, has a favorite prescription for gonor- rhceal puruleacy, which runs as follows : B. — Pulveris cubebse, §vj; Ferri carbonatis, 3iij. M. Now, anybody can understand that such a combination would naturally act well on a debilitated system ; and I should sup- pose it would be a most happy prescription for half the roues of Paris. Where applicable, it would answer as well for the puruloid antrum. I remember, during the past summer, treating a gentleman for a gonorrhoeal difficulty, which he had contracted almost immedi- ately after my getting him over an attack of syphilis. I treated this patient locally over six weeks, the discharge constantly increasing in quantity. At the expiration of this period I put him upon co- paiba, tincture of iron, and quinia, and sent him to the seaside for a few weeks. The discharge at once began to diminish, and after the eighth day disappeared entirely. A success of this kind would not, however, lead to the inference that every man afflicted with a puru- lent discharge should be treated with tonic stimulants. On the contrary, though I have had the opportunity of prescribing very fre- quently for this condition, — gonorrhoea, — yet it is seldom that indi- cations have seemed to me to call for anything more than a strictly local treatment; at any rate, I have generally succeeded, happily and quickly, in getting the patients over their trouble. On a previous page it was suggested that puruloid conditions of the antrum had origin chiefly from two directions: first, from dis- eased teeth ; second, from constitutional disturbance, manifesting itself in the mucous tissue. It was also desired to convey the infer- ence that where the fault was markedly in the first of these direc- tions, the practitioner would err on the right side if, in his first con- sideration of the case, he should incline to look upon the tooth only in the light of an exciting cause, searching farther for what might be a predisposing condition. It is, however, to be inferred that lesions of the cavity may exist, and yet constitutional conditions have really nothing to do with them, and in the treatment need not be taken into the account. As a line in practice, however, running between these two con- ditions, I may allude to the fact that I have met cases where infer- ence of constitutional association seemed most marked, and yet have soon cured my patients without a resort to other than local treatment. < I 670 ORAL DISEASES AND SURGERY. These are the kind of cases in which the medical man must feel his way: if he be an observer, it is not likely that more than a week will pass without j'ielding him just conclusions. Coming now to the investigation of cases where the cause is to be found alone in some cachexia, we have only to refer back to the general features of disease as manifested on mucous membranes. The most common, and indeed not very unfrequeut, cause of en- gorgement of the antrum — particularly mucous engorgement — is simple catarrh of the Schneiderian membrane. The patient takes a cold, the excitement expends itself about the nares ; by simple continuity of structure the lining membrane of the sinus becomes vascularly excited ; perhaps the duplication at the orifice, because of greater nearness to the central ring of inflammation, becomes con- gested to such extent as to close the opening: thus we have the elements for engorgement, and the mucus thus confined will, if not vented, sooner or later act as such a source of irritation that it will become to the membrane of the cavity almost precisely what the virus of gonorrhcea becomes to the same character of membrane lining the urethra. Trouble from this cause is, however, generally so slight and so quickly over that it is seldom prominently marked, either to patient or practitioner. The symptoms designating this condition are, first, simple vascu- lar excitement of the membrane lining the nares, accompanied with increase of mucus. As the grade of inflammatory action advances to complete con- gestion, the excess of mucus associated with the immediately pre- ceding stage is succeeded by a most uncomfortable deficiency in the secretion. This dryness is associated with all nasal inflammations of ad- vanced grade, but when the trouble is to implicate the antrum it is even specially marked. A single moment's consideration of the parts makes this very plain : the nares are the natural outlets for the antral secretions ; in ordinary Schneiderian catarrh the extensive secretory surfaces of the antra are comparatively unafi"ected: of course they serve to lubricate, to a greater or less extent, the pass- ages. When, however, the grade of inflammation is of sufficient extent to congest the duplicatures of membrane which form the nasal outlets, then, because of the retention of the mucus, the ex- treme dryness is induced. This excessive dryness may be said, therefore, to offer the first diagnostic sign of antral engorgement from simple catarrh. From this point the disease advances or de- ANTRUM OF HIGHMOBE, AND ITS DISEASES. 671 clines. If it declines, the trouble may have proved of such trifling inconvenience as scarcely to have attracted the attention of prac- titioner or patient. If, on the contrary, it advances, the patient will soon be made conscious of the engorgement by a sense of growing heaviness in the cheek, attended by pain of a dull, slug- gish character. The progress of the disease, from this condition, is precisely the same as that described as accruing from dental troul)les. Treatment. — This is to be conducted on general principles. Where the disease is seen in its incipient stage, it will, perhaps, be found unnecessary to do more than administer a saline cathartic; or, what I have found a most satisfactory treatment is to administer to the patient at bedtime one-sixth or one-quarter of a grain of sulphate of morphia dissolved in an ounce of the liquor ammonias acetatis. This latter treatment will seldom be found to fail in breaking up these limited congestions. Where, however, the disease has advanced to engorgement, and the antrum is found to be enlarging, it may be necessary, in order to insure against even more serious lesions, that treatment shall be directed immediately to the cavity. To accomplish this, extract the second molar tooth, and penetrate the cavity through the alveolus of the palatine fang ; in this way such medication as may seem indicated may be readily employed. Indeed, for a cure it may be only necessary to keep the wound patulous, leaving the rest to nature, or, if there should seem a lack of vital force, I do not think a much happier stimulant can be employed than the tincture of iodine before recommended. Furuncular Epidemics. — It will be found, I think, the conclusion of every one who has observed in the direction, that during the ex- istence of furuncular epidemics, mucous and purulent engorgements of the antrum are more than usually common. This is not strange, if we consider the epidemic condition in the light of an exciting cause alone ; for in no single instance where my attention has been called in such direction have I been unable to discover a predis- posing cause in a dead or diseased tooth. The same condition of things exists in regions where the intermittents are endemic. All the odontalgias and cephalalgias of such a country are apt to be quotidian, tertian, or quartan. Furuncle is a condition associated, it would seem, with some derangement of the digestive or cutaneous functions. When epidemic, it would be in proof that a condition existed adverse to the performance of certain physiological functions. 672 OEAL DISEASES AND SURGERY. With the existence of a predisposing' cause of disease about the antrum, it is not at all strange that the addition thereto of an ex- citing cause should at once increase the effect of the irritant even to the production of active disease : and such, in truth, is the case : the patient escapes the purulency of boils, but he has puralency of the antrum. Treatment. — This I need scarcely refer to: it consists, first, in removing the source of local irritation ; secondly, in correcting the constitutional disturbances. Scorbutus. — This diathesis, as may be inferred, predisposes to antral purulency and ulceration. To understand the local condition thus induced, it would be only necessary to examine the gums in an individual so afflicted : the condition of the antrum is akin to the condition of the mouth. The treatment, to be successful, must be from the constitutional stand-point. If injection of the cavity seems indicated, it must be gotten at as before directed, or a canula can be passed into it through the natural opening in the middle meatus : the latter is, however, difficult, and therefore liable to objection. The Exanthemata are said to associate, not unfrequently, their sequela? with this cavity. Treatment thus demanded could need no special consideration : it would be a treatment founded on general principles. TJie Mercurial Diathesis. — I have before referred to the troubles of the cavity thus provoked. Mercury holds a ck)uble pathological relation to the antrum ; it predisposes from its constitutional rela- tions, and actively and locally excites, through the periosteal inflam- mation it excites in the alveoli of the teeth. (The same I should also have remarked of scurvy.) Ti'eatment. — The indications here ai"e twofold. Resolve, if pos- sible, the inflammation about the teeth (see chapter on Alveolar Abscess), and eliminate the mercury from, the system. The chlorate of potash and the common muriate of soda are valuable medicines in this direction : the latter I frequently employ, and with marked success. Syphilis. — This is a disease which it might be inferred would, of course, have an affinity for such mucus-lined surfaces as the antrum. Now, mine may be a singular experience, but, in contradiction of many authors who have written on the subject, I must say that, with the wide scope afforded by such hospitals as that of the Uni- versity of Pennsylvania, and of Elockley (in which latter, for over a year, I gave the study of the venereal disease the closest attention), ANTRUM OF HIGHMOBE, AND ITS DISEASES. 673 I was unable to find a single case of diseased antrum which could with justice be attributed to the vice. As remarked on a previous page, cases have been met with where the origin has been traced in such a direction ; and I will not deny that, in some cases, this origin may be justly so traced ; but, in every example that I have seen, the mercury administered for the cure of the syphilis has seemed to me to have much more to do with the condition than any dyscrasia induced by the virus. Among what might be termed the anomalous cases of antral dis- ease, mention may be made with benefit, perhaps, of a case pre- sented at my clinic, November 4, 1871, being a patient under the charge of Dr. Cruise. Patient, infant, two weeks old. One week after birth the atten- tion of the mother was first called to an uncommon restlessness, which, however, was quickly found associated with a growing swell- ing of the right side of the face, the eyelid being soon closed from oedema. Examining the case closely, discovery was made of a dis- tending antrum, every portion of the common wall gradually bulging. Pressure upon, the roof of the mouth, with counter-support to the cheek, caused a slight ejection of bloody pus from the nose. A diagnosis secured, a bistoury was passed through the attenuated, softened wall of the canine fossa, the withdrawal of the blade being attended by much pus and blood. The ti'eatment of the case, continued by Dr. Cruise, consisted in the frequent injection of black tea, of a strength as prepared for the table. Several spiculse of bone came away, leaving the little patient, after two or three weeks, in what might be termed a common state of health. No injury was known to have happened this child in its passage through the pelvic straits. The mother was quite hearty ; the father, however, was scrofulous. Three still-births had preceded the present child. Cases of what may be termed mechanical disease of the antrum will be encountered by every surgeon in the persons of those who, having met with the accident of limited exposure of the cavity, are in the habit of wearing plugs of cotton, wax, or wood in the break, which plugs escape into the cavity. The treatment required is, of course, the simple one of petting away the foreign body, — a matter, however, not always easy to accomplish. 43 CHAPTER XXXI Y. THE APHTHA. Aphthae is a terra which every reader must liave remarlved to be associated (like the word epulis) with some degree of confusion. In the Greek, from which the terra is derived, there are two verbs with the same spelling, — aTzrw. The raeaning of the one is " to set on fire ;" that of the other, to " bind to" or to "fasten upon." The raouth presents ulcers or sores of various signification, — some wliich are characterized by pain of a burning, inflammatory character ; others, chronic, or cold in nature, furnish an inviting soil to a very persistent and almost omnipresent parasite, — the oidium, — this fungus fastening upon and binding such sores in its necklace-like embrace. It has thus very naturally occurred that pathulogists,- seeking an expressive term by which to designate these varying conditions, differently employed the common name as it happened to them to observe or adopt the one or the other of the roots from which the expressions were derived. That such uses of the dissimilar verbs on the part of various authors must have been made, is necessary to be inferred to explain the differences which characterize their descriptions. With such examples of liberty, intentional or unintentional, I may be excused in presenting to my readers the subject after my own manner and views. For the reasons of the double derivation, and for others which I shall proceed to present, the term aphthae cannot, in justice and pathological signification, Ije applied to a particular species of sore, but must, as a noun of multitude, apply to a class, — which class has many species. Thus we may accept as explained and dismissed the various questions of ulceration and non-ulferation, exudation or non- exudation, the oidium or no fungi. The type of the aphihifi is as follows: An aphtha or aphthous patch is a degenerate sore, to be seen, under varying circumstances, upon the mucous surface of the mouth, the fauces, the oesophagus, and, (674) THE APHTHA. 675 quite likely, upon any part of the alimentary canal, and perhaps also the respiratory tract. The most common seat of this patch is the uvula ; next to this the lower lip ; next the tongue. The sore varies in size, from the smallest point to a confluent mass which may cover a large surface ; looks pasty or exudative, is generally oblong in shape, and varies in color from the misty white of hoar-frost to the dirty yellow of scrofulous pus. As most frequently seen, such a patch is one of perhaps several similar sores. This, as described, is the typical case. From it we are prepared to pass to the general view of the subject. An aphtha is a canker; nothing more, nothing less. Thrush, fol- licular inflammation, cancrum oris, gangraeua oris, are all species of a cancroid class, of the class aphthae. What, then, is aphthae?* The modern microscopist exhibits and describes aphthae as patches of a fu]Qgoid excrescence, — the oidium albicans. A pot of paste, a papered wall, a section of apple or other fruit, the leather back of a book or chair, exposed to a confined atmosphere, hot and moist, quickly produces, or rather gives attachment to, the oidium. Oidium albicans is not a disease, is not aphthae; neither is it the expression of disease. It is merely a fungous growth, accidentally associated with a soil and circumstances favorable to it as a habitat. "f Aphthae is, without doubt, the expression of a cachexia, and is not likely to be a merely local disease. Neither, I conceive, is it * The term is here employed as a noun of multitude. f Parasitic fungi (Hogg on the Microscope) — vegetable blights, as they are commonly called— have of late years become objects of earnest attention, on account of the enormous damage done to our growing crops, and also of the many curious facts in their history which have been brought to light. Oidium is a common mildew. It appears that at particular periods of the year the atmosphere is, so to speak, more fully charged with the various spores of fungi than it is at others. In 1854, the Eev. Lord Godolphin Osborne, during the cholera visitation, exposed prepared slif s of glass over cesspools, gully-holes, etc. near the dwell- ings where the disease appeared, and caught what he termed aerozoa, — chiefly minute spores and germs of fungi. From this same year (1854) to the present time, we have amused ourselves by catching these floating atoms, and, so far as we can judge, they are found everywhere, and in and on everj' conceivable thing, if we only look closely enough for them. Even the open mouth is an excellent trap. Of this there is ample evidence, since we find on the delicate membrane lining the mouth of the sucking, crying infant, and on the diphtheritic sore-throat of the adult, the destructive plant oidium albicans. 676 ORAL DISEASES AND SURGERY. possible for the fungus to be peculiar to a sore, as a something- specific, any more than it is peculiar to the paste, the fruit, or the book. It must depend in the one instance, as in the other, upon an accidental association. This accident, in the case of the sore, would seem to be the absence of a sufficient vitality to enable a part to resist the " fastening upon itself of ever-present parasites. The microscopist, if I may be allowed to suggest it, has, in his examina- tions and conclusions, accepted the accident and overlooked the disease. Thrush or muguet, one of the species, is an erythematic inflamma- tion, degenerating after a few days into a condition of curdy exuda- tion. The inflamed surface, after a longer or shorter time, presents small whitish points ; these coalesce, forming the exudate patches. These patches vary in color: as they remain moist and clear, they are considered with least apprehension ; as they grow dry and brown, they are esteemed possessed of dangerous import. Dissections of the cadaver have exhibited aphthae not only upon the oesophageal mucous membrane, but also on other parts of the alimentary canal. They have not as yet, so far as I am aware, been met with upon the respiratory tract ; but there is no good reason why they should not have here a like existence. In an acute attack of thrush, the mouth is hot and the general condition feverish. Milder cases, or those of easy* progress, may, and do, seem — so far as any observable constitutional sympathy is concerned — to have only a local signification. But, if thrush is a distinct disease, could it be possessed of a double signification ? Could it at one time be strictly local, at another systemic? Thrush is common to children prematurely born or to those nursed by unhealthy women. It is a disease which belongs to hot, moist climates, to the situations of uncleanly hos- pitals ; in fact, to any condition recognized to be depressive of the life-force; it is, in short, a systemic adynamic expression, seated on a mucous surface. That it differs from carbuncle or cancrum oris would not seem to be the case in fact, but only in degree. Thrush is, in other words, one expression of a common condition, — a species, not a class. Follicular inflammation — another form of stomatitis very likely to be asthenic — is a term used to signify that the abnormal vascu- lar change is seated in the mucous crypts or follicles. In passing the finger over a surface so inflamed, the studded irregularity pro- duced by the engorgement of the glands is plainly evident. As THE APHTHM. 677 such inflammatioa progresses, the bodies become recognized by the eye as papular eminences standing out from a common erythematic surface. In color they are of a varying red, such variations in shade expressing the constitutional conditions. Follicular inflammation terminates either by resolution or ulcera- tion : when in the latter way, the follicles soften in the centre, sup- purate, and have the bottom filled with a whitish, pasty mass; when in this condition, they are the aphthse of M. Billard. Follicular inflammation appears most frequently in the infant "during the deutitional period, — an explanation existing in a quickly and easily recognized combination of a predisposition and an exci- tant. In its most simple form, — that is, where there is no marked dyscrasia, or where the excitant is not of sufficient intensity to irri- tate to any extent, — the lancing of the gums, or the application of cooling local remedies, may be sufficient to combat or control the manifestations. Where, on the other hand, the conditions predis- posing to the disease exist in a state of balance, as it were, with the natural resistive forces, the addition of a second depressant influ- ence, as that resulting from the irritation of dental development, may very well be understood as giving the mastery to an agent or condition otherwise controlled or held fully in check. Thus we explain to ourselves the real and ai)parent connection of dental irri- tation with the aphthae. From a simple form, or the inflammation of isolated follicles,' the condition, in some ill states of the general system, becomes conflu- ent, such extreme form being most frequently noticed in the typhoid exanthems, or in destructive organic diseases. In confluent follicu- lar inflammation, a prognosis can only be justly made when every associate and collateral influence has been appreciated. The condi- tion will nearly always be found an occasion for anxiety. Cancrum oris, a species of stomatitis, generally accorded a special classification, differs in no wise from that-just considered, except in being more localized, as if the force of an influence had concentrated rather than diffused itself. The complaint known as cancrum oris is an asthenic spreading ulcer. In appearance this ulcer ditt'ers from what has been given the special definition of aphthaj by most writers, only in being more depraved and threatening. It has the same pasty bottom of vary- ing shades of white, the same association of pain, the same variation in persistence. Like other aphthae, cancrum oris seems to l)e, and is, associated with dyscrasia, appearing most commonly in the infants 678 ORAL DISEASES AND SURGERY. of ill-conditioned charities, in the ill housed and poorly fed, — having, in all systemic associations, the precise history of the species alluded to as thrush and glandular inflammation. This form of stomatitis, although confined to no exact locality, is yet most commonly met with on the cheeks or gums. It may com- mence with a phagedenic impression, and very quickly destroy the patient ; or a slight vesicle or pustule may first appear, to be fol- lowed by varying inflammatory associations, precisely as if some local poison was the source of the trouble. The history of cancrum oris differs from that of other cancroid affections only in degree. This is fully proven in the facts that it is associated with the same causes ; that any ordinary canker sore is capable of taking on an ulcerative action ; that the fungus oidium is quite as common to the seat of this as the other affections. In fact, every analogy will demonstrate that the relation is like that which associates the phagedenic with the simjjle venereal sore, being the difference of degree and not of cause or character. Gangrsena oris, sloughing phagedsena, is another expression or species of the common class. It may commence as an acute inflam- mation, quickly deteriorating ; as a species of fatty degeneration of the epithelial tissue ; as a submucous effusion ; or as an eschar which falls from its relations with a rapidity that leaves us at a loss for an explanation, except on the inference that the materies morbi have had the most special concentration. The eschar, formed sooner or later, is ashy in color, or a deadish brown, while the^ still living parts, particularly the external cheek, if this part should be tlie seat of the ulcer, has an erysipelatous blush, — white, semi-livid, and threatening in appearance. Gangrajna oris is markedly a disease of the dentitional period, occurring in ill-fed, ill-clothed, or ill-housed children, between the first and second dentitions. Most conspicuous is the constitutional nature of this affection. It is, it seems to me, a general febrile or inflammatory disturbance, concentrating its greatest force upon some part of the oral cavity, invited or directed, withou.t doubt, by the irritability therein existing, — proof of which inference lies in the fact that in nearly every case we find inflammatory complications, such associated inflammations being most frequently found in the lung-tissue. I take it for granted that the oral concentration saves some other more important part. Gangraena oris, where it does not too quickly kill and separate hs eschar, affords support to parasitic fungi ; the oidium albicans, THE APHTHA. 679 as in the other forms of aphthae, being that most frequeiitl}' met with. Oral gangrene varies, as would be inferred, in degree : thus, com- mencing as a single canker sore, or epithelial degeneration, and terminating with no very serious result, it might be described as the follicular, or other of the simple species. Concentrated, or in its malignant form, it destroys life without affording the physician any extended chance to combat it. In reasonably healthy children gangrene is very uncommon, the ordinary canker being generally the worst manifestation. In children exhausted under the exan- thenis, in those maltreated with mercury, or those laboring under a syphilitic degeneration, the marked or destructive type is exhibited. The decomposition of mucus, or the debris remaining from the food, when lodged upon an aphthous sore, forms the best nidus for the development of fungi ; it is, as it were, a soil ; and it is unde- niable that epithelial scales in varying states of abnormal degenera- tion, inspissated mucus, and particles of decomposed food are general to all such sores. Thus, in sickly children, the fungoid association is most common from the fact of the weakened energy of the parts afflicted; this favoring decomposition and the retention of the debris in the cavity of the mouth, and consequently producing the required soil or habitat of the oidium, as alluded to. In foundling-hospitals, where the sucking-bottle is used, the spores of fungus find, through such vehicle, an easy passage to the mouth, being in this way located and developed. In the nursing infant of an uncleanly mother, the accumulation and retention of the milk will, with favoring atmospheric Influences, quickly develop fungi. It is the fungus and not aphtha that is contagious, as must be plainly seen; hence one can but wonder at the disputes of Guersant, Billard, Yalleix, Duges, and others. Eeview. — Having thus expressed my own views of aphthee, com- mitting myself to the admission that I fail to distinguish it as any special disease, I may, with perhaps greater justice to the subject, present -the opinions of others whose extended observations and judgment have long held them in the light and position of authority. Trousseau and Delpech both describe the aphthae as being sores with the materies morbi deposited beneath the epithelium. Bam- berger {Krankheiten der Mund und 3Iiindhdhle) controverts tliese views, and explains the presence of the soormasse by the fact that it has insinuated itself between, among, and below the epithelial particles. 680 ORAL DISEASES AND SURGERY. "If we take," says Professor Bamberger, " the soorniasse, and place it under the microscope, we find it made up almost exclusively of epithelial scales, old and young, the debris of the food, and of in- spissated mucus, which last is probably only a condition of epithe- lial formation. The color of the mass is not to be hastily judged, as this might have been influenced by the debris of the mouth. "Upon these sores, however, very quickly appears a peculiar organization, which consists of round and oval spores which stick to each other, and in this way form a more or less ramifying series of threads. The longer the sore continues, the more marked is its penetration by these threads or spores. This new organization, or fungus, can never, however, originate or be generated by the organ- ism itself, but is always the result of germs coming from outside sources. It is not peculiar t6 a particular sore, though it occurs most frequently on those of a certain order. Besides the two con- stituent parts, epithelial scales and fungus, there appears sometimes a third constituent, in the form of granules or granulated matter. " From this," continues Professor Bamberger, " we see that aphthae cannot be counted among the products of inflammational and exuda- tional processes, as so frequently considered ; the microscope }ias failed to discover an exudational appearance: also there are wanting the anatomical and clinical appearances of inflammation. True, it may be that it is found in association with a catarrh, but this is an accident, just as one may not sa}^ that the diarrhoea so frequently found in connection with the sore in the infant is the cause of the sore, as he might not say that the sore is the cause of the diarrhoea. There is, in aphtha, no ulceration, the soormasse being capable of being peeled from the surface." Professor Dewees thus refers to the aphthae as exhibited in the infant : "This complaint is generally called the baby's sore-mouth: it consists of a greater or less number of white vesicles on the inside of the mouth. It very generally begins on the inner part of the lower lip, or corners of the mouth, and much resembles' a small coagulum of milk. From this point it sometimes spreads itself very rapidly over the inside of the cheeks, tongue, and gums ; and, at others, it will appear in the same form, and at the same time, on several portions of the mouth; as inner portions of the cheeks, etc. The French, especially M. Billard, make it a difi"erent disease from what they term 'muguet.' But, from a careful examination of the two diseases, I believe them to be the same, difl'ering only in in- THE APHTHM. 681 tensity. I thiuk we have not the disease which he terms ' muguet,' or I do not understand his description : as far as I have been able to compare them, they are identical. The difference may consist in the modification which a hospital may give it; if there be a differ- ence, I think it must be owing to this cause. When this efflores- cence is extensive, the child slavers very much, and is frequently embarrassed in its sucking; it cries, and evidently betrays that it is in pain ; it is very restless and very thirsty, as it evinces by its frequent stirrings, and its disposition to be continued at the breast. The eruption in its mildest form is very white, and looks as if a stratum of milky coagulum were spread over the mouth. It some- times confines itself to the centre of the cheeks, at others to the lower lip, or one side of the tongue. In its severer forms the ap- pearance of the eruption is of a dark-brownish color or extremely red, owing, most probably, to minute portions of blood ; but both are evidently grades of the same affection, changed either by mis- management, constitution, or the force of the remote cause. " This affection is thought to be altogether of a symptomatic kind, or very rarely idiopathic. It is almost uniformly preceded by a deranged condition of the stomach and alimentary canal, and always, we believe, by some disturbances of the stomach itself. The brain always shows signs of participating in this complaint, as there is almost always an unusual inclination to sleep, though the child is frequently disturbed in its nap by some internal irritation, perhaps of the bowels themselves. This disposition to sleep is so well known to nurses that they will frequently tell you 'the child is sleeping for a sore-mouth.' The bowels are often teased by watery, acrid stools, of a greenish color ; their discharge is frequently attended with the eruption of much wind, and, to judge from the noise, it would be supposed there was a very large discharge of faeces, though, upon examination, it is found to be very sparing. "The alvine discharges are frequently very acrid, so much so, sometimes, as to excoriate the verge of the anus and nates very severely, especially when due attention is not paid to cleanliness or to the frequent changing of the diapers. But this never takes place until the disease is pretty well advanced, and has made some progress. It is generally pretty well spread over the mouth, and always shows a violent disease. The stomach is also sometimes much deranged ; vomiting the milk very soon after it is received into the stomach, in the form of a dense curd, mixed with a porra- ceous mucous substance. If the milk be not voided by vomiting, 682 ORAL DISEASES AND SURGERY. the stomach constantly discharg-es, Idv eructations, a gas with a very sour smell. The child, when the disease is sevei'e, soon becomes debilitated, and rapidly emaciates; it is almost constantly harassed by severe colics and profuse diarrhoea; its stomach will scarcely retain the little it can swallow; the oesophagus sometimes be- comes so loaded with aphthae that it can no longer transmit the small quantity which is reluctantly admitted into the mouth ; and the child dies, either from the exhaustion consequent upon the pro- fuseness of the discharges from its bowels, or from inanition. "It is a popular belief that this aphthous efflorescence passes from the mouth through the whole tract of the alimentary canal to the very termination of the rectum ; and the excoriation at this part is offered as evidence of the fact. Whether this be true or not we do not know, for we are not in possession of any facts from dissection which decide the point. We once examined a body which certainly died from aphthae, the examination of which would by no means tend to confirm this common belief. A child, on the tenth day after birth, was observed to have a number of white spots upon several different portions of its mouth, which rapidlv spread over its whole surface. It had the usual premonitory and accompanying symptoms, which increased daily in severity, in spite of every effort to oppose them. It was a feeble, weakly child, of a consumptive, feeble mother. Its sufferings were very great, though under some control from lauda- num, so long as it could be taken b}^ the mouth, or retained by in- jections. Coat after coat of aphthae was thrown off, and each new crop appeared to be more abundant, and less amenable to remedies, until at last, at the end of two weeks of severe suffering, the poor infant could not swallow a drop of the thinnest fluid. Injections of bark and mutton-tea, in conformity with popular opinion, were re- sorted to, but all in vain ; the child, in a few days more, died from absolute starvation, or, at least, the catastrophe was certainh" hurried by the impossibility of receiving nourishment. "We examined the body after death : we found the whole tract of the oesophagus literally blocked up with an aphthous incrustation, to the cardia, and there it suddenly stopped. The inner coat of the stomach bore some marks of inflammation, as did several portions of the intestines; but not a trace of aphthae could be discovered below the place just mentioned. This case would, therefore, create a doubt whether this affection besieges any other parts of the body than those just stated, namely, the mouth, posterior fauces, and the oesophagus to the cardia, since, perhaps, none could have been of THE APHTHAE. 683 greater severity; but it is with us a solitary case, and should not be received for too much. Dr. Heberden says, ' The aphthae are sup- posed not only to infest the mouth and fauces, but to be continued down through the whole intestinal canal. In two who died of lin- gering fever, and whose mouths were covered with aphthae, which hung in rags all over it, there was not the least trace of them that could be found in dissection beyond the fauces. '* The excoriations about the anus can certainly be accounted for, without the presence of aphthae to produce them ; in bad cases, the stools are always ex- tremely acrid, and the parts over which they constantly pass and spread are, at such a tender age, very delicate, and very readily excited to inflammation. " Dr. Grood seems to admit, without hesitation, the transmission of aphthfe through the intestinal canal ; for he says, without reserve, ' The fauces become next affected, and it descends thence through the oesophagus into the stomach, and travels in a continuous line through the entire course of the intestines to the rectum, the faeces being often loaded with aphthous sloughs. 'f " We are afraid there is too much taken for granted in this account ; we know of no decided evidence of the fact, nor does Dr. Good name any authority for the statement. The case alluded to was certainly one of death from aphthae ; but in it the aphthous efflorescence stopped at the cardia. Is it probable that any child could survive this affec- tion did it travel the whole course of the intestinal canal? "We think not: yet aphthae is rarely a dangerous disease in infancy. Dr. Good's description of this affection would certainly lead to the con- clusion that it is the ordinary march of the disease to pass through the bowels and manifest itself at the verge of the anus. This point is far from being settled in the minds of pathologists: even the French are far from having ascertained it with certainty ; it is true M. Billard says he has seen evidences of it in the large and small intestines, as well as the stomach ; but there is no mention of it lower than the ileum. " Now, this cannot be so ; since It is in violent and long-protracted cases alone that the anus discovers any signs of irritation from this cause, which would not be the case were Dr. Good's account correct. * Commentaries, p. 31. " It is well known, too, that in smnlljwx no pus- tules are traced beyond the pharynx and larynx, even in the most severe cases, when the mouth and tongue are thickly covered with the eruption." — Tweedie's Illustrations, p. 65. •f Study of Medicine, vol. ii. p. 391. 684 ORAL DISEASES AND SURGERY. " Dr. Good and others suppose that aphthae communicates itself by a specific contagion,* and give as evidence the excoriations of the nai'se's nipples. We do not hesitate to believe there is a discharge from these little pustules which may be highly acrimonious to the denuded skin ; but we think this is perfectly innoxious to a sound one. For we have never seen sore nipples produced by aphthse, where the skin of these organs was perfectly sound. That they aggravate the tenderness and inflammation, when these parts are tender and abraded, we admit, and so would any other acrid sub- stance, without having recourse to the belief of a specific contagion. If this were the case, why do not the lips of children laboring under this affection betray its influence ? "That this complaint is occasionally epidemic there is every reason to believe; and this circumstance, among some others to be mentioned, renders the opinion so commonly credited (of its being a sympathetic affection) very questionable. We have always con- sidered aphthse as arising from some peculiar condition of the stomach ; but, from some late cases and more mature reflection, we think it may be otherwise. Our reasons for doubt are, — " 1. We have recently seen this affection in two cases where the stomach and bowels were in the most perfect order before the erup- tion, but became disturbed a little during the progress of the disease. " 2. That this complaint has been very often removed by topical applications alone, where the efflorescence has been very consider- able, and where there was no remedy of an}^ kind addressed to the stomach and bowels. f " 3. That we do not uniformly see this complaint where there has existed great disorder of both stomach and bowels, and these of a permanent kind. "4. That, however the stomach and bowels may be disturbed by acidity or other inconvenience, or however long these may continue, if the child has had this complaint, it is not renewed, though the individual is not exempt from a second attack, like measles or small- pox ; for, in certain chronic affections, they may be again visited by aphthse. " 5. That this affection is sometimes epidemic, as stated above ; for Dr. Good informs us that not only all the children of the same * M. Billard declares it not to be contagious. t Query. — Is, then, the unconquerable diarrhoea, sometimes present, a mere accident, or would it not be more easy to account for it by the presence of aphthae? I THE APHTHuE. 685 family, however cautiously separated from one another, but many of those of the same neighborhood, have been known, at times, to suffer from it simultaneously. (Vol. ii. p. 391.) "6. That this disease is almost always ushered in by some cere- bral atfection, as great drowsiness or watchfulness ; the first is by far the most common. " 7. That other portions of mucous membranes are liable to the same kind of eruption, without the condition of stomach or bowels being instrumental in its production; for we have seen it most plentiful within the labia pudendi, as well as on the internal face of the prepuce. " These facts have made us lately question the sympathetic origin of aphthae: yet we admit they are not altogether conclusive in our own mind ; but we thought it proper to suggest the possibility of its being an idiopathic disease of the mucous membrane. " This affection is not confined to early infancy; it shows itself in the more advanced periods of childhood, and from that to any period of human life. It is sure to attend the last stages of almost every long-protracted disease, especially those which may have wasting discharges, such as phthisis piilmoualis, dysentery, or diarrhoea; and when it does appear, it is almost sure to be a fatal harbinger. "This disease is not essentially accompanied with fever; if it accompany any chance affection which is attended by fever, we do not find it to heighten the existing one. "Weakly children, and especially those born before their full period, are more obnoxious to this complaint than the robust and those who have tarried to their full time in the uterus: the children of weakly women, and particularly those who make bad nurses from scarcity of milk, or from its not being of a sufficiently nutritious quality, are more disposed to this affection than the children of hale w^omen, who have plenty of nourishment of good quality. The children fed much upon farinaceous substances are especiallv ex- posed to the attack of this disease, particularly when their food is sweetened with brown sugar or molasses." In the work by M. Jourdain " On the Surgical Diseases of the Mouth" is a chapter on aphthae, so unlike all that precedes it, as connected with modern pathology, that I cannot but think the book owes the presence of the chapter to the translator rather than to the author. "The term aphthae," says this work, "is used alike by ancients and moderns, but in quite a different acceptation. The former define 686 ORAL DISEASES AND SURGERY. aphthae as superficial malignant ulcers, attended with heat, occurring especially in infants, and not confined to the mucous membrane of the mouth. It is at the present day universally applied to those whitish pustules which appear on the mucous membrane of the mouth, and sometimes of the adjoining parts. Inattention to this difference has led many to apply to the latter disease a treatment based upon the definition of the ancients, whereas the two are pal- pably different. "Aphthae have been regarded as ulcers; but ulceration implies solution of continuity, whereas in true aphthae, there is no erosion or decrease of substance, but, on the contrary, an increase ; desqua- mation of the aphthous crust leaves no trace of cicatrization. Theo- rists speak of white, red, nnd l)laclv aphthae, according to the nature of the generating humor; but during a long practice I have never seen them of any other color than white, whitish, or, especially when of an unfavorable character, ash-colored. "They commence by small white spots, usually on the uvula, thence spreading, sometimes over the veil of the palate, sometimes over the tongue, gums, and inside of the lips and cheek. Often they spread still farther into the pharynx and oesophagus. Of their extension beyond this we cannot, of course, have the evidence of sight; but we have other and unequivocal symptoms, which prevent us from regarding as an absurdity the idea of their presence in the oesophagus, stomach, and smaller intestines; as, for instance, in the difficulty of breathing and deglutition ; also in the appearance of the discharges from the stomach and bowels, so frequent in aphthous disease. " The description of aphthae is easier than their etiology. We maintain that they depend in all cases upon the same cause, differing, indeed, in degree of intensity, but never in its nature. We therefore differ from those who assign one cause in adults and another in in- fants. Nor can we agree with the many who make them to arise from excess of serum or of acid in the milk or nourishment given to the infant. The depleting, purging, and starving treatment based upon this hypothesis is most pernicious ; moreover, experience tells us that this very acidity or astringency of aliment will frequently cure aphthous eruptions, or prevent them from coming to maturity ; and a serous flux, determining to the mouth, has caused the complete disappearance of existing aphthte. "What, then, is the true origin of this disease? We believe it to be found in the existence of a slow and imperfect crisis, and to THE APHTHA. 687 arise from a sulphurous humor generated in the larger vessels, and determining to such parts as are, by position or structure, most im- pressible. Observe for a moment the circumstances and character of aphthae. In all fevers, in the young and in the vigorous, their appearance is ever preceded by a crisis more or less distinct, and, according to the violence of the primary disease, marked by more or less severe symptoms. In one case nature struggles successfully with the acrimonious morbific principle, a favorable crisis occurs, and an aphthous eruption brings great relief to the patient; in another case this morbific principle is too abundant, obstinate, or malignant. — no crisis occurs, — no aphthae, — nature succumbs, and the patient dies. Again, we have aphthae through the critical transfer of morbid action from some more or less vital and important organ. In some cases the change proves salutary ; in others there is a reac- tion, the aphthjB disappear, and if the vih vitse be not destroyed, it is often greatly endangered. " Aphthae rarely occur in a perfect and favorable crisis, but rather, as we have before said, in those which are slow and imperfect, such as are met with in a great number of diseases. Thus we find some aphthous eruptions of not only days', but weeks' and mouths' con- tinuance. When, for instance, necessary evacuations have been neglected in the onset of disease, and a cachectic plethora has super- vened, the cure is slow and incomplete without the occurrence of aphthae. Diuretics and gentle enemas aid the recovery ; blood-let- ting and purgatives retard it: the aphthae disappear after fulfilling their sanative purpose, and the patient feels perfectly relieved. Ex- perience, however, shows that the danger is not quite over-: some lurking matter may take fresh increase, give rise to new aphthae, in default of other means of escape from the system, and greatly endanger life ; this may happen twice, or thrice, or oftener. " The causes or antecedent symptoms of aphthte may be mild, and recovery take place with(»ut any or with very simple treatment; or they may be severe and lamentable, ending in suffocation, delirium, or obstinate diarrhoea. This difference we find explained by the varying state of the humors : at one time being crude, and b}^ con- sequence irritating, at another time matured or concocted, by which process of concoction the more hurtful principles are expelled, — a process aided in some inexplicable manner by the continued circu- lation of the animal spirits. Thus it happens that the aphthae of seventh-day crises are usually more unfavorable than those which follow crises of a later date, when the morbid matter has had time to undera-o a thorough concoction. 688 OBAL DISEASES AND SURGERY. "Although aphthffi are most generally preceded by febrile mias- mata, they are not necessarily so. I have seen cases, both among adults and infants, in which they have been neither preceded nor attended by fever. In infants we may properly suspect impurity of the mother's blood. "Certain evacuants have been found more hurtful than beneficial in the treatment of aphthse. This comes from a forgetfulness of the excellent advice of Hippocrates, who tells us to have regard, in the choice of depleting agents, to the channels of evacuation which nature points out in any given case. Now, the vessels concerned in the critical discharge of an aphthous eruption are the lymphatic rather than the venous or arterial vessels. Therefore to the changes of the lymphatic fluid, rather than to those of the blood, is our atten- tion to be mainly directed in the management of this disease. We have frequent evidence of serous or lymphatic engorgement at the outset of aphthous eruptions : in the fever, stupor, and restlessness during sleep, — indicating a fullness of the head and an acrimony of the humors. "Aphthae are more common in some countries than in others, whicli explains the almost total silence of some writers respecting them. This depends upon diiference in climate and mode of living. In warm countries their course is rapid, from the increased perspira- tory action of the skin. But in colder latitudes, where the food is coarser, the habit of body denser, and the humors thicker, their progress is slower, because the secretions of the system generally are more liable to obstruction. In these countries, especially, all discharges which tend to arrest perspiration, such as hemorrhoidal, intestinal, or uterine, whether occurring spontaneously or artificially provoked, are very unfavorable in the treatment of aphtha?. On the contrary, a copious cutaneous or urinary secretion forms often a favor- able crisis. This agrees with the doctrine that aphthae are essentially serous, and most readily cured by a free discharge of serum or lymph. The cause of endemics we leave others to explain ; each country bears in its womb the seeds of its own diseases, and also the means for their cure. External agencies may cause aphthae, not, as the an- cients supposed, by their direct action on the mouth, but indirectly, through the mass of the circulating fluids. " The diagnosis of aphtha is easy ; not so the correct interpreta- tion of their premonitory symptoms. Painful deglutition, dryness of the mouth, a thick, husky voice, heat of the ston)ach, with rum- bling noises, disturbed, unfreshing sleep, — these often precede aph- THE APHTHA. 689 thous eruptions. Urinary symptoms are not to be relied upon, though often useful in prognosis after the appearance of the eruption. In tbe different forms of fever, the obstinacy of the disease is often a precursory symptom ; when, notwithstanding the intestinal, urinary, and other evacuations, there still exist great depression and em- barrassment of the vital functions, the appearance of aphthae will often in a single night bring calm and relief to the patient, as ex- perience has abundantly testified. The physician should follow nature's hint, and seek to aid in the cure of the disease through the same channels. The above symptoms, be it understood, are by no means necessarily followed by aphthous eruptions. "We should be careful in our prognosis: where the system is not weakened, the pre-existing morbid matter well concocted, or the extent of the eruption limited to the palate, we may anticipate a favorable issue. But if the patient be in a reduced and weakened condition, the morbid matter crude, or the aphthae covering the entire membrane of the mouth and pharynx, the disease is much more to be feared. Again, suppression or derangement of the menstrual flux is unfavorable, from its tendency to draw the eruption from the place where alone it can properly mature. Profuse alvine or hemor- rhoidal discharges are also hurtful ; also any catarrhal attack falling upon the throat, causing tbe sudden disappearance of the aphthae. Aphthas occurring in diseases at the onset of which there was in- suflScient evacuation, are grave and dangerous. The disease may occur in persons of either sex, and be of tedious duration; but when the appetite returns, not only is the food highly relished, but it gives, by its new nourishment, relief and salutary benefit." "The term aphthae," says Prof. Wood, in his "Practice of Medi- cine," vol. i. page 501, " was employed by the ancients to signify various inflammatory affections of the mucous membrane of the mouth. Willan proposed to restrict it to a peculiar vesicular eruption upon the membrane, but committed the error of confounding with this aflfection the thrush of early infancy. The two complaints are quite distinct, and should not be similarly designated. Aphthge, in com- pliance with very general custom, is extended to all those small ulcers, with whitish surface, which so frequently appear in the mouth, whatever may be their origin. The most frequent source of aphthae is probably the vesicular eruption occasionally present in erythema. The vesicle is small, oval, or roundish, white or pearl- colored, and consists of a transparent serous fluid under the elevated epithelium. In a few days the epithelium breaks, the serum escapes, 44 690 ORAL DISEASES AND SURGERY. and a small ulcer forms, more or less painful, with a whitish bottom, and usually a red circle of inflammation around it. The vesicles are sometimes distinct and scattered, sometimes numerous and confluent. The distinct variety, though painful, is a light affection, continuing in general only a few days or a week, and is usually confined to the mouth. It produces little or no constitutional disorder, though it may be associated with fever and gastric irritation as an effect. It attacks equally children and adults, but is said to be very common in early infancy. In adults it is frequently occasioned by the irrita- tion of decayed teeth. The confluent variety is much more severe and obstinate. This frequently extends into the fauces and pharynx, and is said to reach even the intestinal canal, though it may be doubted whether the affection of the stomach and bowels is identical with that of the mouth." The French fail in distinguishing, with Prof. Wood, the difference between the pultaceous inflammation of thrush, or muguet, and the aphthae, calling muguet the " aphthes des enfans." They recognize also that there are variations in the expressions of the condition, making a distinction between the muguet benin ou discret, and the confluent, muguet malm ou conjiuent. In Clymer's Aitken's " Science and Practice of Medicine," the subject is thus alluded to: "Follicular inflammation of the mouth, follicular stomatitis, aphthous stomatitis, or aphthae of the mouth, is a disease which usually commences as a simple stomatitis ; but very soon small, round, transparent, grayish or white vesicles appear, and at the base of each is an elevated marginal ring, which is pale and firm. Fluid soon escapes from the ruptured vesicle ; an ulcer forms, which spreads, bounded by a red circle and an elevated border. In some forms of the affection microscopical parasitic plants appear." Treatment. — If we are content to view aphthae simply as a fun- gous sore, oi'iginating from and maintained by the presence of a parasite, — the oidium albicans, — we would find a most admirable application in carbolic acid, admitting that the parasite had an ex- ternal relation only; if, however, these spores come from within and are exudational, such local treatment would be of very temporary service. Yiewing the fungus simply as an accidental parasite external in its relations, our attention is directed primarily to the necessity for cleanliness, and the avoidance of all positions, locations, and circum- stances favoring the development of fungi: carbolic acid, acid nitrate THE APHTHA. 691 of mercury, sulphuric acid, nitrate of silver, or chloride of zinc, will be found destructive to the parasite, and, of necessity, if the circum- stances are changed, equal to the production of a permanent change in the appearance of the part ; that is to say, the application is equal to the removal of the envelope or cover of the disease, but, except by a happy accident, will not beneficially affect the underlying condition, or the disease proper. In the treatment of aphthae, the practitioner finds himself com- pelled, at the very outstart, to consider the constitutional associa- tions. Occurring in connection with acute diseases, it is generally the case that the local expression is found to disappear with the condition exciting it. Thus, in febrile attacks attended with stoma- titis, we direct our remedies to the causes inducing such attacks ; as the functions become harmonized and regulated, the expressions of the irregularity disappear. Aphthae, whatever its form, appearing in connection with the dyscrasic diseases, gives to the practitioner the greatest anxiety and trouble. In our anticipations of what we are to do, we are not to forget that the task before us is the removal, or, at least, the marked amelioration, of the constitutional disease. If this should be syphi- litic, tubercular, or cancerous, the magnitude of the task is evident : hence it is that patients are allowed so frequently and-so unneces- sarily to find themselves subjected to a series of disappointments. Acute aphthae, as manifested in cancrum oris, gangraena oris, and follicular inflammation, demands not unfrequently the most attentive local treatment. This treatment has, however, nothing particularly special in it, and, without doubt, must be appreciated from the general expressions of the subject. Alteratives and soothing appli- cations are such as would naturally commend themselves. Sulphate of copper, in proportions varying from five to thirty grains to the ounce of water, is an excellent application. Iron and quinine in combination are used to great advantage, — twenty-five grains of the latter to one drachm of the muriated tincture. A powder made by combining equal parts of red bark, chalk, and tannic acid is fre- quently found very serviceable. Solutions of alum, and the tinc- tures of capsicum and myrrh, are useful in their places ; also borax, .oxalate of cerium, powdered chlorate of potash, sulphate of iron, etc. Hydrochloric acid, applied by means of a feather or small brush, causes less pain than might be supposed, and is thought by many to be the very best local application that may be employed. Where the parts seem angry and irritable, or phagedenic, com- 692 ORAL DISEASES AND SURGERY. bined with these applications are to be employed the more soothing means: starch, gum, and slippery-elm water being found in such directions very serviceable. Tincture of hamamelis, much diluted, is a good preparation. Another is the phenate of soda. It is to be understood that while the principles which govern the treatment of the aphthae are common to the species, the applications must vary to meet varying local indications. The ordinary white sores, for example, need little more in the way of such direct treatment than the continued application to them of some of the agents mentioned: which one would be best, or, indeed, what would be best, we could not well say, unless considering a particular case. The local treat- ment is not, however, in any of these cases urgent, and it is the general experience that we find ourselves trying first one thing and then another; indeed, it is unfortunately too common that we are soon brought to the conviction that any local application is un- reliable, — not that we cannot cause a sore to disappear, but that to-day, to-morrow, or next week, another comes to take its place. Canker sores seem periodic in some persons ; they come without perceptible cause other than what seems a persistent constitu- tional condition, defy all treatment, and finally disappear of their own accord. Of the special conditions, thrush demands that the bowels should be kept free from costiveness, — oil, the saline cathartics, or aloes being employed as indicated. Where fever attends the local mani- festation, it is well to prescribe the neutral mixture made by fully saturating lemon-juice with the carbonate of potassa ; or, if more agreeable to the patient, the ordinary lemonade may be used. In diarrhoea, which is so frequent an attendant on thrush, some such combination as the following may be used : R. — Hydrargyri cum creta, gr. ij ; Pulveris opii, . Pulveris ipecacuanhse, aa gr. j ; Magnesiae carbonatis, gr. xij. M. Ft. chart. No. xii. Of these powders, the infant may take one, mixed in molasses or other vehicle, every two hours, until the discharge is checked, or until the twelve are taken. In diarrhoea with green discharges it may be sufficient to use the magnesia alone ; or lime-water, which is more convenient of exhibition, may suffice for the correction of the THE APHTHA. 693 acidity : this latter can be rendered palatable by adding to it some of the aromatic waters. A combination, for the knowledge of which I am indebted to my eminent colleague Prof. Penrose, and which it would seem could scarcely be replaced by a better, is as follows : R. — Bismuthi subnitratis, Myristicse pulveris, aa 5ij I Gretas preparatse, 9ij; Syrupi zingiberis, 5iss. M.* Dose, from twenty-five drops to a teaspoonful, according to age, repeated every two hours. In cases associated with much intestinal disturbance, it will in most instances be found satisfactory practice to combine laudanum or paregoric with olive- or castor-oil, administering in such doses as accord with the age of the patient. A child one year of age may take three drops of laudanum or twenty of paregoric, combined with a teaspoonful of the oil ; for an adult a dose would be twenty-five or thirty drops of laudanum to a tablespoonful of the oil. It is also found useful to drink freely of the demulcent waters, marshmallow and gum arable being among the best of these. In debility, — and this is by far the most frequent of the conditions, — combinations of iron and bark, conjoined with the most nutritious articles of diet, will be found indicated : ferrated elixir of cinchona is a pleasant and very reliable preparation, and is freely taken by children. The dose for an adult is one teaspoonful, repeated three or four times a day ; to an infant a year old, ten drops may be given. Concerning the diet, if the patient is beyond the age of infancy, it will be found that the richest food is most advantageously re- ceived ; juicy beef, oysters, malt liquor, wine, etc., being freely allowed. In the infant, the character of the milk of the mother is to be examined : in many cases it will be found needful to furnish a different nurse, or, otherwise, wean the child. Many cases of per- sistent thrush in the infant have quickly disappeared after a change of nurses. Gangrasna oris, the most degenerative and destructive of the aphthae, requires the most persistent vigor in the treatment, both as * The author is assured that his readers will recognize the obligation he places them under in directing attention to this palatable combination. As a medicine for the ordinary diarrhoea of summer, both in the infant and adult, it will seldom be found to disappoint in affording the desired cure. 694 ORAL DISEASES AND SURGERY. regards systemic and local conditions. Sulphate of quinia and the muriated tincture of iron are, in the first direction, most to be relied on. This condition occurs most frequently between the periods of first and second dentition, and is, without doubt, more .common to the miasmatic than to other regions, excepting always the location of ill-kept and ill-ventilated charities. Gangraena oris may have a local excitant, but it is never without a constitutional predisposition. It may commence as a simple sore, gradually degenerating, or, as in carbuncle, destruction may reside in the primary impression. A common form of sloughing stomatitis is its appearance as a whitish or ash-colored eschar situated upon the gums, lips, or cheeks. This eschar quickly falls out, being followed by degeneration of the asso- ciate parts ; the breath becomes offensive, the saliva flows as in ptyalism, while, to add to the discomfort, the ulcer pours out an acrid, corrosive fluid, which not only excoriates the mouth, but seems to provoke the extension of the mortification. If not checked, the ulceration extends to the bone, quickly involving it in the gen- eral destruction, and bringing on the condition of necrosis, — necrosis infantilis, as the disease is, unfortunately, so frequently compelled to be named. The treatment of gangraena oris is precisely that of a carbuncle. We endeavor to circumscribe the action by sloughing out the af- fected part with the aid of caustic ; this accomplished, we stimulate the general system, correct, where possible, all functional disturb- ances, and use for the relief of the local sore such soothing means as seem indicated. I CHAPTER XXXV. HANULA. The subject of ranula is one easily comprehended. A ranula is the analogue of the sebaceous tumor, being simply a tumor of re- tention, a collection, the result of the closure of a tube of outlet. The tumor thus designated is found principally beneath the tongue ; it is a swelling varying in size or in expression according to the cir- cumstances of its existence, at times being observed when not larger than a pea, at others so great in bulk as to throw the tongue back into the fauces. Ranulae will sometimes be met with which fill the whole oral cavity; such dimensions, however, are uncommon. Recalling the anatomy of the salivary glands, we remember that the submaxillary, situated beneath the jaw, has the outlet for its secretions in a tube opening at the side of the fraenum linguas, — the duct of Wharton, as it is called. The lingual gland empties itself on the same line. The parotid, by its tube, the duct of Steno, opens upon the mucous face of the cheek oppositC'the superior second molar tooth. While patulous, these tubes convey into the mouth the secre- tions of their respective glands, and thus the saliva, passing to its recremental purpose, is disposed of. If we were to tie or otherwise obstruct one of these tubes, it would be natural to expect that the secretion accumulating back of the ligature would expauJ and bulge out the duct into the form of a tumor. This is really the very simple history of the formation of a ranula. Ranula, thus provoked and thus formed, varies as much in appear- ance and character as in size. In one case it will look and feel almost precisely like the belly of a frog, the enveloping cyst being thin and attenuated. In other instances the walls are thick. The contents present varying characteristics, being watery, or semi-solid, or solid, even to the hardness of stone, as illustrated in the very in- structive case cited in the chapter on Salivary Calculus. Commonly the contents consist of a yellow, albuminous-like substance, which, for its evacuation, requires pressure upon the tumor after an in- cision has been made. (695) 696 ORAL DISEASES AND SURGERY. A ranula, the contents of which are watery, implies, as a rule, that the disease has been of short existence, the fluid being simply the secretion from the gland unchanged in character. In the ranula of semi-solid consistence an explanation is found in the partial absorption of the more fluid portion, leaving an inspissated mass. In the solid ranula the encystment is the common salivary calculus, — being precisely the same as is found upon the sides of the teeth, excepting in the absence of the common detritus of the mouth. Such a ranula will be found to be of longstanding: absorption of the watery portion has gone on until what remains is the limy portion of the secretion. A thin cyst implies a rapidly-formed tumor unattended by vascular excitement, the envelope being a simple attenuation of the walls of the duct and overlying parts. This form of ranula very frequently ruptures, and thus effects a self-cure. Cysts, thickened and hard, imply tumors of slower growth and the association of vascular changes resulting in the effusion within the cyst-wall, and the organization of a greater or less amount of lymph. Cysts thus thickened may compose the principal bulk of ranulse, the cavities being very small in comparison. A ranula gives trouble from its bulk and location alone, seldom or never degenerating. It does not seem true, either, that harm results to digestion from the loss of the secretion, such loss, indeed, being more apparent than real, the associate glands performing excess of work. A ranula attaining great size would necessarily intrude upon all the surrounding parts, thereby provoking secondary lesions which might very well prove of more serious character and consequence than the original disease : thus, cases are on record where the teeth have been forced from their sockets, where large ulcers have been formed against the inner face of the lower jaw, where necrosis of extensive character has been provoked, etc. Treatment. — This, in principle, consists simply in opening the tumor, evacuating its contents, and so conducting the cure of the wound that it shall not entirely close, securing and preserving in this way an orifice of exit for the secretion. In the rana, or frog-belly tumor (for here there is ranula of both sides), it is found sufficient to catch up with the tenaculum or forceps a portion of the sac, and with the scissors or bistoury cut it off: the edges are then to be cauterized, and the case left to nature. In the thickened cysts such an operation as just suggested might not be easy to accomplish. In such a case take a strand of ligature RANULA. 697 wire (silver is to be preferred), double it upon itself^ half a dozen times, to the extent of the supposed thickness of the sac of the tumor to be operated upon. Take next the continuation of the length of the wire, and closely, yet spirally, bind with it the thick- ness just secured by the half-dozen reflections. Next take a curved needle, and thread the wire to it. Now pass it through the tumor, entering at the centre. When the thickened part of the wire — which is to be bulbed by a perforated shot compressed on its ex- tremity — is brought in contact with the cyst, it is to be let in by an incision just large enough to allow the passage ; pull it now in, until checked by the shot ; fix the needle-end so as to retain the thickened end in place, and the operative part of the proceeding is completed. A second mode, founded on the same principle of drainage, con- sists in taking a delicate rubber tube, and, after cutting through its walls a number of outlets, passing it through the tumor. To retain it in place, the extremities are tied together, having an opening made between the ligature and the tumor. If, when making the little section in the tumor for the passage of the wire or tube, the contents should not at once escape, they are to be pressed or syringed out. If the parts seem particularly indo- lent, there is no objection to the introduction of a stimulating injec- tion. The presence of the drain will, however, in ordinary cases prove sufficiently provocative of the desired action. Iodine in tinc- ture may be used externally over the face of the tumor. In a ranula holding a calculus within the cyst nothing is to be done without using the knife, except, indeed, in certain occasional instances where the orifice of the duct has become patulous and the stone can be seen or felt. In these cases the operator may succeed in drilling or breaking it in pieces, and thus securing its removal. It is much easier, however, even here, to incise down to the stone, and thus take it away. The case alluded to as mentioned in the chapter on Salivary Calculus is as good a study as could be given in the direction. All cysts or tumors found beneath the tongue are not, however, to be esteemed as being of the character just described. Inflamma- tion of the sublingual gland is not unfrequently met with, and the tumefaction is, at times, so considerable as to very closely simulate ranula. Cysts within the substance of the glands, not salivary in character, are other of the conditions encountered, and these more closely simulate the ordinary ranula than the first, particularly when the cyst is simple. Papillary indurations are sometimes met with in the same situation. 698 ORAL DISEASES AND SURGERY. Lipoma simulating ranula is found occasionally referred to.* Writers, prominent among whom is M. Marrant Baker, are found, who incline to doubt the common relation of the condition with the * " Lipoma simulating Eanula. — Mr. F. Churchill exhibited a specimen of lipoma simulating ranula. He said this tumor was removed from under the tongue of an old man, eighty-six years of age. The specimen is unique, so far as the Society is concerned. I have b6en unable to find in the Trans- actions any records of a lipomatous tumor removed from this situation, and there is no such tumor in the Museum of the College of Surgeons. Mr. Liston refers to the removal of fatty tumors under the tongue in his work on Practical Surgery. Mr. Pollock removed a fatty tumor from below the jaw of a lady forty years of age, enveloping the mylo-hyoid muscle ; but in this case the in- trinsic muscles of the tongue do not appear to have been encroached upon by the tumor. In several cases, hardened, putty-like masses have been removed from a ranular cyst, as also phosphatic concretions. During the last session of the Society, Mr. Warren Tay exhibited four or five butter-like masses, which he had removed from a ranular cyst, but ' under the microscope no definite structure could be detected in them. Entangled in the substance composing the masses were some cells and portions of cells looking like debris of epithe- lium.' Dr. Meymott Tidy, after a careful chemical analysis, 'was disposed to regard the bulk of the deposit as adipose.' The history of the case .was as follows : H. T., aged eighty-six, was admitted to the "Westminster General Dispensary, under the care of my colleague. Dr. Waite, who treated him for eczema rubrum of the leg. After consultation with Dr. Waite as to the na- ture of the tumor beneath the tongue, supposing it to be a ranula, I suggested that it should be removed in the usual way. He stated that on several occa- sions fluid had issued from the tumor, after which it was distinctly smaller. The incisive teeth in the lower jaw were intact, and situated just behind these was a movable (apparently pedunculated) tumor, about the size of a walnut, covered by the smooth, glistening mucous membrane of the floor of the mouth. The tumor was also, in part, covered by the sublingual gland ; it was soft and yielding, and I was under the impression that I could detect fluctuation. The distended mucous membrane was being chafed by contact with the sharp edge of the teeth during mastication. The old man had noticed the swelling for twenty-two years. It had gradually increased up to the present time. During the past twelve months, however, it had given him pain, in conse- quence of chafing against the teeth ; he much feared that it was a cancer. From its size it had also interfered with mastication, and acted as a serious impediment to his speech. Having removed a portion of the anterior wall of the tumor, I proceeded to turn out the contents, but found, underlying the mucous membrane, a bright, glistening mass, resembling a cyst-wall ; this was seized with a pair of clutch-forceps and drawn forward, a small portion of it being removed, but still no fluid escaped. I proceeded then to separate the adhesions to the mucous membrane with the spoon-end of a director, but the deep connections were too firm to separate in this way ; the finger also failed to enucleate the mass. The tumor was forcibly drawn forward, and RANULA. 699 Fia. 2J0. salivary ducts, but upon such premises, as must appear to any one who shall see much of the condition, that the arguments advanced carry no weight : the true ranulse arise from salivary lesions influ- encing the relations of the discharge : tumors of kindred position may have the signification of muciparous cysts, or may be expressive of a systemic vice ; because a tumor is beneath the tongue it is not necessarily a ranula. Ranulse are found superficially seated, or deep, according to the part affected and the location of the lesion : thus, ranulae associated with the tubal outlets of the sublingual gland are always entirely superficial, because the part affected is cov- ered only by the mucous membrane. Obstruc- tion of the duct of Wharton at its orifioo yields also a superficial tumor, lying as it does between the mucous membrane and the mylo-hyoid muscle ; occurring, howevei', beneath this muscle, the tumor resulting is deep-seated. Ranulse are of temporary or permanent signification: thus, where only a limited ob- struction exists, a tumor may form suddenly during the excess of secretion at periods of mastication, to drain gradually away as the superexcitation passes off. Or cases are met with where, as the result of accidental inflam- matory conditions, the outlets become obstructed from neighboring exudates, the tumor disappearing as the exudates are absorbed. The existence of true ranula does not necessarily imply that the tube afi"ected is absolutely closed: a ranula may exist where obser- Superficial Ranula, showing seton introduced.* these deep attachments cautiously divided with the knife. In this way the tumor, which was lobulated, and enveloping (probably) the genio-hyoglossi muscles, was removed. Exploring the cavity afterwards, I could feel the sharp borders of the vertical muscles, and I was satisfied that the growth had been entirely removed. There was very little hemorrhage after the operation, and the cavity had completely closed in the course of a week." — Proceedings of the Pathological Society. * This is but a single expression of the superficial ranulse. One treated this very day of writing by the author — being a double tumor — presented the ap- pearance of the whole floor of the mouth being raised on a level witli the teeth. 700 ORAL DISEASES AND SUBGERT. vation discovers the canal patulous and the secretion discharging; here an explanation is found in well-known similar stricture as met with in the relation of the bladder and its urethral canal, urine con- stantly dribbling from the meatus, yet the patient suffering from retention ; or, again, a probe may be passed with all ease into the orifice of a canal, yet a true tumor of retention exist, — here, as referred to, a stricture being deep-seated. Cases of hygrometric or bursal tumors are to be met with occa- sionally upon the neck, which mayor may not be ranular. No more instructive case in such direction has ever fallen under my own observation than that described in the chapter on Salivary Fistula. A tumor precisely similar in appearance to this particular one, but situated beneath the right submaxillary gland, was, at a late clinic of the University Hospital, dissected by my colleague Prof Agnew from the neck of an infant ; but here no association with the gland was discoverable : also, at the same clinic, a tumor of similar loca- tion and appearance from the neck of an adult, with similar absence of discoverable relation. Such tumors have the sigrnification of Flg. 241. Deep-seated Ranula. engorged and enlarged bursse, or at least are to be so treated, and are the analogue to what is so familiar as the " housemaid's knee." RANULA. 701 The salivary glands themselves are occasionally the seat of in- flammatory swellings, which are quite as apt to become indolent as to resolve. I have within my own observation several of these cases, and sometimes have been six months in reducing such an indura- tion. The submaxillary, however, seems to be the gland most dis- posed to take on such conditions, and the tumefaction thus produced is without rather than within the mouth, although it not unfrequently happens that it is first observed by the patient as a hard body on the inner side of the jaw. Another form of tumor which may here be alluded to is found in the submaxillary triangle. In dissecting down to the submaxillary gland, there will be ex- posed, when the body is uncovered by removing the superficial leaf of the triangular fascia, two lymphatic glands. These glands are very apt to indurate, forming sometimes a tumor of considerable size. I have met with them as large as a walnut. It is most com- mon to mistake such indurations for hypertrophy of the submaxil- lary itself Two diagnostic signs distinguish the first: they ar.e not triangular, and they are not so solidly fixed as when the chief gland is the seat of the enlargement. A case of glandular tumor, very suggestive as a study, is recorded in Bell's "Principles of Surgery." The attention of the reader is directed to it : The case was that of " a young woman of Berwick, whose native peculiarity of accent had received a singular aggravation by such an uncouth obliquity and imperfect motion of the tongue as conveyed the notion of her attempting to chew and turn each vocable with her tongue before she proceeded to swallow it, in place of uttering it. " This was produced by a tumor of very great size, and of an appearance so peculiar as plainly to denote its character. It con- sisted in a vast collection of matter in the sublingual gland ; and as that gland is covered by the whole thickness of the tongue within, and by the mylo-hyoidei muscles without, and bounded by the line of the jaw-bone, it had the following singularities of character. It could not be distinguished as a tumor, but bad rather the appear- ance of a general swelling of the lower part of the face, jaw, and neck, such as often accompanies severe toothache or mumps. Upon laying the hand upon the outside of the neck, below the lower jaw- bone, the whole hand was filled with a swelling, apparently solid, but so little convex or circumscribed as to resemble in no degree the tumor of any particular gland, and yet so limited and so firm as not 702 OBAL DISEASES AND SURGERY. at all to resemble the general tumefaction proceeding from toothache. Upon introducing the finger into the mouth, you found the tongue raised, turned edge uppermost, and pressed entirely toward the left side of the mouth, the external tumor being upon the right side. Upon pressing the fingers very firmly down by the side of the tongue, and reaching from without, you could sensibly perceive not so properly a fluctuation as an elasticity, which implied the presence of a fluid ; the tumor seemed elastic like a football, but with a degree of tension which made it seem almost solid. It was by comparing a variety of circumstances, especially the original place and slow growth of the tumor, that I confidently referred it to the sublingual gland. In this I had the advantage of the surgeon under whose particular care she was ; but I did him the justice to send her back to him, again and again, expressing my opinion and my wish at the same time that he should do whatever he might suppose right. By good fortune, she called upon me the day she was to return home, nothing being as yet done to the tumor, but supplied with abundance of blisters and plasters to apply at a fit opportunity to her throat. I felt now that professional ceremonies should give way to essential charities. I placed her in a chair, and almost without her conscious- ness — at least before she was aware — I struck a fine bleeding-lancet deep into the tumor by the side of the fraenum of the tongue, when, from the firm compression of the surrounding parts, the matter, though too gross to pass freely thi'ough such an opening, was spewed out from the orifice, in a manner expressly resembling that in which yellow paint is squeezed out from the bladder upon a painter's pallet. It was of a deep saffron color, thicker than mustard, mixed like gruel with seed-like particles, and exceedingly fetid. I knew that the tumor was not emptied, though the outward swelling was almost gone ; but I also knew that though I should not enlarge the opening, the second secretion from the surface of the sac, which is in all cases thin, would dilute and wash out whatever viscid matter remained ; and when she saw how suddenly my prognostic was fulfilled, she expressed a perfect confidence in whatever I pre- dicted, and a perfect willingness to submit cheerfully to whatever 1 proposed to do. Next day I introduced the point of a probe-pointed bistoury into the orifice made by the lancet; and, knowing that the lingual artery lies on a lower level, imbedded among the muscles, and running along the lower surface of the tumor, while I had over the point and blade of my bistoury nothing but the inside membrane of the mouth, much thickened, I ran it fearlessly and at one stroke. RANULA. 703 as the less painful way, along the whole length of the tumor, when the thickest of the yellow mucus flowed freely, or was raked out with the points of the fingers and the handle of the bistoury; and the tongue, descended now to its natural level, was in a capacity once more of delivering the peculiar dialect of her native city in all its purity. " So tense and apparently solid was this tumor, in consequence of the compression by so many surrounding muscles, that her surgeon mistook it for a solid and strumous swelling. I reckoned that in this, as in all cases of sacculated tumor, the second secretion, which was thinner, would wash out the thicker mucus, and I was not de- ceived ; but she left me too early for me to witness the obliteration of the sac. "I find it, in all such cases, a matter of some importance, es- pecially in a girl, to anticipate the outward suppuration of any sac- culated tumor, by puncturing it, though to a great depth within the mouth and under the tongue, and equally necessary to be at pains in preserving the opening and obliterating the sac : a slight miscon* duct in this respect occasions much distress to the patient and much superfluous labor to the surgeon." Illustrations. — In his own practice the author has treated quite his share of cases in this direction, having had as many as three at a single clinic. True uncomplicated ranula he has almost always been able to cure, without trouble or difficulty, by the use of the drainage seton. Fig. 240 exhibits such a seton applied. As studies, however, it may not be amiss to introduce a few illustrative ex- amples; and, as in the practice of others he finds all that seems necessary, he saves himself the trouble of writing out examples of his own by selecting from other sources. " Ranula. — Operation by Dr. Hamilton. P. R. Cortelyou, House Surgeon. "Dec. 13, 1867. R., of N., aged sixteen years, private patient, admitted to Bellevue under Dr. Hamilton's care. " Soon after birth his father noticed a swelling under his chin, near the median line, which has continued to increase ever since. Now the size of a large orange, nearly in the centre, but inclining a little to the right side. It is not painful or tender; its surface is smooth and elastic. On exploration it was found to contain a thin yellowish fluid. " Examining within the mouth, it was found to have lifted the tongue considerably; but its walls did not present the translucent 704 ORAL DISEASES AND SUBGERY. appearance sometimes seen in ranula, nor could it be decided posi- tively whether the orifices of the ducts on the right side were still open. It became a question what was the source of this enlarge- ment or tumor. " The term ' ranula' has been applied by some surgeons to obstruc- tions of the sublingual ducts, by others to obstructions of the sub- maxillary ducts, and by most surgeons to obstructions of either the one or the other indifferently. Certain writers, also, have extended the term to all encysted tumors in this region, whether occurring in the areolar tissue or in muciparous glands, which present a common external appearance like the throat of a frog. " It was not very clear from which of these several sources this tumor had originated. It was decided, therefore, to proceed as if it were an obstructed duct. Accordingly, Dr. Hamilton made a small incision into the tumor beside the tongue, on the right side, avoiding carefully the ranine artery. This opening was at once enlarged by introducing a pair of bullet forceps and expanding them, so as to tear the wound larger. The sac was emptied, and a piece of lami- naria digitata introduced. On the third day considerable inflamma- tion existed, extending to the root of the tongue and side of the face. There had been also, up to this time, a constant but slight hemorrhage. Both the swelling and bleeding abated from this time. The contents of the sac were examined under the microscope, but not with sufficient care to determine their character. "Feb. 1, 1868, nearly two months after the operation, the father reports that the sac has almost disappeared. A little pus continues to discharge, and there is no tenderness or swelling. The laminaria is taken out daily, and replaced with ease. It is probable that the complete cure will not take place under several mouths. "Dr. Hamilton mentioned that a ranula was said to form occa- sionally in a bursa outside of the genio-hyoid muscle; but he had searched for this bursa and could not find it." '^ Swelling of Submaxillary Gland from Inflammatory Obstruc- tion of its Duct. — Charles D. Hoyt, of Middlesex, Yates county, called upon Dr. Hamilton, December 29, 1846, with a moderate en- largement of the right submaxillary gland, it being apparently, as felt beneath the jaw, of the size of a large Lima bean. He stated that this enlargement occurred about one week before, while eating his breakfast, and that in five minutes it attained the size of a ' walnut with its bark on,' and that it prevented his opening his RANULA. 705 mouth freely. After leaving the table he rubbed it for sorae time, and in half an hour it was reduced to its present size. " From that time the same enlargement occurred every time he ate, and without any reference to what he ate. It enlarged most, however, while eating his first meal in the morning. By rubbing alone could it be reduced. Chewing tobacco seemed rather to diminish than to increase its size. It was not tender, nor red, but when enlarged to its utmost it caused a severe pain, which extended to his ear. " Tincture of iodine externally was first employed by Dr. H. ; but, no result being obtained, he directed him to take a full dose of Epsom salts. This had the desired effect. The enlargement dis- appeared very quickly, and did not return." " Obstruction of both Submaxillary Ducts. — December 17, 1847, John C. Lj^ons, aged twenty, Benton Centre, Yates county, con- sulted Dr. H. He stated that in the latter part of July, while harvesting, the weather being very warm, he discovered in the morning a soreness under his tongue upon the left side, and before night he found there was a tumor at this point. It was oblong and only about half an inch in length. His physician. Dr. Wolcoit, opened it the following day, and it discharged a glairy matter. Since then it had been opened four times ; but, a few days before calling on Dr. H., he discovered that there was a swelling on the opposite side, externally, in the region of the submaxillary gland. When seen by Dr. H. the gland was of the size of a pullet's egg, oblong, not painful or tender. It was increasing in size, but he noticed that it was larger in cold and damp weather. His health was good. He was advised to submit to a low diet, take physic, and apply externally the tincture of iodine. He was never seen again, and the result is not known. During the winter of l5<47 and '48 two similar cases of enlargement of the submaxillary gland were presented in Dr. Hamilton's Surgical Clinic, at the Buffalo Medical College, one of which had resulted in an external salivary fistula. " In a recent report of one of Professor Jarjavay's clinics, copied into the number of the Gazette des Hopitaux of November 23, 1867, similar enlargements of the submaxillary gland are mentioned as occurring in connection with obstructions of Wharton's duct ; but he restricts the application of the term ranula to obstruction of some one of the twenty-eight or thirty excretory ducts of the sub- lingual gland." Ranula. — In one of a series of interesting papers on "Anatomy 45 706 ORAL DISEASES AND SUBGERY. in its Relations with Medicine and Surgery," Professor D. Hayes Agnew makes the following remarks on this subject: "A tumor is met with beneath the end of the tongue, rising from the floor of the mouth, to which the name ranula has been applied. It involves the ducts of the sublingual glands, the excretory orifices of which here open. These become obstructed by some substance, either mechanical or inflammatory, the secretion accumulates behind, dis- tending thera finally into a semi-transparent tumor. Sometimes they are found to be firm and resisting in the texture. In such cases the distention has provoked an inflammatory exudation and its organization into fibrous tissue. The transparency will depend upon the attenuation of the mucous membrane. The san)e morbid condition may be present in a very limited degree, confined even to a single duct, so as to resemble a little vesicle. The cure of such can rarely be accomplished by puncture and evacuation of the con- tents : the wound you make will soon heal, and, as the duct or ducts are not restored to a previous condition, the swelling will be repro- duced. No treatment short of that which contemplates the destruc- tion of the glandular tissue will prove effectual. This is best attained either by injection or excision; the latter I think the preferable, which is readily done by including the mass within two elliptical incisions, and then allowing the wound to heal by granulation or stitching the edges together with the finest silver wire. If it be a small cyst, after clipping it away, the point of a stick of caustic may be carried into the wound for a moment or so. "Another tumor is 'found in this same locality, and which is pro- duced by a salivary calculus becoming arrested near the outlet of the submaxillary duct; and, last, another variety of tumor, which I am disposed to believe is rare, and being connected with the under surface of the top of the tongue, rather than the floor of the mouth, must be referred to the cluster of glands there situated. The sides of the tongue may be bound down by cicatricial tissue, so as to inter- fere with its proper functional movements. Sliould a nerve-filament happen to be included, it may give rise to a very painful condition. This is best remedied by incisions or exsection of the diseased struc- ture." Lately, at the Imperial Society of Surgeons there was exhibited by M. Paulet two salivary calculi found by him in Wharton's duct. In connection with the presentation was reported the unique fact — for such it was thought to be — that the submaxillary glands of both sides were found stuffed with calculi. M. Pana, however, presented RANULA. 707 at the same meeting a single calculus taken by excision from tin's gland.* Eanula treated by Mechanical Pressure. — "Nearly seven years ago," says Dr. Wm. Macdonald, "J. F., aged twenty-two years, and residing in M Street, in this city, consulted me in consequence of being much distressed with a ranula, or a large tumor under her tongue, arising from nn accumulation of saliva and mucus in the ducts of the sublingual gland. For two years after the period this person consulted me, she was attended both by my professional friends and myself, and that without success. During' these two years that this patient was under the surgical and medical treatment both of my medical friends and myself, the following methods of cure were adopted in succession : the ranula was very often opened with a lancet, and injections of rose-water and sulphate of zinc (five grains of the sulphate to the ounce of rose-water) injected by means of a syringe, night and morning, into the cavity of the emptied ranula. Occasionally, when the ranula burst of its own accord, and left an ulcer, considerable portions of the sublingual gland were dissected out ; and on one occasion the actual cautery was proposed to be employed ; but the patient would not consent to the employment of this method of treatment. During the two years the patient was under treatment she took occasionally tonics and alteratives, to- gether with laxatives, as the nature of her case seemed to require, but without any good effect. "In these critical circumstances it occurred to me, about five years ago, that, if the fluid contained in the ranula were completely evacuated, the employment of pressure over the tumor might cause adhesion of almost all the internal surfaces of the tumor, except a fistulous aperture or apertures, analogous to the sublingual duct, through which the saliva would necessarily flow, and by necessary consequence a radical cure would be produced, provided that a per- manent adhesion of both surfaces of the ranula could be eS'ected. " In order to produce such a result, I proceeded to perform the following operation. (I must remark that the size of the tumor at this period was such as to preclude the possibility of swallowing any fluid or solid kind of food.) I introduced a bent needle, armed with a ligature, into the ranula, with the view of enabling me to render the tumor steady while I was opening it with the lancet, and also in order to direct me afterward in injecting the ranula ; this * See chapter on Salivary Calculus. 708 ORAL DISEASES AND SURGERY. being done, I procured a common musket-ball of lead, a little flat- tened, and having a perforation through it, and through this per- foration in the bullet I introduced a yard or so of common tape, which was loosely tied around the neck of the patient, while the bullet remained in the patient's mouth and pressed by gravitation upon the upper covering of the ranula. It is obvious that the tape fixed to the bullet served only the purpose of preventing the patient from swallowing the bullet while it remained in her mouth. The bullet thus kept in the patient's mouth night and day for two weeks produced union by inflammation (caused by mechanical pressure) of both surfaces of the ranula, except two fistulous apertures analogous to sublingual ducts, through which saliva has flowed on each side of the fraenum of the tongue ever since ; and this patient has happily had no return of her troublesome complaint from that period to this date. Now, as nearl}'^ five years have elapsed since the cure of the ranula, we may hope that the disease will not again return." Carcinoma is a condition sometimes met with associated with the floor of the mouth ; when the disease is situated in the sublingual gland it is, without confusion, to be distinguished from either lipoma or ranula. A lipoma affords to the touch the sense of contact with fatty tissue. A ranula, however thick its walls, — except in the case of the encysted calculus, — may be recognized, by the employment of the exploring needle, to be a cyst. A cancerous tumor, especially when of limited size, has an expression of solidity pertaining to neither of the first two, while associated with it is the specific pain, absent in the others. Induration and enlargement of this gland when associated with epithelioma of surrounding parts would of course have explanation in the association.* * See Seirrhus of Tongue ; also chapter on Tumors. I CHAPTER XXXYI. NEURALGIA. The term neuralgia is from the Greek roots veupov, a "nerve," and aXyoq, "pain." It signifies a condition, or an efifect, and not a cause ; or, if this definition is not absolutely a correct one, the excep- tions to the rule it would form are, I am convinced, exceedingly rare. For such reasons it is, as commonly employed, a very decep- tive term, expressing a condition about as definitely as the term sup- puration would convey an idea of the phenomena of inflammation. Neuralgia, as the word has been made to have definite applica- tion, refers to paroxysmal pains, localized or metastatic, presenting no manifestation of any lesion at the seat of pain outside of the single phenomenon. The pains of neuralgia are mostly, although not exclusively, acute in character, are confined to the tract or to the periphery of a certain nerve, remit, or more commonly fully intermit, and are only accom- panied with tenderness of the part involved when an accidental asso- ciate lesion may exist, or when an irritation is so severe or has been so long continued as to have reacted on the neighboring vascular system. When, then, a practitioner has his attention directed to a seat of pain without apparent lesion, the matter of first importance is an appreciation of its cause. To say that such a one has neuralgia, and to treat him with nervines, is to say just nothing, and to do nothing, except indeed by accident. A first duty is to search for a cause, and, if discoverable, remove it, if that be possible. Now, these causes of neuralgia are, as I shall show further on, sometimes very evident, and very easy of removal ; and it will be seen from the illus- trations offered that one, from lack of observation, may utterly fail in giving a relief very easily and naturally afforded by another. Rheumatism and neuralgia are frequently confounded ; but how do the conditions disagree? Rheumatism is always accompanied with vascular perversion ; the pain is not distinctly localized, but is (t09) 710 ORAL DISEASES AND SURGEBY. diffused over a part involved ; it is a soreness, as a general thing, rather than a sharp, acute, concentrated pain. Movement aggra- vates this Soreness, changes in temperature afifect it ; it is not parox- ysmal, although it may be, and generally is, remitting; in short, it has a history, and this history is not difficult to read. Gout is another constitutional condition occasionally mistaken for neuralgia; but such a mistake should not occur, for here, too, is a history. Gout occurs in the high, indolent liver; it is decidedly inflammatory in its local manifestations. It attacks in preference the small joints ; it is accompanied by oedema, by congestion, and by enlargement of the veins; if it is metastatic, the seat of transfer presents like vascular phenomena with the original inflammation. But is there not a condition — a disease — which is, or might be, termed neuralgia ?* — as, for example, gout is a disease with an indi- viduality, or rheumatism is a disease. If, without being influenced by other than my own observations, I were to answer this question, I should incline to say there is not; and my reasons for the denial would lie in the fact that I have in one way or another become con- versant with so many cases which have stubbornly resisted a long course of treatment founded on an abstract neuralgic theory, but which have rapidly and readily yielded on the discovery and re- moval of some true lesion of which the pain was simply a sympa- thetic connection, — as, for instance, otalgia, hemicrania, or even sciatica, from an exposed tooth-pulp, from a splinter of foreign sub- stance, or from the pressure of an exostosis. It is certainly true that there is a class of persons who might be termed neuralgic ; these do not belong strictly to what is called the nervous tempera- ment, but are the anaemic and prostrated. A plethoric temperament disposes to inflammation, but plethora is not inflammation ; it is only a predisposition ; the nervous temperament is only a predisposition. *Dr. Anstie, whose monograph on Neuralgia has attracted much attention, as well as criticism for and against, advances and defends the position that as regards both the seat of what must be the essential part of the morbid pro- cess, and the general nature of the process itself, we must possess very definite information indeed. In the beginning of his third chapter he says, " I ex- pect to convince most readei-s tluit the essential seat of every true neuralgia is the posterior root of the spinal nerve in which the pain is felt, and that the essential condition of the tissue of that nerve-root is atrophy, which is usually non-inflammatory in origin.'" (P. 110 J There can be no doubt that such condition is to be met with as an explanation of peripheral pain ; but such a condition is merely one of the neuralgias. NEURALGIA. 711 It cannot be denied that cases called neuralgia, and treated without ideas of a definite lesion, do very frequently get well ; but has not the indication been accidentally met, just as with the Dewee's car- minative we treat the restless child and cure it without definite idea of the ailment, having in a single medicine the requirement of various conditions ? I think this is so. If neuralgia, then, is simply a phenomenon, — simply the expres- sion of an immediate or distant lesion, — the preliminary treatment must lie in a search after a cause. But is this cause always evident ? It is not, at least to our present acquirements : nevertheless, it exists, and, failing to discover it, we are compelled to desert princi- ples and experimentally treat with the hope of an accidental success. Are there predisposing causes of pain-radiation ? Undoubtedly there are, and these may, and always should, receive a proper degree of attention, as, in guarding against them, it might be that the proper lesion would not in itself be sufficient to inaugurate or maintain the neuralgia. Thus, of the exciting causes, a damp, cold atmosphere is probably one of the most potent. Fatigue, over-excitement, excess in drinking, poor diet, the too free use of coffee or tea, loss of sleep, costiveness, diarrhoea, — in short, anything which interferes with the easy and proper performance of functional life. In miasmatic neighborhoods, neuralgia frequently assumes the periodic type, evidently influenced by the malaria. And it is with- out doubt true that the exhibition of quinine will and does, not un- frequently, cure such cases. Whether this is because the medicine controls the full and complete cause of the trouble, or only removes an exciting cause, in the absence of which nature gains the mastery, I scarcely know, it being a matter of certainty that it is by no means always the case that in the destruction of the periodicity the pain is removed. Syphilis is another of the exciting causes of neuralgia. I have known a patient have great pain from diseased teeth, which could be held completely under control, although not cured, by iodide of potassium. The pain was undoubtedly from the teeth, as with the subsequent removal of these organs the trouble disappeared. * To epitomize the subject, we might say that in a state of health the nervous system represents the poised balance : it is neither excited nor depressed; it works in entire harmony with its require- ments. Apply now a source of irritation, and this harmony or balance is destroyed. According as the amount and extent of irrita- 712 ORAL DISEASES AND SURGERY. tion, so are the amount and extent of derangement. Life, says Bichat, rests upon the tripod of innervation, respiration, circulation. What- ever affects one of these legs affects the whole body. To appreciate the phenomena of neuralgia is, then, to appreciate the phenomena of irritation, — is to search over the economy until whatever lesion exists is exposed and comprehended. If a first view is dii'ected to the nervous system itself, we look for a lesion in the part which, by the expression of pain, seems most markedly implicated. The most decided cases of neuralgia are, without doubt, odontalgic. A tooth decays until the cavity contain- ing the delicate nerve is exposed ; the neuralgia has the simple, single signification of a direct irritation. Exostosis of a tooth-root presses on nerves ramifying in the alveolo-dental membrane; the signification is a similar one. Let us refer to a neuralgia occurring in the stump of amputation. Is the cause not most frequently found in the squeezing and pinching of a nerve caught in the cicatrix ? Is it not the same history where tumors grow about and press upon some nerve-periphery? But I had meant rather just here to call attention to derangement in nerve- substance itself, without associated or influencing lesion, if we might be able to find such derangements. Might I instance neuromatous expansion as found in stumps, and which are, evidently enough, sources of pain ? Are there idiopathic inflammations of nerve-sub- stance ? or do nerves in themselves degenerate and ulcerate? We may look at the subject from a still wider stand-point. There is no earthly doubt that a pure nervous irritation of the system at large may exist. There is certainly an individuality existing in this system. It has a mode of action of its own, and this action, as remarked by Dr. Wood, is susceptible of exaltation, depression, or deprivation in itself, and from the influences of its own peculiar agents. But can or do these vicissitudes express themselves ever, or even occasionally, in sharp neuralgic pains ? Connected with the digestive function we have often nausea and vomiting; with the secretory, disorder of the liver and kidneys; with the respiratory, hurried and otherwise irregular breathing; with the circulatory, a frequent and agitated, though seldom full or energetic, pulse. " As the offices of the brain," suggests Prof Wood, " are various, so also must be the signs of its excessive excitation. Irritation in the brain obeys the general laws of that morbid affection. If moderate, it exalts the healthy functions without otherwise altering them ; if stronger, it more or less degenerates the functions ; in great excess, it entirely NEURALGIA. 713 changes or abolishes them. Thus, sensation and perception may be rendered simply more acute, or may be deranged, producing vertigo, pain, and every variety of disorder in vision, hearing, touch, etc., from buzzing in the ears, unnatural coloring of objects, a sense of tingling, formication, etc., to complete hallucination. The intel- lectual faculties and the emotions may be excited into increased vigor, or may be completely perverted, as in delirium and insanity. The general overseeing faculty of the brain may be simply stimu- lated to increased vigilance, to a more ready and rapid response to all the intimations of its dependent functions ; or it may be thrown into excessive disorder, evinced by restlessness, jactitation, obstinate sleeplessness, etc. The motor faculty may merely impart increased activity and energy to the muscles under the influence of the will; or it may throw off more or less completely subordination to that principle, and give rise to every variety of spasm and convulsion. Finally, all the functions above referred to may be overwhelmed by an excess of irritation, and more or less completely lost in stupor and coma. This is nerve-irritation, from causes or influences which reside in, or in association with, the system, and to be considered alone in connection with the system." Reactions of vascular perversion on the nervous system are to be considered. Coup-de-soleil and apoplexy may be esteemed the opposite conditions in such reactions. How frequently have all the phenomena of partial compression — headache, giddiness, buzzing in the ears, disordered vision, tingling, formication, numbness, drowsi- ness, mental confusion, spasms, convulsions, etc. — been quickly re- solved and removed by the accidental rupture of a nasal vein having communication with a meningeal sinus 1 And how happily, when similar conditions have come on from long-continued chlorosis, has a course of iron relieved them 1 Every portion of the encephalic mass, every portion of its continuation in the spinal canal, every nerve- periphery, requires a certain amount and a certain character of blood to keep it in proper poise and nutrition. Too much blood, and too nutritious, and we have derangement from over-stimulation ; too little, and too poor, we have it from lack of pressure, lack of nutrition, and, in many cases, from effusions. Derangements in respiration act as predisposing causes to neu- ralgia. A patient who labors under an inability to aerate his blood, whatever may be the cause, fails to relieve that fluid of certain poisonous qualities, which, of necessity, sooner or later must disturb the nervous economy. 714 ORAL DISEASES AND SURG ERF. Anything and everything, in short, it may be said, which acts as a depressant in the vital economy, whether by over-stimulation or by under-nutrition, is to be thought of, and considered, in neural derangements ; overstud}', sensual excess, indigestion, hepatic and nephritic diseases, repression of the cutaneous circulation, the de- pressing passions, as fear, grief, melancholy ; the employment of sedative poisons, as opium, tobacco, chloroform ; living in an atmos- phere impregnated with irrespirable gases, — any of these may- assist some otherwise incapable lesion in determining an attack of neuralgia. The most extreme case of nervous mania that has ever come under my own observation, accompanied with general hyperaes- thesia and local neuralgia, was in the person of a carter, addicted to smoking. For three days this man was uncontrollable by any but physical restraint; at the end of which period, having secured a short interval of sleep and quiet, I placed between his lips a pipe of the strongest tobacco. I finally cured the patient, making the sec- tion of a nerve, and treating him with tobacco and sedatives, just as one treats delirium tremens with w4iisky and sedatives. In this case I am entirely satisfied that the local neuralgia was goaded to its intensity by the perverted condition of the general nervous system. Several cases of similar import I can recall, associated with the improper use of opium, and with the abuse of the sexual instincts. In the cases of persons long habituated to the use of opiates as a relief in neuralgic pain, operations which have considered and which have truly relieved the system of the lesion of offense are not apt to be followed by the immediate relief anticipated. Here is a point in which the most practical experience agrees with certain deduc- tions of Dr. Anstie, that " pain involves a lowering of function ;" while, on the other hand, it would not seem so reasonable to admit that it is " not a hyperaesthesia." Pain is of both conditions, and is to have such appreciation if it is to have cure. The first of the propositions finds demonstration plain enough in the exhibitions of the inebriate, who manifests the first symptoms of delirium only on the deprivation of the wonted stimulus, his aberra- tion having the meaning of exhaustion consequent on over-stimula- tion, as shown in what might be termed the synthetical proof of the primary demand for stimulation. From his own practice the author might cite many interesting cases illustrative of the difficulty of affording ease to a patient ad- dicted to, and long dependent on, opiates, even where the original NEURALGIA. 715 disease undoubtedly had been cured, — as, for example, in such in- stances as the removal of cicatrices or of foreign bodies ; these cases, however, are not at all in proof of the neuralgia being a disease in itself, but rather the reverse ; the pain is the expression of weak- ness, of exiiaustion. No lesion remains to be considered. Cure is to be found in getting back the lost equipoise. Exactly what this lost equilibrium may be called is entirely immaterial. Let it be named vaso-motor paralysis, as designated by Dr. Anstie, and let it be said that the paralysis is a " direct extension of the original mor- bid process from the sensory root to the motor, affecting the original fibres in the latter, which are destined to control the calibre of the ocular and facial vessels." Granting the premise of neuralgia being an expression of the presence of an irritant, or accepting the hypothesis of Anstie as to its being a condition of diminished vitality, it must certainly be felt that the hypodermic injection of morphia, — of ob- tunding agents, — so continuously practiced and recommended, has in it only the virtue of covering a wound temporarily from sight and calling it well : indeed, it is much worse than this, it is exhausting more completely that which is already exhausted ; it is medicating an effect and taking no heed of that which is the cause of the effect. The meaning, however, is not designed to be conveyed that the opiates are not justifiably to be used in neuralgic conditions; pain in itself is a cause of exhaustion, and it may prove the lesser of two evils to moderate or annul pain ; but opiates are to be employed as adjuncts. When we find ourselves forced to rely upon them, the confession is extorted that we know solidly nothing at all about the case we are so treating. In a letter to the London Times, republished in the Medical Times and Gazette, Sir Benjamin Brodie expresses his general dis- approbation of the habitual use of tobacco, and makes the following observations on its deleterious effects: "The effects of this habit are indeed various, the difference de- pending on difference of constitution and difference in the mode of life otherwise. But, from the best observations which I have been able to make on the subject, I am led to believe that there are very few who do not suffer harm from it, to a greater or less extent. The earliest symptoms are manifested in the derangement of the nervous system. A large proportion of habitual smokers are rendered lazy and listless, indisposed to bodily, and incapable of much mental, ex- ertion. Others suffer from depression of the spirits, amounting to hypochondriasis, which smoking relieves for a time, though it ag- 716 ORAL DISEASES AND SURGERY. gravates the evil afterward. Occasionally there is a general nervous excitability, which, though very much less in degree, partakes of the nature of the delirium tremens of drunkards. I have known many in- dividuals to suffer from severe nervous pains, sometimes in one, some- times in another part of the body. Almost the worst case of neuralgia that ever came under my observation, was that of a gentleman who consulted the late Dr. Bright and myself. The pains were universal, and never absent; but during the night they were especially intense, so as almost wholly to prevent sleep. Neither the patient himself nor his medical attendant had any doubts that the disease was to be attributed to his former habit of smoking, on the discontinuance of which he slowly and gradually recovered. An eminent surgeon, who has a great experience in ophthalmic diseases, believes that, in some instances, he has been able to trace blindness from amaurosis to excess in tobacco-smoking ; the connection of the two being pretty well established in one case by the fact that, on the practice being left off, the sight of the patient was gradually restored. It would be easy for me to refer to other symptoms indicating deficient power of the nervous system to which smokers are liable ; but it is unnecessary for me to do so; and, indeed, there are some which I would rather leave them to imagine for themselves than undertake the description of them myself in writing. "But the ill effects of tobacco are not confined to the nervous system. In many instances there is a loss of the healthy appetite for food, the imperfect state of the digestion being soon rendered manifest by the loss of flesh and the sallow countenance. It is dif- ficult to say what other diseases may not follow the imperfect as- similation of food continued during a long period of time. So many causes are in operation in the human body which may tend in a greater or less degree to the production of organic changes in it, that it is only in some instances we can venture to pronounce as to the precise manner in which a disease that proves mortal has origi- nated. From cases, however, which have fallen undei» my own ob- servation, and from a consideration of all the circumstances, I cannot entertain a doubt that, if we could obtain accurate statistics on the subject, we should find that the value of life in inveterate smokers is considerably below the average. Nor is this opinion in any degree contradicted by the fact that there are individuals who in spite of the inhalation of tobacco-smoke live to be old, and without any ma- terial derangement of the health; analogous exceptions to the gen- 1 NEURALGIA. 717 eral rule being met with in the case of those who have indulged too freely in the use of spirituous and fermented liquors." With such general considerations of the matter, it may prove most advantageous to pass to illustrations in the recital of individual cases. With the data afforded by such a review, we may with more satisfactory premises appreciate the principles of cure. Case I. — Mrs. B., the wife of an undertaker, suffered for a long time from periodic attacks of pain about the face and head. This person, exceedingly quiet and retiring, spent most of her life in sunless rooms, surrounded by the melancholy paraphernalia pertain- ing to the business of her husband. She was anaemic, and of poor general health and spirits. Although this patient had certain bad teeth, yet the pain had never seemed associated with them ; indeed, so insensible were these organs to ordinary agents of irritation, that a diagnosis was founded alone on her general condition and sur- roundings, and remedies applied entirely in such direction. Tonics were administered, window-shutters were unbowed, exercise and amusement, conjoined with generous living, were advised ; even with this entire change the patient failed to improve, but, on the contrary, grew worse. The diagnosis thus discovered to be at fault, the teeth were extracted; still the condition persisted, and the pain increased. She was now treated for over a year, the pharmacopoeia being exhausted in her case. Called in consultation, and acting on the belief of the existence of a special lesion in all such cases, I determined, with the concurrence of the gentleman in attendance on the case, to make a most careful exploration of her whole system. At this period the pain had assumed and continued the impression of an iron clamp over the head, terminating beneath, and which clamp seemed daily contracting itself. The terror and pain of this impression had become so great as to convert the patient almost into a lunatic. I found, on inquiry, that her internal organs had been most carefully examined, and inferred not to be in fault. My own investigations, therefore, were commenced externally. First, was there any remaining tooth or teeth implicated ? 1 examined for caries, for pulpitis, for nodules, for necrosis, for supernumerai-y teeth, for exposed cementum, but fully assured myself these organs were in no wise involved. I examined the spinal cord, and, through its expressions, the encephalic mass; organically, the trouble could not be found reflex from these points. I examined every articulation, the line of every artery, vein, and nerve, so far as I might follow them. I passed in review every observation and fact which might 718 ORAL DISEASES AND SURGERY. enlighten me, but without success, so far as any discovery of an exciting . cause was concerned. Finally, I returned to the oral cavity. The teeth which had been extracted the year before were the molars and premolars of the left superior jaw. Might there not possibly have been just the smallest particle of one of these teeth left in its socket ? I was making pressure in the canine fossa, when the patient made slight complaint; it was the only point which yielded difference in sensation. Now, what was this sensation, and what did it mean ? It was not pain of which the patient com- plained, not discomfort ; it was simply diff"ereuce of sensation. But it was the only point which had yielded expression; it was there- fore diff"erentially just to infer that here existed something, — the lesion, perhaps, of which we were in search. Acting on this hint, I obtained the consent of my colleague to make an exploratory tre- phine of the antrum, and, on performing the operation, discovered that branches of the intraorbital nerve running across the cavity had enlarged to the size of knitting-needles. These enlarged nerves, of which there were two, I cut away. The patient was immediately relieved, and, although three years have passed, she has bad no recurrence of her neuralgia. Case II. — In October, 1868, I treated and dismissed a patient, a young lady, who shortened a summer and fall campaign to come to Philadelphia for advice concerning neuralgia of the face, and of the ear and scalp. She described iier agony as being sometimes so great that only from chloroform could she get even a temporary relief; had been taking tonics and opiates throughout the summer; had no pain in any of her teeth, although on the upper jaw was a pulpless molar. Examining her mouth, my attention was attracted to a peculiar overriding of the second bicuspid tooth of the lower jaw by the first molar; the employment of a delicate curved probe revealed caries of the first of these teeth exposing the pulp ; the tooth was extracted, and the distant and apparently dissociated neuralgia in- stantly disappeared. A tendency to nervous irritability which exists in this patient may very well be re-aroused by the presence of the upper dead molar ; if this should prove to be the case, she is advised to have it extracted. Case III. — " Softenivg of Inferior Dental Nerve ; Exostosis of Infra-orbital Canal ; Trephining; Cure. Professor Greene's Clinic in the Medical School of Maine. — Mrs. W., aged fifty-four. About three years ago, patient began to suff"er from pain at the angle of the lower NEURALGIA. 719 jaw on the right side. This was paroxysmal in its character ; but the attacks were so frequent and severe as to unfit her for usefulness or enjoyment. Her sufferings hud been much increased during the past year, and the pain now affected the whole side of the face, being quite severe in the infra- and siipra-ov\)\\.?i\ regions. There was no tenderness or swelling ; no apparent derangement of the general health that was not referable to the local suffering. She had undergone most thorough medical treatment, both general and local, in the hands of good physicians, with no avail. Hypodermic injections of morphine and atropia had failed to afford any perma- nent relief. Professor Greene said, that from the fact that there was no failure of the general health previous to the local trouble, and none now except the debility, fairly attributable to the long- continued pain, and also the fact that the various plans of treatment, whether alterative or tonic, combined with the most powerful ano- dynes, had failed, it was probable that the disease was local in its character. Whether the inferior dental nerve alone was involved, or whether the main trunk or the fifth pair was diseased, was doubtful ; but, as the pain was so completely localized at the angle of the jaw at the outset, and so remained for many months, the probabilities were that the pain along the other branches was reflex. At any rate, it was one of those cases where we are justified in tre- phining the jaw and exposing the nerve. We might find the nerve inflamed or softened, or pressed upon by a little bony tumor pro- jecting within the dental canal. Oftentimes these cases were asso- ciated with and dependent upon ostitis or caries, but here there was no evidence of diseased bone. The two last molars had been ex- tracted years before, but the parts seemed healthy. Dr. G. had operated in one case where tlie nerve and the surrounding bone appeared perfectly healthy, but perfect relief followed division of the nerve. " Ether was given, and a curved incision, with its convexity look- ing downward and backward, made over the angle of the jaw, the bone carefully exposed, and with a small trephine a button of bone removed, exposing the dental canal. The nerve was found so much softened as to lacerate readily when the attempt was made to raise it from its bed. The exposed portion was all removed, the wound closed with silver sutures, and a wet compress applied. The relief from pain at this point was immediate and complete. The lady slept well without anodynes, and in a week returned home, well, with the exception of some pain still existing in the infra-orbital region. 720 OBAL DISEASES AND SURGERY. " At tbe end of six weeks she returned, complaining of a great increase of suflFeriug. The pain was well localized, and entirely neuralgic in its character. Ether was again administered, and by a curved incision the nerve was exposed at its exit from the infra- orbital foramen. It appeared to be perfectly healthy ; but, upon cutting away the walls of the canal for half an inch, a little sharp exostosis was seen upon the right side, pressing upon and flattening the nerve. This was removed, the wound closed, and simple dress- ings applied. The relief was immediate and complete." Case IY. — Neuralgia of Neck and Arm from, Carious Molar. — Dr. Hyde Salter, well known in connection with clinical practice, had suffered much from attacks of inflammation in the left lower anterior molar, which was extensively excavated by caries. At the age of seventeen these acute symptoms had ceased for two or three years, leaving nothing but a grumbling uneasiness in it. At this time neuralgic pains began to extend from the tooth down into the neck and left side, and thence over the collar-bone down the left arm, — these pains enduring several days and then remitting. There was no actual pain in the tooth itself, nor any tenderness in it, nor in the adjacent gum, nor any appearance of inflammation. The situation of the pain in the neck and clavicular and supramaxillary regions was exactly that of the descending cutaneous branches of the cervical plexus, and the part of the arm where the aching was the most intense and intolerable was at the insertion of the deltoid. These symptoms disappeared with the extraction of the offending tooth, and have never since returned. Case Y. — Intense Neuralgia of the Eyeball and Face ; Altera- tion of the Color of the Iris; Carious Teeth. — Mrs. C, aged thirty, had suffered for ten years from severe neuralgia, affecting the left eyeball and left side of the head and face, the iris of the affected eye having changed from a deep and bright hazel to a dull gray. The left lower dens sapientiae and the first upper bicuspid being found badly carious, these were extracted, and the operation was attended by a terrible paroxysm of neuralgia ; but after this had subsided the patient experienced relief for about three months, when, the old pain returning, the second upper bicuspid was found to be carious and intensely tender, and upon its removal a consider- able exostosis was found on the root. The pain vanished with the tooth. — (Guy^s Hospital Reports.) Case YI. — Neuralgia of Loxcer Jaw; Necrosis. — M. C, a laborer, applied for treatment, complaining of unbearable pain NEURALGIA. 721 situated about the roots of the inferior central incisor teeth. The most careful examination revealed no explanation, and the patient was dismissed for the day with an opiate prescription. A second examination, and many succeeding ones, failed to yield a diagnosis, opiates being continued during the period. At the end of some three weeks an inflammation supervened, resisted all treatment, and finally terminated in a necrosis, which cast off the two teeth with their alveoli; the exfoliation completed, the neuralgia disap- peared. Case VII. — Dr. Benjamin Rush relates a case of neuralgia in the nates, which, resisting other means of treatment, finally yielded to the extraction of a tooth. Case VIII. — Megrim. — A protege of the Princess of Conde was bled in the arm and foot twenty times for megrim of five years' standing. It at last being thought advisable to open the jugular vein, the princess applied to M. Petot to perform the operation. But this surgeon, not seeing the necessity for so frequent depletion, begged to examine the mouth, and found in the lower jaw, in which the patient had for a long time had pain and numbness, eighteen, instead of sixteen, teeth, resulting in a very crowded denture. By extracting the second molar on either side, he gave complete and permanent relief in twenty-four hours. Case IX. — Neuralgia Faciei and Odontalgia from 3Ienstrual Irregularities. — A lady of rank (Rayer), long suffering from amen- orrhoea, was subject to frequent epistaxis, pain in the side, and swelling of the abdomen and feet. These symptoms were overcome, and for a year she enjoyed good health ; but la.st summer, in conse- quence of mental distress, a severe neuralgia came on, which was cured for a time, but soon returned with the following curious symptoms: every evening the pains recurred, preceded by the dis- charge from between the upper canine and bicuspis of the left side of a matter which was at first thick, viscid, and bloody, but after- ward clear and so profuse as to fill a small vessel. The pains con- tinued the whole night. No remedies gave any relief but opiates, which suppressed both the pain and discharge and gave sleep. Case X. — A nun (Wepser), aged forty, was seized, atone of her menstrual periods, with pain in the head, eyes, and teeth. A tooth on the left side was extracted, but without relief; the pain passed to the right side, and for five weeks, with occasional intervals of from half a day to two days, caused much suffering, first on one side of the head, then on the other, the principal seat of the pain 46 722 OBAL DISEASES AND SURGERY. being a space two or three fingers broad on the side of the head. When the attacks were violent they were preceded by a strongly- marked chill, the throbbing of the temporal artery was very per- ceptible, the eye injected, and when the paroxysms were at their height flushings were experienced. In the treatment of this case, as tlie teeth were discovered to be not at all in fault, the surgeon opened an issue in each arm and a third on the neck, all three of which were made to discharge freely. Attention was also paid to the nervous system, with a view to give it tone and strength. Not much regard was paid to the amenorrhoea, because at such age the menses are usually very scant. In both the above cases the practitioners failed of a successful treatment, and evidently for the reason that, in each case, treatment was misdirected. A reflected or radiated irritability of the uterus was without doubt the lesion, — an ulcer or other local lesion being the offense. Case XI. — One of the most impressive cases of neuralgia ever treated b}^ the author has the following history. A Mr. B., serving in the war of the rebellion, received, as near as memory serves to recall the case, three gunshot wounds, — one in which a small minie- ball passed through the tarsal bones, a second in the arm, a third perhaps in the chest; the exact locations of the two latter are not distinctly recalled, as they did not associate with the case. After dismissal from the service, and after, upon his return home, being engaged for a long period in the occupation of a carter, the patient commenced to experience pain in the knee-joint and down the back of the leg, this pain during a period of months increasing to such extent in severity as to require a constant watch being kept to pre- vent suicide. The author feels justified in asserting that seldom is wit- nessed greater expression of agony in a human being than was the almost constant condition of this man. Spending two months in the observation and clinical study of this case, the conclusion eventu- ally forced itself upon the mind- that associated with the track of the ball through the foot existed some lesion of the anterior tibial nerve. Not that at this point there was pain, tenderness, or indeed expression of any kind, but a diagnosis by exclusion seemed to centre the trouble here : the author mentions particularly the absence of all signs, because he could find no one to second his conclusions or to indorse a proposition to make section of the nerve above the ankle. The nerve, however, was exposed and a section of an inch removed. From the moment of the operation the patient NEURALGIA. 728 was entirely free from his neuralgia, although tenderness about the knee upon pressure continued for some little time, while the super- ficial portions overlying both malleoli sloughed and remained in an ulcerating condition over three months.* Affections of the Nervous System dependent on Diseases of the Permanent Teeth. — Mr. Salter contributes to Guy's Hospital Reports a most interesting paper under the foregoing title, which contains much information of direct and practical value. "Disorders of this kind," says Mr. Salter, " are divided into those which are reflex, secondary, and remote ; and those which are direct, imme- diate, and from contiguity. In the former category would rank epilepsy, neuralgia, paralysis ; in the latter, local pain, facial palsy, some forms of amaurosis, etc. In other instances, such as those in which exalted sensibility of the tegumentary nerves of the face, or erratic pains through the maxillary nerves, are associated with toothache, it might be difficult to say whether the phenomena are mostly reflex or direct ; they probably comprise both conditions. . . . The posterior lower molars are but little removed from the tonsils and Eustachian tube, from the parotid region, and from the external auditory passage. The fangs of the upper back teeth are close to the orbit and its all-important contents ; and more posteriorly they approach the spheno-maxillary fossa and fissure. • Thus it is easy to account for the nervous complications which are directly entailed by the spread of inflammation from the periosteum of dis- eased teeth. "By far the commonest reflex nervous disturbances to w^hich dental irritation gives rise are neuralgic pains of the head ; and this is especially the case where the upper teeth are implicated. In the * Nutritive changes in connective tissue consequent on nerve-wounds, founded on an observation of one hundred and sixty cases, are referred to by Dr. S. Weir Mitchell in his valuable contribution to the study of nerve-lesions, "Injuries of Nerves." "In looking over my notes," says this writer, "I find that oedema was apt to come on suddenly ; sometimes the swelling came and went without obvious cause, and sometimes it was very persistent and accompanied with congestion of the skin. In generalized atrophic condition of a limb, the connective tissue shared the loss which fell upon the other tissues, seeming to disappear quite as rapidly as they. It is, however, indicative of the difficulties which surround these cases, that in a single instance I have seen a nerve-wound giving rise to an hj'pertrophic state of the connective tissues. The case is so unusual that I have been unable to match it either from my own material or from the records of others. Such a condition of Sclerosis of the areolar tissues is, however, a rare accident of spinal myelitis." 724 ORAL DISEASES AND SURGERY. supra- and infraorbital nerves, the globe of the eye, the temples, and particularly a spot near the vertex, a little on one side (the side of the affected tooth), in all these regions ' dental neuralgia' is really very common; and I have observed, not unfrequently, that, where the pain has continued long, the integument has become hot, and tender, and red. . . . " The several branches of the trigeminus appear to be the most susceptible of reflex affection caused by the dental irritation of one of them ', but next to the different elements of the fifth nerve, the branches of the cervical and brachial plexuses are most commonly involved. Thus, pains in the neck, shoulder, acromion process, in- sertion of the deltoid, or bend of the elbow, are by no means un- common, and with them occasionally a loss of motor power, a weary sense of fatigue in the flexor muscles, and an inability to grasp firmly with the hand. It would really seem that there is occasion- allv, and in some individuals, a special and exceptional communica- tion between the fifth nerve and those of the arm. Dr. Anstie has seen two instances in which wounds of branches of the ulnar nerve have caused reflex neuralgia of the fifth nerve. And he remarks upon this circumstance, ' That the mental perception of the patient should, in each of these cases, refer the pain, not to any point in the course of the injured nerve, but to the branches of the trigeminal, affords, in my opinion, a strong suggestion that that portion of the central nervous system with which the trigeminus is directly con- nected, presents some congenital or acquired peculiarity of organi- zation.' This idea is fully borne out by what one occasionally, but only occasionally and exceptionally, sees in the occurrence of brachial neuralgia and paralysis caused by dental irritation of the branches of the fifth nerve. " Reflex nervous irritation, dependent upon dental disease, is most uncertain and capricious in its manifestations. One person will suffer much from a comparatively slight cause, while in others the same condition more severely developed will produce no such result. There is, unquestionably, in some persons a neuralgic diath- esis ; and it is not improbable also that, in some individuals, there may be a congenital or induced peculiarity in the centric or, perhaps, collateral relations of certain nerves, by which the exalted polarity of one may be passed on and so reflected upon another with ab- normal facility. In persons obnoxious to these forms of neuralgia from dental irritation, nothing is so liable to produce an attack as exhaustion or depressed nutrition ; and patients will often tell you NEURALGIA. 725 that the attacks only come on when they are very tired, or have gone long without food. "Pain is only one of the phenomena of reflex dental nerve irrita- tion. It may induce muscular spasm, muscular- parahjsis, paral- ysis of some of the nerves of special sense, perverted nutrition. "As regards the teeth themselves which excite this exalted ner- vous irritability, nearly all their diseases appear capable of causing this condition. Thus : " Caries, with or without exposure of the pulp ; exostosis ; hy- pertrophy of the crusta petrosa ; nodular developments of dentine in the pulp cavity ; periostitis, plastic or superlative ; impaction of permanent teeth in the maxillary bones ; crowding of teeth from insufficient room. " Each and all of the above-enumerated abnormities of teeth have caused manifestations of reflex nervous irritation, though, as I have remarked, they may exist in the severest forms without producing any such result." Mr. Salter then records a series of cases illustrative of the vari- ous pathological conditions referred to, of which the following is a brief abstract : KEFLEX AFFECTIONS. " Facial Neuralgia from Dentine Excrescence in Pulp Gavity. — A woman complained of severe neuralgic pains obviously connected with an upper central incisor. The pain was of a gnawing character, abiding, but not constantly severe ; frequently merely a conscious- ness of the presence of the tooth, but at other times sharp and dart- ing, flashing up the side of the face, etc., through all the branches of the superior maxillary division of the fifth nerve of that side, and considerably augmented by sudden pressure, a tap upon the tooth, or marked change of temperature. The tooth was apparently sound, though somewhat elongated and slightly loose. No exostosis was found on the root after extraction, but on making a section of it (vertical, from side to side) an excrescence of dentine was dis- covered growing from the side of the pulp cavity, and occupying, for a short space, more than half its diameter. The removal of the tooth, though accompanied with a violent paroxysm of neuralgic agony, was followed by a total cessation of the pain, which never recurred. " Cranial Neuralgia from an Impacted Canine Tooth. — Miss 726 ORAL DISEASES AND SURGERY. B had ' cut ' all the permanent teeth in due course and position, except the left upper canine, the proper space for which was oblit- erated by the contact of the lateral incisor and first bicuspis. At the time jvhen the right upper canine appeared, a hard swelling was noticed in the palate, on the left side, and toward the front of the mouth, and this slowly developed into a prominent rounded ridge, extending obliquely behind the left incisors and left first bicuspis. No inconvenience was felt up to the age of eighteen, when severe headache, confined to a spot on the vertex toward the left side, attended b}" local heat, etc., temporarily relieved by pressure, made its appearance. This headache, which was recurrent in its nature, lasted until the patient was twenty-six, no actual pain being felt in the impacted tooth, although the region about it became hot and tender upon the supervention of the headache. The removal of the tooth by Mr. Cartwright — an operation involving much chipping away of the bony cavity in which it was imbedded — was followed by immediate and permanent relief, thirty years having elapsed with no return of the symptoms. "Intense and General Neuralgia from Exostosis on Fangs of Teeth. — Miss B. P. had gone through her first dentition with- out trouble, but, on account of some crowding on the advent of the permanent teeth, an upper and lower bicuspis on either side were extracted to make room. During adolescence she was attacked by neuralgic pains, at first confined to branches of the trigeminus, but afterward extending to the arms, legs, etc., indeed, nearly the whole body. The teeth, though apparently sound, had a tendency to elongate and spread, especially the upper incisors, with which the pain was at first chiefly associated. The offending teeth always gave pain on being slightly struck. Mr. Bell removed, from time to time, the teeth most obviously connected with the neuralgia, in each instance with temporary relief of the suffering, and in every case the fangs of the extracted teeth were found inc rusted with nodular exostosis, though the teeth themselves were free from caries. When Mr. Salter saw Miss P. (in 1851), only the two lower left bicuspids remained, and these were causing a continuance of the neuralgia, which ceased after their removal. On the fangs of both these teeth were the expected nodules of exostosis. This patient is stated to have been remarkably anaemic, the gums being * like wax stained of the palest pink,' and the alveoli remaining white and bloodless for some seconds after extraction before blood enough oozed from the broken vessels to partially fill the hollow sockets. NEURALGIA. 7-21 " Neuralgia of the Arm from Carious Teeth and from undue Presiiure of Artificial Teeth. — In the case of Mrs. E., caries of aii}^ of the lower teeth on the left side has been immediately followed by severe neuralgic pain at the spot, small and circumscribed, on the front of the left forearm, about two inches below the line of flexion. Having now lost all her teeth, and wearing a complete artificial set, whenever the lower denture hurts the jaw on that side, the same symptom is manifested. The right side has never been similarly aflfected. " Chronic Trismus from Impaction of Lower Dens Sapientise. — In a man aged twenty-three, with large teeth and comparatively small maxillary bones, the lower wisdom-teeth were imbedded, and unable,' from want of room, to come into place. The result was re- current pain and swelling within the mouth, followed by a sudden attack of ' lock-jaw,' apparently caused by contraction of the left masseter muscle, which, after four months' duration, was cured by extraction of the left second molar, the wisdom-tooth being out of reach. The posterior fang of the extracted tooth was much eroded by absorption. " Wry-neck from Carious Teeth of Loiver Jaw. — A young woman whose head had, for more than six months, been drawn down nenrly to the left shoulder, with considerable pain, was relieved in a few days by the removal of a stump and a partially decayed tooth from the left side of the lower jaw. ^'Epilepsy from Carious Tooth. — A boy, aged thirteen, under the care of Dr. Ramskill, had frequent attacks of epilepsy, occun-ing about seven or eight o'clock in the evening. Examination detected ' a molar tooth considerably decayed, with a swollen gum around it, and partly growing over into the cavity.' It was not very tender to the touch, nor did the examination give rise to toothache. The extraction of this tooth was followed by cessation of the fits. " Tetanus from Mechanical Irritation of the Pxdp. — The case of a gentleman (quoted from Tomes^s Dental Surgery), who, having broken off a front tooth, went immediately to a prominent denti.st in Paris and had an artificial crown pivoted with a gold peg upon the fang. After severe pain for four or five days, trismus set in, and was soon followed by tetanus and death. "Neuralgia of Face, Neck, and Arm, ivith Partial Paralysis of the latter, from Carious Wisdom-Tooth. — Miss W. 'was suffer- ing from constant aching pain in the left side of the face and neck, and in the left arm. The pain sometimes became intensely severe. 728 ORAL DISEASES AND SURGERY. The arm had lost nearly all muscular power.' These symptoms, after resisting- all medical treatment for two years, disappeared in a few hours after the removal of the tooth. "Amaurosis caused by Crowding of Teeth.— In this case (re- ported by Mr. Hancock in the Lancet of 1859, p. 80), a boy, aged eleven, whose sight had been previously unimpaired, found upon waking one morning that he was entirely blind. About a month afterward he w^as admitted to Charing Cross Hospital, where it was discovered that his teeth were ' much crowded and wedged together ; the jaws, in fact, not being large enough for them.' Accordingly, two permanent and four milk molar teeth were extracted, and ' on the same evening the boy could distinguish light from darkness, and on the following morning could make out objects. From this time bis sight rapidly improved, and he was dismissed cured on the 28th (eleven days after), the only treatment beyond the removal of the teeth being two doses of aperient medicine.' "Dr. AVatson ('Lectures on Physic,' fourth ed., vol. ii. p. 351) mentions a very similar case. But the blindness was confined to one eye ; it recurred two or three times, and was on each occasion cured by tooth-extraction. " Deaf ness from Carious Teeth. — Mr. Cattlin reports the case of a lady who had for about three months suffered acute pain in a diseased right lower molar, and in the corresponding ear and side of the neck, and who had been deaf for four days. 'The inflamed tooth was extracted, and hearing returned within an hour after the operation.' " Perverted Nutrition from Dental Ne?^vous Irritation. — Under this heading three cases are quoted from Mr. Hilton's work (' On the Influence of Mechanical and Physiological Rest,' etc.), in which the tongue was decidedly furred only on the side corresponding with carious or painful teeth ; one in which the hair of the left temple was bleached by unilateral neuralgia, arising from a carious molar tooth; and one in which ulceration of the auditory canal, ac- companied with offensive discharges from the ear, and enlargement of one of the cervical glands, was traced to a diseased lower molar on the same side, and subsided soon after the extraction of the tooth." In a paper on " Affections of the Eye from Dental Diseases," read before the Missouri State Medical Association by Dr. H. Z. Gill, the following instructive case is cited : "Mr. F. S., of Illinois, aged thirty-three; Irishman by birth ; farmer NEURALGIA. 729 bj occupation. Patient was sent to me by a medical friend, Feb. 12, 1812. The history of the case, as he gave it, is as follows. In the early part of the winter of 1870-11, he was attacked with neuralgia of the head and face. It was very severe at times, and continued so till the middle of the summer following. The neuralgia affected both sides of his head, and his vision to such an extent that he could not read. After the pain left him, in the middle of summer, his sight improved. In December, 1811, he was again attacked with neuralgia of the head and dimness of vision. Before he came to me he had been under treatment for the neuralgia, but I believe nothing had been done to relieve the amblyopia. He could scarcely see well enough to go on the street with safety ; could make out No. 16 of Jaeger's test-types. He had been able to sleep but little for several weeks, on account of the severe neuralgia. Ophthalmoscopic examination of the eye showed retinal effusion ; the retinal artery was very indistinct. The painful points of Valleix (points of dou- loureux) were well mai'ked, more especially on the left side of the head. The patient having lived in a region of country where ague at times prevails, I was prepared to learn that his treatment had been largely antiperiodic. I now sought for some definite source of irritation, inquiring first concerning his teeth, to which his answer was that he had no toothache, that his teeth were good. I then examined them by inspection, and by percussion with the handle of the forceps, yet elicited nothing, except that the teeth were not at all painful ; but there was decay in some of them at the margin of the gum. Having myself suffered from sensitive dentine, I determined to examine more carefully and minutely in the decayed spots. When he came again, in a day or two afterward, I made an examination of each tooth, and was rewarded by finding what appeared to be exposed necrosis of the alveolar process of the superior maxillary bone of the left side, but which proved to be a deposit of tartar, as large as the little finger-nail, attached to the fangs of the first and second molar teeth, the gum being intact around the necks of the teeth. I again percussed these teeth with considerable force before the patient acknowledged any soreness connected with them. I advised him to have them removed immediately, believing them to be the source of the neuralgia, and this latter the cause of the amblyopia. " After two or three days' consideration, he consented, and on the 16th I extracted, at the first sitting, the first and second molars and the second bicuspid. On examination of the teeth I found extensive 730 ORAL DISEASES AND SURGERY. nlceratioa around the fangs of the molars, extending in some degree to the second bicuspis. Believing the dens sapientiae not to be im- plicated, it was not extracted. Three or four daj^s later, I extracted the first bicuspis, believing that it was somewhat involved. Im- provement of the neuralgia and amblyopia commenced at once. On the 21st he read No. 14 of Jaeger, and on the 24th he read No. 6. His general condition steadily improved. " March 4. — Reads No. 2 with some difficulty. "Went home March 8 and returned March 13. Has had pain in his head only a part of one day, he thinks from riding in the wind ; reads now No. 2 with consider- able ease. Sleeps well. Called twice afterward, and went home on the 21st of March. After the extraction of the teeth, he called to mind the fact that about eight years since he had received a blow on his jaw while breaking a colt. The face was swollen for a few days and quite painful, but all uneasiness soon disappeared ; and he had entirely forgotten the circumstance until reminded of it by the extraction of the teeth. " In one part of the ' field of vision' there was greater defect than in the remainder ; and evidently, from the appearance of the fundus, there was, early in the case while under my care, retinal efi"usion. The specimens of teeth are preserved. The rapid im- provement must be ascribed almost entirely to the extraction of the teeth, thus removing the source of irritation." From the illustrations given, it will be inferred that the removal of any discovered lesion of irritation is the primary indication in every case of neuralgia. The idea has been advanced that there is seldom or never a neuralgia proper, but that such pain is simply an expression. It is unfortunately the case, however, that too often we are compelled to discover our weakness in a search after causes, and are thus rendered unable to treat a case scientifically, but are driven to empiricism. Even yet, however, we may render more than an accidental service; and the principle on which we would found such treatment is that of soothing and quieting, either as ap- plications would refer to the system at large, or to the particular part involved. Nervines, where there is general nervous disturb- ance, independent, so far as we discover, of other derangements, will be found sometimes to act very happily. The tinctures of va- lerian and gentian, in equal proportion, given in tablespoonful doses, make a fine combination. Bromide of potassium, where it seems necessary to keep up a continuous impression, is given with advan- tage in doses often grains, dissolved in a wineorlass of water, from 1 NEURALGIA. 731 two to ten times a day. If administered, however, in a paroxysm, forty to sixty grains will be found not too much, and it sometimes will be well to combine with it small doses of opium or morphia. R. — Potassii bromidi, gr. xx ; Morphias acetatis, gr. ^ to \, according to severity of pain ; Aquae, 5j. M. To be repeated as required. Valerianate of zinc is a favorite preparation with many practi- tioners. It may be made into pills with conserve of rose, or any preferred vehicle, each pill to contain from one-half to a full grain, to be given twice or thrice a day. Tincture of Indian hemp is prescribed iu doses of five drops, re- peated three times a day. Where there is disturbance of the visceral health, it has been found occasionally successful to produce rapid but moderate saliva- tion. Aconite made into quarter-grain pills, and administered cau- tiously, three or four times a day, is recommended. Digitalis in tincture, or the tincture of veratrum viride, in condi- tions of undue circulatory excitement, exhibited in five-drop doses until such excitement is subdued, will sometimes quickly relieve the pain. Colchicum, where there is a supposed gouty association, may always be employed. The wine of the root is the best preparation. In rheumatic neuralgia, or pain associated with a rheumatic con- dition, the following formula will be found very i-eliable ; certainly so, if some other existing lesion is not too antagonistic : R. — Potassii iodidi, 3ss ; Extracti belladonnas, gr. vj ; Yini colchici radicis, 5ss; Tincturse guiaici ammoniats, ^vj ; Aquae cinnamomi, 5vj. M. Sig. — A tablespoonful to be taken in a wineglass of water three times a day ; if it should purge, five drops of laudanum may be added to each dose. Arsenic is frequently used with decided benefit. It may be ex- hibited in granules of the twentieth of a grain three times a day. It acts well in cutaoeous neural"ria. 732 ORAL DISEASES AND SURGERY. Donovan's solution — the liq. hydrarg. arsen. et iod. — is a favorite with many practitioners. Dose, five drops three times a day, avoid- ing salivation. It is an alterative, having a variety of significations. In all cases associated with lassitude and anaemia, the following may be prescribed : Or, Or, R. — Elixirii gentiante ferrates, §vj. Sig. — Teaspoonful four times a day. R. — Tinctur^e ferri chloridi, §j ; Quinias sulphatis, 5j- M. Sig. — 15 to 20 drops three to four times a day. R. — Syrupi ferri pyrophosphatis, 5vj; Quiniae sulphatis, 5j- M. Sig. — Teaspoonful four times daily. Opium and ether, given in full doses before a paroxysm, with ten or fifteeu grains of quinine administered after the pain has ceased, will, it is asserted, at once make an impression, and frequently abridge the next paroxysm. Success is claimed for the exhibition of opium to the production of narcotism. Such treatment is only, however, commendable as an occasional expedient. Muriate of ammonia, in doses of half a drachm three or four times a day, has been given with advantage. A very soothing effect is produced by placing a lump of the ammonia on a burning coal and thus impregnating the atmosphere of a room. Oil of turpentine is frequently applauded by English practitioners. It may be given in doses of from one-half to a full drachm. Chloroform, or chloroform combined with camphor, is recom- mended. A formula used by Dr. Wood is as follows: R. — Chloroformi, f3ij ; Caniphorae, 3j- Mix with the yolk of an egg and ^vj of water, and direct a table- spoonful to be taken every half- hour, every hour, or every two hours, according to the urgency of the case, until relief is obtained, or some decided effects are experienced from the medicines, either on the stomach or brain. Or the chloral hydrate may replace this. Vermifuge medicines are frequently prescribed with benefit, par- ticularly in the case of children ; parasites frequently keeping up an NEURALGIA. 733 irritation, although presenting no definite signs. Of these medicines, one of the very best is the combination of spigelia and senna. R. — Syrupi spigelise et sennae, ^iv. Sig. — Teaspoonful doses three times a day. Four ounces will commonly be found enough to destroy any worms which may be present in the intestines. Cathartics are generally indicated in spasmodic attacks of neu- ralgia; especially is this the case when there is costiveness, furred tongue, sick headache or stomach, giddiness, etc. It is generally satisfactory practice to precede the purgation with a few quarter- grain doses of calomel. The character of the purgative is to be influenced by the condition of the patient. Sulphate of magnesia is generally found applicable. Blue mass, colocynth, and jalap, or the compound cathartic pill, I have mostly found objectionable. Where febrile disturbance is present, particularly do I think this combina- tion will be found to do much more harm than good. The ordinary Seidlitz powder, repeated three or four times within the day, is a very happy and really refreshing medicine. If it should not do good, it will certainly do no harm. Strychnine is an empirical anti-neuralgic medicine of much repu- tation. It may be prescribed in quantities of two grains, divided into eighty pills, one to be taken three times a day. Of local remedies there is a great variety. A formula long cele- l)rated under the name of Rauque's liniment, is as follows: R. — Extract! belladonnge, 9ij ; ^theris, ^j ; Aquae lauro-cerasi, §ij. M. Sig. — Let it be rubbed on the part and saturated flannel be ap- plied. The endermic application of morphia is a common practice. The medicine may be used on a blistered surface, or subcutaneously injected, — syringes for the latter purpose being made by all instru- ment-makers. To make a subcutaneous injection, it is only neces- sary to thrust the needle-point of the syringe into the rete mucosura, or it may be passed completely beneath the skin into the underlying cellular structure. Hot and moist applications are generally found of much service in quieting pain, — the part to be enveloped in old and loose flannel, 734 ORAL DISEASES AND SURGERY. and evaporation prevented by an investment with oiled silk or other material. In affections of the fifth pair, Dr. Richab, of Strasburg, attributes great good to one grain of quinine and two of common snuff, intro- duced into the nostril of the painful side. It is said in many cases " to act like a charm." Professor Charles Meigs introduced, several years back, a plan of treatment with sulphuric ether, which has yielded greater tem- porary success than anything else I have ever tried. He confused the nerve-currents by taking a piece of sponge saturated with ether, and, by a continuous but irregular round, touching, here and there, different neighboring surfaces, until the pain would disappear. If, for example, the pain was in the forehead, he would touch over the supraorbital nerve, over the infraorbital, over the anterior dental, over the facial, over the cervical, — alternating the touches to these parts for a period varying from five minutes to half an hour. In most cases the pain will, for the time, be relieved. Ci'easote, much diluted in simple cerate, is sometimes found very useful as a local obtunder, — five drops of creasote to the ounce of cerate or lard; to be rubbed over the affected part, little bv little, until relief is obtained. Dr. Kirby directs a liniment made of one drachm of tincture of aconite to seven of fresh palm oil, or with two ounces of camphor liniment, — a half drachm of the former, or double the quantity of the latter, to be rubbed in twice or thrice a day, according to its effects. It must be watched, however, as the medicine is cumula- tive; if its poisonous effects appear, stimulants are to be given. Dr. Grave's neuralgic plaster is compounded as follows: B. — Pulveris opii, 3ij ; Camphorse, 5ss.; Picis Burgundicce, q. s. M. Stupe the parts with warm water before applying it. Cazenave's pomade is thus made : B.- — Chloroformi, 5j ; Potassii cyanidi, S'jss; Adipis, §iij ; Cerse albae, q. s. Rub into the part a piece of the ointment the size of a pigeon's e^g, and cover with oilskin. NEURALGIA. 735 " Canea treated successfully by the Spine-bag. By Jolin Chap- man, M.D., M.R.C.P., M.S.C.S., Physician to the Farringdon Dis- pensary. — The cure of neuralg-ia, whether the disease be treated by drugs given internally, or by application of various kinds at the seat of pain, or by the two methods conjointly, is confessedly almost always difficult, and iu a large proportion of cases impossible. The cases reported below have been treated by a method altogether new. By stating each case with extreme brevity, I am enabled to present at one view within a small compass the results of several experi- ments ; and I do this in the hope that they may produce such an impression on the minds of professional readers as may impel them to acquaint themselves with the pathological and therapeutical prin- ciples of which these results are an expression. I shall hereafter publish an exposition of these principles, illustrated by reports of cases in extenso, and shall then give a full description of the treat- ment adopted. " 1. Facial Neuralgia. — T. H., a gentleman, aged thirty-five, who had been suffering during the previous fortnight, requested my advice March 18, 1865. He was in great pain, which had been continuous from the previous day, and which had wholly deprived him of sleep. The pain was chiefly on the right side of the face and head ; but during the morning preceding my visit the left side had become invaded. The affected parts were very tender, and somewhat swollen. The head was rather hot, the face flushed, the tongue thinly coated with whitish fur; pulse 92, full and strong. Several medicines prescribed by two physicians in succession had proved of no avail. "I applied a ten-inch spinal water-bag, containing water at 130° F., to the cervico-dorsal region, and shortly afterward left the pa- tient's room. Within half an hour I returned, when I found him asleep. The treatment was continued for two days by means of heat; afterward I used ice (at first in the lumbar region) ; and from the time he first fell asleep he continued free of pain, which has not since returned. "2. Facial Neuralgia. — Fraulein S., aged about twenty-five, con- sulted me February 3, 1867, on account of neuralgia affecting the infraorbital and dental branches of the trifacial nerve. The pain was not confined to one side of the face, but was sometimes most acute on one side, sometimes on the other ; it increased at evening, and kept her awake the greater part of each night. !She had been suffering in this wav for about three weeks before I saw her. Her 736 ORAL DISEASES AND SURGERY. general health was good. The affected parts presented no trace of hypersemia. " She was treated by means of ice, and experienced almost imme- diate relief. After three days of treatment she felt and slept very much better; and before the end of the fifth day the pain had wholly ceased. Nearly a year afterward she told me that it had never returned. " 3. Facial Neuralgia. — Mademoiselle M., aged twenty, consulted me in August, 1S67, when she was suflfering from acute facial neural- gia, the chief foci of which were the infraorbital foramen, and the mental foramen of the right side. The extreme pain came on in fits, sometimes at 8 a.m., sometimes at 2 P.M., but between the paroxysms the face continued to ache, and at times the patient had pain at the back of the head. She had suffered in this way about a fortnight before coming to me, and had several similar attacks during the preceding year. " The treatment consisted in the application of the double-col- umned hot-water bag. The malady was immediately subdued : no distinct paroxysm occurred after the first application of heat ; all pain rapidly and completely subsided, and since that date has not returned. " 4. Dental Neuralgia. — A. W. B., a Russian gentleman, suffer- ing from dental neuralgia, consulted me in September, 1867. The malady was chiefly confined to the teeth of both upper and lower jaw, but no particular tooth or teeth seemed to be especially affected. The pain was intermittent, and so severe as to interfere seriously with the patient's daily occupation. No cause of the disorder, which had continued some weeks, could be discovered, and the face, so far from showing any sign of hyperaemia over the seat of pain, seemed cooler than normal. In the course of the first day of treat- ment by means of the spinal ice-bag, the pain was completely sub- dued ; the cold was persisted in for some lime, and during the remainder of the patient's stay in England he continued free from suffering. " 5. Dental Neuralgia. — H. E., female, aged twenty-one, suffering from violent and continuous pain, spreading over the teeth and gums of both the upper and lower jaw, consulted me, January H, 1868. The pain was most intense in the lower jaw and on the left side ; she had intense headache also. The forehead and cheeks were notably hotter than normal, and she complained of great heat in the roof of the mouth as well as in the gums, — which were swollen and NEURALGIA. 737 sore. During the previous week she had had several teeth stopped with gold ; one of them became most especially painful, and there was threatening of an abscess at its root. "The treatment consisted in the application of cold across the occiput, and of heat over the ilio-spinal region, — in the first instance separately, and afterward simultaneously. The pain was speedily and completely annulled ; it recurred, and was again annulled by the same method on several occasions. The patient volunteered the statement that during the application of the heat her mouth became perceptibly cooler. "•6. Facial and Brachial Neuralgia. — Mary A. T., aged forty-four, first consulted me at the Farringdon Dispensary, December 28, 1861, when she was suffering from neuralgia of the right side of the head, face, and neck, and along the right shoulder and arm, extending to the fingers. The right half of the tongue was also afifected. The pain, which was exactly limited to the median line, was described by the patient ' like as if something is pulling the flesh off the bone, it's so dreadful, and sometimes as if the parts were screwed up in a vice.' " She was treated by means of ice applied along the whole spine. She improved immediately and rapidly, and as early as January 15, informed me that she had not had 'a bit of neuralgia' during the whole of the preceding week. Up to this date (February 29) the pains have not returned." Facial Neuralgia from Exposed Tooth Pulp. — Mrs. H. had suf- fered for several years with frequent intense and persistent facial neuralgia; had been under the care of four physicians ; taken most of the sedative, antispasmodic, tonic, and alterative remedies which could be named ; had been forbidden to go out of the house after sundown ; was not allowed to put her hands in cold water, etc. When consulted in reference to her condition, I requested that a thorough examination of her teeth should be made by a competent dentist, with a view of ascertaining if the trouble did not originate there. This was acceded to, but reluctantly, because no pain had been felt in the teeth. It was, therefore, with some show of gratifica- tion that I was assured subsequently that the teeth were all sound. I begged, as a special favor, another and more thorough examination, which, very much to my gratification, discovered an exposed pulp. This having been treated, the neuralgia disappeared, and has not since returned, a period of two years having elapsed. — (J. W. While.) Surgical Interference by Operation. — Interference by direct 47 738 ORAL DISEASES AND SURGERY. operation has not, as a general thing, been so satisfactory as could be desired. Operative surgery in neuralgia refers to the division or resection of nerves. In facial neuralgia, where such interference is most frequently practiced, the history of the majority of cases has cer- tainly not made sufficient offset to balance the risks incurred. It is undoubtedly true that cases occur where it would seem that nothing else can be done. But when sections are made of healthy nerve-cords one should be well satisfied that he has an otherwise irremediable condition in the nerve-substance external to his line of section. Following the history of reported cases from nerve-section, the inquirer will often have occasion for surprise at the difference between the actual and the descriptive results. And this must continue to be the case so long as operations are made without proper diagnostic perceptions; not that operative means are to be discountenanced, but it ma}^ with propriety be assumed that a sur- geon should find the indorsement of operative means only in a diag- nosis which discovers to him the true seat of the lesion of offense. As an example of the heroic practice occasionally pursued in this direction, both in our own country and in Europe, the following may be cited from a report in Gurer's " Progress of Surgery" (Berlin, 1863-65). The patient, a woman, submitted to various sections of the supra- and infraorbital nerves for a period of five years, but, finding no relief, repeated extirpations of the cicatrices were made, the common carotid tied, the ascending ramus of the lower jaw trephined, and the inferior dental nerve exsected, to- gether with the mylo-hyoid and lingualis, causing necrosis of the bone, which had to be removed to the articulation. Five months later the neuralgia returned, when the infraorbital nerve was ex- sected nearly to the foramen rotundum. This was followed by an osteoplastic resection of the upper part of the superior maxillary bone, but saving the alveolar process as in Langenbeck's operation. In another German case ( Vierteljahraschrift fur die practische Heilkmide) the powerful galvano-caustic apparatus of Middeldorpff's was employed, at once destroying everything in the spheno-max- illary fossa, being followed by a gush of blood from the internal maxillary artery, which instantly filled the orbit and all surrounding tissues. For operations practiced, and the mode of performing them, see chapter on Resections. Anomalous Nervoxis Disturbances from Diseased Teeth. — As a NEURALGIA. 739 continuation of the subject of reflex or associate disturbances, it may not be without advantage to add the following series of clinical ob- servations, abstracted from various journals which from time to time have come under the observation of the author : "Dr. B., a dentist, consulted me in reference to his eyes, which 'would not,' as he expressed it, 'focus together:' could see dis- tinctly with either eye, but not with both at once; was unable, in consequence, to practice his profession ; had consulted several phy- sicians ; been blistered, cupped, and had various applications made to the eye, but it was gradually growing worse. The pupil of the right eye was very much enlarged. "I pronounced a carious and diseased first superior molar to be the exciting cause. It was extracted, with almost immediate relief and a permanent cure." — {Dr. J. W. White.) Facial Paralysis. — Dr. Chas. Bacon reported to the New York State Medical Society the following interesting case of facial paral- ysis : " The paralysis occurred first on the left side, and was caused probably by irritation of the facial or seventh nerve, by the erup- tion of the dens sapientise of the upper maxilla of the same side, and exposure to cold. The swollen gum was freely excised, mus- tard pediluvia were employed, active catharsis procured, and the camphorated liniment with tincture of opium applied to the mas- toid region and to the angle of the jaw, and subsequently electro- magnetism to the same region was resorted to, followed by a blister to the mastoid region, the denuded surface produced by it being sprinkled, twice a day for two days, with one-eighth of a grain of strychnine, and then a few doses (fifteen drops) of a solution of three grains of strychnine in 3j of alcohol were taken. At the end of some seventeen months the paralysis had entirely disappeared. For about ten months the patient enjoyed uninterrupted good health, when he was again attacked with facial palsy of the right side. The gum of this side was swollen, A treatment somewhat similar to that pursued in the first attack was directed. At the period when the report was drawn up, about four weeks from the date of tlie second attack, the paralysis was lessened in extent, and the general health of the patient was good. The gum was less swollen, but the tooth had not yet made its appearance." la Mr. Waite's little book on " The Gums," p. 29, are recorded ten cases of paralysis from pressure upon the maxillary nerve, one being of the leg, the other of the arm. 740 OBAL DISEASES AND SURGERY. "Neuralgia loith Deafness, cured instantaneously by the Extrac- tion of a Tooth. — M. Ed. Vautier records (Gazette des Hopitaux) a case of such character. The subject of it was a very nervous, slender woman, who had suffered for about four months with intense neuralgic pains, radiating through almost all the teeth, and also the muscles of the anterior region of the left side of the head. There was constant lachrymation of the left eye, and from the mo- ment of the attack complete deafness in the ear of the same side. A number of physicians had been consulted, and sulphate of quinia, flying blisters, and atropia, in succession, tried without giving relief "When seen by Dr. B., she was suffering severely; had long been deprived of sleep, and could not chew her food. The teeth were examined with care, but no one could be found carious. The wisdom- tooth on the left side seemed, however, slightly painful on being touched, and loose. She was advised to have this tooth extracted, but, with some temper, refused. However, some days afterward, her physician again advising it, she consented, and the tooth was ex- tracted by M. Vautier. The pains at once ceased, and her hearing was restored. A month has since elapsed without any return of her complaint. She seems to be permanently cured." — {Dental Cosmos.) " Cases of Convulsions arising from Carious Teeth. — St. Bar- tholomew's Hospital. — Notes furnished by Mr. Alfred Coleman : "Case I. — L. C. G., aged seven years, a moderately healthy-look- ing child up to the age of four years and a half, when he had scar- latina severely, followed by glandular swellings. About four months since he was observed to avoid using his fingers, and would attempt to take up a cup between the backs of his two hands, for which his mother, thinking it was a childish trick, always scolded him, and tried to make him take it up in the proper way, but without much success. Fancying his right arm was diminishing in size, she took him to Mr. Coote, who sent him to Mr. Coleman to examine his mouth. This was on a Saturday. In the afternoon of the same day, after having been seen by Mr. Coleman, the child was attacked with a fit of what his mother described as shivering in the right arm, the arm and fingers being drawn up as well as convulsed; his speech also seemed affected. Shortly afterward, this was succeeded by another tit of the same character, which commenced with a feel- ing of pins and needles in the right shoulder, extending to the arm and hand. From the Saturday to the Sunday evening inclusive he had ten such atta,cks. On the Monday he had an epileptic fit, which NEUBALGIA. 741 lasted two hours, soon afterward followed by another, which did not last so long. " Wednesday. — The child has had no more epileptic fits ; but the lesser seizures still continue, occurring very frequently. He appears much alarmed at them. His mouth and cheek are drawn up during a fit, and he cannot speak; but says, 'Mother, it is going,' as the attack is leaving him. On this day Mr. Coleman extracted his four temporary second molar teeth, all of which were decayed, but had given him little or no pain. "May, 1861. — Has remained perfectly free from the before-men- tioned seizures since the removal of the teeth until within the last two days, during which he has had seven slight attacks. One of the first temporary teeth was found to be carious, and it Nyas removed about a week after this. His mother called and stated that he had one very slight attack since the removal of the tooth ; she promised to bring him should a second occur, but neither mother nor child has been seen since that time. " Case II. — M. J., aged about twenty-three years ; is healthy-look- ing, and enjoys very good health; suffers much from toothache, and during the tits has a tingling sensation in the palms of his hands and soles of his feet, but especially in the left arm. Several of his teeth were decayed, but not so much so as to require removal ; they were filled with gold, since which he has had no return of pain or the accompanying sensations." "Amaurosis consequent on Acute 'Abscess'' of the Antrum, pro- duced by a Carious Tooth. — By S. J. A. Salter, M.B., F.L.S. Read before the Royal Medical and Chirurgical Society. — The case upon which this paper was based was one of unusual severity, and of exceptional complications. The patient, a young woman twenty- four years of age, was attacked with violent toothache in the right upper first molar, which was followed by enormous swelling of the side of the face, and intense pain. The eyeball then became pro- truded, and she soon after perceived that the eye was blind. Shortly after the establishment of these symptoms, 'abscess' of the antrum pointed at the inner and then at the outer canthus, and a large dis- charge of pus at both orifices followed ; these orifices soon closed, and the general symptoms of the part continued unchanged, — the swelling of the face, protrusion of the globe, and blindness. This state of things lasted for about three weeks, when the patient was sent to Guy's Hospital, and admitted. 'At this time the patient exhibited hideous disfigurement from 742 ORAL DISEASES AND SURGERY. swelling of the face, oedema of the lids, and lividitj of the surround- ing integument. Upon examining the mouth, it was found that the carious remains of the first upper right molar appeared to be asso- ciated with and to have caused the disease. Together with the other contiguous carious teeth, this was removed, and led, by an ab- sorbed opening, through the floor of the antrum. The hemorrhage which followed the operation was discharged partly through the nose and partly through the orifices in the cheek, as well as from the tooth-socket, showing a common association of these openings with the antrum. The condition of the eye constituted the most important symptom, and the most distressing. The sight was utterly gone ; the globe prominent and everted. There was general deep-seated inflammation of the fibrous textures of the eye. The pupil was large and rigidly fixed ; it did not move co-ordinately with the other under any circumstances. Some abatement of the symp- toms followed the extraction of the tooth ; but it was soon found that there was a considerable sequestrum of dead bone, which was re- moved. The necrosis involved the front part of the floor of the orbit, the upper cheek portion of the superior maxilla, with the infra- orbital foramen, and a large plate of bone from the inner (nasal) wall of the antrum. The removal of the dead bone was followed by the immediate and complete cessation of all inflammator}^ symp- toms; but the eye remained sightless, and the pupil rigidly fixed. About five weeks after the removal of the dead bone, it was noticed that the pupil of the affected eye moved with that of the other, under the influence of light, though vision in it had not returned. The eye was frequently examined at this stage with the ophthalmo- scope. All the structures, including the retina, appeared healthy, except the termination of the optic nerve, which was perfectly white and anaemic, while that of the other eye was pink and natural. " The author referred to two other cases essentially similar to his own. The first (unpublished) occurred in the practice of Mr. Pol- lock, of St. George's Hospital. The patient had intense inflamma- tion of the entire maxillary region on one side, caused by a carious tooth. It implicated the whole face and the contents of the orbit, but was not attended by 'abscess' of the antrum or necrosis of bone. The inflammation completely ceased on the removal of the tooth, but the sight was permanently lost; the pupil was at first fixed, but afterward moved with that of the other eye. "Another example, closely resembling these, was published by NEUBALGIA. 743 Dr. Bi-uck, in Casper's ' WochenschrifL' for 1851. It was, however, more chronic, and the loss of vision was only temporary. " The author concluded his paper by suggesting that the serious ophthalmic symptoms depended on the nerves of the eye being in- volved in a plastic inflammation in their course, external to the skull and before their distribution ; that the optic nerve was permanently damaged, as shown by the permanent blindness; and that the third nerve was temporarily implicated, as shown by the temporary fixed- ness of the pupil ; and the eversion of the eye from the first seemed to indicate that the sixth nerve was less or not at all involved. Finally, the author left it an open question whether the anaemia of the optic nerve, as displayed by the ophthalmoscope, is to be looked upon as a cause or consequence of its suspended function." — {Lancet.) Sympathetic Action. — In the course of an article on "Amaurosis and other Disorders of the Eye, resulting from Injury of the Terminal Branches of the Fifth Pair of Nerves," in the American Journal of the Medical Sciences for July, Dr. D. Lente gives the following interesting observations upon the sympathetic relations of the teeth and eye : " Middlemore says ' amaurosis may arise during the period of dentition ; it may take place from the irritation of a carious tooth ; from laceration or other injury of the supraorbital nerve.' He relates a case in which Mr. Howship removed an encysted tumor from the scalp, which produced ' marked and permanent improvement in vision.'' Another case, in which M. Demours removed a tumor from the neighborhood of the eye, and thus produced amaurosis. Another from the Edinburgh Medical and Surgical Journal, ' which would appear,' he says, 'to prove that wounds of the infraorbital nerve may restore the sight of an eye which has long been lost from an amaurotic affection.' ' A man was affected with perfect gutta serena of the right eye, and had the sight of the eye restored, he thinks, in consequence of receiving a smart blow in the neighborhood of the infraorbital nerve of the right side of the face.' Another still more striking case, in which a person received 'a wound just above the right eyebrow from a piece of glass, which was removed imme- diately after the accident.' When the wound had healed, ' the sight of the right eye was very nearly lost ; he has had a painful sensation in the neighborhood of the cicatrix, and a singular sense of creeping, and pinching and quivering of the upper eyelid and the integuments of forehead.' ' I made a free incision of the cicatrix down to the bone, and all uneasiness at once ceased, and the eye, shortly after, assumed 744 ORAL DISEASES AND SURGERY. its healthy character and functions, and vision was permanently restored.^ Lawrence, after relating two or three cases of amaurosis following wounds and the formation of cicatrices over the brows, remarks, ' It is still a matter of doubt whether injuiy of the frontal nerve may cause amaurosis.' And yet, he adds, 'injury or other irritation of the trigeminus may bring on impaired vision or amau- rosis.' ' The sympathy between the trigeminus and the immediate nervous apparatus of vision affords the only explanation of some apparently obscure cases, in which amaurosis seems to have de- pended on a carious tooth, or on some other local affection seated in the head.' " The following remarks by Marshall Hall were reported in the London Lancet: 'These experiments,' alluding to those made by Magendie, 'are not the only evidence we possess of the influence of the fifth pair on vision.' 'In an interesting case under my own care, a partial amaurosis of the right eye has arisen appar- ently from the caries of the upper canine tooth of the right side.' It was augmented by unsuccessful efforts at extraction. It has not ceased, however, since extraction was effected. ' These facts,' says he, speaking of this and other cases, ' with the similar results from wounds or tumors of the supraorbital branch of the fifth, appear to me to confirm the extraordinary experiments of Magendie.' Hennen says, 'I have met with one or two cases of amaurosis from wounds of the supraorbital nerve.' ' Scarpa,' he says, ' doubts of the pos- sibility of the cure of amaurosis from this cause, and mentioiis Val- salva's case as the only one on record.' Mr. Hey, however, states another in the 3Iedical OhaervationH and Inquiries, vol. v. M. Larrey mentions another. Vicq d'Azyr, who gives a case of amau- rosis from a wound of this nerve, in the Histoire de la Societe Royale de Medecine, annee 1T76, says he has 'since divided this nerve in quadrupeds, but without producing any such effect.' " That defective vision may result as the direct consequence of irritation of the terminal branches of the fifth pair may also be in- ferred from the effects of remedial applications to these nerves, and from the phenomena observed to follow irritations and injuries of other branches not so immediatel}^ connected with the eye. Some of these instances it will be proper to mention. A friend of the writer, a distinguished surgeon of New York City, was inca})aci- tated for business by violent neuralgia of the face ; after having suffered some time with it, he noticed that one of his molar teeth was defective, and went to a dentist to have it examined, — not NEURALGIA. 745 supposing, however, that it had any connection with his neui-algia, since it gave him no pain. Its removal was advised. The operation was scarcliely over before the doctor experienced complete relief from his excessive pain. ' I felt,' he said, 'as if I could have shouted for joy.' A lady, a short time since, applied to me to extract a tooth for her little daughter, which, she said, had been causing her excruciating pain day and night; but, on examination, I could discover no defect, and prescribed some anodyne remedy, which gave only temporary relief. A dentist was called in, who also declined extracting a sound tooth, but on a second visit, and a closer examination, detected an unsound tooth at some distance from the offending one, and extracted it. The pain instantly ceased, and did not recur. Mackenzie relates a remarkable case in point. A man had violent neuralgia of the eye, soon succeeded by amau- rosis, and continuing, notwithstanding various treatment, from the autumn of 1825 until the beginning of 1827. At this time M. Galenzowski, to whom he applied, 'found vision of the left eye lost and the pupil dilated. He extracted a decayed tooth from the left upper jaw, and, to his astonishment and that of the patient, found, attached to its root, a splinter of wood, supposed to have been origi- nally attached to a toothpick of wood. Nine days after, the patient had entifely regained his sight.' Mackenzie relates another equally remarkable case, occurring in the practice of Dr. Van Zandt, of St. Louis, ' of a young man affected with complete amaurosis, excited by the persistence of two deciduous teeth. As soon as they were extracted, the patient looked up as if terrified, audi found his vision restored.' 'Morgagni, Notta, Deval, Tavignot, and others,' says M. Echeverria, 'have known amaurosis to be caused by neuralgia, and to disappear as soon as the neuralgia was cured.' (The italics in the above references are my own. — L.) Such cases as these might be multiplied, but it is scarcely necessary." * * * " There are several features in the rather remarkable history of Antoinette H. which require some notice before concluding this article. It was objected by a very distinguished oculist, to whom the case " [one in which part of a gun cap was accidentally driven into the pericranium of the left side of the forehead, producing amaurotic and other disturbance] " was related, soon after its occur- rence, that, the wound being on the left side, the amaurotic symp- toms should have affected the left eye, and not the right. But this is not more remarkable than that disease in one tooth should occa- sion a violent toothache in another perfectly sound ; or that irritation 746 ORAL DISEASES AND SUBGERY. of the nerves of the stomach by acidity should induce violent neu- ralgia of the supraorbital nerve ; or that an irritating application to the mucous surface of the eyelid should determine also an immediate irritation of the Schneiderian membrane, succeeded by violent sneez- ing ; or that simply touching the membrana tympani with a probe should sometimes give immediate relief to a toothache." — {Dental Cosmos.) " Facial Paralysis. — Dr. Coale reports the following case. The patient was a healthy, well-regulated girl, aged eighteen, who at first noticed that her face was somewhat stiff, and in twenty-four hours completely paralyzed on the left side. There was great distortion on laughing or talking, a staring left eye, and tenderness of the whole left side of the face. The tongue was not at all affected, the disease being confined to the portio dura. No cause could be found for it, unless it were that she had defective teeth in each jaw, as much, however, on one side of the mouth as the other. The treat- ment consisted of leeches to the place of exit of the nerves, strychnia, etc., but with no benefit. After the lapse of three weeks, she was advised to have her carious teeth removed, and thirteen were accord- ingly extracted. This was followed by manifest improvement in the course of five days. Electro-galvanism was then gently em- ployed, and the patient recovered. " Dr. T3ier said that several years ago he had under his care a lady with severe sciatica, for which all the usual remedies had been tried in vain. Finding that she had several decayed teeth, he ex- tracted four or five of them, with benefit. The remainder were sub- sequently drawn, after which the patient had no more pain. "In 1853, a boy, aged nineteen, was brought to the New Hamp- shire Asylum in a state of mania. Dr. Tyler ascertained that he had had a tooth extracted some time previous, and that one of the fangs had broken ofiF, and remained in the jaw. Suppuration took place, the pus discharging outwardly, and the boy was suddenly attacked with mania. The fang was removed. The fistulous opening closed, and the patient quickly recovered from his mania. " In another case of mania, the patient being a young lady, several decayed teeth were removed. The patient remained to some extent under the influence of the ether, which was given at the operation, for twenty-four hours. After that she was cured of the mania." Insanity sometimes caused by Diseased Teeth. — James Trudean, M.D., of Paris, says, " M. Esquirol told me that he had cured a young lady, who was insane, of her mania by the extraction of her NEURALGIA. 747 second molar tooth, which was preventing the growth of a wisdom- tooth." Ex)ilepsy from Diseased Teeth. — Dr. Rush (" Medical Inquiries and Observations") says, "Some time in the year 1801, I was con- sulted by the father of a young gentleman in Baltimore, who had been afflicted with epilepsy. I inquired into the state of his teeth, and was informed that several of them in his upper jaw were much decayed. I directed them to be extracted, and advised him after- ward to lose a few ounces of blood at any time that he felt the premonitory symptoms of a recurrence of his fits. He followed my advice, in consequence of which I had lately the pleasure of hearing, from his brother, that he was perfectly cured." Paralysis from Dental Irritation. — The American Journal of Dental Science, New Series, vol. i. p. 504, quotes from the London Lancet, as reported by J. L. Levison, of Brighton, the following case: "Miss , a young lady, was brpught in a carriage to my residence to have her mouth examined. On being removed, she was supported by a lady on one side and a man-servant on the other, and her entire muscular system seemed paralyzed. Her legs trailed on the ground like useless appendages ; her arms, when raised, fell powerless immediately, when unsupported ; and even the muscles of the tongue were paralyzed, and in her efforts to speak, this im- portant organ remained in a quiescent state. On examining the mouth, I perceived a dens sapientiae of the lower jaw very carious, and deeply imbedded in the temporal muscle, just below the ridge of the coronoid process, in which locality there was extensive in- flammation. I suggested the removal of the tooth ; and, though I had anticipated some advantage from the opei'ation, the actual result astonished me. She instantly obtained the free use of her tongue, which she immediately used to communicate an important fact, viz., that ever since the tooth I had extracted had been making its way through the gum she could date the gradual loss of power over her limbs, etc. I saw her about a month afterward ; she could then use her hand and arm, — she was writing a letter ! Since then I have not heard what progress she has made." Sir Astley Cooper, in speaking of the effects of slight irritation, says, " M. Toulmin, of Hackney, attended a lady on account of her suffering unusually from a diseased tooth, and she appeared to be afflicted with hemiplegia, M. Toulmin extracted the tooth, and in a short time the paralytic affection entirely subsided." Catalepsy from Toothache. — The Dental Recorder, vol. viii. No. 748 ORAL DISEASES AND SURGERY. 1, p. 197 (1854), quotes from Tlie Stethoscope, as reported by Dr. Hilton, the following- ease : " Willis, a plowboj (October last), was complaining of toothache early in the morning; half an hour after commencing work was observed lying a short distance from the plow, apparently dead. He was carried to the house, nearly a mile, and the doctor (five miles distant) sent for. In the belief that the effect might be produced through the dental nerve, the tooth was extracted, when the boy immediately got up and expressed himself as well as ever; and has continued well since. He had been an unusually healthy boy, and had never had a physician to see him before." The following interesting and, in a neuralgic aspect, suggestive cases were collated by Dr. Abraham Robertson, of Virginia, and published in the Dental Goamos : " Chorea is sometimes caused by Dental Irritation. — The Ameri- can Journal of Dental Science, vol. vi.. New Series, p. 146, quotes from the Denial News Letter the following "Case. — Dr. Billard sa\'s, after an examination of the case, which was one of what is commonly called St. Vitus's dance, that he found several stumps in both jaws, the gums entirely covering some of them, and on pressure of the same it caused her great pain, and pus exuded on the slightest pressure. *****! proceeded to give ether, and it took a double quantity to make her insensible to pain. I then took out eight stumps and some small pieces of dead alveoli, which had caused a continuous irritation of the parts. Since that time, the author states, the paroxysms grew less frequent, and now the patient, Miss L., enjoys her usual health." " Erysipelas from a Diseased Tooth; Death of Patient. — The following case was reported by Dr. Thompson, of the 'Seanjan's 'Retreat' (N. Y.), and furnished to the New York 3Iedical Gazette, in which it was published, vol. iii. p. 263 (1852), by Dr. Sayer, of that city. " Case. — Charles Lunt, aged thirty, Swede, arrived June 28 from Havre. Admitted into hospital, at the date just mentioned, for an inflammatory tumefaction of left cheek and parotid gland of three days' standing, as patient stated, from toothache, with which he had been annoyed for several days previous to the swollen face. Patient otherwise healthy, and of a stout, robust appearance. "On admission, the tooth of which he complained was extracted; there discharged, in cutting about the tooth, a considerable quantity of fetid pus. After extraction of the tooth, a powder of calomel NEURALGIA. 749 and rhubarb was given, and an emollient poultice applied to the face. The latter was continued, and antiphlogistic remedies pursued, but without much relief to the pain or reduction of the swelling, — when, after several days, the inflammation assumed an erysipelatous char- acter. The affected parts were now painted wtth a strong solution of nitrate of silver, evaporating lotions applied, and the remedies indicated by the constitutional symptoms administered internally. This treatment persisted in, the inflammation, in a short time, greatly subsided, and these promised hopes of a speedy recovery. Suddenly, however, the erysipelas commenced to spread, and the accompany- ing symptoms to increase in violence, until the palpebra of the (left) eye and parts adjacent became involved. As the disease advanced, pus was formed in several places, which was evacuated. The con- junctiva, partaking of the contiguous inflammation, became swollen and oedematous. The other tissues of the eye also soon became involved, and now occurred delirium and other symptoms indicative of the extension of the inflammation to the brain. This being ap- prehended, a vigorous revulsive antiphlogistic course of treatment was adopted, but without much relief to the patient. The symp- toms just alluded to continuing, and gradually increasing in violence, the disease on the fourth day of their occurrence proved fatal." "Vicarious Menstruation from Decayed Teeth. — Dr. Rush, 'Medical Observations and Inquiries,' says, in the second number of a work entitled ' Bibliotheque Germanique Medico-Chirurgicale,' published in Paris by Dr. Bluver and Dr. Delaroche, there is an account published by Dr. Siebold of a young woman who had been affected for several months with great inflammation, pain, and ulcers in her right upper and lower jaws, at the usual time of the appear- ance of the catamenia, which at that period were always deficient in quantity. Upon inspecting the seats of these morbid affections the doctor discovered several of the molars in both jaws to be de- cayed. He directed them to be drawn, in consequence of which the woman was relieved of the monthly disease in her mouth, and afterward had a regular discharge of her catamenia." " Dr. S. P. Hullihen reported the following " Case. — A young lady, about seventeen years of age, applied with a fungous growth in each of the second molars of the lower jaw, which bad assumed rather a novel character. She stated that the fungi had made their appearance in both teeth at the same time, about four years before, and that for the last two years she had been much troubled with a bleeding from them, which took place 750 ORAL DISEASES AND SURGEBY. regularly once a roonth, and continued several days. She being very anxious to have the teeth saved, I destroyed, to all appear- ance, the morbid growth, and plugged the teeth. In a few days they became sore and painful. The plugs were removed, and a slight bleeding commence, which continued three or four days, and then the tumors entirely disappeared. I was, therefore, induced to plug them again ; but in about three weeks the teeth became sore : the plugs were removed, and a bleeding ensued as before. I now sus- pected it to be a vicarious menstruation, and mentioned the case to the family physician. At his request I plugged them again, and the result was precisely as before. The teeth were then removed, and the patient was put under a course of treatment by her physician, which effected a cure. "As somewhat allied to this, I will here venture the opinion, although I have no case in mind by which to illustrate the fact, that other uterine diseases are often greatly aggravated, if not induced, by this san)e cause. And, improbable as it may at first seem, especially do I believe this to be true in relation to one of the most common afflictions — a very severe affliction, too — of the females of our country, prolapsus of the uterus. " This much, at least, is certain : general debility, however in- duced, is a most common cause of this complaint ; and I have often observed that when it is not complicated with other diseases, as in- flammation, ulceration, etc., it may readily be cured, often by topical applications only, or by topical applications in conjunction with tonics and healthful exercise in the open air, and sometimes by the tonics and exercise without any topical treatment, or perhaps by Dr. Meigs's cure alone, of 'six miles' walk a day, commencing with small doses, and increasing according to ability ;' but if from any cause the general health afterward suffers, and debility ensues, a recurrence of the prolapsus will also be likely to ensue. And since diseased teeth, by the nervous irritation they produce, by the de- rangement they cause in the digestive and respiratory organs, are a most common and potent cause of such debility, they must neces- sarily be the cause, indirectly at least, of this kind of suffering." Epilepsy connected with Denial Irritation. — " I. D., aged thirteen, has had epilepsy eighteen months. Had no fits in infancy, no ner- vous affection up to the period of present illness. Family history good. First attack occurred after eating some crab-fish for supper. It was long and violent. The second occurred after two months' interval ; cause of this not known. The third occurred in fourteen NEURALGIA. 751 days, and they have recurred at varying intervals, — from one week to three weeks. They always occur during the night. He screams sometimes, and not unfrequently bites his tongue. Latterly his mother has noticed that some days he rubs his left cheek, complain- ing of face-ache, after which the fit follows. He is a healthy-looking boy; tolerabh^ well-fleshed, although the muscles feel somewhat flabby. He is intelligent, and does not appear to have suffered in apprehension or memory; no headache or vertigo. Organic func- tions tolerably well performed ; no inter-paroxysmal phenomena. On examining the mouth, there is to be seen a molar tooth consider- ably decayed, with a swollen gum around it, and partly growing over into the cavity ; it is not very tender to touch, and the exami- nation does not give rise to toothache. On questioning, I find the sensation which the boy experiences before a fit does not seem to be one of pain, but rather of an indefinite uneasiness. He always has a fit the night on which this uneasiness comes on. Has never felt it during the day; it is always about seven to eight o'clock. I desired the mother to have the tooth extracted, and ordered a simple saline, with a quarter of a grain of belladonna, to be taken twice daily. This was in June. The tooth was extracted next day. I saw this boy once a fortnight from that time for four months, but he has had no recurrence of the fit. " In this case I believe an unfelt aura commenced about the gum surrounding the tooth, and w^as not recognized till some degree of inflammation arose, and thus a modification of pain became asso- ciated with the aura, and directed attention to it. I have, at the present moment, another and very similar case to this. The extrac- tion of the tooth has not yet been performed, so that I cannot give you the result. When epilepsy occurs in children, I always examine the mouth, with the twofold view of observing the vault as to height, narrowness, etc., inasmuch as no observation about the cranial de- velopment can be complete without such examination, and of ascer- taining whether any cause of eccentric irritation may spring from decayed or crowded teeth. I would observe here that, later, the dentes sapientiae often become a source of considerable irritation, and, therefore, of complication, at least in the epilepsy of young- persons." — (Dr. J. S. Kamskill, Medical Times and Gazette.) Many very interesting and instructive cases of neuralgia may be found by the reader reported by Dr. S. Weir Mitchell in his work on "Injuries of the Nerves," which can only be studied with the result of adding indorsement to the inference of the local origin of this complaint. 752 ORAL DISEASES AND SURGERY. Among the reports of the clinical services of the author will be found two by Dr. De Forrest Willard, where in one instance an old man who had suffered with neuralgia of the head for sixty years, and who many years back had endured section of the facial nerve, was cured by the removal of an imbedded tooth-fang conjoined with the extraction of an abraded inferior incisor. In the second case, a German aged about fifty, a neuralgia which had been under every variety of treatment for several years was clearly demon- strated to depend on calcification of dental pulps. The use of the constant galvanic current is credited with the cure of many cases of neuralgia, — the Weiss battery, used with from ten to fifteen cells, being, in this direction, highly commended by Drs. Anstie, Buzzard, Joseph Stead, and others. The Stohrer battery, made by the Galvano-Faradic Company, of New York, is highly spoken of by Dr. S. Weir Mitchell. Batteries made in Philadelphia are quite equal to any others, either of foreign or domestic make. In sixteen cases of treatment by battery application, Dr Buzzard reports "ten followed by very great and well-marked relief, two by moderate relief, and four by very slight relief." " Dr. Anstie refers to two cases, — one of severe neuralgia in the right cervico-brachialis, in a married woman aged forty-eight; the other of a double cervico-occipital neuralgia, in an unniarried needle-woman aged thirty. In the former case a cure was effected; in the latter, not. The constant current was employed, with the strength of ten cells, afterward increased to fifteen ; the positive pole in the first case being applied alternately on the various foci of pain, the negative pole being applied by the right side of the three lower cervical vertebrae. The pain was at once diminished, and ceased altogether at the end of thirteen days; and a secondary anaesthesia of the skin, with secondary paralysis of the deltoid and trapezius, was removed at the end of twenty-four days' treatment. The cure was found persistent six weeks later. Dr. Anstie re- marks that the effect of the constant current in neuralgia is re- markable, but that there are as yet some unexplained anomalies in its action. In the large majority of cases it acts as a palliative most strikingly. In a not inconsiderable number of cases it ap- pears to cure the disease absolutely; in a few examples it fails to produce any good eflfeots. As a general rule, it is far less eflective in the neuralgias of old persons with degenerated tissues than in younger subjects ; but occasionally even a young person, NEURALGIA. 753 like the second of his cases, fails to derive benefit from it." — {Lancet and Neio Remedies.) A writer in The American Practitioner recommends dropping into the meatus auditorius from four to ten drops of the following mixture, remarking it to be " very rare, with the use of this liquid, that relief is not obtained in a few minutes, and the patient asleep in half an hour, whatever may have been the severity of the pains, and that without having been in the least danger. Absorption takes place almost as rapidly as from a denuded surface, and it is, therefore, unnecessary to blister the patient when we wish to use narcotics, since they act almost as rapidly by the auditory passage. R. — Extracti opii, Extracti belladonnge, Extracti stramonii, aa pars j ; Aquae pruni Yirginiani, partes xij. " If it should happen," says this writer, " that at the end of eight or ten minutes the pain does not yield to the remedy (which some- times happens when the quantity used has been too small, or when we have to treat a neuralgia which has already required the use of narcotics in any way), it is necessary to use a second dose, at least equal to the first, but in the opposite case, in order to obtain promptly that relief which is only too frequently momentary, of facial neuralgias of long standing." Alluding to the extemporaneous character of the preparation, it is suggested that it may be preserved, if care is taken to keep it cool, by pouring on its surface from two to four drops of sweet almond oil. Among the recipes found in Dr. Napheys's "Modern Therapeu- tics," which have been selected from the most eminent practitioners, are the following, which may not be without service to many readers : Wm. Aitken, M.D., Edinburgh : When the neuralgia is superficial, compresses steeped in the fol- lowing solution : B. — Atropiae sulphatis, gr. v ; Aquae destillatis, f^iij. Renew the compresses several times in twenty-four hours, con- tinue them for at least an hour each time, and cover them with oil- skin to prevent evaporation. 48 754 ORAL DISEASES AND SURGEBY. Brown-Sequard : R. — Extract! belladonnae, gv. \ ; Extract! stramonii, gr. \ ; Extract! cannabis Indicae, gr. ^ ; Extract! acon!t!, gr. J ; Extract! byoscyam!, gr. | ; Extract! con!!, gr. j ; Pulver!s glycyrrhizae, q. s. For one p!ll. To be used w!th care, and not over four a day. Dr. Da Costa : R. — Aconitise, gr. ij ; Yeratriae, gr. xv ; Glyceriuae, f5ij ; Cerati ad!p!s, '^v]. M. To be rubbed over the painful part, care being taken to see that there is no abrasion of the skin. Dr. Wm. Hammond: R. — Extracti belladonnae, gr. v. Divide into twenty pills. One three times a day. Liniment of Guy's Hospital : R. — Liquoris plumb! subacctatis, Tincturae opii, Mellis, aa 5'j ; Confectionis rosae, §j. Fiat linimentum. London Hospital : R. — Tincturae aconiti, Liniment! saponis, aa f^j. To be used as an anodyne liniment. A liniment recommended by Dr. Napheys as an elegant sedative is as follows : R. — Atropiae sulphatis, gr. viij ; Morphiae sulphatis, gr. xvj ; Aconitiae, gr. ij ; Acid! sulphuric! diluti, "Iv ; Alcoholis, f^ss ; Ole! olivse, q. s. ad f^iv. M. I NEURALGIA. 755 Or, if a stimulant effect is also desired : R. — Cbloroformi, f^ss ; Spiritus terebinthinae, f^j ; Campboris, 5j I Olei lavandulffi, ^^Ixx; Olei olivae, q. s. ad f^vj. M. The first four ingredients should be mixed before adding the oil, and the liniment should be well shaken before it is applied. Dr. Felix von Niemeyer, University of Tiibingen : R. — Extracti hyoscyarai, Zinci oxidi, aa 9ij. M. Divide into eleven pills. Begin with one pill morning and even- ing, and increase to twenty or thirty of them daily. These, known as the Meglin pills, have a good reputation in Germany. Edward Wakes, M.D., London : R. — Potass® bicarbonatis, 5ss ; Extracti ergotae fluidi, f3j ; Infusi ergotae, f^vj. M. Two tablespoonfuls every four hours in tic-douloureux. One of the most intractable neuralgiae of the head ever met with in the practice of the author, yielded to compression of the facial arteries. Methodical rubbing of a neuralgic seat is recommended by Dr. S. Weir Mitchell. In a case, noted by this author, of contusion of the ulnar nerve subject to intense neuralgia, the nerve being hardened and enlarged, tender, and enduring no application of electricity, the pain was re- lieved by hypodermic injections ; but after using many remedies, and at last the actual cautery over the nerve-trunk without altering its size or tenderness, slow and careful manipulation was tried to test if it could be enabled to bear pressure. After a course of gentle friction, lasting half an hour, the object was attained, three sittings enabling the parts to be rubbed and even kneaded quite roughly. Concerning the odonto-neuralgiae, the reader is referred to the chapter on Odontalgia. CHAPTER XXXYI I, THE TONGUE AND ITS DISEASES. Of medical diseases the tongue has long been esteemed a reliable sentinel : hence, many and varied must be its expressions of functional derangements in the system at large. To term such expressions disease, however, could not by any means be proper, the sympathetic relationship being evident to the most superficial observer. In the foot-note the reader will find such medical aspect of the subject con- sidered with all fullness.* * " In drawing inferences from the condition of this organ, it is important to know whether the appearances it may present are the result of local disease in the mouth, or of the sympathies which connect it with other parts of the system. In general, there is little difficulty in coming to a correct conclusion upon this point: it is only necessary that the ^attention should be directed toward it. This organ seems to have been designed as an index, to the eye as well as to the ear, of the state of the system, so numerous and diversified are the morbid aff"ections which modify its healthy appearance. It not only par- ticipates in all general derangements of the whole system, serving as one of the surest guides to a correct judgment in relation to the degree, progress, and precise stage of the disease, but especially also sympathizes with the different parts of the digestive tube, at one extremity of which it is placed. " The bulk of the tongue may be increased or diminished. Its enlargement, when not so considerable as to be very obvious, may often be known by the appearance of indentations on its sides, made by the pressure of the teeth. This is occasionally one of the first signs of the mercurial influence. Its contraction, when not the mere e9"ect of dryness, is usually the result of a diminished supply of blood, and indicates either a general deficiency of the circulating fluid, or great feebleness of the heart's action. Like every other part naturally moist, it shrinks by drying ; and, under such circumstances, no general inference can be deduced from its mere loss of volume. " Its color is often greatly and significantly modified. Morbid floridness of the tongue is the consequence either of the condition of the blood, or of its greater abundance in the organ. In the former case an unduly arterialized state of the mass of the blood is indicated ; in the latter, either over-excite- ment of the circulation generally, or phlogosis of the stomach. Redness of the tongue, not the result of local causes exclusively, has been supposed by some pathologists to be an almost certain sign of gastric inflammation or irritation. But this is far from being the case. It is often seen when no (756) THE TONGUE AND ITS DISEASES. 757 Of organic or surgical diseases the tongue seems to have its full share. These diseases are of a twofold relation : local, as reference evidence of gastritis is presented, either by the symptoms or upon dissection, and is not unfrequcntly absent when that disease exists. Serious practical injury may result from this error. The red tongue can be considered as having special reference to the stomach only when other symptoms point in the same direction, and even then is by no means a certain sign. A livid or pur-ple color of the tongue is usually dependent upon an insufficient aeration of the blood, and is a valuable sign in connection with the same color of the lips. Not unfrequently the tongue is morbidly joaie; and this state is a sign of defici(mcy of the blood in general, or of its red corpuscles in particular, or of great prostration of the circulating forces. " Its condition as to dryness and moiature is often highly significant. But caution is necessary not to mistake dryness from temporary and unimportant causes, for that which results from general disease. In persons who sleep habitually with their mouths open, the tongue is apt to be dry in the morning ; and the same cause often produces the same etfect in sickness. On visiting a patient we find the tongue unexpectedly dry, and begin to feel some appre- hension, until we learn that the patient has been breathing for some time through the mouth alone. A stoppage of the nostrils often gives rise to this phenomenon. In all doubtful cases it is only necessarj' to request the patient to close his mouth and then move the tongue about so as to moisten it. If he succeed satisfactorily, we may conclude that the dryness was accidental, and of no account. Another caution is requisite: to take care, namely, that a really dry tongue should not be mistaken for a moist one, in consequence of the patient having recently taken a liquid into his mouth. Dryness may- exist in different degrees, from mere clamminess to perfect aridity. It de- pends on a deficiency of saliva, or of mucus, or both, and indicates a general tendency to diminished secretion. It not unfrequently occurs, as a sympa- thetic affection, in ulcerative inflammation of the small intestine. It affords sometimes the most important therapeutical indications. " The temperature of the tongue serves as a guide to that of the body gen- erally. When cold, it evinces, for the most part, great prostration of the powers of life. It proves that the process of calorification is failing at the very fountain ; for the breath must be cool before the tongue can become so in any considerable degree. This coldness of the tongue has been frequently noticed in severe cases of epidemic cholera. But we must take care not to confound coolness from local causes, as from ice in the mouth, or from the patient having slept long with the mouth open in a cold atmosphere, with that proceeding from the state of the system. Heat of the tongue, except when arising from inflammation of the organ, may be considered as a sign of a general elevation of temperature. " But the condition usually denominated a furred tongue is, perhaps, the most valuable diagnostic symptom aff"orded by that very important little member. In this state the tongue is covered with a morbid coating, which adheres so firmly that it cannot be removed without removing a portion of 758 ORAL DISEASES AND SURGERY. is had to some direct cause demanding only local attention ; indirect, as constitutional ofiFense is the agent against which a treatment is to be directed. the surface along with it. Occasionally deposits take place from the saliva and the mucus of the mouth; but these are easily removable, and must be distinguished from the genuine fur. The latter proceeds from a secretory process of the tongue itself, and seems to be incorporated with the superficial layer of epithelium. It is almost always confined to the upper surface, where the structure of the membrane is papillary. Though very generally a sign of disease, it is not always so. Some persons have a furred tongue habitually, more especially upon rising in the morning ; and, though in the greater number of these there is probably some chronic disorder of digestion, yet in others the health appears to be perfect. " A furred tongue almost always accompanies fever, and is one of the most decided characteristics of that affection. Indeed, when considerable in degree, and not dependent upon stomatitis of any kind, it may very generally be re- garded as a febrile symptom. When the fur is white, thickish, tolerably uni- form, and accompanied with moisture, it usually indicates an open, active state of fever, in which, though the obvious symptoms may possibly be violent, there is not apt to be any lurking mischief, nor any malignant tend- ency. When short, very adhesive, and rather scanty, permitting the redness of the tongue to appear through it, and attended with some disposition to dryness, it is often a sign of a protracted and obstinate form of fever, which is apt to assume a low, nervous, or typhoid form. A yellowish hue of the fur is usually indicative of bilious disorder, being produced either by the vomit- ing of bile, or, what is probably much more frequent, by direct secretion from the tongue, consequent upon deficient secretion by the liver, or an excessive production of bilious matter in the blood. Not unfrequently this color of the tongue is accompanied with a bitter taste. It is common in miasmatic fevers and hepatic diseases. A brown or black tongue is usually indicative of a low state of the system and an impaired condition of the blood. It is owing to the secretion of a dark matter, apparently identical with that which collects about the teeth and lips in typhous fevers, and probably consisting of blood modified in its passage out of the vessels. The same action would seem to take place in the tongue as that which, in the stomach and bowels, occasions the black discharges so common in malignant fevers. It may depend on an enfeebled state of the secreting tissue, or a diseased state of the blood, or on both united. Yery frequently this darkness of the tongue supervenes upon a previously white coating, and indicates a deteriorated state of the vital forces and probably of the blood. • The caution should be observed, not to ccmfound this discoloration with that which may proceed from accidental causes, as from the chewing of liquorice, tobacco, burnt coffee-grains, etc. In many instances, the white fur of the tongue is modified by red points, which are the tops of the swollen and projecting papillae. This appearance is not uncommon in eruptive febrile diseases, especially scarlet fever and measles. When con- sequent upon a dyspeptic state of the stomach, the fur is most copious in the THE TONGUE AND ITS DISEASES. 759 Of local injuries, reference may be made to ulcers caused by jagged and projecting teeth-roots, to cuts and contusions from falls and morning before breakfast. In some persons, emptiness of the stomach is said always to induce this state of the tongue. "The manner in which a furred tongue becomes clean affords valuable indications. When the fur slowly recedes from the tip and edges, thinning gradually as it retires, it intimates a favorable convalescence. A portion of fur often lingers near the root of the tongue, long after the disease has given way. In another mode of cleaning, the fur loosens and separates in flakes, often beginning at the middle or near the root, sometimes in large patches, or over almost the whole tongue at once, leaving a smooth, red, glossy sur- face, as though the papillary structure had been lost. In such cases, if acute, and if the tongue remains moist, convalescence almost always takes place, though usually tedious, and sometimes very lingering. In threatening fevers, it is VQVj desirable to witness this phenomenon ; and, as it is often preceded by a feeling of soreness in the fauces, this may be considered, when it occurs 'in such cases, as an auspicious circumstance. Much stress was laid upon this as a prognostic symptom by the late Dr. Joseph Parrish, of Philadelphia. Sometimes the fur recurs once and again, before it ultimately disappears; and weeks and even months are occasionally consumed in the struggling and apparently uncertain advance of the system toward health. In less favor- able cases, the tongue, after having commenced the process of cleaning, as just described, or even after completing it, instead of continuing moist, be- comes as dry as a chip, with an aggravation of all the symptoms, and no little increase of danger. The indication is still more unfavorable when, in addition to its dryness, the surface becomes gashed, chapped, or fissured, or exhibits a rough, scaly appearance. " This smooth, red, and glossy state of the tongue, sometimes with moisture and sometimes with dryness, is not uncommon in chronic diseases, in which it is generally a bad sign, and is supposed to indicate serious organic derange- ment of the alimentary mucous membrane. A still worse condition, how- ever, is an aphthous state of the tongue, which is apt to come on in the advanced stages of chronic diseases, and is generally to be received, under these circumstances, as a fatal sign, though of itself, and occurring in ordi- nary health, it is in no degree alarming. "A loss or depravation of taste is not uncommon, and is generally of little consequence, depending upon a mere derangement of the surface which re- ceives the gustatory impressions. But when of a paralytic nature it is much more serious, as it generally indicates disease within the encephalon. " The only other point requiring consideration refers io i\ie movements oi the tongue. When, in acute febrile diseases, these are not under the control of the patient, when upon being requested to protrude his tongue he is un- able to do so, or when the organ trembles much in the attempt, the symptom is exceedingly unfavorable, indicating either great prostration, or dangerous cerebral disease. Of similar unfavorable prognostication, under the same circumstances, is the occurrence of a diflicult and hesitating utterance, like 760 ORAL DISEASES AND SURGERY. blows, to bites inflicted under various circumstances by the teeth, to papular hypertrophies, to epithelial indurations and ulcerations, to stings from insects in fruit-season, to burns, scalds, the incautious or accidental mastication of acrid or irritating substances, to glossitis, from the excessive use of tobacco, from operations performed on neighboring parts, from mustard administered in strength in neces- sity for sudden emesis, etc. Of associate or constitutional diseases, the most prominent are the syphilitic and mercurial impressions appearing in the form of acute or chronic inflammations, indurations, fissures, ulcers, and cysts. Malignant manifestations, particularly the expressive scirrhus, have here also not unfrequently a first expression. With the almost exhaustive observations of the quotation from Pro- fessor Wood, given in the foot-note, is to be associated the fact that in some nervous, irritable persons the tongue is found habitually furred, yet without any symptoms of gastric or other derangement. Some persons get furred tongue the moment their stomachs are empty ; others have their tongues coated always after a meal and while digestion is going on, the coating passing away as the function ceases. Mental and moral emotions have a decided influence. Dr. Wright, in one of his clinical lectures, mentions the following striking illustration : "In calling upon a certain patient," says this gentleman, "the first thing I did was to look at his tongue. I found it, as usual, very pale, flabby, and moist, but without any coating. After having made other necessary inquiries, I was informed by my patient that his heart, which had long been disturbed by mental emotions, had on the previous evening beaten with unusual violence and irregularity. On my asking if he could account for it, he told me that he had just then received the distressing intelligence that an uncle, from whom he expected a competency, had not left him a shilling. This pitiable tale, told with much earnestness and visible feeling, occupied little more than twenty minutes. At the end of that time I again looked at his tongue, and found it coated with a thick, white fur." The most frequent disease of the tongue met with is perhaps syphilis. Syphilitic ulcers, the most common of the manifestations, appear on any part of the organ, but are most common on the sides stammering. The inclination of the tongue toward one side when pro- truded usually indicates palsy, and is one of the common attendants upon hemiplegia." — Wood. THE TONGUE AND ITS DISEASES. 761 and under surface. Such ulcers are almost invariably accom- panied by associations of their origin, — psoriasis on the body, nodes, falling of the hair, lymphatic induration of the posterior cer- vical ganglia. A syphilitic ulcer on the tongue has the appearance of chancre, hard or soft; we meet with them where the ulceration is quite deep and the edges are heavily indurated. ' Again, where there is neither excavation nor induration, we nevertheless know, from the associations, and from the peculiar characteristic appearance of the base, that they are venereal. A second form of syphilitic disease of the tongue is observed in the induration and hypertrophy of circumscribed patches of mucous membrane. The induration in these cases is so markedly localized that, if it were not for their varying locations, — being always, how- ever, on the dorsum, — one might readily believe them to be enlarged eircumvallate papillae ; the patches are quite as large as a dime piece, are elevated, and are as isolated as a fungiform wart. The author has seen two such patches on the dorsum of a tongue, and at the same time a large ulcer on its under surface. Cracks and fissures are other syphilitic indications met with on the tongue. It may happen in some instances that these fissures are so deep as to seem to divide the organ into a number of parts ; they always, so far as the author has observed, run lengthwise. These fissures are at times unbearably sore, denying the patient comfort either in eating or in rest. Indurations of the raucous membrane of the sides of the tongue from this cause are occasionally observed, or it maybe that a general thickening exists, or, indeed, that the whole organ is indurated. In this latter condition the disease has sometimes been mistaken for cancer ; but such an error could arise only from a failure to observe the associations of the case.* " Syphiloma {Gummata Syphilitica) of the Tongue. Dr. Neumann, of Vienna [Allgemehie Wiener Medizinische Zeitung, and Half-Yearly Abstract). — The dorsum of the tongue, as is well known, is frequently at its centre or lateral portions, more i-arely at the root of the organ, the seat of infiltrations, — the so-called syphilitic gummatous tumors, the size, superficial aspect, and pro- gress of which undergo many variations. These tumors, which are of firm consistency, are seated partly under the mucous membrane, partly in the muscular tissue of the tongue, and are developed from small infiltrations of the size of a pea to prominent nodules as large as a bean or hazelnut, or even larger. The growth sometimes extends laterally, so as to form level patches: in cases of this kind a greater part of the tongue, especially its edges, feels thickened, infiltrated, and hard as cartilage. In this aflfection the mucous 762 ORAL DISEASES AND SURGERY. Sometimes the dorsum presents red patches, the result, evidently, of a loss of the epithelial covering. These patches are perfectly smooth, not ulcerated, but are painfully sensitive to hot or cold impressions ; this condition will be met with where the dorsum seems literally skinned. By those familiar with the diagnostic description of the tubercular ulcer as insisted on by M. Tielert, it will be seen that with such a condition his premises become to a marked degree confused. To Prof Sigmund we are indebted for the knowledge of the fact that the raw ulcerations on the sides of the tongue called syphilitic psoriasis are very contagious, a diseased child poisoning the nurse, and the diseased nurse poisoning the child by chewing its food first in her own mouth. menibrane covering the growth is either smooth or covered by numerous papillarj' growths, which occupy a large portion of the tongue in the form of broad-based watery formations, or the surface of the dorsum may be trav- ersed by shallow furrows, or by deep fissures crossing in various directions, — rhagades ; or, again, if the mucous membrane be irritated by the sharp edge of a decayed tooth, it may present superficial patches of gangrenous tissue. " The whole volume of the tongue is increased to a considerable extent. Finally, the disease may proceed by softening of the nodules to a more or less extensive and deep loss of substance, in consequence of which the tongue on the affected side presents large cavities, which, when the loss of substance has aflPected the root of the tongue, exert a considerable influence upon the consonance of the speech. The movements of the tongue, also, as in speak- ing, masticating, and swallowing, cause much pain. These new formations, consisting partly of granulation tissue and partly of connective tissue, — which tissue, in its further development, becomes either soft and jelly-like, or is converted into adipose tissue, and forms dry yellow lumps, — were described by Eobin and E. Wagner as syphiloma. They present granular cell contents, and their cells and nuclei lie in peculiar hollow spaces — alveolar formation. "In cases of this kind one has to distinguish the infiltration of sj'philis from that of cancer. Hardness, rapid growth, painfulness, and an uneven surface, are, indeed, symptoms which speak more for cancer than for syphilis ; the existence, however, of a sharply-defined loss of substance, and the pres- ence on the dorsum of the tongue of warty or condylomatous growths, are indicative of gummatous deposit. In cancerous growths of the size of syphi- litic gummata, the submaxillary glands would certainl}- be enlarged. In doubtful cases the diagnosis might be determined by means of the microscope. In some cases the distinction may be indicated by the course taken by the disease. In syphilitic gummata the breaking down of the tumor commences deeply, and proceeds to the surface ; in cancer the opposite takes place, loss of substance commences superficially, and gradually extends to the centre of the growth." THE TONGUE AND ITS DISEASES. 763 The treatment of syphilis in the tongue has, with one special ex- ception, the twofold sig-niBcation of constitutional and local, — the exception being that of chancre. It has without doubt occurred that a man has gotten a chancre upon his tongue. Mercury, in some of its various forms, seems to be looked upon by most practitioners as having in this direction something specific in its nature; without doubt, however, it is a greatly-abused medicine, and should be used with more caution and judgment than generally characterize its exhibition. Where ulcers or other manifestations upon the tongue are second- ary in their signification, and mercury has not been used upon the case, it is marvelous how at times, under its influence, such mani- festations can be made to disappear. How this medicine is to be used is perhaps best left to be directed by the apparent requirements of individual cases. Of one thing, however, we may be sure : its best effects are not to be obtained by salivating the patient. Mercury in the form of the bichloride is a favorite preparation ; it may be given in doses of the tenth to the twentieth of a grain dissolved in water or the fluid extract of sarsaparilla, three times a day. The hydrargyrum cum creta, combined with Dover's powder, is a combi- nation which may be used with benefit where dryness and other lack of function are found in the skin. Impression by inunction is another mode of exhibiting the medicine. A lump of mercurial ointment, the size of a large pea, may be rubbed into the inner face of the thighs night and morning. Calomel in quarter-grain doses, com- bined with small quantities of sugar to render it palatable, may be given every two or three hours, until the patient remarks the cop- pery taste. Blue pill, in five-grain doses, answers very well if there be no hepatic disturbance, as manifested by gastric derangement and sick-headache. Of the various mercurial preparations, the preference will be found to reside with the bichloride : in this form the impression of the medicine is gradually secured. If necessary, it may be given continuously for a month. Combined with the mercurials, it is a common experience that tonics are generally found indicated, — a something to counteract the degenerative tendency which appears to reside in every dose of a mercurial administered. Iron, quinine, gentian, and the red bark are excellent preparations. A prescription which will be found to be a very good one is as follows: 764 ORAL DISEASES AND SURGERY. R. — Hydrargyri chloridi corrosivi, gr. iv ; Tincturae cinchonae eompositse, §vj. M. Sig. — A teaspooiiful three times a day. A second, admirable in cases associated with nervous disturbance, is the combination with the mercurial of the pyrophosphate of iron : R. — Hydrargyri chloridi corrosivi, gr. vj ; Syrupi ferri pyrophosphatis, 5^j- M. Sig. — A teaspoonful three times a day. In syphilitic disease of the tongue, tertiary in its type, mercury will seldom be found admissible. The system is broken down : the process of cure must be one of regenerative repair. These are the patients for the sea-shore and the hill-side. You will not get them well if you cannot build them up. Conjoined with the tonic medication of these cases, very ex- perienced authorities commend, for its alterative influence, the use of the iodide of potassium. Where it is thought desirable to use this medicine, ten grains as a dose for the adult may be given three times a day. It is most conveniently exhibited in water, or, if taste is consulted, in the fluid extract of sarsaparilla. Tertiary symptoms, as M. Ricord observes, do not inevitably occur in the course of syphilis, but they are very likely to do so if the treatment of the primarv and secondary symptoms be not conducted with the greatest care. As soon as the tertiary period has set in, mercury must be abandoned, and iodide of potassium given. Nay, further, as mercury taken in time may prevent or retard sec- ondary symptoms, and so may be regarded as a prophylactic against them, so may iodide of potassium be regarded as a prophylactic against tertiary symptoms ; and therefore M. Ricord, from the premises of his great experience, teaches " that to render the treat- ment of secondary syphilis complete and rational, it should always be followed by the exhibition of iodide of potassium. This substance is, however, not only useless when employed against secondary symptoms and those of transition, but very often hurtful ; yet, when secondaries have been of long standing, it may produce beneficial effects ; it is also useful as an adjuvant of mercury in those atfectioqB which in some degree lie between the secondary and strictly tertiary manifestations; and, finally, it is indispensable for combating the symptoms of a decided tertiary nature. In order to become well acquainted with the proper manner of administering the iodide of THE TONGUE AND ITS DISEASES. 765 potassium, we should take the trouble of studying its effects, inde- pendently of its curative action. First let us see how it acts on the skin. It may produce on the cutaneous surface diverse psydracious and acnoid eruptions. The pustules are generally surrounded by a vividly red areola, and the usual seat of these eruptions is below the umbilical region, as the nates, thighs, etc., whereas the common acne (not to mention its other characters) is mostly situated in the upper half of the body. To these peculiarities, it may be added that the pustules will fall in immediately the administration of the iodide is interrupted. Exanthemata, impetigo, and lichen are very apt to be produced by the use of this salt; and what you ought especially to keep in mind is, that ecchymosis and purpura in the inferior extrem- ities are sometimes caused by the action of the iodide of potassium. The effects of the latter on mucous membranes should also be care- fully observed. It may cause inflammation of the conjunctiva; the submucous cellular tissue lying under gets infiltrated and puffed up ; the eyelids turn red and oedematous, and, when the inflammation and effusion are not arrested, the internal parts of the eye become involved in the affection, and photophobia is the result of this state of things. The normal mucous secretion is always a little increased, but it does not take the muco-purulent character, as in the case of catarrhal ophthalmia. Coryza, of a more or less severe nature, often exists at the same time ; it is preceded and accompanied by headache, and a pretty abundant mucous secretion ; but this coryza never reaches the suppurative state ; it never produces more than a catar- rho-serous flux. These affections never give rise to any fever, and they disappear as soon as the iodide is given up. This coryza is an accident which we should not overlook ; for it is of importance to avoid it when we have to treat a tertiary affection of the nasal fossae. As for the effect of the iodide on the intestinal canal, I have to state that persons enjoying good health can bear very large doses of it ; I have given as much as fifteen drachms a day. M. Fuche has often given ten drachms per diem, after commencing with six ; and it has been noticed that it improves the appetite of the persons who use it. With some patients a certain pleurodynic sensation, corresponding to the cardiac extremity of the stomach, is felt after its ingestion ; but it never causes vomiting. The submucous cellular tissue of the stomach may, by the use of tliis iodide, undergo the same modifica- tions which we have noticed the conjunctiva to be subject to : a sort of hyper-secretion and intestinal ptyalism takes place, and much of the fluid which ought to have been secreted by the skin is rejected 766 ORAL DISEASES AND SURGERY. by the mouth. This liquid has a slight taste of iodine ; it is not fetid in the least; the gums are not swollen, and there is no fetor in the breath, as happens in mercurial ptyalism. The same effect may be produced on the other portions of the intestinal canal ; tlie patients are then seized with abundant serous diarrhoea. The iodine is elim- inated from the system by the kidnej'S ; half an hour after the inges. tion of it, its presence may be ascertained in the urine; and it should be remembered that the presence of iodine in the blood increases the renal secretion. I have even observed a case of polydipsia which went on as long as the iodide was used, but disappeared when the latter was discontinued, and gradually sprang up again as the use of the salt was resumed. " The effects of the iodide of potassium on the circulation are of a sedative kind; it diminishes the number of arterial pulsations, and lowers their force, but they may regain their normal standard if the remedy act beneficially on the system ; the same arterial en- ergy may also reappear when the iodide causes a slight phlegmasia. This salt is somewhat antiplastic ; for it has rather a tendency to liquefy the blood, and may even produce the peculiar hemorrhages of purpura. When the effect of the iodide on the nervous system is carefully watched, it is found to cause a certain excitement of the nervous centres, followed by a little uncertainty in the movements and in the intelligence." A combination much employed by Sir Astley Cooper, in cases where the iodide of potassium seemed not to favor the patient, was the liquor arsenici et hydrargyri hydriodatis, — Donovan's solution. Concerning the local treatment of the venereal affections of the tongue, with which, in a work like this, we would seem to have most to do, little is to be added outside of the suggestions offered on previous pages. The treatment is principally to be constitutional in character : direct medication is perhaps to be esteemed simply as palliative. As a local application of a common signification, lactuca sativa five ounces, honey one ounce and a half, and alum one drachm and a half, is a favorite with Ricord. Another consists of a decoction of hemlock, six ounces and a half, to bichloride of mercury, three grains. From my own experience, I have suggested the use of acids applied to the ulcers in cases where the dyscrasia has been corrected or nearly so. It is surprising with what rapidity a syphilitic ulcer will occasionally respond to almost any of the mineral acids. In a bad case of mucous tubercles I once treated, I got my patient THE TONGUE AND ITS DISEASES. 767 well by daily salt-baths and the local use of a paint composed of sulphate of quinia and iron ; twenty-five grains of the former to two drachms of the muriated tincture forming the combination. The tubercles were painted twice a day for two months. Borax is a soothing application ; it may be rubbed with water into a cream, and thus be applied ad libitum. A species of local specific, to be used on the part and rinsed away after a few moments, is composed as follows: R. — Aquse destillatae, 5ixss ; Ferri perchloridi, Acidi acetici, Acidi h3^drochlorici, aa 5j. M. This may be repeated three times a day. Fissures and fistulas are sometimes, in their chronic form, cauter- ized, nitric acid, pure or dilute, being used for the purpose. In a case of long-standing fissure of the tongue, the author on one occasion cut out the induration, the patient making a rapid recovery. Chloride of zinc, twenty grains to the ounce of water, will be found a useful application in chronic syphilitic conditions, whether of ulcer, fistula, or fissure. "In smokers and persons addicted to strong drinks or fed on irritating diet, the lips, cheeks, tongue, and especially the fauces, as pointed out by Dr. Charles Drysdale, and as has frequently been observed by the author, become the seat of interminable eruptions of mucous syphilitic lesions, just as in the external genitalia of women." These habits are not to be indulged in by persons so afflicted. Mercurial enlargement and induration of the tongue is a condition frequently demanding treatment. One of the first effects of this medicine is often seen in the markings made upon the sides of this organ by an otherwise not observed swelling which has crowded it against the teeth. -The tongue tumefied by the impressions of calo- mel may become so enlarged as to fill the whole mouth. One par- ticular case I recall, where, to prevent the patient from being smoth- ered, I was compelled to dnig the tongue forward over the lower jaw, and thus fix it until relief could be otherwise secured. Mercurial ulceration of the tongue is another of the offenses of this medicine. Such ulcerations are in appearance indolent and yet irritable, and are associated with similar conditions of the gums, and with salivation: the diagnosis is very plainly marked. 768 ORAL DISEASES AND SURGERY. The rational treatment of the mercurial conditions refers to the correction of the local impressions, together with elimination from, and support applied to, the system at large. In rapid swellings of the tongue, it may be found necessary to resort to the use of leeches combined with most marked derivation. In the case above referred to, forty common leeches were applied to the throat, the patient was profusely sweated, and these applications were succeeded by a saline cathartic. Such treatment, combined, if the circulation is sthenic, with some arterial depressant, as digitalis, aconite, or veratrum, will commonly relieve from the immediate danger. Unless, however, the ptyalism has been acutely excited, and the subject is strong and vigorous, this treatment will be succeeded by great lassitude and depression ; but such depression is a necessity, and has perhaps saved the life. A local treatment in cases of this kind is simply palliative and soothing. The lactuca sativa and honey, recommended in the syphi- litic sore-mouth, is an excellent gargle. Sage-tea, combined to a full saturation with chlorate of potassa, is another agreeable ap- plication. Common table-tea is very grateful to a patient. In combination with these, or any similar demulcent gargle, great relief has been derived from the free exhibition, internally, of the bromide of potassium. R. — Potassii bromidi, 5ss ; Aqu-ae, o^i'j- ^^■ Sig. — Tablespoonful repeated occasionally as the patient is found nervous. Twenty grains, as here directed, may be prescribed three times a day at the least. The author has given eighty at a single dose. The acute conditions of a mercurial glossitis combated, the prac- titioner may find it desirable to attend to the more general require- ments of the case. The system is to be protected against further impressions of the agent, while at the same tinle it will generally be found that a present support is demanded. Chlorate of potassa, the antagonist of the mercurials, has now obtained in this direc- tion an almost universal use: it may be administered in full satu- ration, in tablespoonful doses, three or four times a day. A very good way to prescribe this salt is to order one ounce placed in an eight-ounce bottle, which is to be kept filled with water until all is dissolved. As each dose is taken, the patient replaces it with fresh water. THE TONGUE AND ITS DISEASES. 769 In the treatment of the mercurial ulcer, the local applications suggested have been various. Bismuth, red bark, and borax, in equal proportions, act sometimes very happily. Chlorate of potassa, tannic acid, and glycerine form another excellent combination. Solu- tions of sulphate of copper or zinc, one grain to the ounce of water, are cleansing and stimulating applications. Iron, opium, chalk- powder, aromatic powder, are all, in their turn and place, useful. If phagedsena intervene or threaten, the potassio-tartrate of iron, as recommended by Ricord in the similar ulcers of syphilis, is not to be omitted: it may be used in the strength of thirty grains to the ounce. It should also be administered internally in doses varying from five to ten grains repeated every two hours. Chronic phagedsena, which in some degree associates itself more or less frequently with mercurial ulcers, is best treated by the poten- tial cauterants. Of these, a favorite is creasote: this is to be applied with care, however, as it may provoke secondary inflammation. Carbolic acid is a useful article, and will sometimes prove very reliable. Nitric and hydrochloric acids are highly recommended by many practitioners: when applied, every recess of the sore is to be burned, and this should be repeated daily until healthy granula- tions are provoked. SciRRHUs. — Of the third form of constitutional impressions, scirrhous carcinoma may now engage our consideration. This scirrhus of the tongue, from the circumstances of its association and position, is to be deemed a necessarily dangerous, if not fatal, disease. Scirrhus in other parts may be cured ; that is to say, being removed, it may not reappear in the part of removal, — although, being a con- stitutional condition, the disease is seldom, if indeed ever, perma- nently destroyed. That scirrhous carcinoma is not, however, at least in its incipiency, so formidable an expression as the encephaloid, seems to be the universal impression : there is a fixedness, an appar- ent isolation about it, which always invites operation ; that is to say, as is expressed in the chapter on Tumors, it exhibits the existence of an antagonism on the part of the vital force which invites and promises good from assistance. Situated in the tongue, such isolation is, however, unfortunately, not so marked as when found in many other parts: the disease ap- pears here as an induration rather than as what might be termed a lump, and this induration has not, commonly, a definite boundary; hence, if it be removed by operation, one is at a loss to say whether such removal has been complete. 49 770 ORAL DISEASES AND SURGERY. A carcinomatous scirrhus is to be distinguished from scirrhus of local signification, — first, by its resistance to treatment; and, second, bv the peculiar darting, lancinating pains which, sooner or later, always appear in it; these pains are markedly diagnostic. Again, a scirrhous carcinoma is apt to have a hereditary history : a generation may have escaped, but it is apt to be discovered somewhere in the family. Local medication to a carcinomatous scirrhus is perhaps worse than useless. If it is not widely cut away, it is better, a hundred times, to let it alone. Many a tumor of this class that would have remained dormant for years has been excited to the most destructive malignancy by over-officious meddling with it. If a practitioner does not know the character of a tumefaction upon a tongue, he cannot act more wisely than in doing notliing at all, until, at least, time and continued observation have made the diagnosis plain to him. At a period very various as to time, a scirrhous carcinoma ulcer- ates. If the tumor has attained any size, fungous granulations sprout forth, giving that expression known as fungus haematodes ; if, on the contrary, the tumor ulcerates while small, it is irregular, puckered, everted in its edges or elevated, and covered with abun- dant granulations : the discharge may be thin and sanious, or purulent, the latter character being, however, rare: it differs from the syphilitic sore in its grauulative bottom. A section of scirrhous carcinoma presents a stroma dense, abun- dant, and closely meshed. A fibrous struc- ture is always more or less marked, par- ticularly in its occult state, such structure assimilating both the white and yellow tissues, being perhaps really these tissues. A diagnostic sign is a peculiar creak or cry given under the knife. Another is a shrinkage or contraction in the centre of a section. Still another is a creamy juice, which may often be scraped from it. In looking at a microscopic slice of scirrhous carcinoma, the areolae existing in the stroma are found filled with gran- ules, nuclei, and nucleated cells: these cells being of most diversified form and common to no tissue, the term heteroclitic is justly applied to Fig. 242. W^^ A microscopic viewof tlie cancer- cells filling the interstices among tlie bundles of the fibro-cellular tissue in the skin of the breast. Magnified about two hundred times. (After Paget.) THE TONGUE AND ITS DISEASES. 771 them. The appearance of such a section is exhibited in the engrav- ing, Fig. 242.* *" It is well known that whenever a special predisposition to abnormal action exists in the vital economy, a very slight thing is sufficient to act as an exciting cause of disease. This is especially the case in many affections of both an organic and dynamic character, examples of which we have occa- sionally presented, among which was the apparent development of cancer from the irritation produced by rough or decayed teeth. Additional evidence upon this point is furnished by the following cases from the clinical report on epithelial cancer, by Mr. Jonathan Hutchinson, in the Medical. Times and Gazette: 'George P., aged thirty-six, a. dark, sallow, but healthy-looking man, was admitted, December 29, 1853, into St. Bartholomew's Hospital, under the care of Mr. Stanley, for a cancerous ulcer in the middle of the right margin of the tongue, about an inch in length, half an inch in width, and half a line to a line in depth. The base was irregular, not granular, nor dis- tinctly nodular or warty ; it was clean and moderately florid, and while in the hospital, and being guarded from the teeth by an ivory cover for them, it became level, and skinned over very thinly, yet enough to prevent its bleeding when lightly rubbed. The borders of the ulcer were upraised, with a somewhat lobed or glandular surface. This was especially the case with the upper border, which, occupying a portion of the dorsum of the tongue, over- hung a little the adjacent mucous membrane. The elevated border felt firm, tense, and nearly hard ; the base of the ulcer was equally so, and these char- acters were evidently derived from morbid deposits at and for about two to three lines beyond the ulcerated surface. At the border this deposit did not involve the very surface-layer of the mucous membrane, which was tensely stretched over it, but discernible with its small vessels. The rest of the tongue appeared to be all healthy. One lymph-gland by the side of the facial artery was slightly enlarged, firm, but not hard. The teeth by the side of the ulcer were not rough, but neither were they clean, and, as already said, the ulcer became smoother and skinned over when protected from them. " ' He said that nine months previously his tongue had become sore through the " fretting" of a decayed tooth at this part. He allowed the tooth to re- main for six months, the sore extending all the time until it had reached its present dimensions. At length, three months ago, the tooth was drawn ; the sore remained, and he was not aware of any change in its character. It was always very painful, and the pain extended from it over the whole cheek and the side of the head and jaw. Many of the cervical lymphatic glands under the right side of the jaw had been enlarged, but they had subsided two months previously; and the one by the facial artery had only in the last week been enlarged. His great-aunt died of cancer of the throat (sufficiently proved) ; but no other relative was known to have had cancer. He never had any syphilis or well-marked struma.' "After an ineffectual effort to remove the disease by constitutional treat- ment with iodide of potassium, the part was excised : the troublesome symp- 772 ORAL DISEASES AND SUBGERY. As scirrhous carcinoma always begins upon the sides of the tongue, jagged and sharp teeth irritating the parts may be supposed to have some influence in its localization ; such teeth, under all cir- cumstances, should be removed or smoothly dressed. In the treatment of scirrhus of the tongue by amputation, several modes are employed. One, that of the French school, is by means of an instrument known as the ecraseur of Chassaignac. This is simply a delicate chain arranged from a handle, which little by little crushes off the part. Another mode, that of strangulation, consists in the introduction of circumscribing ligatures, which, being drawn tightly, cutoff all circulation from the diseased part, thus compelling its separation.* Another means of treatment widely employed, and in instances recommended by very high authority, consists in the use of caustic remedies ; of these there is a great variety, — arsenic, toms subsided, the patient recovered, and is still in good health, — eleven years after the operation. " ' Caroline C, aged thirty-five, a married woman, and the mother of three children, was admitted, February, 1855, into Middlesex Hospital, under the care of Mr. De Morgan. She was subject to dyspepsia; but during the last few years she had been in rather better health. She had broken teeth on the right side of her mouth, which had irritated the tongue. Two years before her admission she noticed that her tongue was sore, and a year ago a lump began to form in it. Mr. De Morgan removed the right side and tip of the tongue by ligature. He made an incision in the median line beneath the jaw, and dissected his way upward, and then, having passed the ligature, tied it over a wooden bridge, which was fixed as a sort of tourniquet. In ten days or a fortnight it had separated. On March 19 both the wound below the jaw and that of the tongue were quite healed. There was then, however, suspi- cious hardening about the cicatrix. The disease soon afterward returned in the stump, and in the course of a few months the woman died.' " ' Daniel H., aged forty-six, was admitted, November 2, 1860, into St. Thomas's Hospital, under the care of Mr. McMurdo. He stated that twelve months ago he experienced a soreness of his tongue on the left side, which he imagined was due to irritation of some decayed teeth. Several had been removed in consequence, but nothing was done for the tongue. The ulcer in the latter grew more painful, and five months ago the glands below the jaw began to enlarge. There is at present an ulcer on the left and under side of the tongue. This half of the tongue is hardened, swollen, and very painful ; and he speaks with great diflBculty, from pain in moving the tongue, which is also not able to be much moved, from being swollen and tied down by the ulceration and induration. He suffers a great deal of pain. His health has generally been good, and he says that, except for the local distress, he feels well. He is, however, very sallow, haggard, and emaciated.' " * See operations on a succeeding page. THE TONGUE AND ITS DISEASES. 773 however, forming the base of most of them. No remedies require to be used with more judgment and caution. If the practitioner desires to try a caustic, my own experience would suggest chloride of zinc : R. — Zinci chloridi, Aluminis pulveris, aa gr. v; Acidi tannici, gr. ij ; Ferri persulphatis, gr. iij ; Glycerinae, q. s. for a paste. M. To apply this paste, draw the tongue forward, bold, and dry it carefully in a napkin. Lay some crystals of zinc on the part, and cover over with the paste. This may be allowed to remain as long as the tongue can be kept dry. Finally, wash the debris away, and the application is completed. It may happen, after such an application, that severe general glossitis will supervene ; this will be unfortunate, and will imply that much more harm than good has been done. In making a caustic impression under such circumstances, the parts should be quickly killed, not excited and provoked. . The galvanic cautery, a means suggested originally by Heider, and lately made quite practical by Hilton, is thought by many to be greatly preferable to the potential cauterants : this consists of a long, delicate-bladed forceps transmitting copper wires, which, being applied to the part to be acted upon, are instantly heated by the galvanic current, thus destroying the vitality of the part outright. Injection of persulphate of iron is still another means much em- ployed and commended. My own experience with it, however, has not led me to look upon it as a specific. The arrows of Maisonneuve, tipped with zinc, may be used by those who do not fear a resulting inflammation. Two, three, or more of these arrows may be made to circumscribe the tumor, pre- cisely as practiced by this surgeon in his operations upon the mam- mary gland. Epithelioma.* — Except as situated upon the lower lip, in no situ- ation has the author more frequently met with epithelioma of cancer- * To the histologist, who, judging entirely of the character of a patho- logical new formation by its cell expression, the distinction here assumed between scirrhus and epithelioma will serve to exhibit the author as not accepting the assumed identity of the conditions. What he has to say on this subject will be found in the chapters on Tu7nors. 774 ORAL DISEASES AND SURGERY. ous expression than upon the tongue. Situated upon the sides and along the fraenum, the disease is commonly first noticed as an irreg- ular puckered patch of more or less hardness, and almost from the very beginning has associated with it a characteristic pain. More frequently than otherwise, instead of one patch, a sufficiently close observation will discover the affected side studded, — a matter which is not long in being made evident enough to the patient. After a time, differing in different individuals, these patches sprout forth the giant granulations so characteristic of this disease, the surface of the sore becoming foul and ragged, and inclining to spread over neigh- boring parts. Ill a case at present under the care of the writer, in which preparation is being made for the amputation of the full tongue, the disease exists as an infiltration, involving the entire right half, but not passing the raphe. In no cases of disease does there seem to exist greater reluctance on the part of the general practitioner to the admission of the exist- ence of a fatal malady than in this of epithelioma of the tongue ; and this, perhaps, is not to be wondered at, seeing that not unfrequently an ulcer of such signification will lie in a dormant condition for a period of several months, looking to the inexperienced scarcely as formidable as a syphilitic sore. Such oversight is always of lament- able consequence, as tlius the most promising period for the em- ployment of operative means has been suffered to pass without advantage. Cancerous epithelioma, so frequently confounded with syphilis, is to be distinguished from the latter expression not only by its location, but with most assurance by its appearance ; the first being characterized by isolated giant granulation of rough surface, the latter by a soft, pasty base. The two are really very unlike, and should deceive no one: even the primary chancre here sometimes found bears no resemblance to epithelial carcinoma. The progress of lingual epithelioma of this expression is of the most distressing character: the organ enlarges and stiffens, masti- cation and deglutition become functions of most difficult and painful performance, the saliva dribbles constantly over the chin, and the patient finally perishes from starvation and exhaustion. Cancerous epithelioma of the tongue must either have attempted with it the most radical extirpation, or be soothed into quiet, and into such abeyance as is possible to be secured. Of the latter means, advantage has been taken of a partial paralysis, securing immunity from pain through section of the lingual nerve ; while it has also THE TONGUE AND ITS DISEASES. 775 been deemed that much control over the progress of the disease has been secured by ligation of the lingual artery of the affected side. In the practice of the author, where operative means of any class have not been thought advisable, the patients have expressed them- selves as receiving the greatest relief from the local employment, by means of an atomizer, of the following combination : B. — Acidi carbolici fluidi, 5j 5 Sodse sulphitis, 5J ; Aquse, ^x. Systemic lingual epithelioma most frequently makes its appear- ance either at the side of the base of the organ or near the tip. Frequently, however, where jagged teeth exist in the arch, it may arise as an abrasion, the location being without doubt influenced by the irritant. Such a lesion is not apt to be appreciated in its true character until its refusal to heal after the extraction of the offending tooth is noticed. Still another cause of localization in this direction arises from a malarticulation of the posterior teeth, the tongue on each occlusion being caught and fretted. The peculiar articulation referred to is to be seen when the molars of both jaws incline inward, striking above at the buccal angle and leaving a space with the base looking inward. The author has at the present time under his care two cases of lingual epithelioma which have been thus located. Tubercle. — Scrofula, as a dyscrasia, differs from tuberculosis in not being the expression of a materia peccans. Tubercle repre- sents a specific condition, the scientific cure of which must lie in the discovery of an antidotal specific. Tubercle has been discov- ered as a deposit in almost every organ of the body, being, how- ever, as uncommon to the tongue as it is the reverse to the lungs. The existence of lingual tubercular tumor is not, however, to be doubted, the microscope revealing all the elements of the expression so fully studied in the examinations of Langhaus. A tubercular tumor of the tongue finds its diagnosis most simply in association: the finding, for example, of tubercle in the lungs, the mesentery, or other parts. Also, when it appears in children, it is to be judged from its so frequent association with scrofulosis. The child will be likely to have tumid, pouting lips, the lax, protuberant abdomen, etc. Still again, as time advances, the diagnosis becomes verified by the rapid tendency to break down and create an indolent resisting ulcer. 776 ORAL DISEASES AND SURGERY. In the treatment of the tuberculous tumor or ulcer, the iodine preparations, by universal consent, have come to be most relied on, in this medicine being found the nearest approach to a specific. In the absence of a complete specific, however, it is most important to afford to the vital force the greatest possible amount of resistive power ; and this is to be done only by an attention to, and an ob- servance of, those common hygienic and dietetic laws which keep well people in robust health. The local treatment of lingual tuberculosis consists in the use of stimulating applications to the part, the best of which agents would seem to be iodine in tincture. M. Trelat, a French surgeon, recom- mends touching such ulcers with the actual cautery, affirming this treatment to be the only one ever found of service in his own prac- tice. Cystic Tumors. — Cystic tumors of the tongue, while not, as I am now satisfied, frequent, are yet not sufficiently rare to make allusion to them unnecessary. That known as meliceris is round, free from pain, and filled with a glutinous, honey-like substance. A peculiarity of this cyst is the fungiform character of its bottom, this portion looking pyogenic. A second order of cysts contains lymph, sometimes fairly colloid in consistence and appearance, at other times flaky, tubercular, or, it may be, puriform.* * " There is a disease of the tongue which I have seen every now and then, and which I am sure is very often mistaken for cancer, though it is of a dif- ferent nature. It is a curable disease, although it looks like a malignant one in many respects. The first thing of which the patient complains is enlarge- ment of the tongue, with some pain. On examination, you find a tumor in one part of it, not very well defined, nor with any distinct margin. It is a softish tumor, and increases in size, and perhaps another tumor appears in a diflferent part of the tongue, and that increases also. There may be three or four of these soft elastic tumors, with no very defined margins, in various parts of the tongue. This is the first stage of the disease. " In the second stage there is a small formation of matter in one of these tumors, — a little abscess, which breaks externally, discharging two or three drops of pus. When the abscess has burst it does not heal, but another forms in one of the other tumors. These abscesses may assume the form of ulcers, and the ulcers have a particular appearance. In the first instance it is a very narrow streak of ulceration, but on introducing a probe you find that the ulcer is the external orifice to a sort of fissure in the tongue. The probe passes in obliquely ; the tongue is, as it were, undermined by the ulcer, a flap of the substance of the tongue being over it. " The disease n.ow becomes more painful, and at last the ulcers may spread externally. In some instances they occujiy a very considerable portion of the THE TONGUE AND ITS DISEASES. 777 A form of cystic tumor, being a cystiform hypertrophy of a cir- cumvallate papilla, is met with occasionally on the back part of the dorsum. These tumors have been known to attain the size of a walnut. To the touch they are very solid, the walls being greatly indurated. If satisfied that there is no malignant association, the practitioner may puncture the sac and introduce a tent. Iodine may be used both externally and by injection. Ranular cysts, fre- surface of the tongue, but generally they burrow internally, and do not spread much toward the surface. This is a very distressing state of things, and a man may remain in this state for a long time. The glands of the neck do not become atfected, nor does the general health suffer, except from the diffi- culty of swallowing food. This is one inconvenience experienced by the patient; and he also labors vmder a difficulty of articulation. The tongue, from its enlarged state, may become stiff, not sufiiciently pliable for the pur- poses of speech, and the patient either speaks thick or lisps. " In some instances the disease may be relieved by a course of sarsaparilla, with small doses of bichloride of mercury. A strong decoction of sarsaparilla, with from a quarter to half a grain of bichloride of mercury, may be taken in the course of the day. Of course, if there be anything wrong in the gen- eral health, you should endeavor to get that corrected, and attend especially to the state of the bowels and the secretion of the liver. If the secretions of the digestive organs be unhealthy, a dose of senna and salts may be given every other morning, and blue pill every other night. When the patient is brought into this state, one remedy, as I have said, is sarsaparilla with bichloride of mercury ; but, according to my experience, this is not the best remedy. The remedy best adapted for these cases is a solution of arsenic. Give the patient five minims three times daily, in a draught, gradually in- creasing the dose to ten minims. It should be taken in full doses, so that it may begin to produce some of its poisonous effects on the system. When it begins to act as a poison, it will show itself in various ways. Some- times there is a sense of heat, a burning pain in the rectum ; sometimes griping, purging, and sickness, and nervous tremblings. A patient who is taking arsenic, especiallj' in pretty large doses, ought to be carefully watched. At first you may see him every two or three days, and then every day ; and as soon as the arsenic begins to operate as a poison, leave it off. When this effect is produced, the disease of the tongue generally gets well ; but at any rate leave off the arsenic, and the poisoning will not go too far ; it will do no harm. If, after a time, you find that the disease is relieved, but not entirely cured, you may try another course of arsenic. Perhaps it may take a consid- erable time to get the tongue quite well. Sarsaparilla, with the bichloride of mercury, may be given at one time ; and at another, ar.senic. You cannot give either of these remedies forever, and indeed the arsenic can only be given for a very limited period ; but it is astonishing what bad tongues of this de- scription I have seen get well under these modes of treatment, especially under the use of arsenic." — Brodie. 778 ORAL DISEASES AND SURGEBY. quently described as lingual cysts, are classified by themselves. (See Ranula.) Acute Glossitis. — Acute inflammation of the tongue, whether of idiopathic or of traumatic character, is always to be looked on with concern. The causes inducing this condition are various. Viewed as a distinct condition, — and this view, no matter what the cause, will always force itself on the attention of the practitioner when called to a case, — the most urgent necessity will nearly always be felt for a treatment that shall abort or resolve the phenomena as quickly as possible. It is true that all glossal inflammations are not dangerous ; but they all inspire with a sense of danger. Acute glossitis, idiopathic in form, commonly begins with a sense of enlargement and stiffness of some part of the organ, generally the anterior part; this soon becomes red, painful, and percjeptibly swollen. At this stage the condition may rest, and after some little time commence to decline. On the other hand, a single hour may witness the spread of the inflammation to an extent which shall threaten or perhaps produce suffocation. In still other instances the advance is gradual ; the circulation sympathizing, the pulse grows rapid and irritable, the skin becomes hot, only to decline to the cold sweating stage; and suppuration or perhaps gangrene terminates the action.* * " Glossitis, Acute. — Michael M., aged thirty-six years, employed as a boat- man by the Barrow Navigation Company, presented himself at the Meath Street Dispen.«ary, Dublin, on the 14th of January, 1871. His appearance was charac- teristic of the affection from which he suffered. His countenance was anxious, the tongue protruded between the teeth, his speech was thick, or what might be termed the glossitic speech ; his breathing was distressed. On inquiry, he ascer- tained that the man had got a severe wetting some days previously, and had his feet also immersed in water. He shivered, and felt a soreness at the root of the tongue. He had not been taking any medicine, and up to the time of severe wetting was in robust health. In addition to the symptoms detailed, he had a dribbling of saliva from the mouth, with headache and dysphagia. The pain in the tongue, as the disease advanced, was described by him as of a stinging nature. On examination, he (Mr. Croly) found the tongue cov- ered with a white exudation, like a false membrane. The organ was large, protruded, and exquisitely tender to the touch. The sublingual space was infiltrated and chemosed, and the fringe beneath the tongue resembled a cock's comb. The tonsillitic regions were natural, and bore pressure without causing any uneasiness. He got the patient to open his mouth sufficiently to enable him to introduce his little finger, and the man winced when he de- pressed his tongue. He observed that the palate and tonsillitic regions, as seen internally, were not in the slightest degree altered. He considered from i THE TONGUE AND ITS DISEASES. 779 The dangerous character of a severe glossitis demands the most energetic treatment. Leeches direct to the organ or beneath the the patient's general symptoms, and the infiltrated condition of the tongue, caused by the exudation of lymph in addition to the engorgement with blood and serum, that no time should be lost in giving him relief by the knife. He accordingly introduced a sharp-pointed bistoury far back, and made a free incision at each side, parallel with the raphe. The wounds gaped and bled freely, and the patient's speech became suddenly better. He next punctured freely the chemosed sublingual space. A warm bath and a purgative draught were prescribed, and he warned the man against cold, and recommended him to come into hospital, but he declined. On the following day he culled at the dispensary, and was much improved. The tongue was still tender to the touch, but the symptoms were so much relieved that, notwithstanding his advice to the contrary, he returned by boat to the country that evening, and he had heard nothing of him since. The notes of the next case to which he would call their attention were sent to him by Dr. Barry, of Kanturk. He visited a man, aged forty, whose respiration, articulation, and deglutition were very painfully affected. His tongue protruded between his teeth, and was so engorged as to fill all the space up to the palate ; and the tissues from the chin to the larynx were infiltrated. With some difficulty, Dr. Barry intro- duced a long and narrow bistoury on the flat, and, having turned the blade on its edge, he made two longitudinal incisions parallel to the raphe, with in- stantaneous relief. There was a copious flow of blood, which relieved the danger of impending suffocation, and the patient recovered in a few days, and was now in good health. The notes of the following three cases were kindly given to him by Dr. Leeper, of Keady. Dr. Leeper called the cases ' Glossitis.' The first was followed by an attack of delirium tremens, and after that by diffuse inflammation of the left leg. Mr. , of full habit of body, a free liver, of intemperate habits, dined at a club with seven friends on New Year's eve. He left the hot dining-room late, and drove home, a distance of .six miles, the night being bitterly cold and frosty. Next morning he awoke with sore throat, some difficulty of swallowing, and had a dry, parched, and swollen tongue. These symptoms rapidly increased, and Dr. Leeper was asked to see him at ten o'clock a.m. The tongue was then greatly swollen, filling up the mouth, and protruding an inch between the teeth. It was of a dark-brown, almost mahogany, color. The sublingual glands were swollen, and the sub- lingual spaces filled up to a level with the incisors. The submaxillary glands were not much affected. It was impossible to see either the tonsils or fauces ; but the roof of the mouth was covered with red erythematous patches. When the tongue was well moistened he could swallow and speak without much difficulty. Six leeches were applied to the under surface of the tongue and sublingual space. They rapidly filled themselves, and from the bites there was a very considerable flow of blood, which gave immediate relief. Before two hours he could keep the tongue in the mouth, and swallow with ease. Dr. Leeper considered that the leeching, purging, and sudden withdrawal of his accustomed stimulant and food brought on an attack of delirium tremens. 780 ORAL DISEASES AND SURGERY. jaw, bleeding from the arm, catharsis, diaphoresis, — any or all of these means are successively to be brought into requisition. A plan The next case was one of acute glossitis, treated by free incisions on the dor- sum of the tongue. P. R., a farm-laborer, was attending a corn-mill, getting oatmeal prepared. When there, he assisted the kilnman in turning the oats when drying, got into a profuse perspiration, and soon afterward exposed himself, on a cold, biting day in March, and was chilled. This was followed by swelling of the tongue, and difficulty of swallowing. Dr. Leeper saw him the next day. The tongue was greatly swollen, especially at the back part ; there was an abundant flow of saliva from the mouth, and the surface of the tongue was covered with a dirty-white, creamy-looking paste. He was speak- ing thick, and said he would soon choke if not relieved. There was no en- largement of the tonsils or the submaxillary glands. Dr. Leeper made with a lancet, the only instrument he had with him, two incisions on the dorsum of the tongue, parallel to the raphe. There was a discharge of four or five ounces of blood and serum from these incisions. He received a message next day to say that the man was much worse, and on visiting him found the tongue more swollen, protruding from the mouth, and that deglutition and speech were more difficult than on the day before. He introduced a sharp- pointed bistoury, and made two long and pretty deep incisions on the dorsum from the base to the tip of the tongue. These bled profusely, and gave im- mediate relief, and the next day the patient could swallow without difficulty, but the speech was thick. His recovery from this time was rapid. In the third of Dr. Leeper's cases, the patient was forty-five years of age. After exposure to cold he complained of pain and deafness in the right ear, and these were soon followed by difficult}' of speaking. These symptoms, after having lasted upward of a fortnight, were succeeded by rapid swelling of the right side of the tongue. When Dr. Leeper saw him, there was a profuse flow of saliva, so much so, that he thought he must be laboring under the influence of mercury ; but there was no mercurial fetor, nor were the gums affected. The right side of the tongue was as much aff"ected as it could be, but the left was not engaged. The tonsils were not enlarged ; neither the sali- vary nor the submaxillary glands were swollen. The root of the tongue was hard and swollen. Any attempt to swallow was followed by a squirt through the nose and mouth, with coughing. It seemed as if the epiglottis could not act, and that the fluid passed into the larynx. Some milk was injected (by means of a large elastic catheter attached to an elastic bag) into the cesopha- gus. He sometimes succeeded in swallowing, but the attempt far oftener failed, and was very distressing to him. Dr. Leeper made a free incision, on the dorsum, from the back to the tip of the tongue on the right side, but the discharge of blood was inconsiderable, less than he could have supposed from the extent of the incision. Fomentations with hot chamomile-tea were used and kept in the mouth, and his health supported as well as possible with milk and beef-tea. Next day he was worse, and Dr. Leeper made a still deeper and more extensive incision on the right side of the tongue. There was no dis- charge of blood or serum, at least not more than two ounces, and no relief i THE TONGUE AND ITS DISEASES. 781 of treatment, as reliable as any in character, is as follows : place on the back of the neck a cataplasm of mustard and red pepper; put the feet in water as hot as can be endured ; give a full dose of sulphate of magnesia. If now the disease does not seem to be held in check, wrap the patient in shawls or in blankets and admin- ister spirits of Mindererus until full diaphoresis is secured. If even from it. Mr. Young, of Monaghan, saw the patient the next day, and ad- vised leeches to the side and under surface of the tongue. These induced profuse bleeding, which was kept up by cold water in the mouth, Dr. Young thinking that cold water promoted bleeding from leech-bites better than hot. The swelling of the tongue subsided at once after the leeching, but the right side of it remained thicker and harder than the left, and the man's speaking was still difficult and imperfect. Mr. Croly proceeded to say that it was superfluous to go into the subject more fully, as it had been already discussed at a previous meeting. He would only state that he thought the case he had detailed was a very well-marked case of idiopathic glossitis. The man work- ing on a river and getting a severe wetting, not taking any mercury, the tongue becoming greatlj' swollen, the characteristic voice, the absence of any tonsillitic inflammation, — all these features showed that it was a typical case of idiopathic glossitis. " Mr. Richardson said he had a case of this kind a short time ago in the Adelaide Hospital. There was rapid swelling of the right side of the tongue and chemosis of the floor of the mouth. In that case he not only made an incision from the base to the point of the tongue, along the dorsum, but he also made a few punctures in the chemosis on the floor of the mouth, and the man was well in a few days. An exfoliation of mucous membrane followed, which, however, did not interfere with recovery. As there was some doubt regarding the period at which the treatment by long incisions was introduced, he wished to state that he had found in the Memoirs of the French Academy of Surgery several cases of this kind recorded. In one of these cases, pub- lished by De la Motte in 1725, tbe tongue became greatly swollen in less than five liours. It soon filled the mouth, and protruded from between the teeth. Bleedings from the jugular vein, arm, and foot were performed without relief, but a rapid cure followed three deep incisions along the dorsum, extending from base to apex. The patient could speak in an hour after the incisions were made. In another case, that occurred in 1744, rapid swelling of one side of the tongue took place in a woman.; respiration was obstructed, and deglu- tition impossible. It was cured by one long, deep incision. Louis mentions a case that occurred in the military hospital at Metz in the year 1740. The tongue became spontaneously swollen. Alexander Benedictus, wlio published the case, mentioned that M. Casteras, the senior physician of the hospital, directed him to scarify the tongue lightly. This, however, was not sufficient, and the patient died in two days in consequence of the swelling. As Louis truly observes, life might have been saved by a couple of deep incisions along the dorsum of the tongue." 782 ORAL DISEASES AND SURGERY. yet control is not secured, let ten, twenty, or thirty American leeches, or a third of the number of Swedish, be placed beneath the jaw. If the 'action is still unconquered, blood pro re uata is to be taken from the arm, and the tongue itself is to be freely incised. If yet the swelling goes on, and suffocation be threatened, laryngotomy or tracheotomy becomes a necessity. (See these operations.)* * " Mr. J. Z. Laurence exhibited before the North London Medical Society the tongue of a woman who had died of acute inflammation of the organ. She had been under Mr. Laurence's care for acute rheumatism, when, on the evening of the 5th November, he was called to her, and found her sitting up in the bed, with a countenance expressive of the greatest anxiety, her face pale and bedewed with sweat; she breathed at long intervals, and laboriously ; pulse 130. The cause of this was evident ; she could not open her mouth to speak, for a swelling of the left half of the tongue, which was red, dry, and glassj'. On the night of the 2d and 3d she had had severe rigors. Mr. Laurence at once made three free incisions into the tongue, and about half a pint of blood escaped. About two hours after the bleeding had ceased, the submaxillary region began to swell, twelve leeches were applied, and on the following morning the right half of the tongue began to swell, and by the afternoon it had attained full as great a size as the left. With this was a corresponding engorgement of the tissues about the jaw; the local depletion had had very little effect in reducing the swelling of the left side of the tongue; generally she was worse ; rigors now came on, and the pulse intermitted three or four beats. Mr. Quain saw her, and proposed incising the right half of the tongue, but both patient and friends objected. Mr. Laurence saw her the last time alive the same night ; her surface was deadly cold ; pulse not percep- tible at the wrist, yet, strangely enough, the respiration went on tranquilly, though feebly. Mr. Laurence at once perceived that she was dyijig of slow asphyxia, and that her only chance was in tracheotomy ; this was proposed with more impressive force than a surgeon almost dare do. She and her husband doggedly refused. Next morning she was dead. " Autopsy. — No organic disease was discoverable. The whole of the tongue was swollen, pale, and soft from maceration in a puro-serous fluid, which infil- trated the substance. The superior apertui-e of the larynx was greatly narrowed by serous efifusion ; the rima glottidis to a less extent; below this point the whole of the trachea was perfectly unobstructed ; the submaxillary region and anterior triangles of the neck were infiltrated with a serous fiuid, which, among the suprahyoid muscles, liad assumed a purulent aspect. The lungs were singularly healthj^ ; the heart, kidneys, and bladder presented no signs of disease. " From the above facts, it follows that tracheotomy would in all probability have saved the woman's life; and Mr. Laurence believes he proposed it at the proper time. It is true there wag, throughout the case, not one fit of suflToca- tion. On the contrary, she died choked in the most gradual conceivable manner ; and were he to meet with another case, he would not defer the operation until the patient was in his last gasp, as was too commonly the THE TONGUE AND ITS DISEASES. 783 Abscess. — In depraved and tainted conditions of the system, abscesses, of what might be called a cold character, occasionally form among the deeper muscles of the tongue; such abscesses are not necessarily associated with any marked inflammatory phe- nomena, but may have attention first directed toward them by the swelling which appears on the under surface. The proper treatment in these cases will be found in voiding the matter through puncture as soon as fluctuation is perceived ; otlier- Avise it has happened that the pus has dissected its way down the neck, pointing in front of the hyoid bone, creating much derange- ment, and threatening even a fatal result. Treat these cases by local stimulating injections and the internal administration of tonic medicines. Acute abscess is one of the terminations of glossitis. (See foot-note for illustration.)* case, but resort to it as soon as he saw the patient sinking, previous measures not having ameliorated his condition. A curious pathological fact, which Mr. Laurence noticed and pointed out to Mr. Phillips, who attended the case with him, was the successive and separate invasion of the two halves of the tongue by the intiammatory action, offering a remarkable instance of the dependence of pathological changes on the anatomical distribution of the blood-vessels." * The following suggestive case of abscess of the tongue, ending fatally from hemorrhage, is related by Mr. Ward, being presented before the London Medical Society : " E. T., aged seven, was born with a slight red enlargement in the centre of the tongue. ]Sfo inconvenience or difficulty in the ordinary motions of the tongue, or in swallowing, had ever been experienced; the general health had always been good. In the night of Sept. 27, having been in her usual health at bedtime, she was attacked with pain and swelling under the chin and both sides of the lower jaw; slept very little, and the following morning had pain in the tongue, with great difficulty in speaking, or swallowing any- thing but liquids. She had an aperient powder at night, and the lower jaw was fomented frequently. In this state she continued for two or three days, and was visited by me on Oct. 1, when the following appearances were noted : — Face flushed ; eyes very bright ; countenance anxious ; great swelling, redness, and extreme tenderness of the parts under the lower jaw ; very slight swelling of the tongue itself, which is covered with a thick, brown fur ; is unable to open the mouth wide, or move the tongue beyond the teeth, or to speak, and has great pain in the mouth ; pulse very quick and sharp; great heat of skin, and thirst urgent; bowels confined. Ordered eight leeches to be applied under the chin ; to take, at bedtime, four grains of calomel ; James's powder and sugar, of each three grains; a saline mixture, containing a scruple of nitrate of potash ; one tablespoonful every three or four hours. " Oct. 2. Slept more last night than since first attacked ; fever great; pain 784 ORAL DISEASES AND SURGERY. Neuralgia of the Tongue. — The only neuralgia of the tongue which seems special and peculiar to the organ has its seat about the slightly relieved; swelling and redness less; mouth nearly closed ; was able to swallow the powder in Jelly, but refuses the mixture, of which very little has been taken; bowels freely relieved, evacuations dark and offensive; to take calomel and James's powder, of each three grains, and jalap, five grains, at bedtime ; use a chloride-of-soda gargle, warm, to the mouth, by means of a syringe. Fluids taken in the mouth return by the nose. "4th. Less fever; rests better at night; difficulty in swallowing or speak- ing the same ; can open the mouth sufficiently to allow the tongue to be seen, which is nearly fixed, very little swollen, and still thickly coated; the breath extremely fetid ; external redness and swelling still considerable ; the tender- ness great; pulse soft, quick, and weak; the bowels act freely; was able to pass my finger into the mouth ; under each side of the tongue distinct fluctua- tion can be felt; while pressing on the left side the lining membrane gave way, and was followed by a profuse discharge of fetid pus, mixed with blood ; the point of the finger passed easily to the depth of the first joint, under the tongue, giving the sensation of a large pulp cavity ; the tongue not very tender, can be moved from side to side by means of a small teaspoon, but not voluntarily. Apply strong poppy fomentation frequently, and linseed poul- tice ; continue the chloride-of-soda gargle under the tongue, with the syringe, and take, of a mixture consisting of six grains of quinine, a teaspoonful every four hours ; give a little port wine and water frequently, and milk or thin arrowroot for drink. " 6th. The pain less since the use of the poppy fomentation, generally sleeping for some hours after using it ; the discharge of pus and saliva very copious and offensive ; lies with the head on the left side to allow the free exit of the discharge, otherwise the mouth is constantly filled ; fever less, as also the swelling and tenderness ; redness gone ; great debility and considera- ble wasting of the body already ; can swallow fluid, and is eager for the wine ; very little quinine has been taken ; bowels act twice a day ; can open the mouth wider, but is still unable to protrude the tongue, which is cleaner and moister ; on slightly raising it by the handle of a spoon, a large jagged open- ing may be seen on the left under side of the lower jaw, from which, by gentle pressure under the chin, a profuse discharge of thick pus wells up, of which I pressed out at least two ounces ; pulse soft and weak. Continue the external applications; apply the chloride-of-soda gargle frequently to the mouth and under the tongue, with the syringe ; take a mixture consisting of two ounces and a half of decoction of bark, syrup of orange-peel, and tincture of bark, of each two drachms, a fourth part three times a day; continue the wine, and give strong beef-tea and arrowroot frequently. "9th. Altogether improved; discharge less, but still fetid; takes fluid nourishment frequently, and the wine ; the general swelling and the tender- ness reduced ; more on the left side under the jaw than the right, and is un- able to protrude the tongue farther. Continue all the applications and .the mixture. THE TONGUE AND ITS DISEASES. 785 extreme tip; the pain, which is very irregular in its coming and going, is of the most acute character, seeming indeed as if the " llth. Has not rested so well the last two nights, and has had more pain, particularly on the right side, which is more swollen and very tender, the left side being almost in its natural state ; the discharge has been profuse, but thinner; the tongue is moist and clean; not very tender, but less movable; the opening under the left side of the tongue smaller ; fever returned ; has constant hacking cough; not able to swallow so well, or to speak so as to be understood. Apply six leeches under right side of lower jaw ; continue the fomentations and poultices ; also, bark mixture and port wine. " 12th. Has slept very little, from the frequent coughing, which tires her very much ; discharge from the mouth less and thinner, but still fetid ; emacia- tion extreme; has changed the })osition of lying to the right side ; left angle of the mouth drawn down ; the swelling and tenderness on the right side very much increased since yesterday ; feels soft ; is more prominent in the centre, and appears pointing here ; the finger in the mouth can detect very distinct fluctuation under the tongue, which is thickly coated and very tender; takes very little nourishment, only a teaspoonful at a time: prefers wine to other things. Continue the fomentations and poultices. " 13th. Has had a bad night ; is very irritable and feverish ; mouth nearly closed; unable to examine the tongue; the swelling about the same; the right cheek and under side of the jaw of a dusky red color, and very shining ; so tender that she has again changed the position ; lying on the left side ; cough less ; pulse very small and weak ; takes scarcely anything ; discharge more copious, thicker, and slightly tinged with blood ; it now appears to come from the right side. In the evening, while coughing, a large gush of blood took place from the mouth, mixed with pus, and flowed freely for more than ten minutes. By applying ice internally and externally (which I had directed to be in readiness), the hemorrhage was arrested. A cold lotion was applied externally, and an alum gargle frequently to the mouth. " 14th. Has slept very little; unable to lie down, from the constant dis- charge of fetid pus and saliva from the mouth ; the swelling of the right cheek and side of the jaw less ; very tender, of a dull, -yellowish color ; able to open the mouth so as to examine the tongue, which does not appear en- larged ; no power of moving it herself; is thickly coated with a dark fur, and when pressed upon, a profuse discharge of thick pus fills the mouth im- mediately ; no return of the hemorrhage ; is very pale and faint; pulse very small and weak; has taken more nourishment since last night than for some days before, such as port wine, i.^inglass in milk, beef-tea, jelly, etc. Con- tinue the lotion and alum gargle to the mouth witli a syringe. At half-past seven P.M., in the act of swallowing a small piece of bread-and-butter, profuse hemorrhage occurred from the mouth, and more than a pint of blood was lost before it was again arrested by the free application of ice ; it was of a bright arterial color. She became faint, and expired at nine p.m. "On the day following I made a post-mortem examination of the pai'ts afl'ected. The parotid, submaxillary glands, and other parts, having tjeen 49 786 ORAL DISEASES AND SURGERY. organ might be in the grasp of red-hot pincers. This neuralgia, as I hav^e met with it, has been in the persons of middle-aged men : of the cause of it I have no conception. Yanzetti, for the cure of such a neuralgia, has recommended and practiced the operation of section of the lingual nerve, — accomplished by first drawing the tongue forward and to one side, and exposing the nerve, through incision of the mucous membrane on the border of the internal pterygoid muscle. An excellent obtunder is found in the combination sug- gested in the paragraph on Epithelioma. Lingual neuralgijB origi- nating in the offense of jagged teeth have their cause too evident to need comment. Effusions. — The tongue is occasionally the seat of formidable congestions or effusions. I have known an inflamed tongue so swell in a single hour as almost to prevent respiration. The organ, when enlargement increases to an extent which threatens suffoca- tion, looks so vascular that one hesitates to use the knife. I am sure, however, I suggest the very best practice when I say incise fceely, — cut deeply from behind forward, on each side of the median line, avoiding, however, in the depth of the cut, the ranine arteries. A wound thus made will bleed for a time freely, even alarmingly ; but the common experience is that such cuts soon close, and are devoid of danger. Velpeau has recommended the opening of the ranine veins in congestion. Leeches are also applied direct to the tongue. Erysipelas. — A formidable danger in the tongue is the presence of erysipelas : this may be idiopathic, but is most frequently trau- matic, operatioGS about the jaws being, occasionally, provocative of this condition. The treatment of erysipelas in the tongue is the same as its treatment elsewhere. Iron and quiuia, internally and locally, should be freely enfployed. If this be not found effective, then make brought into view, were found (on the right side) so much softened, decom- posed, and mixed with coagulated blood and pus, as to be recognized with difficulty, and it was impossible to trace from what vessel the hemorrhage proceeded, such was the destruction of the parts. On the left side, the glands were of a greenish color, very much softened, and bathed in pus. A probe passed readily by the side of the jaw into the mouth. I divided the trachea just above the sternum, and dissected the larynx and tongue carefully out. The morbid state of the tongue is shown in the preparation before the society. " In the discussion which ensued, the case was considered a very remarkable one. The remarks had reference chiefly to the cause of the disease, respecting which various opinions were expressed. THE TONGUE AND ITS DISEASES. 787 incisions. The practitioner is, however, never to forget to extend his observations over any functional disturbances which may exist. Bites op Insects. — The most severe and threatening glossitis ever met with by the author was the result of the sting of a wasp taken into the mouth while eating blackberries. The tongue in these accidents is apt to swell enormously, but, happily, tends to a rapid self-cure. If seen immediately, no better application may be employed than the phenate of soda ; dilute ammonia is also a favorite prepara- tion : later, we can onlj^ treat such an inflammation like any other of the sthenic type. It is well, however, to remember that the swelling in these cases is from effusion rather than a congestion ; incisions, if necessary, may always be freely made. Iodine, in these instances, sometimes acts very happily ; paint the tongue thoroughly, and hold cold water in the mouth. If, unfortunately, erysipelas should super- vene, the iron and quinia combination is at once to be resorted to.* In these cases the pain becomes excessive, the parts may assume a livid hue, and there seems to be a decided tendency to gangrene ; particularly does this occur in depraved and broken-down persons. Free incisions are never to be neglected : the degraded expression of the erysipelas in these cases depends upon the separation of the molecules — if the expression may be used — from their base of sup- ply ; the incisions, draining the organ, allow contraction of the parts, and thus restore the circulatory relationship. In ulcers or tumefactions of the tongue provoked by irritating teeth, it is seldom necessary to do more than remove the source of offense. Cases occur, however, where some after-treatment is de- manded, the provoked ulcer being indolent, or, in some instances, even semi-gangrenous. For all such sores, the best wash that I have ever used is water, changed in color to a milky blue by the addition of the compound tincture of capsicum. Where a part is simply indurated and not ulcerated, presenting no evident cause, it is better, for a time at least, to leave the case to nature. My own rule is, never to meddle with a non-explainable induration except from ne- cessity. In all these cases injudicious meddling will be found very bad practice. Erectile Tumors. — Of this character of lingual tumors the author * R. — Tincture ferri chloridi, gij ; Quiniae sulphatis, gr. xv ; Tiucturse cinchonsE, ^ij to ^ss. M. The author believes thai this combination, as a local application, is an ap- proach to a specific in erysipelas. 788 ORAL DISEASES AND SURGERY. has met thus far with some five cases. Of these, the most marked was in the person of a babe nine months of age, for whose relief an operation was successfully performed at the University clinic. This tumor, which was congenital, occupied the whole anterior third of the tongue, protruded from and filled up the oral fissure to a consid- erable extent, was of a dark red or purple color, enlarged very much when the child cried, was soft and fluctuating, and through manipulation could be made temporarily to disappear. A mode of operation which in two weeks resulted in a perfect cure, consisted in first strangulating the mass with a double ligature, and, after three days, effecting separation through the instrumen- tality of a wire ecraseur. The principle of the treatment of erectile tumors of the tongue is the common principle applicable to this class of tumors wherever found. (See Erectile Tumors.) Fatty Tumors. — These, like the erectile, are uncommon. A case which I once saw exhibited the tumor looking like a mass of very smooth fat, encysted by the mucous membrane: the situation was the inferior left surface of the organ. As the patient would speak, the tumor would bulge out over his lower teeth, presenting a most unsightly appearance. He was not willing to submit to an opera- tion ; and it was with a feeling of disappointment that I found my- self unable to follow the history of the case. Metastatic Disease. — An example herewith given explains, without other remarks, a character of trouble rare, yet sometimes met with, upon the tongue. We may recognize in the disappearance and reappearance of the various exanthems an explanation of the condition. "I have been consulted," says Mr. Wm. McClure, in a paper read before the Harveian Society, "by a young married lady, for rather a curious afl'ection. She informs me that her tongue becomes occasionally bestudded with small ulcerations, and, after- ward, when these get well, the palm of her left hand becomes affected with a sort of psoriasis palmaris. The tongue is at present quite well, but the palm of her hand is covered with the eruption. When this gets better, however, she expects her tongue to become again the seat of disease, for thus they have alternated for a considerable time past, — she says about two years. The chief reason for which she consults me at present, however, is that she has gout in one of her feet. I believe that the whole series of her complaints depends on some derangement of the digestive organs, though that is not made very apparent by external symptoms. I gave her an alterative THE TONGUE AND ITS DISEASES. 789 pill, and a tonic mixture, combined with colchicum and an alkali. The gout has already disappeared, and even the hand is much im- proved. As soon as the gout was got rid of, I substituted for the tonic mixture — in which, as I have just said, were wine of colchicum and carbonate of soda — a mixture composed of the extract of sarsa- parilla combined with the iodide of potassium. As a local applica- tion to her hand I prescribed an ointment composed of pure iodine, iodide of potassium, and hog's lard; but this was found, upon trial, to give her so much pain, and produced so much irritation, that I was forced to abandon its use after a few days' trial. For it I sub- stituted the following ointment, viz. : white oxide of mercury four grains, and extract of conium a drachm, rubbed up with seven drachms of prepared hog's lard. This ointment was ordered to be rubbed into the palm of her hand every day, both morning and evening. Besides these remedies, local and general, she took occa- sionally an alterative and aperient pill, made up of blue pill and the compound extract of colocyuth. The consequence has been, after a month's steady use of the remedies, that the hand has become quite well, the skin being now, for the first time these two years, soft, white, flexible, smooth, and completely free from itching, heat, and every unpleasant appearance and feeling. Nor has the tongue as yet shown any tendency to alternate disease, as before ; so that we have reason to hope — the constitution having been set to rights by the means employed — the former chain of morbid sympathy between the distant organs of which we have been speaking, and by which a metastasis of the psoriasis, from the one to the other alternately, took place so often, for so long a time, has been at last broken and destroyed, permitting both to remain in their healthy condition." Urticaria, a very common skin-trouble, I have myself met with as having a similar metastatic relation. In this case a wheal would appear either upon the cheek or the tongue whenever ice-cream was eaten. Hypertrophy. — This condition has beien met with and described by various writers.* Hypertrophy may be complete, involving the * " A case is related by Zacchias, of a male infant well made except that the tongue projected three fingers' breadth from the mouth : the child could suck, and lived until the age of fourteen months. Bertholin mentions a case of linguas portentosa magnitudo, where a male child was born with, the tongue out of its mouth as large as a filbert: as the child grew its tongue enlarged to the size of a calf's heart. A case is recorded by Dr. Humphrey of a child, eleven years of age, whose tongue from the upper lip to its tip measured 790 ORAL DISEASES AND SURGERY. whole organ, or the enlargement may pertain to particular tissues alone. A case is described bj Mr. Paget, involving the muscular substances exclusively, the primitive fasciculi being found to divide in a dichotomous manner. The epithelium is another of the tissues most frequently found affected, instances being on record where this structure has thickened so as to resemble a coat of mail. Granular hypertrophy, a condition of enlargement of the papillary structure, is sometimes seen in the form of a mass of warty excrescences cover- ing the whole body of the tongue ; at other times it is confined to some portions more or less limited in extent. The treatment of a hypertrophied tongue must be governed by the circumstances and character of each particular case. In epithe- lial hypertrophy the best results seem to have been secured through the use of arsenic, — from the thirtieth to the twentieth of a grain being administered three times a day, its effect being carefully noted. Donovan's solution, the liquor arsenici et hydrargyri hj^driodatis, given in five-drop doses, has been highly commended ; also the solu- tion of Lugol. In granular or papillar}'^ hypertrophy, the use of chromic acid will be found desirable, the various excrescences being touched daily with the crystals. Another excellent application is the solution of the perchloride of iron. Cutting the warts away in mass, by the use of a pair of scissors, may be practiced where the parts are not too vascular. Pyroligueous acid is another favorite means of cure. In a true h3q5ertrophy of the organ — prolapsus, as it is frequently miscalled — that is, where the body has enlarged as a result of con- genital impressions, medicinal appliances are of little service. This disease is markedly one of young life, commencing generally very soon after birth, and progressing tardily but surely until death or an operation may give relief. Unaccountable though it may seem, hypertrophy is confined almost exclusively to female children, — this sex being affected in the proportion of five to one. As may be inferred, hypertrophy of the tongue presents various degrees of enlargement, cases being on record where the organ has hung from the mouth, resting upon the breast. In the cases of ele- three and a half inches ; from the under lip to its tip, one and a half inches ; from the angle of the mouth round the sides and tip to the opposite angle, six and a half inches. The circumference of the widest part, which was about the middle of the protruded portion, measured six and a half inches circular measurement." — Holmes. THE TONGUE AND ITS DISEASES. 791 phantiasis, the mucous membrane looks more like the bark of a tree than anything else, being rough, dry, and crusted. In the treatment of hypertrophy we consider the character of the trouble from the aspects of activity and chronicity. Where the first of these characters exists, most may be hoped for from medication ; where the latter obtains, little may be expected except from operation. Compression, recommended by Lasser and indorsed by Professor Syme, it may not be amiss to try before proceeding to excision ; but the treatment will certainly be found to have much more of failure than of success in it. The author lately had at his clinic a boy in whom congenital h3^pertrophy had enlarged one side of the tongue to a bulk fully double that of the other. As the opposite to hypertrophy, reference may be made to a condition sometimes, though unfrequently, met with, of atrophy. A case described by Dupuytren found its explanation in a post-mortem, which revealed the presence of hydatids at the base of the cerebellum ; one of which, wedging itself into the anterior condyloid foramen, had compressed the lingual nerve and thus obliterated its function. Operations practiced upon the Tongue. — From surgical neces- sity, or from accident, it sometimes becomes necessary to amputate a part or even the whole of the tongue. Surprising as it may seem, such amputations, even when of the complete organ, interfere very little with the speech, and do not entirely obliterate the sense of taste. Mr. Nunneley, an English surgeon, lately exhibited to the Pathological Society of London a patient from whom he had re- moved the whole of the organ, this being effected by a submental opening, the patient, a man aged thirty-five, never having a bad symptom. The disease, which had existed sixteen or eighteen months, became worse two months before the operation, and, from the pain and difficulty of speaking, the impossibility of mastication, and difficulty of deglutition, was fast wearing the patient out. When shown to the society, the patient had recovered strength and flesh ; indeed, said that he felt as well as ever : he talked with great dis- tinctness, and swallowed with facility. A second interesting case is reported by the late James Syme, F.R.S.E., Surgeon-in-Ordiuary to the Queen in Scotland, and Pro- fessor of Clinical Surgery in the University of Edinburgh. "About twelve months ago," says Mr. Syme, "I communicated a case in which the tongue had been completel}^ removed by ex- cision, on account of extensive disease that threatened to prove fatal by preventing the admission of nourishment. This account 792 ORAL DISEASES AND SURGERY. was necessarily limited to the operation and its immediate effects, as sufficient time had not elapsed for determining whether or not the relief afforded would prove permanent, or how far the powers of deglutition, articulation, and taste would be restored. After his return home to Manchester, the patient sent me favorable reports of his progress, but certainly not such as to convey any adequate idea of the improvement that had taken place since he came under my care. He was then emaciated and bent down by long-continued suffering, unable to articulate, so as to require a slate and pencil for expressing his wishes, and swallowing even fluids with such extreme difficulty as to feel on the point of starvation. My surprise may, therefore, be imagined when, on the 10th of September last, he un- expectedly made his appearance, erect and vigorous, and, seeing that I did not recognize him, announced his name in a loud, clear voice. The feeling thus excited was not lessened by learning that, while traveling in the Highlands, he had dined at tables-cfhole and entered into conversation without betraying the deficiency under which he labored. Yery much astonished by a result so much better than could have been anticipated, I requested a number of my medical friends to join me in examining the state of matters. Professor Goodsir and Mr. Nasmyth having satisfied themselves that no vestige of the tongue remained, various observations were made with regard to articulation and other functions of the absent organ; and Mr. Annandale afterward instituted a more particular inquiry, of which he has given me the following report: "'The lips and jaw-bone, where divided, were soundly united without any deformity. The opening between the mouth and pharynx was much diminished in size and irregular in shape from contraction of the fauces and soft palate, which were drawn downward and forward more to the right than the left side, from the mucous mem- brane at that part having participated in the disease and been removed along with the tongue. Mr. W. says that he can swallow as well as ever, provided that the food is either finely divided or fluid. He is also able to masticate solid substances, although diffi- culty is sometimes experienced from their getting into awkward parts of the mouth. In ordinary speech his words are wonderfully clear and distinct, and he can sing without any difficulty. All the vowels and words composed of them are articulated perfectly, and also the following consonants : B, C, F, H, K, L, M, N, P, Q, R, Y, W. D is pronounced " dthe," J " the," G like " sjee," " S" is a lisp. His taste is impaired, but still enables him to distinguish THE TONGUE AND ITS DISEASES. 793 different articles and their respective qualities, as grouse from par- tridge, bitters from sweets, good beer from bad beer, etc. He has remarked that the seat of sensation lies somewhere in the throat, since there is no recognition of taste previous to the act of swallow- ing ; and, in order to ascertain the truth on this point more pre- cisely, the following experiments were made : " ' 1. A strong solution of salt was applied by means of a camel's-hair brush to the fauces, palate, floor of the mouth, lips, and inner surface of the cheek, with the result of something being felt in the mouth, but no idea formed as to its nature. " ' 2. About a quarter of a teaspoonful of finely-powdered sugar was placed on the floor of the mouth, and, having been allowed to remain there a few seconds, was then brought thoroughly into con- tact with every part of the cavity without any recognition of its nature ; but when a little water was added and swallowed, the taste was immediately perceived. " ' 3. The same experiment was repeated with another substance (salt), and with the same result.' "It has long been known that large portions of the tongue may be removed without destroying or materially impairing the power of articulation ; but I am not aware of any case on record in which it has remained so perfect after complete removal of the organ.* Of * Complete extirpation of the tongue ha? now heen practiced with success by a number of surgeons, among them by Fiddes, Heath, Nunneley, Annan- dale, Rizzoli, and Sedillot. Excision of Tongue. — " The removal of the entire tongue is altogether a modern surgical operation. Though, for time out of mind, greater or less portions of the tongue have been removed by cutting instruments, escharotics, actual cautery, or ligatures, the importance of the organ in deglutition and articulation, the difficulty of reaching its base, and especially the fear of not being able to arrest the hemorrhage, owing to the depth of the wound, the size of the arteries, and their near origin from the carotids, have not un- reasonably deterred attempts at more than partial amputation of it. I believe it was Mr. Syme who first suggested an operation for its entire removal, and performed it in the presence of many members of the association, when its meeting was held in Edinburgh. Unfortunately, that patient, as well as a second, died a few days after the operation; and a solemn warning was pub- lished by Mr. Syme, who declared that the operation was so serious that further attempts were not justifiable, as no one could recover from it. Subse- quently, I believe, in a third case, Mr. Sj'me was, by a like proceeding, re- warded with success; and Mr. Fiddes, in Jamaica, and Dr. G. Buchanan, in Glasgow, have also succeeded by the jilan laid down by Mr. Syme. How- 794 OEAL DISEASES AND SURGERY. the facts above mentioned, the one that seems most curious is the connection between taste aud deglutition; from which it appears that the latter is essential for the full perception of the former. If the pleasure of taste could be perfectly gratified by mastication without deglutition, there would be no limit to the consumption of food ; but the instinctive desire to swallow an agreeable morsel affords a check to any such abuse." Mr. Paget reports the following case: " On the 20th of February a little girl, about three years of age, was brought into the operating theatre of St. Bartholomew's Hos- pital with hypertroph}^ aud prolapsus of the tongue, which com- menced when she was some six months old. It now protruded nearly two inches, and hung downward, completely filling the circle of the lips ; its end was dry, and excoriated with hardened epithe- lium, a sort of crust having formed of the size of a shilling ; several of the papillae also were enlarged, and in places gave to the tongue a warty or granular appearance. The lower jaw had a^lready begun to be deformed, and expanded downward and outward; the teeth were gradually separating from one another in the mental portion of the jaw, and there was dripping of saliva. An examination of the tongue by Mr. Paget showed that the organ was truly hyper- trophied, and the part not prolapsed completel}" filled the cavity of the mouth. " Chloroform was carefully given to the child, and the chain of an ecraseur was passed around the tongue within the mouth, the jaws being kept open by a metal gag. The chain was slowly drawn home, and the prolapsed and hypertrophied portion was detached with little or no bleeding. ever, believing that the severity of the operation depended farmore upon the method of proceeding than upon the mere removal of the tongue itself, I devised what I hoped would prove to be a less formidable one, and which experience has proved to be so. Up to the present time I have removed the entire tongue nineteen times, and Dr. Fenwick, of Montreal, has done the same operation once, without any untoward symptom following in a single instance. In most cases the patient has not required any after-treatment, being able to sit up the following day, and in ten days to be considered well. In the majority of operations not a drachm of blood has been lost. In two cases only has there been any hemorrhage, and in those not more than half an ounce of blood was lost. In one a point of hot wire, and in the other a ligature, at once arrested the bleeding. The little constitutional disturbance which follows this operation is surprising : indeed, in the majoritj^ of cases there is none." — Thomas Nunneley, F.E.C.S. THE TONGUE AND ITS DISEASES. 795 " On examination of the piece remox^ed, its structure was found to be similar to that of the natural organ, both in texture and color : it was simply a redundancy of growth from hypertrophy. "The subsequent progress of the case was reported as most satis- factory, a good recovery being recorded." Partial amputations of the tongue have been very frequent. Union, in many of the cases, is very rapid and perfect. In one case, that of a child, where a kind of a flap operation was made, I got reliable union in a single day, and had no trouble with the case afterward. Amputation of the tongue, complete or partial, is practiced with ligature, knife, and ecraseur. The author, from his own experience, gives the preference to the last means. Operations. — For a surgical study of the tongue, and the opera- tions practiced upon the organ, the reader will turn to Plate XII. Subfig. 1, in plate, is a front view of the anatomical relations of the parts about the fauces, as shown with the mouth wide open. 1, the dorsum of the tongue; 2, 3, the tonsils; 4, the uvula ; 5, the anterior half arch ; 6, the posterior half arch, with the tonsil between it and 5; T, the soft pabite. Subfig. 2 represents a side view of a vertical section of the mouth and tongue, showing the relations of the vessels and nerves of the tongue. 1, the lingual artery; 2, its sublingual branch, — the veins accompanying the arteries ; 3, the hypoglossal nerve; 4, the raniue terminations of the lingual vessels. Subfig. 3 represents the situation and associations of a disease compelling amputation of a section of the tongue. The lines, 1, 2, 3, form a Y, which is to cil"cumscribe the growth ; it should, how- ever, have been placed much farther back. Subfig. 4 exhibits the operation of excising the tongue, as prac- ticed with scissors. When the knife is used, the sections are similarly made. If, in such an operation, the hemorrhage is threat- ening, it is better to ligate quickly the vessels of one side before making the section of the o|^her ; this suggestion, however, only holds good when the bleeding orifices are freely exposed and can be reached without effort or difficulty. Subfig. 5 shows the preceding operation completed, and the flaps united by ligatures. 1, 2, represent the sutures: wire pins or waxed silk may be used. Let them be left in only long enough to secure the union ; this, if no undue inflammation supervenes, will be accomplished in from twenty-four to forty-eight hours. 796 ORAL DISEASES AND SURGERY. Subfig. 6 is the lingua vitula, or lingual hypertrophy. The par- ticular case here represented was a patient of Dr. Harris, of Phila- delphia, and was the first operation performed in the United States. The case is thus described by Prof. Smith in his System of Surgery : " The patient, aged nineteen, had the tongue enlarged at birth. A short time previous to the operation it projected beyond the upper incisors at least three inches. Its circumference was six inches, and its vertical thickness one inch and a half; it filled up the jaws so completely that it was necessary to have his food cut iato small pieces and introduced at the side of the tongue." The operation practiced by Dr. Harris was accomplished as fol- lows: "The tongue being elevated, a strong ligature was passed through its top so as to control its movements. The under surface was then dissected from the floor of the mouth about three-fourths of an inch behind the anterior part of the jaw, and a strong, straight bistoury introduced into the organ at a point where the dissection terminated, whence it was pushed through between the median line and the left rauine artery, and, being drawn laterally and forward, was made to cut a flap, w^hich terminated near the first bicuspid tooth. The left ranine artery being then secured with a ligature, the bistoury was again introduced in a corresponding position on the right side, and the opposite, or right flap, made in a similar manner. The artery of this side being now secured, and the space intervening, or central portion, divided by strong scissors, the in- cisions or flaps resembled the letter Y, and, being approximated by these interrupted sutures, made a pointed, well-formed tongue of the ordinary length. A year subsequently the patient articulated distinctly, and was relieved of all deformity." Fig. 243. — Amputation by Strangulatiox. In another case, somewhat similar to this, under the care of the same surgeon, a ligature was applied to the enlarged portion, iu THE TOJSIGUE AND ITS DISEASES. 797 order to cause it to slough oflf; but the irritation, Prof. Smith informs us, was so great that Dr. Harris found himself subsequently com- pelled to amputate the end of the tongue with a catlin. In this patient the organ protruded four inches ; its circumference was over six inches, and its vertical thickness nearly two inches. Fig. 243k represents a condition of resisting ulcer (met with quite frequently by every practicing surgeon), together with a manner of treatment by strangulation. With such ulcers and such manner of treatment the author has had quite a large experience, but, as before remarked, he gives the preference to the ecraseur. . . Fig 244 A mode of using the ligature, more convenient than that exhibited in the diagram, and quite as effectual, consists in the passage of the double thread, exactly as is represented in this case by the threads occupying the middle posi- tion ; separating this double ligature, it may be made to circumscribe any portion of the tongue simply by the passage of pins : as, for example, if in the places of the first and second threads, as shown, pins were placed, it must be seen that, by separating the double middle ligatures and casting them back of the pins, the part included would be precisely the same as found here with the six ligatures. By such use of the double ligatures the author has amputated full half the tongue twice within four months. Such a mode of employing the double ligature, not alone for the tongue, but in any other situation, is shown in Fig. 244. The Eoraseur. — Fig. 245 exhibits the ecraseur of the inventor of the instrument, the French surgeon M. Chassaignac. Of the two forms shown, the one to the right will be found most to com- mend itself, the direction of the chain being best conti'olled by it. To use the ecraseur, it is simply necessary to arrange the chain back of the part to be amputated, the handle being next slowly turned, whereupon the chain, little by little, is retracted, until finally — the time should seldom be less than half an hour — the portion of tissue drops off", without, quite as likely as not, the loss of a single drop of blood ; as exhibited in the case of an amputation of the tongue, performed at a recent clinic by the author before his class, where the operation was strictly devoid of hemorrhage. As a substitute for the chain of the Chassaignac instrument, a common annealed wire is used by many with the most complete 798 ORAL DISEASES AND SURGERY. success. The use of such a wire is highly commended b\^ M. Maison- neuve, of Paris, who has published a memoir on what he terms the Fig. 215. — Chassaignac's Eckaseur. Fig. 246. *' ligature extemporanee.^^ Fig. 246 exhibits this ecraseur, and the mode of its application. A screw like that of Graefe's serre-uceud, or any other convenient means, may be emplo3^ed to tighten the wire. A very convenient instrument of such character is furnished at a trifling price b}^ Mr. Kolbe, of Pliiladelphia, and may be procured of most surgical cutlers. With such form of ecraseur, the author has succeeded in amputating without trouble fully two-thirds of the tongue. Amputation of the tongue in full, an operation now attracting considerable attention, is variously practiced. A mode known as that of Regnoli, shown in Fig. 247, consists in opening into the oral cavity from the neck, and, by means of a loop in the tip, drawing the organ downward. To open into the cavity by this plan, the operator commences by making a curvilinear incision corresponding to the arch of the jaw, extending nearly from angle to angle. Joining this first incision is a second of vertical direction, extending to the THE TONGUE AND ITS DISEASES. 799 hyoid bone. The flaps are next to be reflected, and, after incising the lingual muscles from the bone, the tongue is caught by the tip and drawn out of the mouth. Complete control of the organ being thus secured, the knife or ecraseur is employed to make the separation. Fig. 247. — Kegnoli's Operation. Fig. 248. — Syme's Operation. A second manner of operation is that which was practiced by Mr. Syme. This is shown in Fig. 248, and is as follows. A first inci- sion divides the lower lip in its exact median line, being carried down to the hyoid bone. Next the bone, by means of a saw, is separated at the symphysis; this may or may not necessitate the removal of the two front teeth. Placing the fioger as a guide beneath the tongue, the surgeon next incises the mucous membrane, together w^ith the muscular attachments. At this stage attention may be given to the hemorrhage, or the tongue, as shown, may be drawn forward and the amputation completed by the ecraseur. Statistics favor the Regnoli operation rather than that of Mr, Syme, the section of the jaw in the latter complicating to a marked extent the process of cure. Still another operation, practiced by Mr. Nunneley, of Leeds, has yielded a success most satisfactory, since of nineteen cases in which this surgeon has operated, removing the whole or a large por- tion of the tongue, every one resulted in recovery. The operation, as practiced by Mr. Nunneley, consists in a slight incision, a punc- ture, indeed, made in the exact middle line of the throat, — a little nearer the base of the jaw than the hyoid bone, the bistoury being passed upward until it emerges at the frtenum ; through this wound 800 ORAL DISEASES AND SURGERY. is now drawn up the chain of the ecraseur, the loop being cast about the base of the tongue. Next, with a volsella, or by any other con- venient means, the organ is pulled outward and upward. To control and secure the loop of the chain about the base, two strong curved pins are passed from below, through the tongue, to the base ; the loop thus controlled, the ablation is made as in the previous cases. A fourth process is that practiced by Mr. Paget. Separating first the general attachments of the genio-hyo-glgssal muscles, this surgeon dissects along the floor of the mouth, thus liberating the tongue, whereupon the organ is caught, drawn forward, and removed with the ecraseur. In limited ablations, the surgeon, not having at command the ecraseur, may use with satisfaction the ligature as described a page back. A point of importance, however, to consider in the use of this means, is the danger of cutting the ligature out ; it is really a nice point to draw tight enough, yet not too tight. I have seen a ligature cut through a tongue almost with the facility of a knife, compli- cating matters most seriously by the hemorrhage which followed. Another matter is correspondence in size of the ligature with the needle used. A needle, larger than the thread which is to occupy the line of its passage, will not unfrequently have its use associated with an oozing of blood, so persistent as to compel the repetition of an operation. In the use of the ecraseur the surgeon will also not unfrequently find himself confronted by hemorrhage, and particularly may such a result be anticipated where abundance of time has not been allowed for the ablation : the rule with this instrument should be, " never make haste." Shock, inflammatory perversions, and septsemia, are the dangers associated with operations upon the tongue, and which the prudent surgeon will guard against by every precaution known to the science. After an operation of magnitude upon this organ, I believe it is always prophylactic practice to prescribe veratrum viride, bromide of potassium, and morphia; while as a local detergent, nothing better can be used than the phenate of soda, or, if inflam- mation supervenes, this conjoined with the fluid extract of hamamelis Yirginicus. ToNGUE-TiE. — The condition denominated tongue-tie is frequently met with in young children, and, indeed, occasionally in the adult. Tongue-tie is simply a shortening or curtailment of the anterior THE TONGUE AND ITS DISEASES. 801 mucous frseuum. A tongue that cannot be projected beyond the teeth, and in the attempt at projection has its tip drawn downward, is tied, and a tongue so tied cannot perform its various offices com- fortably and naturally. Upon examining the mouth of a child thus afflicted, the tip of the tongue will not unfrequently be found fixed to the floor of the mouth, incapable, indeed, of any movement. These, however, are extreme cases, the usual condition being simply curtailment of na.tural motion. Tongue-tie is of two kinds, adventitious and congenital. Of the first, that arising from ulceration is the most common. A person having a bad ulcer under the tongue, particularly if on the side of the fraenum, is almost sure to have this fold shortened as the result of cicatrization. A second expression of this first form is one described by Prof. Dewees, exceedingly rare, 1 imagine, but worthy of note. "There is found attached," says Dr. Dewees, "to the fraenum of the tongues of new-born children a nearly transparent, whitish membrane, which pursues the natural frrenum through its whole course, continues beyond the point where the fraenum stops, and terminates near the extremity of the tongue itself; so that the tongue is tied down, as it were, to its proper bed. " In consequence of this disposition of the frasnum, the child cannot elevate the tongue or protrude it beyond the lips, and in attempts to suck cannot apply it with sufficient force or certainty to the nipple to make a complete exhaustion; therefore it sucks but imperfectly; and this is accompanied by a clucking kind of noise. Whenever this is observed, the mouth should be examined, and it will almost always be found in the situation just described ; but not necessarily, as there may be clucking without this mem brane ; but this membrane, we believe, is never without the clucking. "This membrane is easily discovered by provoking the child to cry, or by elevating the point of the tongue by the extremity of the little finger. In making the attempt to raise the tongue, the child is almost sure to cry ; and then this membrane is readily discovered, as it is now fully upon the stretch. " This defect is easily remedied. It should be done in the follow- ing manner. Let the child be laid across the lap of the nurse, with its face toward a proper light, and the operator stand behind the head, so that he does not intercept the light. The chin of the child must be genth^ depressed by the forefinger of the nurse. When the chin is thus depressed, the little finger of the left hand of the ope-r- 50 802 ORAL DISEASES AND SUBGERY. ator must be insinuated between the side of the tongue, near its tip, and the inner corresponding portion of the jaw, until it can lift up the point of the tongue; which being done, the membrane is imme- diately brought into view, and upon the stretch ; or, should the child now begin to cry, as it almost always does, tjae o})erator can easilj' place his finger under the tongue, and keep this false frsenum tense, while, by a single stroke directly across it by a sharp gum lancet, he divides it to the true fraenum : the operatioi\ is then finished. We have never known it necessary to repeat this operation. The incision through the membrane never yields more than a small drop of blood ; no hemorrhage can ensue, as this tissue is but very slightly vascular." A third of the adventitious forms, occurring in the adult, is the result of induration of the fraenum. This is occasionally vene- real in character, or it may be cancerous. In these cases the baud gradually thickens until the motion of the tongue is markedly impaired. The cancerous is distinguished in its incipiency from the venereal disease by the greater pain associated with the move- ments of the parts: in the first, the pain is acute and sharp ; in the second, it is soreness rather than pain. If the induration is malig- nant, the parts may be excised, but the hope of cure is very slight ; if venereal, we pursue the specific treatment conjoined with such general and local combinations as may seem demanded by the circ\jmstances of the case. Donovan's solution, given in five-drop doses, is quite reliable. The practitioner is to avoid over-irritation of the fraenum. Congenital tongue-tie is quickly appreciated by lifting the tip of the organ. These cases differ very much, the fraenum, at times, being observed to run as in the normal course, except that it is much shortened. In other instances the fold passes forward almost to the apex. This fold may be free or tight. If the former, it forms a septum between the lateral aspects of the floor of the mouth, but is not otherwise inconvenient; if the latter, it ties the tongue more or less closely. The relief of a congenital tie consists in nicking or cutting the contracted fraenum. This operation, although of the simplest nature, requires to be performed with some care. A fraenum too freely cut will permit of the tongue being pulled quite far back into the fauces ; cases are on record where sulfocation has nearly resulted from such an accident. Again, it must not be forgotten that the ranine vessels inosculate just in front of the fraenum on the under surface i THE TONGUE AND ITS DISEASES. 803 of the tongue, and might veiy easily be divided in an operation. Many children have lost their lives from such an accident. A proper operation consists in making a simple nick midway be- tween the tongue and the floor of the mouth : a rupture of the part thus effected, the motions of the tongue will quickly secure all the latitude required. Should an operation, unfortunately, open a vessel, the best practice would be to secure it with a ligature ; but this is not always easy of accomplishment, the artery retracting within its loose sheath. An instrument devised by M. Petit to control such a hemorrhage consists of a piece of ivory, cut fork-shape, — the prongs, of which there are two, passing on either side of the frsenum, the short handle resting against the inside of the jaw. To apply this instrument, introduce against the bleeding vessel a tuft of lint saturated with alum-water or other astringent, then place the fork about it, and secure it by pressing it down with the tongue, over and around which, and the jaw, a roller is to be thrown. A much better means, however, would be the use of the thimble com- press, referred to on page 310. Guersent, in his " Surgical Diseases of Children," recommends the serre-fine, or the retention, for a time, of agaric against the part. Another means, where the wounded vessel is not too far retracted to be caught, would be the employ- ment of torsion. The use of nitrate of silver or of Monsel's salts in these cases cannot be too forcibly discountenanced, the injury done by them to the tender parts making secondary hemorrhage almost a necessity. Swallowing ttje tongue, as it is called, is a disagreeable accident, and may occur without section of the fraenum. Dr. Dewees mentions one case in which a child became choked several times a day from such a recession. It was always, however, relieved by the nurse, who would press the organ down with the handle of a spoon and then draw it forward. To operate for tongue-tie, it is best to place the body of the infant upon the lap of the nurse, the head being received upon or between the knees of the surgeon ; the tip of the tongue is then raised, and the cut, or nick, made with a pair of curved scissors. CHAPTER XXXYIII. TUMORS. In the following- pages the author proposes, after much reflec- tion, and after a thorough study of the views and observations of the latest writers, German, English, and American, to present to his readers the subject of tumors, precisely as in his own clinical service he meets with, classifies, and treats such conditions. He disregards to a certain extent the classification of others, because that which is here adopted seems to him most rationally, philoso- phically, and naturally to introduce and evolve the subject. The text of the chapter is to be understood as being of a strictly clinical signification. In the foot-notes — which, however, a student is advised not to read until he has mastered the practical signification of the text, thus guarding himself against confusion — will be found the views and expressions of pathological histology. Such classification of the tumors as is here offered, it is be- lieved, opens the subject to the ordinary practitioner with all necessary practical clearness, while it must be seen to limit in no way the examinations and inquiries of the most inquisitive microscopist. The surgical expression " tumor" is a terra having its origin in the Latin verb tumeo, to "swell," and, therefore, necessarily applies to any unnatural enlargement of a part, no matter upon what it may depend or from what cause it may arise. A tumor is a swelling which varies in its nature from that which has a signification in some accidental and, it may be, evanescent functional derangement — as, for example, a foot oedematous from exhausting exercise, an abdomen swollen from accumulated flatus, a duct expanded from obstruction of its outlet — to that character of an outgrowth which is without explanation in itself or in any phys- iological or anatomical association, — a something which, by exclu- sion, must be classified as an expression of constitutional meaning (804) J TUMORS. 805 and signification, — a vice. (In the foot-note will be found the argu- ment of Billroth against this premise.*) * " When Ji part of the body is abnormally enlarged, we make a distinction as to whether the enlargement is caused by an abnormal increase of the volume of the difterent elements (simple hypertrophy), or by a formation of new ele. ments which are deposited between the old ones. The new formation may be analogous to the matrix or mother tissue (homoplastic), or not (heteroplastic). The homoplastic new formation proceeds either from simple division of the existing elements (thus, a cartilage cell by segmentation forms two, then four, cartilage cells: then it is called hyperplastic, numerical hypertrophy), or at first apparently indifferent, small, round cells form from the existing cellular elements, and from these a tissue analogous to the matrix is developed, — homoplastic new formation in strict sense. Heteroplastic new formation always begins with the development of primary cell tissue, so-called indilfer- ent formative cells (granulation stage of tumors — Virchow), and from these develops the tissue heterologous to the matrix, as cartilage in the testicle, epidermis in the brain, etc. "This nomenclature proposed by Virchow seemed perfectly suitable and natural in a purely anatomical point of view ; and I can still accept it, if the term heteroplastic be limited, and if we dismiss the idea that homoplastic is synonymous with benignant, and heteroplastic with malignant. We must here add that there is everj^ probability that wandering cells escaping from vessels very materially aid in the formation of tumors, at least in the forma- tion of tumors of the connective-tissue series. But, apart from this, we should err if we supposed that in the above nomenclature all cases of new formations, even considered in a purely anatomical point of view, could be easily labeled, ready to be placed away in a museum. The simple numerical hypertrophies and hyperplasise, although in some cases difficult to distinguish, are at least theoretically separable; the same way with those new formations which do not consist of similar, well-formed tissue elements. A connective- tissue tumor occurring in connective tissue would always be termed homo- plastic; found in bone, brain, or the liver, it would be heteroplastic, etc. Well-developed alveolar cancerous tissue also usually presents no difficulty of classification, for it does not normally occur in any part of the body ; it is everywhere heterologous. But what shall we say of the neoplasias which have no fully-developed or entirely abnormal form of tissue, but consist of elements that cannot be found elsewhere ? What becomes of them ? or can anytliing develop from them (indifferent formative cells, primary cell tissue, granulation tumors) ? and where shall we place those neoplasiis which are not completed tissue, but are evidently normal tissue in the stage of development? According to the above definition of heterology and homology, inflammatory new formation is at first heterologous everywhere ; but the connective-tissue cicatrix developing from it subsequently becomes a homologous neoplasia in connective tissue ; in muscles it almost always remains heterologous ; the same way in the brain and in the bones, if it does not ossify. You see that here parts which from their nature and mode of origin naturally belong 806 ORAL DISEASES AND SURGERY. The study of tumors is to be pursued from a twofold stand-point, clinical and histological. The first has to do with that classification of the conditions which directs the practice demanded. The second analyzes under the microscope the histogeny of a growth, and describes the expressions of its anatomy. Clinically, experience would seem fairly to demonstrate that a rational primary distinction of the tumors is found in separating them into two classes. One class embraces every tumor that pos- sesses a local self-explanation, as, for example, sebaceous tumors, ranulfe, hernise, hydrocele. The other class comprises all that remainder, the explanation of which has to be sought outside of a local condition ; examples in this latter direction being recognized in the nodes of syphilis, the degenerating glandular enlargements of tuberculosis, the multitudinous expressions of cancer. All tumors of the first class are, m themselves, of a necessity, benign. All tumors of the second class are to be viewed, not in themselves, but in the dyscrasia of which they are simply ex- pressions. Tumors of the first class, having only a local signification, de- mand only a local treatment ; tumors of the second class, having, save in the accident of the habitat, no local signification, but being of constitutional relation, are capable of rational treatment only through remedy directed to the vice as it exists in the system at large. Tumors of the first class may be termed homologous, indicating together are sundered by the anatomical nomenclature. But let us leave inflammatory neoplasia out of the question. Every tumor resulting from indifl:erent formative cells must exhibit a series of stages of development, if the cells are transformed to one or several sorts of tissue. " Wherever they are grouped together, indifferent formative cells are heterologous ; if a neoplasia shows only such elements, we will let it pass for heterologous ; but if it appears that a number of these cells have been trans- formed into spindle-cells, the question arises, where does this neoplasia belong ? Spindle-cells collected in groups are heteroplastic in all parts of the body ; but these cell? occur in fcetal connective tissue, fcetal muscles, and fcetal nerves. "What would finally become of the spindle-cells of this tumor ? If found in muscles, should not this tumor still be called homologous? On this point we can only decide arbitrarily. You may look at it from different points of view. Now, what shall we do with tumors which contain the most different complete and incomplete tissues? I will stop here, to avoid making you skeptical: it is my duty to help you learn, not to throw obstacles in your way. ' ' — Billroth. « TUMORS. 807 by this term, not likeness to associated tissue as exhibited by some of the' neoplasias, but that a tumor is part and parcel of the location in which it exists. Tumors of the second class may be distinguished as heterologous, indicating simply neoplasia, no matter what the likeness, a some- thing which is strictly foreign to any local expression of the pa7't in which it is found* * " All new formations, not hyperplastic, contain in themselves a qualitative departure from the normal processes of development and growth. It there- fore appears difficvilt, at the first view, to place them upon a physiological basis. There are, however, not so much actually existing, as much more artificially produced difiiculties, which stand in our way; above all, a trans- mitted custom of regarding the deviating evil as a hspov, something foreign introduced into the organism, of ascribing it to a parasitic existence, even a kind of personality. This view, from which the term 'heteroplasia' has arisen, has a certain justification : 1st. In the pr'esence of those new forma- tions which are caused by a definite poison introduced into the body, and conformedly present themselves in the most various organs in the same manner, thus in syphilis, tuberculosis, typhus abdominalis. 2d. In the sense that every organ has its own peculiar new formations, which always recur in the same forms with slight modifications, so that we, if they have pro- gressed up to a certain point, may thereupon base a sure diagnosis and pro- gress. It is, however, unjustifiable and injurious to the progress of true science if one neglects, in the study and description of what the new forma- tions of the various organs have in common, the right of the individual organ, which requires that one regard the pathological new formations as a disturbance of its development, its nutrition, or its decomposition. But be it well understood I am very far from disputing the usefulness, nay, the necessity, of general observations of pathological new formations. These observations, however, ought to proceed more upon establishing the principle of development than upon finding out certain anatomical models, according to which a new formation, for example cancer, is built, as well in this as in that organ. Moreover, if I understand our time, it is tired of purely external, anatomical classifications, and decides with me that it has become scandalous in the inexhaustible multiplicity of concrete forms. We -will, of course, therefore speak in what follows of cancers and sarcomas ; we will take pains to delineate the laws of their production and their growth in bold out- lines, also not to exclude observations upon their effects upon the entire organ- ism, therewith, however, constantly reflecting upon the description of the individual forms in the special part, and remaining conscious that the knowl- edge of these is at least just as important to the physician as is the general comprehension. " — Rindfleisch. " Upon an anatomical basis we must separate those tumors which are the result of an actual formative process (pseudoplasms) from those which have a different origin. The latter correspond to the majority of what were for- 808 ORAL DISEASES AND SURGERY. • Clinical Illustrations, in Diagnosis. — A patient presents himself to the surgeon, having a tumor in his groin. What is the merly called tumores cystici. Those tumors which are not the product of a real growth owe their existence either to material that comes direct from the blood, or to the accumulation of certain secretions. If the material comes from the blood, it may be deposited in three forms : 1, Blood in substance, — extravasation : 2, serum, containing water, salts, and albumen, — transudation ; or, finally, 3, a certain amount of fibrin with the serum, — exudation. In some instances there will be found an exudation and an extravasation together in the form of a hemorrhagic exudation; or with a large amount of serum there Avill be found a small quantity of fibrin, — a serous exudation. " Those tumors which represent the accumulation of certain secretions diflfer in the following respects : the contents may be chiefly fluid, or chiefly organized elements, or may consist of both. These cystic tumors form a class by them.selves. The accumulation takes place in a pre-existing space, which becomes dilated or ectasic in proportion to the accumulation of the secretion. These tumors could be called ectases, but there is something besides ectasis, namelj', the retained secretion. We shall, therefore, call them dilatation or retention tumors. " The tumors of the first class, which'consist chiefly of the elements of the blood (extravasations, transudations, or exudations), may either originate in a pre-existing space, or form for themselves a new space. These we shall call extravasation or exudation tumors. " In this way, leaving out the entozoa and simple swellings, we obtain three large groups or classes : first, the exudation and extravasation tumors ; second, the dilatation and retention tumors; and last, the true pseudoplasms or neoplasms, — the growths in the strict sense of the word. The last class, as we have already seen, may be again divided into three smaller classes : the simple histoid, the organoid, and the teratoid tumors. Unfortunately, the classification cannot stop here, for there are many tumors in which ditfercnt varieties are combined together. These are called combination tumors. In some cases these combination tumors are exceedingly difficult to comprehend. "All heterologous tumors are not malignant. Quite a number of them are practically benign, and may be carried without ever causing any special trouble. In the first place, there are degrees of heterology. The tissues belonging to the group of copnective substances are more nearly related to ehch other than to the epithelial tissues. If, therefore, a cartilaginous or bony tumor originates in the midst of connective tissue, or a myxoma (mucous tissue) in adipose tissue, the heterology in these cases will be far less than if an epidermoidal tumor were to originate in the midst of a Ij-mphatic gland. A matter of still greater importance is the extent to which a tumor can pro- duce fluid material, that may be pressed out like a juice. This parenchyma- tous juice is at one time deposited within the cells (intracellular), at another between them (intercellular). A tumor containing much juice possesses to a high degree the power of infection. A dry epidermoidal tumor is much less dangerous than a moist one ; a soft cancer is much more suspicious than a TUMORS. 809 nature of this tumor ? It might have the local signification of a hernia ; of an undescended testicle ; of a hydrocele of the spermatic cord ; of an inflamed lymphatic gland. It might have the consti- tutional explanation of syphilitic or of tuberculous bubo. It might be a cancer. To satisfy himself of the particular condition repre- sented, the surgeon can only proceed as follows. First, he must recall the anatomy of the part. In the groin of the human male is a canal, — the inguinal canal. This canal is entered by a ring from the abdominal cavity, and has an outlet in a second existing in the aponeurosis of the external oblique muscle. In this canal lie, en- veloped in a sheath, the spermatic vessels. This canal constitutes the passage transmitting the testicle from the abdomen to the scro- tum. The entrance to this canal may permit of the insinuation of a knuckle of omentum or intestine. In this inguinal region exist a number of lymphatic glands. This, then, is the anatomy, and these are the data. Is the tumor a hernia ? There is no impulse on cough ; no doughy feel ; no diminution in size when the patient lies down ; no ability to thrust the tumor into the abdomen ; no enlargement of the internal inguinal ring. The tumor is not a hernia. Is it an un- descended testicle? The testicle is to be felt in its place in the scro- tum. The tumor is not a testicle. Is it hydrocele of the spermatic cord ? Thei'e is no fluctuation on percussion ; no ability to change the position ; no fluid as test is made with the exploring-needle or suction syringe. It is not hydrocele. Is it an inflamed gland of a local inflammatory signification ? It has no such history. The tumor, then, is not of immediate signification ; this, it would seem, we must know to a certainty. By exclusion, then, such tumor is exhibited as belonging to the second class. The only question now is as to the vice represented. Syphilis and tuberculosis have a history. If such history does not exist, then a final exclusion pronounces the condi- tion — whether rightly or wrongly need not here be discussed — a cancer. Example. — At a late clinic of the University Hospital there ap- peared before the class five patients. These patients, suffering alike from swollen, enlarged cheeks, were ranged side by side for diag- nosis. Patient 1 w^as found to have the tumefaction dependent on hard one. The fewer vessels a honor possesses, the more will its infecting power be restricted to the immediate neighborliood ; but the richet it is in blood- and lymph-vessels, the closer the contact of these two fluids xoiih the parenchymatous juices, and the easier luill the infection become general." — Virchow: Abstract from Lectures, made by Drs. Buck and Delafield. 810 ORAL DISEASES AND SURGERY. a periodontitis; patient 2 was laboring under caries of the jaw; patient 3 suffered from necrosis ; patient 4 had a lymph effusion con- sequent on a fracture ; patient 5, with very limited swelling of the cheek, associated with enlargement of the maxilla, presented in his case no local or common systemic explanation ; it became thus a necessity to pronounce the disease associated with the vice of cancer. The first four patients, their cases being self-explaining, were quickly made well ; the last — whose case was without an accounting explanation— died, and died from that condition which, in its developed state, was by all called carcinoma. With the premises of the preceding pages, for the purposes of the chapter, assumed, it is to be understood that any tumor, wher- ever situated, being without a history which explains it, is to be called and treated as cancer. But here at once may seem to rise insurmountable objections to such classification. It might be urged, for example, that a spindle-cell sarcoma which shall not destroy life has no more explanation of its origin than has an encephaloma, which in a single year runs to a fatal end. Such objection, however, influences only the histologist ; the clinician recognizes no prac- tical difference between the two conditions : they are, he assumes, but expressions of a common vice.* But the one will kill, and the other may not. If this is urged, the objection is admitted; but * " Over no group of tumors has there so long been uncertainty about their anatomical position and extent as about sarcoma. The old name, taken from aap^, flesh, merely meant that on section the tumor had a fleshy look. Of course, this did not make a diagnosis, as it was greatly a matter of choice what should be called flesh. The attempt to employ the name sarcoma solely for tumors composed of muscle filaments (Schule), that is, to identify it with those tumors now called ' myoma,' was not popular. Subsequently the term became somewhat more definite, — it was made to include all tumors rich in cells which have no decided alveolar formation, and were not carcinomatous. It is onh' for the last ten years that the following histological definition has received general acceptance, and has become quite common. A sarcoma is a tumor consisting of tissue belonging to the developmental series of connective- tissue substances (connective tissue, cartilage, bone, muscles, and nerves), which, as a rule, does not go on to the formation of a perfect tissue, but to peculiar degenerations of the developmental forms. Some pathologists would gladly see muscles and nerves excluded from this definition ; but when speak- ing of the spindle-celled sarcoma I shall show why I cannot admit this. If it is desired to term the inflammatory neoplasiie in their various stages examples of sarcoma (Rindflcisch), I assent to it, as this definition would agree pretty well with mine." — Billroth. 4 TUMORS. 811 it has an explanation which is easily made evident. There is, we say, but one non-explaining vice ; this vice puts oti various phases. These phases are influenced by the malignancy of the poison, or by relation with the conditions of the individual into whose system it has found ingress. This we may illustrate by an example. Four men go from a healthy to a malarious district ; all live in the same house, and all impregnate their systems with the same poison. In a week one succumbs to a quotidian ; in two weeks the second has a tertian; in three weeks the third dies from congestive chill; while the fourth, preserved by an inherent resistive force, antagonizes the miasma entirely. Thus also in the cancer vice : one man, either from the concentration of the virus or from the absence of antago- nizing power, dies quickly from a medullary expression; while an- other maintains a tumor for years, in the expression of simple sar- coma, succumbing finally in the battle, which, by the accident of some loss of force, gives a mastery to the abeyant vice, the sarcoma being quickly degraded into that which the microscope has distinguished from it as carcinoma. (See Sarcomatous Carcinoma.) The premise, then, is to be maintained, that any and every tumor which cannot be proved benign is to be deemed malignant. A self-explaining tumor expresses its own name; a non-explaining tumor demands from us no special regard for the distinctions of nomenclature, except as in an adjectival way the distinctions classify, for convenience in description, what are to be regarded as varying expressions of a common disease. (See Fibroma.) Urging the conviction that in the preceding few and very simple rules lies the fullness of a proper clinical diagnosis of tumors, appli- cable to any and all cases, we may now, without the chance of becoming confused, proceed to acquaint ourselves with the tumors pertaining to the parts which it is the special object of this volume to study. Before doing this, however, a comprehensive discussion of the subject at large may, with greater justice to our distinctions, invite the attention of the student.* * But it is to be asked whether or not, outside of the negation of the self- explaining tumors, there is a something that may distinguish a cancerous tumor ? If there is, the author knows nothing about it ; but this negation has a wide meaning. According as a man knows of a certainty what is not cancer, his inference of cancer becomes reliable and valuable : he calls that a cancer which has its place outside of the positive diagnostic. But is there not some special histological expression which characterizes 812 ORAL DISEASES AND SURGERY. 1. Relationship. — Homologous tumors tend, as would be in- ferred, to preserve their individuality; a malignant growth, on the contrary, represents simply the nidus of a vice flowing in from all parts,* and unless this poison become exhausted, or be powerfully resisted, it is seen to tend to infiltration and a commingling with all adjacent tissues. 2. Homologous tumors progress regularly, are apt to remain stationary after attaining some certain size, as in an odontocele, or they may degenerate and slough, as seen frequently in nsevi and in the sebaceous growths. In structure, homologous tumors are akin with the parts in which they are found ; they do not possess other than a single formative capacity. The tumors of a vice, on the contrary, have, as a rule, associated with them the evidences of their systemic character. They are not amenable to a local cure : if one be removed, a second comes to take its place, appearing either in the site of removal or in some other locality. f The cure of a vice tumor resides either in the use of a specific, antidoting the poison of the vice, or in affording such increase of the natural resisting force that the destructive tendency is retarded or over- come. 3. Homologous tumors are commonh^ single, or, if multiple, — for example, sebaceous cysts, — are confined to a common tissue and a common association. The vice tumors exhibit their constitutional association in the tendency, as just remarked, to reproduction not only in various parts, but in various tissues. 4. Homologous tumors, if painful, express a common pain. Vice tumors are apt to have a character of pain peculiar to themselves. 1. Simple LiJIamviatory Tumora. — A simple inflammatory tumor refers to a swelling (which is of varying nature), associated with an inflammation : thus, it may depend on simple excess of blood in a part, or on effusion of serum or of lymph. Vascular excitement, of a grade which brings a perverted circula- tion under cognizance as inflammation, never increases the dimen- cancer, — some peculiar heteroclitic cell ? Once it was thought so ; but now it is known that the spindle-cells, deemed a few years back entirely diagnostic, are also found in foetal connective tissue, muscles, and nerves. Spindle-cells afford information to diagnosis from location and combinations alone. * This view has the indorsement of the eminent surgeon and pathologist, Mr. Paget. f This is attempted to be explained by Yirchowon the principle influencing syphilitic absorption, or rather, to express him more critically, by embolism. TUMOBS. 813 sions of a part through excess of nutritive or formative action ; on the contrary, the nutrition of an inflamed part is always diminished, this being amply demonstrated by the disorganization of suppura- tion. p]ven, however, in the cases where I'esolution occurs, the tissues are always left relaxed and degenerate, and in themselves are, without doubt, of less consistence by weight or bulk than before the attack. It is, however, as is well understood, a characteristic of vessels engaged in inflammatory action to relieve their distention through effusion, and thus, as such effused material may be serum, tibro-serum, blood, or lymph, tumefaction is produced, which is persistent or otherwise according to character and associations. Concerning the first, — the simple, unmixed watery effusions, — they are found most frequently associated with low degrees of inflamma- tion, as in certain articular affections, in encephalocele, hydrocele, etc. In such effusions there can be no tendency either to coagulation or to organization : a tumor is formed, but it is simply a water-bag. Fibro-serum, or serum containing fibrin, has in it, however, an organizing force proportioned to the quantity of fibrin contained, approaching to this extent the nature and character of lymph : such fibro-serum is seen, on withdrawal from the body, to differ from serum proper in the ability it possesses to assume a jelly-like con- sistence, and, indeed, to show the fibre-cell, as exhibited in the peri- toneal and pleural efl'usions. Fortunately, however, while excluded from the air, fibro-serum seldom manifests any tendency to coagulate, thus remaining as susceptible to the action of the absorbents as is the more simple effusion. Fibro-serum is the liquor sanguinis of Babing- ton, the plasma of Schultz, the mucago or mucilage of Harvey. Lymph, another of the exudates of an engorged vessel, finds its most practical expression when viewed as the agent of nutrition; it is that pabulum in which reside the elements of life, and is in a state of constant transmission to every part of the organism : only as the result of over-pressure or engorgement, however, is it likely to be found in excess in any one part; but when so found it compels a tumefaction, to the proportion, of course, of the amount exuded. Between lymph and the vitalizing principle — the vis vitse — there exists the most marked affinity ; so that the circumstances must be adverse indeed where exuded lymph does not tend to organization. Corpuscular lymph, as it is sometimes termed, to distinguish a less vital from fibrinous lymph, is, when employed — as is not uncommon 814 ORAL DISEASES AND SURGERY. — to express the existence of two kinds of Ij'mph, a physiological misnomer, — the difference lying not in kind, but in character: thus, while lymph exuded by a vigorous organization tends always to immediate organization, cells being developed in the blastema, and fibres developing from cells, in a specifically diseased person, or in one deficient in the vital element, the recognition of cause for de- generation is sufficient explanation of a corpuscular variety. Cor- puscular lymph is protoplasm the grade of organization of which fails to rise to a proper development; the ver}'' common admixture of these two varieties is evidence enough of the oneness. Lymph tumors have associated vyith them a threefold sequelte : — the contents are absorbed ; or they organize ; or they degenerate and are gotten clear of in suppuration : or the three conditions may coexist, part of the lymph being absorbed, part being thrown off by degeneration and suppuration, and a portion affiliating itself with the surrounding parts. 2. Hypertrophic Tumors. — Hypertrophy is an expression of unbalanced nutrition, — a part, from some reason (recognizable, or not so), developing in excess of its fellow-parts. Hypertrophic tumors differ from all others, however, in their perfect and complete conformity with the parts with which they may be associated. So marked and characteristic is this that it is only through comparison with neighboring parts that the tumefaction or enlargement is to be perceived. Hypertrophy may ensue from the opposite conditions of excessive supply or of diminished waste. The enlarged biceps muscle of the blacksmith, and the gastrocnemii of the ballet-dancer, are illustrations of hypertrophy from super-nutrition. Enlarged glands from tuberculosis are not justly to be considered in such a connection, being specific hypertrophies: the first are hardly to be pronounced pathological, the latter are necessarily so ; the first have no expression but health, the latter none but disease. 8. Tumors xchich result from Interference ivith Function. — The appreciation of this class of tumors, of which there are a great number, is commonly without confusion or difficulty. It is, of course, required that the observer shall draw his inferences from the data of an anatomical and physiological knowledge. The opened spinal canal gives the protruding meninges, — the fluid of the cord filling the fluctuating cyst; obstructed sebaceous ducts yield wens ; relaxed veins afford varices; occlusion of the antral foramen compels engorgement of this cavity ; an unclosed umbilicus, or attenuation of its structures, and hernia follows ; a tooth out of the dental TUMORS. 815 arch, yet developing within the structure of the bone, and odon- tocele is apt to ensue. So of all this class of tumors we have similar simple and single significations; the pathology of each is peculiar to itself, but may be esteemed as almost strictly mechanical. 4. Blood Effusion. — It not unfrequently happens that an inflam- matory engorgement is associated with rupture of certain of the minute blood-vessels, thus allowing of the mechanical pouring out of the blood into neighboring parts. Such tumors find diagnosis in the suddenness of their formation and the associated inflammatory condition ; they are simply blood-bags, which may be more or less sacculated according to the circumstances of location. A blood effu- sion differs so markedly from a najvus or erectile growth, that by no possibility could these be confounded. Blood effusions may be absorbed, may be organized, or may degenerate and break down, being gotten clear of through the suppurative process. Another class of blood tumors are of traumatic signification. A hsematocele is not unfrequently resultant from injury rupturing vessels. The common blood blister is an example familiar to every one. Histological Distinctions. — A common classification of tumors, as employed b}' nearly all writers, is founded on what are termed the histological aspects of the growths described. The philosophy of such classification finds condemnation in the changes constantly occurring, and in the fact that the clinical history of the conditions demonstrates the expressions to be phenomenal, just as, though in more marked degree, the expressions of vascular perversion which we denominate inflammation are phenomenal. The classes of tumors, as histologically described, are as follows : Cystoma Cystic. Enchondroma ...Cartilaginous. Fibroma Fibrous. Lipoma Fatty. Osteoma Osseous. Dentinoma Dentinal. Hsematoma Blood. Encephaloma.... Brain-like. Scirrhoma Marble-like. Melanoma Like black pigment. Myxoma Mucus-like. Adenoma Glandular. Angionoma Vascular. Sarcoma Fleshy. Neuroma Nerve-like. Hygroma Water-like. Steatoma Lard-like. Myeloma Marrow-like. Meliceroma Honey-like. Atheroma Gruel-like. Chloroma Like green pigment 816 OBAL DISEASES AND SURGERY. A single moment's reflection will show that no conflict can exist between such a histological classification and the clinical one here proposed. An angionoma may be homologous or heterologous. A hematoma may be benign or malignant. Let us analyze, in illus- tration, some of the terms. We say, for example, of a certain tumor, that it is a cystoma. Using this term, we imply in it a cystiform character of growth, — this, and nothing more. The tumor may readily enough be what we have called homologous ; for should the cyst be in tbe jaw-bones, and should we make examination, we might remark the absence of certain teeth from the arch affected, and, on chiseling off the vault of the cyst, we might find the lost teeth as an explanation of the growth: the cyst would be a self-explaining odontocele. Again, examining a similar form of cyst, we find no teeth absent from the arch ; no diseased teeth, nothing that has in it the sem- blance of explanation ; the most accurate inspection, founded on the most profound knowledge of the parts, reveals no cause why a cyst should have developed in such place and at such time. Here the most experienced surgeon has but a single resource. He must act on the premise that the condition is the expression of constitu- tional vice, — not that this would necessarily be so, but that he does not know it be otherwise ; and therefore, not seeing or knowing what is to be done, his best plan will be to do nothing, — awaiting develop- ment, — or else treat the cyst with the latitude of cancer. Take a third condition of cyst, — a cyst in the substance of the lip. Is this homologous, or is it heterologous ? Is it a self-explaining condition, or does it express the habitat of a vice ? In the substance of the lip are secreting glands of three characters, mucous, sebaceous, and sudoriparous; each of these, for the purpose of clinical study, may be described as a secreting cyst-like body with a patulous tube running from it to a free surface, through which tube is constantly being discharged the fluid formed in the cyst. Suppose now any one of these tubes to be accidentally occluded, we find ourselves led at once to an apprehension of a diagnosis. Should a labial cyst be mucous in its character, it will be a soft, more or less elastic tumor, will be situated upon the oral aspect of the lip, and if explored by the needle will yield the characteristic discharge. Should the cyst, on the contrary, be of a sebaceous nature, it will be related with the external tissue, will roll loosely under the touch, and if explored will exhibit cheese-like contents. The sudoriparous cyst is, of course, of very rare occurrence ; if TUMOES. 817 existing, it would also lie in the external tissue, and would be found to have much more elastic walls than either of the others. A cyst sometimes will be found in the lip dependent upon dental abscess. A case is at the present time under treatment by the author where such a cyst has been of eleven years' standing ; during all this period the tumor has not been of less size than an ordinary shell- bark-nut. The sac was found very thick, and the surface ulcerated. A treatment which consisted simply in the extraction of two dead teeth, has resulted in the entire disappearance of the cyst. The alveoli of these teeth were found to associate with the tumor.* We pass to other of these synonyms. Let us take the terms scirrhoma, myxoma, encephaloma, myeloma: these are names given to tumors because of peculiarities of structure. The clinical placing of them, however, is the practical matter. Whatever name the his- tologist employs for the designation of a tumor, whatever may be the histology of the growth, its clinical place, if no local explana- tion exists, is with cancer. Here only may it be placed as treatment is concerned, and with such latitude of doubt, however profound may be his histological learning, is the surgeon made to feel that he must treat it. Scirrhoma is a term employed to designate solidity, hardness ; the cancer vice, influenced by the associations of a part in which it is found, by its own character, or by some peculiarity or idiosyncrasy of the individual, exhibits itself as a hard nodule ; remove this nodule, and not unlikely the return of the disease is in the form of a brain- like substance, — encephaloma ; or that might come, which, cut into, would exude a mucus-like substance, and we might call it a myx- oma; or perhaps a section would exhibit marrow-like contents, — myeloma; or there might be a cyst with gruel-like contents, — atheroma. Or, diffused throughout the substance of any of these differently appearing conditions, there might be a black coloring- matter, — then we might express the tumor as a melanoma; should the pigment be of a green shade, we would call it chloroma ; or should we designate the tumor for the first time, on seeing it in a state of * The hydatid, being a cyst of parasitic origin, is not introduced. Sucli a cyst, being an accident, as it were, can be conformed to no rule. For pur- poses of treatment, however, these tumors, however much they might be misjudged, have every requirement met in such operations as consider the circumscribed and antagonized cancer growth (which see). The clinical distinction makes necessarily unimportant the mistake — as treatment is concerned — of classifying the hydatids with the cancer vice. 51 818 ORAL DISEASES AND SURGERY. fungous proliferation, we should call it a hsematoma. Yet, with all these various significations, we would mean, in truth, but a single thing: and to clinically classify any or all of these phases we would need but one common term, — that is, taking it for granted that the tumors were without local explanation. In such exposition of terms, which are seen to be simply expressive of types, — synonyms we may with all propriety call them, — any confusion must certainly be found dispelled. These various terms, as employed in writing, are, however, of great assistance in expression; it is only necessary to bear in mind that their meaning and relation are adjectival. CHAPTER XXXIX. THE TUMORS OF THE MOUTH. THE EPULIDES. The Epulides. — The tumors of the mouth most frequently met with are those seen growing upon the gums, and known as the epulic. These growths are, in almost all instances, first to be observed , making their way from about the neck of some particular tooth, pushing out, apparently, from the socket, being found to originate from the odonto-alveolar membrane. As the epulides, like other tumors, classify themselves into self- explaining and non-explaining, the term epulis, still in quite com- mon use, is without proper signification when employed as a noun substantive, being possessed of an adjectival sense only. This term is derived from the Greek words ^-c and oZXa, signifying " upon the gums," and will be seen, therefore, to express simply position, so that, in employing it, one can only express that the growth spoken of is upon these parts. Histologically expressed, the epulic tumors might be classified as follows: epulo-fungoid, epulo-erectile, epulo-fibroid, epulo-fibro-recur- ring, epulo-sarcomatous, epulo-myeloid, epulo-carcinomatous, epulo- cartilaginous, etc. Clinically classified, we have to concern our- selves only with the benignancy or malignancy of the growths, as thus alone may we be led to a required treatment. The single epulic tumor which may with certainty be known as benign is the pulp-fungoid. A second form, which is usually found so, is the erectile. Any of the epulides which does not exhibit itself as one or the other of these forms is to be deemed cancerous, and treated with the latitude given to cancer. Xo other inference in- sures the best good for the patient. An epulo-fungoid growth is self-explaining. An erectile tumor is fairly so from analogy with the naevi : it is, in fact, a nasvus. No other of the epulides possess explanation of their presence or development. The epulo-fungoid growths demand a treatment pecu- (819) 820 ORAL DISEASES AND SURGERY. liar to themselves ; so, also, do the erectile. All the other epulides are to be treated on a common principle. From such data, which may be accepted as solidly reliable, the surgeon is led to perceive that an appreciation of the first two insures the clinical understand- Ins: of all the other conditions. The Epulo-Fungoid Tumor. — By an epulo-fungoid tumor is meant a fungoid growth of an exposed degenerating dental pulp. This tumor is as common as it is simple and harmless, and is certainly to be seen in a thousand cases to one of any other form. The fungoid pulp tumor is met with under the various aspects exhibited in Fig. 249. Referring back to Fig. 44 and description, the dental pulp is recognized as a stroma of delicate connective tissue, in which stroma ramify blood-vessels and nerve-fibrillae ; this structure occupies the cavity of the tooth, and is liable, through the accidents of decay or fracture, to become exposed. Fig. -49. ^ When exposed, it is not unlikely to undergo fungoid degeneration. Fig. 249, Subfig. 1, is an outline drawing representing the walls of a tooth-root envel- oping its pulp, which pulp, slightly fungous, projects a trifle above the level of its cavity. In molar roots, the crown being gone, such form of pulp tumor is very com- mon. No difficulty exists, however, in its recognition, as the boundary-walls of the cavity are plainly to be observed. A form of such tumor, a trifle complicated, is exhibited in Subfig. 2 : here, as is seen, the fungus is of such extent as to overlie the bound- aries of its canal ; any confusion is avoided, however, by thrusting the mass aside, when its character is at once made evident. Sub- fig. 3 represents another condition : here the mass has increased to such an extent that it not only conceals the canal, but also rests upon the surrounding gum, to which, not unlikely, it will be found to have formed attachments. Still another form is exhibited in Subfig. 4. Here a tooth-root may be below the border of its socket. No Epulo- or dental fungoid tumor. TUMORS OF THE MOUTH. 821 Fig. 2oO. pulp projects from the face of the canal, but a break exists upon one side of the root, out of which grows the fungous mass. Such a growth, little by little, insures the absorption of the alveolus upon the side at which it projects, and rising, finally, above the free face of the gum, exhibits a condition well calculated to mis- lead. Such a tumor is readily distinguishable from the odonto- periosteal growths by the nature of the growth, being of a livid asthenic appearance, not common to any other of the epulides. This last form of tumor is not at all frequent, depending for its ex- istence upon such a break in the continuity of a tooth-root as seldom occurs. It is to be remembered, however, that a decay commencing at the free surface may run along the root of a tooth, out of which track may project the fungus. Fungus of the dental pulp, of an extent and character described in conditions 3 and 4, is, however, as unfre- quently to be met with as conditions 1 and 2 are common. A form of epulides simulating, as location is concerned, the pulp-fungus, is exhibited in Fig. 250. In this instance the tumor, while seen to arise from the pulp cavity of the fang, when traced, is found to be an outgrowth of that aspect of the odonto-periosteai growth . ' simulating pulp-fungoid. odonto-penosteal membrane which adjoins the bone ; the growth has passed through an opening in the root, and has progressed, as shown in the dotted lines, until, reaching the margin, the tumor becomes exposed. The drawing shows the tooth in section. To mistake this last form of growth for the ordinary pulp- fungus would be to err necessarily in the treatment, the four condi- tions represented in Fig. 249 requiring either the destruction of the fungus by means of cauterization, or the extrac- tion of the affected fang; while this necessitates section of the portion of the jaw found implicated. Still another form of epulic tumor* con- sists, as exhibited in Fig. 251, of a ulitic out- growth, the result of irritating influences asso- ciated with double proximal dental caries ; the gum tissue, semi-strangulated, rises and fills the cavities. A similar expression of tumefaction Fig. 251. — Ulitic Tumor. * This, from its simplicity, is to be classed with the pulp-fungoid, as it is equally self-explaining. 822 ORAL DISEASES AND SURGERY. is not unfrequently met with in the interspace existing between teeth in which the Y-cut has been made ; indeed, these growths are to be met with where they have not only completely filled this in- terspace, but so projected above the grinding face of the teeth as to be injured at every occlusion of the jaws. The treatment consists either in extracting one of the approximating teeth, in so altering the relation of the necks of the teeth as to obviate the strangulation, or, after cutting away the mass, and by means of cotton wedges forcing the structure entirely clear of the cavity, in restoring by con- tour filling the original relation of the parts. A temporary treatment consists in keeping the cavities filled with plugs of cotton saturated with gum saudarac. Reviewing the tumors just described, it is seen that, with a single exception, — that shown in Fig. 250, — all are self-explaining. Epulo-Erectile Tumor. — This is a vascular growth, the analogue of the ntevi ; it is commonly associated with the capillary system, and has its character marked by its variation in size and appearance as influenced by the conditions of the circulatory system at large, — excitement increasing its turgescence, quiet reducing it. Erectile in a general appearance, epulo-erectile tumors present, however, decided features of variation. Thus, some represent a congeries of vessels which would seem to need the merest scratch to result in profuse hemorrhage. A more common feature of vascularity, however, exists in a likeness with the tissue of the corpus cavernosum penis, the cellular stroma being thinned into a series of communicating cells, which are found congested or otherwise, as circumstances control. Erectile tumors are also not unfrequently fouud quite solid, simulating fibrous structure: this depending on some vascular per- version which has produced excess of the fibro-cellular element ; indeed, it has sometimes happened that spontaneous cure has been effected through lymph effusions. The surgeon, acting on the hint furnished by nature, employs such process as one of his means of cure. Of the various forms of the epulo-erectile tumor, the spongoid is, however, by far the most common, — is, indeed, to be considered the type : stimulation of the circulation will fill it at times to bursting ; pressure may almost completely empty it. "Whether an erectile tumor may come under the definition of arterial, venous, or capillary, depends siuiply on the vessels most involved. The term aneurism by anastomosis, applied to these tumors by John Bell, seems to have had its foundation in that variety in which the arterioles are most implicated. This species, TUMORS OF THE 3I0UTH. 823 when congested, presents the arterial hue, and, when accidentally wounded, is the most troublesome, as control of hemorrhage is concerned. The venous variety is made up of a congeries of venules: the tumor is dark and commonly somewhat sluggish in aspect. The capillary form is intermediate between the arterial and the venous, and constitutes the spongoid form. The under- lying bone of the erectile epulides will almost invariably be found involved, being softened and spongy. Erectile tumors sometimes, though rarely, make their first appearance as- a red pimple upon the gum, growing in a polypoid form until they may attain the size of a cherry. Treatment. — Erectile tumors involving the bone can be cured only by a section which includes this structure. The diagnosis is easily secured by passing an exploring-needle through the soft tissue : if the bone is implicated, the needle will be found to enter it freely, and may be moved about among the loose stroma; if the needle does not pierce the bone, and the tumor is at all pedunculated, it may be strangulated; or, even where the base is broad, the ligature may yet be used, transfixing first the base with one or more needles for the proper directing of the thread. A second mode of treatment is by injection; the ordinary hypo- dermic syringe being employed, charged with one of Monsel's solutions of iron, with a very concentrated tincture of iodine, or with the glacial acetic acid. Any substance which will coagulate the blood may be employed, and not unfrequently is found to answer a very satisfactory end. The employment of this means of cure is not, however, unattended with risk. Still another method consists in the application of caustics, such as chloride of zinc, Vienna paste, the London paste, or the strong mineral acids. An anxiety, how- ever, which must always accompany the employment of these agents, is the fear of hemorrhage on the casting of the slough ; and such anxiety is so well grounded that experience soon teaches that this means of cure is applicable only in the least vascular of the growths. The seton, as an agent, finds not unfrequently its most happy ser- vice in the erectile epulides. The needle used is that employed by the surgeon in the passing of the ordinary ligature silk. The seton may be soaked or not in some caustic solution; the thread is always to be the thickest that the eye of the needle will admit, in this way insuring the occlusion of the transfixed vessels and guarding against bleeding. When hemorrhage associates itself 824 ORAL DISEASES AND SURGERY. with such transfixion, alum-water may be held in the mouth; or, if this does not answer, tannic acid ma}' be drawn into the wound b}' coatings the seton and moving it gently backw^ard and forward. Should even this not control the bleeding, a knitting-needle heated to whiteness may be thrust through the wound, or the saturated tincture of iodine may be injected. On two or three occasions the author has found himself enabled to control such a hemorrhage by casting a ligature around the parts, as best might be done, thus cutting off the circulation ; indeed, the practitioner, using the seton, will on some occasions find the employment of the ligature forced on him. Such hemorrhages are, however, very infrequent, and may not be met with in one out of a hundred cases. They are most commonly associated with the arterial variety of tumor. Electrolysis is another means of treatment sometimes employed (see Ti^eatment of Nsevi), and is highl}^ lauded in its application ; the object should be the coagulation of the blood, rather than a cauterization of the stroma of the tumor. Although destruction is preferred by many as the best service of electrolysis, it is to be recognized that the mode of using the agent suggested has the ad- vantage, inasmuch as it is a certain insurance against hemorrhage. A practice of " piecemeal removal" has been introduced into P^nglish surgery, consisting in teasing or tearing or twisting away fragment after fragment ; the princii)le being to avoid hemor- rhage, as in the torsion of arteries. This is a practice, however, which the inexperienced will do well to avoid ; not but that, in certain cases, it is a good plan of treatment, but frequently it has troublesome associations, not the least of which is active hemorrhage. Still another treatment, employed where a tumor has no asso- ciation with the bone, is the employment of the serres-fines : these are spring-wire forceps ; they are to be made of a size propor- tioned to the requirements, and may be clamped over the mass. In using these clamps, regard must be had to the nature of the serra- tions, these being deep or shallow according to the vascularity of the part to be grasped ; the pressure of these clamps will not un- frequently result in a coagulative and inflammatory action, which proves the cure of the tumor. An application somewhat on the principle of the serres-fines is the employment of pressure. The parts having first been emptied by forcing out the blood, a well-adjusted compress is to be bound tightly over the tumor, and retained in place continuously for TUMORS OF THE MOUTH. 825 several clays : this treatment, when the growth is small, will often effect a cure. An admirable plan of securing a desired pressure in these cases is to take an impression in wax of the jaw on which the tumor is situated, and, obtaining thus a model, make a plate precisely as for artificial teeth, having bands to hold it firmly in place, fitted to clasp neighboring teeth ; by now placing over the tumor a layer of cotton-wool, and compressing it by fitting the plate in place, pressure of a very effective type will be found to have been secured. Advantage is also gained by employing astringents in conjunction with the plate ; saturating the wool with a diluted solution of Mon- sel's solution of the persulphate of iron answers a very good pur- pose, or tannic acid or alum may be used. The erectile forms of the epulides, while not so clearly explainable as the pulp-fungoid, are yet to be esteemed as of local signification and of innocent type. An analysis of an erectile growth exhibits it as a tuft of vascular tissue. We recognize in it vascular anatomical perversion, not the offspring of a vice. From the consideration of the epulides as described, we proceed to that of forms, all of which experience will assure us are best es- teemed, and with most benefit and promise to the patient treated, as belonging to the second class: the author so treats them because, while they may not all express a vice, he cannot prove that they do not. By treating them with the latitude given to cancer, nothing detrimental to an innocent growth is done, but everything possible, with our present knowledge, should the disease be cancer. This practice the writer himself shall continue to pursue — finding in it the commendation of his highest intelligence — until the typical some- thing is discovered which shall allow him to know a cancer in all its expressions, just as to-day one might not easily be deceived in the herniiB or ranul^. The Epulides not Self-explaining. — We pass now to that consideration which includes every other epulic tumor which may be met with in the mouth : histologically, we would class these as myeloid, sarcoid, myxoid, fibroid, scirrhoid, encephaloid, etc. ; clin- ically, we are not concerned to give them any name : the single con- cern with our classification being as to the self-explainability or non- explainability of a tumor. With the epulides the author has had much to do ; he may be pardoned for suggesting that perhaps few in this direction have had wider opportunities of observation; and, 826 ORAL DISEASES AND SURGERY. as the result of such an experience, he believes that he advances the highest truth, and that which will be found to redound to the greatest good of a patient, when he teaches that that is to be called, viewed, and treated as cancer which cannot he proved not to he cancer."^ Cancer is treated in consideration of a twofold expression belong- ing to the condition. When infiltrated, that is, when parts adjacent to a tumor seem to be in marked sympathy, being engorged and shading dimly away into the healthy structure ; when glands are indurated and dyscrasia is marked ; then, not knowing any antidote to the virus, a surgeon can do nothing for a patient. When, on the contrary, a cancer expression is strictly localized, when a tumefaction does not shade gradually away, but possesses a strict individuality, like the concentric fibroid, — a spindle-celled, or even a giant-celled, sarcoma, — then, let it be epulic, or wherever situated, ablation is indorsed, on the principle of assistance rendered to a something which offers its highest expression of attempt to help itself. Thus, accepting the premises, we are to fiud in the character of an epulic tumor the practice pertaining to it. It would seem impossible for indecision or confusion to exist; only may it pertain to the con- science of the surgeon to be certain that he keeps pace with the diagnostic intelligence of his age. Presenting Figs. 252-256 as illustrations of some of the various expressions of the epulides, attention may be directed, with benefit to many, perhaps, to a description of the cases, together with the practice adopted, and the results. Case, J'ig. 252. — Some four years ago, Mrs. T., the sister of a medical friend, was brought by her brother to my office for consultation on a tumor (about the size of an ordinary pea) growing from the alveolus of an upper molar tooth. I thought this tumor belonged to the class pulp-fungoid. There was the broken palatine fang in the jaw, but so deep as to be only fairly discernible to the probe ; I could not see the origin of the growth, but inferred its character; * The author of course sees that here are involved the learning, experi- ence, and judgment of an observer. But with all grades of experience, he must perceive his position equally to hold. A man can handle and treat a matter only as he comprehends it ; it is the fatal misfortune of all cancer- atHicted patients that the highest intelligence has not yet arrived at the apprehension of what cancer is. It is a great misfortune for a patient to fall into the hands of a practitioner who does not know — to the extent of the known — what is not cancer. TUMORS OF THE MOUTH. 827 and, by separating carefully the alveolus from the fang, I was en- abled, after some little trouble, to get the root from its bed. The Epulic Tumors. Fig. 252. Fio. 2")4a. Fig. 253. Fig. 254 6. Fig. 255. Fig. 256. little tumor proved to be an outgrowth of the periodonteal membrane, and not au excrescence from the pulp ; in character it was distinctly 828 ORAL DISEASES AND SURGEBY. and decidedly fibrous, — it was, then, histologically classifiable as an epulo-fibroid tumor. It did not look like a growth from the periodon- teum, but rather as if its origin was in the crusta petrosa, and it had carried the membrane before it, somewhat as the infundibuliform fascia is made a tunic to the descending intestine in an oblique inguinal hernia. The removal of the fang brought the growth cleanly away. Of course, no scraping or cutting of the parts was necessary : the growth was evidently an emanation of the dental aspect of the periodonteum, and had in no way involved its alveolar reflection. No treatment of any kind outside of the removal of the tooth was employed. The patient remains perfectly cured. This is the only growth of just such relations that I have ever met with. Case, Fig. 253. Epiilo- Erectile Tumor. — Mrs. J. presented herself some time in 1862, with a livid, threatening-looking tumor, the size of a hickory-nut, occupying the left alveolar face of the upper jaw, extending from the lateral incisor back to near the tuberosity. This tumor diminished in size during sleep, and increased during the time of any excitement which tended to accelerate the circulation, sometimes seeming like a solid body, at other times like a spongy mass ; it was evidently erectile in its nature, analogous to the ordinary ngevi. It was an epulo-erectile tumor. Separating the growth from the gum, its association with the periosteum was plainly evident; and the probe revealed extensive involvement of the neighboring bone. An operation, which resulted in complete cure, was performed as follows: the lip being held well out of the way by an assistant, an incision was made, extending from the central incisor tooth of the affected side back to the tuber- osity, a similar cut being carried back on the palatine face of the tumor to the place of beginning : these cuts were made freely through the soft parts down to the bone, and completely circumscribed the tumor, with a reasonable margin to spare. The central incisor was next extracted, and, with the ordinary cutting-forceps, a cut was made through its alveolus, extending almost to the labio-nasal angle. A second pair of cutting-forceps was now taken up, and, by two cuts the width of its blades, the involved bone was removed ; the section extending, as is evident, from the situation of the left central incisor to the tuberosity. Considerable hemorrhage attended the operation, although the section was well outside of the vessels involved, three ligatures being required. Treatment by excision of the bone was here necessitated from the implication of that tissue. After- Treatment. — The lady being of very full habit and of mark- TUMORS OF THE MOUTH. 829 edly sanguine temperament, magnesias sulph. ^ss was ordered the evening of the operation. As an opiate, morph. sulph. gr. ss. Day after Operation. — Marked inflammatory action, attended with considerable swelling of the tissues of the face. R. — Plumbi acetatis, 5'j ; Tincturae opii, ^ij ; Aquae, §xvj. Ordered a cloth wet with this preparation to be kept continuously upon the face. Third day. Inflammation increasing ; eyes completely closed from the great oedema of the lids ; mag. sulph. reordered, together with hot pediluvia; eyelids heavily painted with tincture of iodine. Fourth day. Erysipelas set in ; the face looking like a glistening red ball ; patient restless, nervous, and frightened ; painted the whole face with tincture of iodine, officinal strength ; the lead-water and laudanum continued ; iron and quinine internally.* R. — Tincturae ferri chloridi, 5i'j I Quini^ sulphatis, gr. xxv. Sig. — Fifteen drops in water every three hours. Also a diaphoretic : R. — Liquoris ammoniae acetatis, ^ij. Sig. — Tablespoonful every ten minutes until the induction of pro- fuse perspiration. Sixth day. Erysipelas evidently yielding ; iron and quinine ; paint- ing with iodine, lead-water, and laudanum, continued. Seventh day. Much improved ; the erysipelatous redness gone ; skin wrinkling ; patient can see a little from one eye ; continued the painting with the iodine, and the application of the lead-water lotion. Ninth day. Inflammation all gone ; patient quite comfortable ; the exposed bone covered with a thin layer of healthy granulations ; case progressing well. Twelfth day. Patient attending to household duties ; mouth of course very tender, but advancing rapidly toward a cure. * The author, for such erysipelatous inflammations, now always employs for local use the combination recommended of iron, quinia, and cinchona. 830 ORAL DISEASES AND SURGERY. Tiventy-fifth day. Patient may be called well ; needs no further attention. To complete the case, artificial teeth have been inserted, the plate being made to fill up the place of the lost bone. No one would ever suppose, in looking at the lady, that she had lost such a portion of the jaw. At this writing (1872) the patient remains cured. Case, Figs. 254 a and 254 h. — Recurring epulo-fihrous tumor. — These two views, from life, represent the case of a young lady as an epulic tumor appeared when first operated on, and as it reappeared and was reoperated on some four months after the first operation. The patient, a young lady of much more than ordinary personal attraction, applied for treatment of the tumor as represented in the first view. The necessity for an operation having been explained to the patient and her parents, I made the following suggestions. First, that a section be made which should simply remove the tumor and the alveolar process connected with it. If this should succeed, there would be no deformity. Second, if the growth should reappear, a second operation to be performed, which should remove the bone proper, except a simple rim of continuity. Third, if this, too, should fail, then the complete section of the bone to be made ; this, of course, would be deforming, but it would be the only resource. In December, ISGG, the first of the operations was performed ; the bone outside the section looked perfectly Fig. 2.')7. healthy, and gave every promise of a satis- factory result. In two weeks healthy granu- lations had covered the bone, and in one month the patient was dismissed cured. The following March, however, a small tu- Section of bone as first and , ■, •, • ,i . /< xi afterward made. ^ercle appeared in the very centre of the site of the original tumor, and in the course of three weeks half a dozen new tumors or lobules had sprung up. The second operation, as proposed, was now performed, the con- tinuity and natural arch of the bone being preserved unbroken. This was successful. The patient now (1872) remains perfectly well. The site of the removed bone is occupied by artificial teeth ; and not the slightest deformity is to be observed. Fig. 255. — This figure exhibits a case operated on in 1836 by the celebrated English surgeon Mr. Liston. The following is a sum- mary of it, given by that gentleman in a paper on " The Tumors of the Jaws :" J TUMORS OF THE MOUTH. 831 "The patient had labored under the disease for eight years, and had been subject to a partial removal of the growth when of in- considerable size. The tumor was of Gbrous nature as regards its disposition, form, and intimate structure. It differed somewhat, how- ever, in outward appearance, in consequence of its exposed situation. The growth sprang originally from the gums and sockets of the in- cisors and canine teeth of the left side ; at an early period it pro- truded from the mouth, unconfined and uninfluenced by the pressure of the lips or cheek. It had assumed a most formidable size and appearance, concealed the palate and pharynx, and gave rise to great inconvenience and suffering. The surface had been broken by ulceration, but upon close inspection of the projecting part, and of that covered by the cheek, it was found to possess a firm consist- ence, and to present a peculiar botryoidal arrangement of its parts. "An operation proved perfectly successful." Case — not illustrated. — Mrs. S., of Camden, N. J.; epulo- fibroid tumor of left superior jaw. This growth was the size of a large walnut, the bulging of the cheek quite deforming the patient; growing very rapidly ; painless. Patient had been confined with her fourth child five weeks before presenting herself. 0];)eration. — This was performed three weeks later. The tumor, or all that portion of it which was free of the bone, was cleanly removed with the scalpel, together WMth a margin of surrounding healthy tissue. This step exposed the bone, which was found carious. This was to be removed, which was easily effected by the use of the gouge, little by little being cut away until healthy struc- ture was exposed. The surgeon recognizes such healthy structure both by its feel under the instrument and by its appearance ; healthy living bone being white, studded with minute bleeding points. Hemorrhage during the operation was considerable, but was con- trolled, without ligature, by throwing alum-water into the wound from an ordinary syringe. After- Treatment. — Very little required; a w^ash of the perman- ganate of potash, five grains to the ounce of water, was given as a disinfectant, there being for a few days a somewhat disagreeable odor from a decomposing blood-clot. No antiphlogistic or systemic treatment of any kind was required, not a bad symptom having ap- peared, the patient being entirely well three weeks after the day of operation. In this case the floor of the antrum was removed and the cavity wholly exposed. At the completion of the cure, it was, however, closed up. 832 ORAL DISEASES AND SUBGERY. Case — not illustrated. — Mrs. T., West Chestnut Street. Tumor of four years' growth ; loose in structure, occupying one-half of the roof of the mouth, giving a most disgusting and threatening appear- ance. The growth had first appeared between the bicuspid and first molar teeth, and at the time of my first seeing it had entirely de- stroyed the inner alveolar plate of all the portion of the jaw with which it was associated. In raising the tumor from its bed, all the underlying palatine process, so far as could be seen, was found to be diseased. Operation. — This consisted in cutting away with the scalpel as much of the growth as possible, and completing the operation on the bone with the gouge; hemorrhage very profuse, the use of a com- press being necessary for its arrestation, and this only effected after several hours. After- Treatment. — Very little required ; some over-inflammatory action, which quickly and readily yielded to low diet for a few days, and a single dose of sulphate of magnesia. In three weeks the case was in condition to be dismissed. These special illustrations, all of them, with the exception of the third, being without the pale of our first classification, are given because they serve to show that there is an order of fibrous tumors ; or, on the other hand, an antagonizing condition of the system, which, fully appreciated, would afford to the surgeon an ability to prognose the result of operations on them with the same certainty as in the removal of a pulp-fungoid. To be able to distinguish this class, or species, or condition, would certainly signifj- a step gained, — one of the many steps to be made, without doubt, by those who shall come after us. But such ability to distinguish does not yet exist. We may infer, but we cannot be certain. CHAPTER XL. THE TUMORS OP THE MOUTH. EXOSTOSIS AND SUBACUTE INFLAMMATOKY TUMOKS. The term exostosis, as the reader will remember, is derived from the Greek words sS, "out of," and orr-so-^, a "bone:" it denotes an osseous tumor which forms at the surface of bones, or in their cavi- ties ; the first is called exostosis, the latter enostosis. The following varieties have been named : "Ivory exostosis, that which is ivory-like;" lamina exostosis, that which is made up of distinct fibres or layers ; spongy exostosis, that which is like the spongy tissue of bone. Hyperostosis is precisely the same thing as exostosis, both being inflammatory hypertrophies. Inflammatory osseous tumors are hyperostoses. Because, however, there are great differences in the expressions of these conditions, I shall write of them under special heads. Exostosis, as commonly met with in the mouth, is strictly benign. It is generally recognizable by its extreme slowness of growth, the entire absence of pain, — except when it meets with some peculiar obstruction, — and its freedom from surrounding disease. It does not tend markedly to ulceration, and does not, except mechanically, affect the parts even most directly associated with it. True exostosis has its origin in local irritation, perhaps always. It is true that reference is made by authors to an ossific diathesis, but, as is truly remarked by Miller, "A skeleton so susceptible is prone rather to the more common inflammatory products of caries, abscesses, ulcers, and necrosis." That local irritation is the chief cause of exostosis is satisfactorily proven, I think, by reference to parts most subject to this interfer- ence. The teeth, for example, are found exostosed in a thousand instances to one of any other bone, and certainly no bones are so 52 ' ( 833 ) 834 ORAL DISEASES AND SURGERY. constantly found in irritative conditions. I use the term "bone," reminding the reader that the portion of the tooth which takes on this morbid action is almost in every proper sense true bone. Non-specific exostosis, occurring on any portion of the maxillary bones removed from the alveolar borders, is an exceedingly infrequent affection. With every opportunity for observation, I am surprised at the fewness of the cases I have seen ; and these, with a very few exceptions, have been small, and of little consequence. Around the base of the alveolar processes, however, and particu- larly on the lingual aspect of the lower jaw, this affection, in a minor form, is exceedingly common; certainly I have seen hundreds of examples, the enlargements varying from the size of a small shot to that of a rifle-ball. As pathological relations are concerned, they seem of little consequence ; I never knew one to result in any harm ; and the treatment I have adopted in such cases has been coaimonly the very simple one of letting them alone. It is Jiot improbable, though, that cases may present when opera- tions seem demanded. I have felt called to operate upon some two or three of such as I have met w^ith. The mode of procedure is simply to lay off from the tumor the soft parts, and, with a chisel, cut away the mass ; there is no hemorrhage or other trouble attend- ant on the operation. (See Hyperostosii<.) Exostosis of the fangs of the teeth — exostosis dentium, the usual seat of the disease in the maxillary regions — finds location both in the cemental and dentinal structures of these organs ; for while I have seen two or three cases where the crowns of the teeth were enlarged, as if from a species of exostosis or hypertrophy, yet these were so anomalous that I may describe the growth as being asso- ciated exclusively with the fangs ; and even here, I think, it will be found in the majority of instances confined mostly to the apex, growing, bulb-like, as it were, about the end of the root. The diagnosis of exostosis in these situations is not always with- out confusion. The most frequent pathognomonic feature, however, is a sense of continued uneasiness about the parts, not generally amounting to pain, but serving as a constant reminder of the pres- ence of the tooth. The tooth itself may or may not be carious. Pressure, or the stroke of an instrument, does not, in ordinary cases, either increase or diminish the soreness; the sense of fullness about the parts is particularly observed where the absorption of the alveo- lus is not proportionably active with the exostosis. In these latter cases, the extremest symptoms of neuralgia are not unfrequently TUMORS OF THE MOUTH. 835 produced, and, if not comprehended, are of course treated without avail. One of the most remarkable cases of dental exostosis on record is related by Mr. Fox. The subject was a young lady, who, at the time she sought the professional aid and advice of this practitioner, ' had suflfered so severely and so long that the palpebrae of one eye had been closed for nearly two months, and the secretion of saliva had for some time been so copious as to flow from her mouth whenever it was opened. She had tried every remedy which had been recommended by the ablest professional advisers, without de- riving any permanent benefit, and was only relieved by the extraction of every one of her teeth. The surgeon may infer from the mention of this case that he is likely to meet with many gradations of the trouble. The cure will consist in the removal of the affected member: this, after the diag- nosis, is always easily accomplished with the aid of a pair of cutting- forceps. Warty Teeth. — In this association reference may be made to an anomalous confusion and development of teeth-germs to which the term warty has been applied. Upon another page we shall discuss them under the aspect of dentigerous cysts. The rarity of these warty teeth permits few the opportunity of seeing them. Among the recorded examples are four by S. J. A. Salter, one by Mr. John Tomes, two by Wedl, two by M. Oudet, two by M. Forget, and one by Mr. Harrison. To teeth of such anomalous development M. Broces has applied a name that has now come into general use, namely, odontomata. These he. with all propriety and clinical justice, has classified into circumscribed and diffused, — the first including all masses in which recognition of the tooth exists ; the second, those where it is lost in an anatomical confusion of the structures. pj^. 9-g The odontoma described from the practice of M. Forget, on a succeeding page, constitutes the most marked example of the latter on record. Fig. 258 is an example of the former. Examples of the circumscribed odontomata are given on Plate I., Subfigs. 1 and 3. A form of dental exostosis termed by Mr. Salter the enamel nodule exhibits a pearl-like odontc.mii. excrescence growing from a tooth. Excrescences of this kind are considered to be essentially submerged cusps, being composed of a cone of dentine enveloped by a cap of enamel. 836 ORAL DISEASES AND SURGERY. Fig. As au illustration of extreme dental hypertrophy, combined with the existence of an enamel nodule, attention may be directed to a specimen belonging to the Philadelphia Dental College, exhibited in Fig. 259. This mass is two and a half inches in length by two and five-eighths inches in circumference; it was associated with the roots of a left superior molar, and was extracted from the mouth of a laborer by S. H. Whitman, of Newport, Perry County, Pennsylvania. In examining this specimen, it is observed that to the right of the palatine root, and connected with it, is a portion of enamel ; being an out- growth, as has been inferred, either of a wisdom or of a supernumerary tooth, — most likely, how- ever, a production of the tunica propria of the tooth itself Mr. Salter describes such cusps as being clothed with a pulp, — the enamel pulp. A microscopical section of this growth is figured (Fig. 260) and described by my friend Dr. J. H. McQuillen, through whom, I believe, the specimen was received by the museum: "A first or outer section presented only the lacunae and canaliculi characteristic of cementum. A second cut differed somewhat from this, in having, in addition, certain spaces of no definite shape, and ap- parently being the blending of a number of the lacunae. In a third section the lacunae were quite numer- ous, and the canaliculi starting from them were of considerable length, and pursued a tortuous or curved direction, resembling very much the appearance and course taken by the dentinal tubuli in secondary dentine. Fig. 260 is from a drawing as seen under the microscope. A few canals (cut transversely), evidently for the passage of blood-vessels, were observed, but no Haversian canals, as in bone, with the lacunae and canaliculi arranged in concentric layers around them." In the venereal, scorbutic, and tubercular hypertrophies or exos- toses of the maxillary bones, the features of the common disease TUMORS OF THE MOUTH. 837 become quickly evident m the local trouble ; so remarkably so, indeed, that no one would be likely to misunderstand things, pre- supposing the general disease to be understood. The growths are rapid, painful, and almost always more or less amenable to con- stitutional treatment. Scrofulous and scorbutic tumors differ from the venereal in being more loose and spongy in structure, and, in consequence, more apt to run into abscess, being possessed, as it were, of elements for their own destruction. In these forms of maxillary disease, the lesion is commonly heralded by deep-seated, dull pains, which precede by some time the visible enlargement of the part. After the tumefactive process sets in, it goes on, if uncombated, until the parietes of the bone are completely disparted. Associated with this enlargement is an unhealthy condition of the soft parts. As the disease advances, the centre of the tumor softens, while the character of the pain changes, becoming sharp and throbbing ; as pus forms, sinuses are created, and thus ulcerations occur on the face of the tumor. Enlargement of the maxillae from these causes is, however, very uncommon, and might only escape being con- founded with cancer by observation of the association with the disease at large. The treatment of inflammatory tumors of these and similar types is to be conducted in consideration of their twofold requirements. The systemic influences are to be corrected, while, locally, I think I am justified in asserting that, as a rule, they will succumb to the treatment commonly directed against similar abscesses of the soft parts. I have great confidence in the use of tents and stimulating injections. Thei'e is a simple inflammatory tumefaction of the maxilla some- times met with, which might be mistaken for specific exostosis. It is to be distinguished, hov/ever, by the greater rapidity of the swelling and by the greater soreness attendant on it; it comes as a cold in the head, or on the chest, — without, in the majority of cases, the patient being able to assign any cause, — and it is found soon to give way to the same class of antiphlogistics. This tumefaction is extra- rather than intramaxillary ; it is simply a peri- osteal exudate, and has, of course, no constitutional associative lesion. In this connection, attention may be directed to a form of tumor frequently found in the mouth, which, clinically, is classible with the exostoses. I allude to an apparent expansion of bone fre- 838 ORAL DISEASES AND SURGERY. quently found in association with a strumous diathesis, and so in- variably in connection with periodonteally diseased teeth or roots of teeth ; not always, however, are these expansions or growths in association with the strumous condition, as I have treated them in individuals whose constitutional condition seemed perfect. These tumors have a common history. The nerve of a tooth dies, and the periodonteum takes on a chronic irritative condition, or per- haps a tooth has been fractured in attempts at extraction, and the root, or some portion, has been left in the socket. After a time, sooner or later, a slight swelling, apparently of the gum, is ob- served. This may readily be taken for a chronic alveolar abscess ; there is no pain, however, associated with the enlargement, which is soon seen to differ from the abscess in the slowness of its evolution ; it is also hard, and perfectly unyielding under pressure. As we watch the case, month after month, we find it gradually to grow, giving to the observer the impression of an expansion of the bone under the gums, although, as we understand, there are no special or marked signs of such cystiform condition. If we pass an exploriug-needle into the tumor, it feels as if it were cutting its way through spongy bone ; and so indeed it is, as dissection will reveal to us that the cancellated structure has taken on hyper- trophic action, and it is such spongy enlargement that bulges out the overlying parts and makes the tumor. I have treated quite a number of these growths, and invariably in connection with the in- ferior jaw. I do not think they would often be found in the superior, such chronic conditions being here more apt to induce caries, which disease we know to be as uncommon to the lower as it is common to the upper jaw. These tumors, so far as I have seen them, either remain fixed in character, after growing to the size of half a walnut, or, in ver}^ bad subjects, they degenerate into abscess, and, dis- charging thus the offending body, cure themselves. Such sponta- neous cure is, however, not common. The surgical treatment of these tumors is both simple and effectual. It is enough, not unfrequently, to remove the tooth or root, particularly if, in connection with such removal, we keep the socket open for a few weeks with a tent of cotton or sponge. A very certain method, and one which I am in the habit of employing in my own practice, consists in cutting away, with a delicate gouge, the enlarged mass : this is easily accomplished by using the opening made in the extraction of the tooth as a means of ingress to the mass ; it can in this way be cut out, piece by piece, without any TUMORS OF THE MOUTH. 539 external incision, and with a wound not larger than that made by the preliminary extraction. After such operation the parts are to be well syringed, and a tent kept in the tooth-socket, to insure granulations from the circumference of the wound. In two or three weeks the cure will commonly be found complete. In this connection attention may be directed to an obscurity which sometimes exists in the diagnostic relationship of diseased teeth, — that is, no teeth or roots of teeth may seem to be present. A sufficiently close observation, however, will always detect in the neighborhood a fistulous opening ; it may be very minute, but it is seldom, if ever, absent. If a probe be passed into this orifice, it will lead to the ofifeudina,- ag-ent. Fig. 261. — Hyfkrostosis. HYPEKOSTOSIS. In connection with the simple tumors, reference may now be made to general facial hyperostosis sometimes existing. In a work published by Mr. Heath, being the Jacksonian prize essay for 1867 of the Royal College of Surgeons, England, the following illustrative diagram and description of a case are given: The patient, when about forty-five years of age, and apparently in perfect health, was exposed to a cold wind ; immediately after which he perceived an itching and heat in his eyes, and swelling of the face rapidly supervened. A small tumor formed just below the inner angle of each eye, which burst, and after twelve weeks he was able to resume his employment. He suf- fered from inflammatory attacks in the tumors, with much pain in the head on more than one occasion, and consulted many medical men ; but no treatment relieved the disease or retarded the growth of the tumors, which increased slowly and were of stony hardness. The eyes were pro- jected from the orbits by the tumors, and th^ right eye inflamed and burst, while the left was accidentally rup- tured by a blow. The patient lived to over sixty years of age, and died of apoplexy, having been occa- sionally maniacal during the last two years of life. The portrait is taken from the work of Mr. Howship (" Practical Observations on 840 ORAL DISEASES AND SUBGERY. Surgery"). The skull of the patient is preserved in the College of Surgeons, and shows, as might be anticipated from the portrait, two large masses of almost exactly symmetrical form and arrangement, which have partially coalesced in the median line. The growths are as hard as ivory, and consist of very close, cancellous structure. They project more than three inches from the face, and an inch be- yond the malar bones on each side. The man attributed the growths to repeated blows received on the face in fighting. The skull of a Peruvian (3093, College of Surgeons, London) is also alluded to by this same author. In this case the disease is of a more diffused character, all the bones of the face, as well as the frontal and the adjacent parts of the sphenoid and parietal, being enlarged and thickened in a remarkable manner. The nasal fossae and orbits are nearly closed, the superior maxillary bones having grown into great knobbed and tubercular masses, in which their original form can hardly be discovered. The hard palate is similarly diseased. The lower jaw is enormously enlarged at its right angle, and in the greater part of its right half it measures upwards of five inches in circumference, and all but three of its alveoli are closed up. A section of the lower jaw shows that its interior is composed of an almost uniformly hard and compact, but finely porous, bone. There is no history attached to the specimen. Hyperostosis is simply exostosis or enostosis. It is analogous to hypertrophy of the soft parts, and must have a similar history. As can be very well understood, varieties in form and character present themselves. These growths are sometimes associated ex- clusively with the face of a bone, as in the ordinary exostosis. In these cases the periosteum may separate the two bodies. In other cases there is hypertrophy of the bone proper. The condition is one of disease only as there is a lack of correspondence in other parts. Any section of a hyperostosed part exhibits the peculiar features of bone-substance ; it may be, as is often seen, that the cellular substance is compressed and much altered, but there is the distinction to be observed between it and a cortical boundary, and -'•the analysis remains the same, — that is, as the constituent parts are concerned. When these hypertrophies associate exclusively with the endosteum, as in long bones, they obliterate or diminish the medullary canal, and, if of sufficient size, expand the external parts into a tumor, greater or less in size. The history of any form of hyperostosis is the history of certain of the phenomena of inflammation ; there is, from some cause or TUMORS OF THE MOUTH. 841 other, irritation attended with vascular changes, the effusion of plastic matter associated with osseous transformation. What this source of irritation is, and how to control it, are matters which necessarily invite the attention of the surgeon. Reference has been made on a preceding page to the hypertro- phies of the specific conditions ; such enlargements are easy enough to understand, even if not so easy to remove. But the hyperostoses here considered are not of such character, but seem to be of an entirely local signification ; hence a local source of offense may not be sought for in vain, as, for example, in Mr. Howship's case, where the ostitis might very plausibly be attributed to the blows received. The inflammatory thickening of bone, alluded to a few pages back in connection with diseased teeth-roots, is but another exhibition of the results of local irritation. That the hyperostoses are to be viewed, and in every way treated, as simple overgrowths, is certainly well exhibited by Mr. Quekett, who, submitting to microscopic examination portions of all the osseous tumors in the Royal College of Surgeons, confirms the position in all particulars. The rates of the growths of such tumors are, I presume, influenced by individual susceptibilities or peculiarities ; there is certainly in this respect the greatest possible difference. In the Osteographia of Mr. Cheselden is an engraving of an osseous tumor surrounding the head of a tibia, which measures exactly one yard in circumference. An imposing growth is also figured in Mr. Paget's Surgical Pathology. In this latter case, as Prof. Clark describes the tumor, the hardest parts have neither Haversian canals nor lacunae. In the less hard parts the canals are very large, and the lacunae are not arranged in circles around them, and everywhere the lacunae are of irregular or distorted form. A remarkable specimen of an osseous tumor of the left upper maxilla (Fig. 262), from the Traite de Pathologie Externe, found in the Musee Dupuytren, is described in Mr. Heath's essay as being limited behind by the pterygoid process, internally by the intermax- illary suture, above and externally by the malar bone. The tumor