ORAL DISEASES SURGERY. ^^ A/, /^tr^^yt, A TREATISE DISEASES AND SURGERY MOUTH, JAWS ASSOCIATE PARTS. BY JAMES E. GAERETSOE", M.D., D.D.S., LATE LECTURER OX ANATOMY AND SURGERY IX THE PHILADELPHIA SCHOOL OF ANATOMY; UTE PROFESSOR OP THE PRINCIPLES AND PRACTICE OF OEXERAL SURGERY IN THE PHILADEL- PHIA DENTAL COLLEGE; MEMBER OF THE PHILADELPHIA PATHOLOGICAL SOCIETY; MEMBER OF THE ODONTOGRAPHIC SOCIETY OF PENNSYLVANIA, ETC. ETC. f tT«s!tt' atfd with ^\tt\ llatf;s antl nMtnftoujsi Woo^-ruts/. PHILADELPHIA: J. B. LIPPINCOTT & CO. 1869. Entered, according to Act of Congress, in the year 1869, by J. B. LIPriNCOTT & CO., In the Clerk's OiBce of the District Court of the United States for the Eastern District of Pennsylvania. l/UD PREFACE. In the fulfillment of many promises made from time to time to his students and other friends, the author has prepared the following pages, as embody- ing the results of his observations and experiences during a somewhat extended 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 offered 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 there- of, 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. (V) ACKNOWLEDGMENT. The first three hundred pages of this work were scarcely through the press when the author received the grateful encouragement of finding it adopted as a text-book by several of the oldest and most influ- ential of the Dental Colleges of the United States; for such a manifestation of interest and confidence he would express his appreciation. To S. S. White, Esq., who, with great generosity, placed at the command of the publishers all of his large collection of cuts illustrative of dental sur- gery, thanks are especially due, as this kindness has done much to enhance the value of the work. (vii) CONTENTS. CHAPTEE I. PAGE Surgical Anatomy of the Mouth and Face 17 CHAPTEK II. The Mouth 44 CHAPTEPv III. Fifth Pair of Nerves 63 CHAPTEK IV. Dentition 79 CHAPTER V. Associate Lesions of First Dentition 88 CHAPTEE VI. Anomalies oT Second Dentition and their Surgical Eelations 116 CHAPTEE VII. The Teeth and their Diseases — Alveolar Abscess 140 CHAPTEE VIII. The Teeth and their Diseases — Trismus 147 CHAPTEE IX. The Diseases of the Teeth — Caries 163 CHAPTEE X. Diseases of the Teeth — Odontalgia 201 (ix) X CONTENTS. CHAPTER XI. PAGE Diseases of the Teeth — Salivary Calculus 213 CHAPTER XII. Diseases of the Teeth — Denudation 221 CHAPTER XIII. The Extraction of Teeth 223 CHAPTER XIV. General Remarks on Extraction 234 CHAPTER XV. General Anaesthesia 242 CHAPTER XVI. General Ana?sthesia 252 CHAPTER XVII. Salivary Fistule 267 CHAPTER XVIII. The Tonsil Glands 272 CHAPTER XIX. , The Gums and their Diseases 280 CHAPTER XX. Caries of the Maxillse 303 CHAPTER XXI. Necrosis 309 CHAPTER XXII. The Tumors of the Mouth 327 CHAPTER XXIII. Exostosis and Subacute Inflammatory Tumors 353 CONTENTS. xi CHAPTER XXIV. Page The Epulides 362 CHAPTER XXV. Osteo-sarcoma 37I CHAPTER XXVI. Osteo-carcinoma 386 CHAPTER XXVII. Epithelioma 395 CHAPTER XXVIII. Tumors of Parts Associated with the Mouth 405 CHAPTER XXIX. The Antrum of Highmore, and its Diseases 419 CHAPTER XXX. Neuralgia 435 CHAPTER XXXI. Wounds of the Mouth and Associate Parts 472 CHAPTER XXXII. Ozsena 497 CHAPTER XXXIII. Fractures of the Maxillary Bones 510 CHAPTER XXXIV. Dislocation of the Inferior Maxilla 524 CHAPTER XXXV. Operations upon the Lips and Cheek 531 xii CONTENTS. CHAPTER XXXYI. PAGE Operations upon the Lips and Cheek 548 CHAPTER XXXVII. The Tongue and its Diseases 562 CHAPTER XXXVIII. The Aphthte COO CHAPTER XXXIX. Ranula 621 CHAPTER XL. Palatine Defects and their Treatment 633 CHAPTER XLI. Obturators 652 CHAPTER XLII. Resection of the Maxillary Bones 679 LIST OF ILLUSTRATIONS. FIG. PAGK 1. Front and lateral region of the skull 18 2. Superior maxillary bone of the left side — outer view .. 21 3. Superior maxillary bone of the left side — inner view 21 4. Inferior maxillary bone 26 5. Posterior view of the right palate bone 29 6. Exterior view of the right palate bone 29 7. The vomer — view of left side 31 8. Articular relations of vomer 32 9. Position and relations of turbinated bones 33 10. Ethmoid bone — general view 34 11. The sphenoid bone — upper view 36 12. The sphenoid bone — front view 37 13. Anterior view of the left nasal bone 40 14. Outer view of the right malar bone 41 15. External view of the right lachrymal bone 42 16. The hyoid bone 43 17. Muscles of the head and neck 46 18. Arteries of the face ; 47 19. The common carotid, with its divisions 48 20. Nerves of the face 49 21. Veins of the head and neck 51 22. Sectional view of the nose, mouth, pharynx 53 23. Upper surface of the tongue 55 24. Diagram of the papillae of the tongue, moderately magnified 56 25. PapilliB of the tongue, highly magnified 56 26. Vertical section of the articulation of the lower jaw 61 27. External view of the temporo-maxillary articulation 61 28. Trifacial division and ganglia 64 29. Superior maxillary nerve 67 30. Inferior maxillary nerve 69 31. Ophthalmic ganglion — the outer part of the right orbit removed 72 ( xiii ) xiv LIST OF ILLUSTBATIONS. Fia. PAQB 32. View of the spheno-palatine ganglion, the outer wall of the left nasal cavity, and the olfactory nerve 73 83. General appearance of the first set or milk teeth 86 34. Forms of chisels used in dentistry 188 35. File, with carrier 189 36. Hoe excavators and modifications 190 37. Hatchet excavators and modifications 190 38. Eose drills and spear drills 191 39. Instruments employed in introducing, condensing, and polishing gold and tin fillings 195 40. Instrunifints employed in removing tartar from teeth 219 41 and 42. Denudation 221 43 and 44. Diagram of teeth 223 45. Incisor forceps for superior jaw 225 46. Incisor forceps for inferior jaw 225 47. The Maynard forceps — right and left 225 48. The ordinary molar forceps — right and left 226 49. Maynard forceps for inferior molars 227 50. The Physick forceps 227 51. Forceps for wisdom teeth 228 52. The elevator — various forms 229 53. Relation of fractured roots to alveolar line 230 54. The screw 231 55. Spray apparatus — hand instrument 240 56. Spray apparatus — foot instrument 241 57. Salivary fistule — from life 267 58. The tonsil glands 272 59. Hypertrophied tonsil 274 00. View of the air-tubes 277 yi. View of gums inflamed by vulcanite plate 294 62. View of case of congenital hypertrophy 295 63. View of chronic ulitis, with recession 297 64. Appearance of patient with phosphor-necrosis 319 65. Sequestrum after measles 323 66. Odontocele 334 67. Dental tumor 339 68. Dental tumor 340 69. Dental tumor 341 70. Microscopic section 342 LIST OF ILLUSTRATIONS. XV FIO. PAGH 71. Antral cyst 349 72. Secondary cyst of the antrum 351 73. Hyperostosis 358 74. Osseous tumor 360 75. Small epulo-fibroid tumor — from life 364 76. Epulo-erectile tumor 365 77 and 78. Epulic tumors 368 79. Section of bone as first and afterward made 369 80. Fibrous epulis of upper jaw 370 81. Osteo-sarcoraatus tumor 385 82. Cysto-sarcoma 385 88. Epithelial tumor of lip .397 84. Epithelial ulcer of gum 398 85. Epithelial ulceration of lip and tongue 399 86. Small Sebaceous tumor, showing its sacculated condition 406 87. Cartilaginous cyst 408 88. Lobulated lipomatous tumor — after Miller 409 89. Microscopic structure of an adipose tumor (Bennet) 410 90. View of fatty tumor removed from under the tongue (Listen) 410 91. Venous tumor 413 92. Crossed or knotted bandage 474 93. Barton's bandage 515 94. Gibson's bandage 516 95. The yard bandage 517 96. One of Dr. Gunning's splints 518 97. Dr. Gunning's second splint 518 98. Dr. Gunning's third splint 519 99. Dr. Gunning's fourth splint 519 100. Complete Dislocation of jaw 524 101. Manner of reducing a luxated jaw 528 102. Vertico-mental sling or cap 529 103. Mouth-stretcher 553 104. A microscopic view of cancer-cells 576 105. Palatine defect 660 106. Obturator 661 107. Palatine defect G62 108. Obturator 663 109. Palatine defect 664 110. Obturator 665 xvi LIST OF ILLUSTRATIONS. TIG. PAGE 111. Palatine defect 666 112. Oral defect 667 113. Obturator 668 114. The face, without nose 671 115. Internal view of superior arch 672 116 and 117. Nose, with attachments 674 118. The face, with nose 676 119. Mouth-stretcher applied 687 120. View of position of inferior maxillary nerve 690 PLATES. I. Anomalies in dentition 127, 128 II. Anomalies in dentition 130,131 III. Anomalies in dentition 133, 134 IV. Dental tumor — with microscopic appearance of 136 V. Anomalies in dentition 137,139 VI. View of the anatomy of the side of the face and some of the opera- tions practiced on it 271 VII. A view of the operations performed on the trachea 279 VIII. Appearance and position of some of the tumors seen about the neck 404 IX. Hare-lip and other conditions 548 X. The operations of cheiloplasty and genioplasty 556 XI. Rhinoplastic and cheiloplastic operations 559 XII. .Operations practiced on the tongue and tonsils 595 XIII. Eesections of the upper and lower jaws 681 DISEASES OF THE MOUTH ASSOCIATE PARTS. CHAPTER I. SURGICAL ANATOMY OF THE MOUTH AND FACE. 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 perver- sion on an understanding of normal characteristics. In presenting these photographs of the various parts associated with oral surgery, we add the suggestion that the bones represented 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, is to make it a point to yearly dissect them. In Fig. 1 the lateral aspect of the face 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 maxillary 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 the lateral aspect is triangular. 2 (H) 18 ORAL DISEASES AND SURGERV. Bounded circumferentially by the supraorbital ridge of the frontal bone, the nasal process of the superior maxillary, and the malar bones, we find a pyramidal cavity, the orbital, for the accommoda- tion of the organ of sight. Looking at the natural bone, no less than seven pieces are observed entering into the composition of this cavity, some of which pieces in their relations closely affect some of the 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 or- bital, which is a part of the superior maxilla; glancing at the natu- FiG. 1. — Front aisD Lateral Region of the Skull. The SKULl, seen partlt in front and on the right side. 1, frontal bone ; 2, parietal bone; 3, temporal bone, its squamous portion; 4, the sphenoid bone, temporal surface of its great wing; 5, ethmoid bono, its orbital surface; 6, superior maxillary bone ; 7, malar bone ; 8, lachrj'mal bone ; 9, nasal bone ; 10, inferior maxillary bone, a, orbital plate of the frontal bone ; b, temporal surface ; c, orbital surface of the great wing of the sphenoid bone; d, mastoid portion of the temporal bone ; «, orbital surface of the malar bone; /, orbital plate of the superior maxillary bone ; g, infraorbital foramen ; ft, mental fora- men; J, symphysis ; J, ramus ; A:, coronoid process; ?, neck supporting the condyle; m, angle; n, lachrymo-nasal duct. ral 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 press- ure 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 undisturbed in operations demanding ex- ensive interference with the bone of which it is a part. At the JNAT03IY OF THE MOUTH AND FACE. 19 inner inferior aspect of the cavity a groove will be observed, the lachrymal, being the entrance to a canal, the ductus ad nasum, carry- ing 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 blindness of several months' standing has been cured by the extraction of a diseased tooth-root which had affected the antrum to its engorgement. Closure of the lachrymal canal is almost certain to occur if the nasal process becomes inflamed, and such inflammation I have fre- quently 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, Avith 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 easily 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 sapientijB. 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 processes 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 subject to take on patho- logical action than any other portion of the ossa corpora. 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 20 ORAL DISEASES AND SURGERY. center of the bone, and conducting beneath the teeth the dental artery and nerve. The size, general character, and inlet of this canal should be observed, as not unfrequently injuries to the 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 locations and character of bone. The relationship of the teeth to 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 greatly to vary in character : in some being of such loose structure that the teeth are capalde of the easiest separation ; in other instances being so firm and unyielding that it is quite a matter of 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 an ease 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 the 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 the most serious if not fatal consequences. The nasal bones are frequently the seat of syijhilitic degeneration. Their destruction compels the falling in of the nasal arch, thus yielding the flattening of the bridge occasionally ob- served, — 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. There would seem to be here less vital resistance than in other parts of the bone, as necrosis of a tooth is almost necessarily as- sociated with necrosis of the superficial surface of its alveolus. This AXAT03IY OF THE MOUTH AND FACE. 21 plate is, however, quite thin, and its loss seldom seems of much consequence. The position of a groove for the passage of the facial artery is to be noticed, as location and distance 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 bone. With such general observation of the surgical features of the bones in their conjunction, we pass to a more accurate comprehen- sion, by examining the pieces in their separate capacities. Pigs. 2 and 3. — Superior Maxillary Bone. Superior maxulart bone of the left side, outer view. 1, body; 2, tuberosity; 3, alve- olar border; 4, orbital plate; 5, nasal process ; 6, nasal notch; 7, nasal spine; 8, lachrymal 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 pio- cess of the frontal bone ; 14, incisor teeth ; 15, canine tooth ; 16, premolar teeth ; 17, large molar teeth. Superior maxillary bone of the left side, inner view. 1, nasal surface of the 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 lachrymo-nasal duct; 9, maxil- lary sinus ; 10, palate plate, its articulating border for the right maxillary bone ; 11, in- cisive foramen continuous with the naso- palatine canals; 12, tuberosity; LS, 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, moi'e or less irregular, solid piece. Looking at it closelv, 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. 22 ORAL DISEASES AND SURGERY. differing, indeed, in shape in almost every bone ; generally, how- 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 how far back- ward, what in the mean of cases is its relation to the roots of the various teeth, which of its boundaries are the thinnest, are matters worthy of l)eing most attentively studied, because of their very practi- cal signification, and which study can only be made by an observer 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 fossee, 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 be 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. In 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 ANATOJIY OF THE MOUTH AND FACE. 23 excavated for the wisdom tooth. This tuljevcle, as implied in its 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 seen to be somewhat concave ; behind it has a 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 l)one, 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 the bone, is observed standing above the orbital surface. Rising from the anterior facial surface of the bone, it continues somewhat triangularly upward, until it ends in an irregular semi-cell-like extremity. These semi-cells articulate with the ethmoid, closing in, and completing the anterior ethmoidal cells, also with the frontal bone, completing the lower boundary of the sinus of this bone. Lined in the recent state with the Schneiderian membrane, which membrane is continued into the cells of the eth- moid 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. Externally, 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 tendo oculi has its attachment on this surface, while near, on the same plane, is a line giving origin to the levator labii superior alseque nasi and orbicularis palpebrarum muscles. An- teriorly, the border of the process is thin, and serrated for articula- tion 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 annexation with the lachrymal bone ; the canal, traced downward, is found to have somewhat an hour-glass shape, being considerably contracted in the center, 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 24 ORAL DISEASES AND SURGERY. position, is here observed separate; falling at direct right angle from the facial aspect of the bone, it is observed by this relation 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 inft-aorbital ridge is simply the rim made by the bending downward of this orbital surface. Running along the free edge is observed three distinct ai'ticular 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 open- ing, we find it directed to the groove on the orbital face, the intra- orbital. Passing the bristle now from the groove toward the fora- men, 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 in this drawing to ad- vantage. It is a complete curve, and gives attachment by its con- tinuous 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, to 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 Avhich the outer surface of the bone gives origin, are numerous. From the second bicuspid, back to the tuberosity, is a rough line for the trumpeters, or buccinator (a similar line existing on the inferior maxilla). Above this first line, and below the malar process, certain fibers 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 alas nasi. ANATOAIY OF THE MOUTH AND FACE. 25 Turning now toward us the inner face of the bone, we see the 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 and 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 raises itself into a ridge, which is the one side of a groove receiving into articu- lation 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 center 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 palate bone, this being the line of separation in amputation ; third, the position of entrance of naso-palatine nerve, paralj'^sis of the parts supplied by this nerve being a frequent result of illy applied pieces of dental apparatus. To these three might be added a fourth, the position of the artery occupying the posterior palatine canal, an arter^^ 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 divid- ing 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, 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, w^hich is the slit lying between the upper 26 ORAL DISEASES AND SURGERY. aud middle crests. The opening of the antrum, seen in the back 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, aud 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: orbicularis palpe- brarum, inferior oblique of orbit, the elevator of superior lip and wing of nose, the proper elevator of lip, the angular elevator, com- pressor naris, depressor of ala, masseter, and buccinator. INFEKIOR MAXILLAEY BONE. The inferior maxillary bone, the largest and strongest bone of the face, consists of a body, horseshoe in shape, and 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 Fio. 4. — Inferior Maxillary Boxe. 1, body; 2, ramus; 3, symphysis; 4, base ; 5, angle; 6, mental foramen; 7, condyle; 8, coronoid process ; 9, semihmar notch ; 10, inferior dental foramen, the entrance of the corresponding canal; 11, alveolar border; 12, incisor teeth; 13, canine tooth; 14, premo- lars; 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 veiy considerable blows. The rami, curved ANAT03IY OF THE MOUTH AND FACE. 27 and angular at the base, terminate above in two processes : the 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 project- ing lower jaw.J Looking at the external face of the body, the attention is first attracted by a prominent foramen situated beneath the bicuspid teeth. This foramen is called the mental, and from it passes out, to be distributed to the lip and gum, the inferior dental artery and nerve ; the situation of the foramen represents the line of relation between the hard and spongy portions. It is at this opening that section of the nerve is occasionally made for severe and resisting mental neuralgia. A bristle passed into this foramen, looking 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 forward, 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 at- tachment 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 center line, called the symphysis, represents the position or di- vision existing in the young bone, union of the two halves not occurring until about the end of the first year. The levator menti 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 or an hypertrophy, for the greater strength of the part. Viewed from above downward, the body of the lower jaw is con- cave ; 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 an- terior of these processes is a thin, flattened, triangular eminence, 28 ORAL DISEASES A.VD SURGERY. giving attachment to the masseter and temporal muscles. The pos- terior 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. The process articulates the bone with the occipital, and is occasionally the seat of fracture and luxation. The internal face of the bone presents the same general view with 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 opposite 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 symphysis 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 fossag are called after the name of the glands. It will be observed that these fossae lying above the ridge, the lingual glands must be within the mouth, while the submaxillary fossa 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 the border so nearly approaches the second molar that there is no room left 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 difference 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 accurate meas- urement, as just within it is performed the operation of section of the nerve. A groove, the mylo-hyoid, transmits to the muscles of the ridge an arter}^, which comes from the inferior maxillary 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 ANATOMF OF THE MOUTH AND FACE. 29 muscle, while to the face of the condyloid is attached the pterygoideus externus, the internal pterygoid being attached 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 is the internal carotid and internal maxillary arteries. Figs. 5 and 6. — Palate Bone. Posterior view of the right palate bone. 1, palate plate ; 2, nasal plate ; 3, pyramidal process ; 4, articular border for the left i)alate bone; 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 of 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, pj'ramidal 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 fospae: 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 Avith 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 veiy markedly to resemble the letter L. Studying it in detail, we may remark, first, the spine, situated at the base of the interpalatal suture, and which gives attachment to the motores uvu]89 muscles ; passing toward the vertical portion, the concave character of both 30 ORAL DISEASES AXD 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 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 ai'e seen the 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, inclosing 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 surface entering into the composi- tion of this 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 AXATOMY OF THE MOUTH AND FACE. 31 that name. Above 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 uvula, the internal and external pterygoid. THE VOMEE. The vomer, plowshare-shaped, constitutes a portion of the sep- tum narum. It articulates below with the interpalatine suture of the superior maxillae and palate bones; above, with the perpen- dicular plate of the ethmoid ; by its base with the laminae and ros- FiG. 7. — The Vomer. View of left side. 1, 1, broad groove receiving the rostrum of the sphenoid bone; 2, 2, inferior border articulating 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. trum of 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 interpalatine canal. 32 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 to completely obliterate one of the nares, requiring an operation for its relief. The vomer is also subject to syphilitic attacks, and frequently breaks down, allowing the arch of the nose to fall in. Fig. 8. — Articular Kelations of Vomer. J 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 pterygoid process. The articulation is seen to be with six bones : the two superior maxillary, two palate, the sphenoid, and 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 in- closed are called the meatuses. 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 outlet of ANATOMT OF THE MOUTH AND FACE. 33 the lachrymal canal. The middle meatus is the space bounded below by the upper surface of the inferior scroll ; above by the lower sur- face of the middle scroll. A foramen seen in this meatus is the outlet Fig. 9. — Position and Eelations of Turbinated Bones. View of the outer wall of the right nasal ross.i. 1, frontal bone ; 2, its orbital plate ; 3, its nasal spine; 4, nasal bone; 5, ethmoid bone; 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-nasal duct ; 10, nasal spine of the superior maxillary bono ; 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 process ; 16, nasal plate of the palate bone ; 17, its palate plate ; 18, posterior palatine foi-amen ; 19, superior meatus of the nose; 20, middle meatus; 21, inferior meatus; 22, fi-ontal 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. 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. Yiewed 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 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 3 34 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 narum, it is convex. If the external surface was 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 palate. No muscles are attached to it. THE ETHMOID BONE. Fig. 10. -Ethmoid Boxe — Gexekal View. A horizontal cribriform plate of bone, with a crest along its middle ; a perpendicular plate dropping down from the center of this first piece ; two little oblong square boxes, hung on either side of the perpendicular 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 attachment 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, the crest is seen to tei'minate in two little 1, orbital surface of the lateral mass; 2, posterior extremity of the crihriform plate, which 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 advance of the latter are the ethmoidal wings; 4, anterior extremity of the nasal plate ; 5, the ethmoidal sinuses. Looked at anteriorlv. ANATOMY OF THE MOUTH AND FACE. 35 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 numerou^s 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 nares, 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, very square, and very smooth. In 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 36 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 Avedged 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 communica- tion 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 — XJppek Vieav. 1, pituitaiy fossa; 2, olivary process ; 3, declivity; 4, anterior cliiioid process; 5, pos- terior clinoid process; 6, posterior border of the body; 7, cerebral surface of the great wing ; 8, articular sui-face for the frontal bone ; 9, articular border for the temporal bone ; 10, spinous process ; 11, small wing; 12, border articulating with the orbital plate of the frontal bone; 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 in- ternal 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. ANAT03IF OF THE MOUTH AND FACE. 37 The Icg-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 bone 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 fos8!B ; 11, position of the pterygo-palatiue canal ; 12, pterygoid canal ; 13, internal ptery- goid 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 surface, a first attention is 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, called the pituitary body; hence is called by many authors the pituitary de- pression or fossa: 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 to the body 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 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 rest- ing in it the commissure of the. optic nerve; hence 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 ethmoidal bone, and is called the ethmoidal spine ; be- tween this spine and the optic groove is a slight eminence falling off" on either side into a line of depression ; these lines lodge the 38 ORAL DISEASES AND SURGERY. olfactory nerves. Two foramina, seen on this surface at either ter- minus of the optic groove, are called optic foramina; they transmit to the orbital cavities the optic nerves and ophthalmic arteries. From the back of the saddle the surface is seen to slope gradually downward; this concave plane lodges the medulla oblongata, and terminates at the line of union with the occipital bone. On either side is situated a tortuous depression, in which lies the internal carotid arteries and cavernous sinuses. 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 la- mellae, — the sphenoidal turbinated bones, as they are called. These lamellae w^e find imperfectly close sinuses which hollow out the sub- stance of the body, and which, in articulation, are found to com- municate with the upper part of the nose, and frequently with the ethfnoidal 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 this 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 jjrocesses. 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 pharyngeal nerve. The posterior surface in most bones exhibits simply a quadri- lateral 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 meningeal artery. A fourth foramen is occasionally found in the great wing — ANA TOM F OF THE MOUTH AND FACE. 39 the vesalii. When existing, it is occupied by a small vein. The ,u^ '^ii /■ ^ N^^^lVi^ i^-7 ^ti^^ (128) ANOMALIES OF SECOND DENTITION. 129 PLATE II. YlQ. 1. — Eepresents a cyst occupying the whole extent of the right half of the body of the lower jaw, and of the coronoid apophysis. The ex- ternal wall of the cyst has been removed, and permits a view of the cavity, bounded by the internal wall 6, 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. Eight side of the inferior jaw, aifected 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. IPXj^TIE XX. 1?,0) IPHL-A^TE XI. (131 132 ORAL DISEASES AND SURGERY. PLATE III. ANOMALIES IN POSITION OF THE TEETH. Fio. 1. — a. Incisor tooth retroverted, and directed toward the intramaxil- lary symphysis. Fig. 2. — c. Canine tooth developed in the thick part of the floor of the nasal fossae, 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 fossas. Figs. 3 and 4. — Two other examples of anomalies in the position of the teeth. (133) I'XjJ^TE III. 134 J ANOMALIES OF SECOND DENTITION. 135 PLATE IV. Fig. 1. — a, a. Second grinding tooth of a horse, natural size, with considera- ble development of the roots, transformed into two spheroidal swellings. 5, h. Portions of the maxillary bone sheathed in the tnmor, 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). — Kepresents 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, b. Kepresents 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 in the normal teeth. ff, h. Osteoplasts, or characteristic cavities of the cement. They are especially remarkable for their size in all the preparations taken from this piece. /. Proper substances 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. :pi.jLTEi i-v. Eg (130) b b Fi$.i (137) 138 OKAL DISEASES AND SUBGEEF. PLATE V. Fig. 1. — Intraniaxillary 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 mollities 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. I=IjJLTE "V. E^.3 ( 133 ) CHAPTER VII. 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, I may now direct attention. Alveolar or dental abscess is 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 periodonteum, is discharging, through some convenient orifice of exit, pus secreted by or formed in such membrane. The local features of such an 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 membrane occurs, the old pyogenic membrane. This, in its unhealthy condition, fails to or- ganize the lymph constantly exuded or effused by it. The degene- ration of this lymph is pus. As such membrane grows thicker and thicker, and such pus accumulates, it becomes evident that space and vent are made necessities ; thus absorption, through the press- ure, is secured, and the matter, sooner or later, finds egress, giving generally that peculiar fistule in the gum, called parulis or gum- boil; the most vulnerable wall of the surrounding osseous parietes yielding first, thus giving the direction and locating the fistule. 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 gi'anted, judging from observation, that it is the severest (140) THE TEETH AND THEIR DISEASES. 141 form of odontalgia. The condition of acute pain, however, is con- fined to the period intervening between the acute inflammatory attacks and the escape of the pus, the period, properly speaking, of periodontitis. An alveolar abscess fully formed, pain is limited to soreness. The cure 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 sufiBciently healthy character to fill with organizable granulations the fistule. The appreciation of the treatment 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 pre- vious chapter, leaving us here nothing to add, except that if such means as were recommended fail in securing resolution, the more formidable 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 tinct. of iodine, so alveolar abscess can very frequently be aborted by the following 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 of a delicate tent, keep the wound patulous for a few hours. This little operation is, I believe, original with myself; indeed, I do not know that it ever has been performed even yet by any one else; but I am well assured, through a pleasant experience, that it very 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 the operation will, I think, be at once recognized. I cannot here help excepting to the common practice of ordering blisters and warm fomentations to the face in incipient abscess ; the 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 I have 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 blister or poultice. Leeches, general blood-letting, vigorous antiphlogistic medication, any and every means that promises any good, should come between the periodontitis and the abscess. 142 ORAL DISEASES AND SURGEBY. 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 bothering some young practitioner, I shall feel well repaid for the trouble of collecting them. A few vears ago I saw, in consultation with a Dr. B., of this city, Mrs. , who had been afflicted with a running ulcer at the ape.x 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 beer most carefully examined, and that there was not an unhealthy tooth in the mouth. A superficial examination seemed to verify the truth of the as- surance. Not satisfied, however, by such exajnination, with a steel instrument I commenced striking each tooth separately ; the patient thought that in the left inferior lateral incisor she experienced a sen- sation 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 in- cisor alluded to had lost its pulp — it showed a slight opacity. I was now convinced that the disease was alveolar abscess, and predicated on my examination that an opening made into the affected tooth would discover the death of its pulp ; this was done, and the tooth found dead, as anticipated. The offending organ was ex- tracted, 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 tubules 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 tubules 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. THE TEETH AND THEIR DISEASES. 143 A dead tooth, however, can always be distinguished by the tests which I have given. The pathology of .this case may be summed up very briefly. The death of the pulp provoked periosteal difficulty. The inflammation, uncombated, 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 an}'- directly local treatment, or that not addressed to the true seat of trouble. In another Consultation saw Miss B , a young lady, nineteen years of age. In this patient, a fistule in the very center 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 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 dis- missed 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. The operation is very simple, and will be successful if the pus should have found its way even so far externally as to have but the skin between it and the atmos- phere. Care nmst, however, be taken not to wound the facial artery or the duct of Steno. Abscesses, associated with the wisdom teeth, sometimes vent in the parotid region ; in these cases it is not uncommon 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 remem- bered, of the deep cervical — compelling this lengthened dissection. 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 expansion of the outer plate of the bone. These cysts give no sense of fluctua- 144 ORAL DISEASES AND SURGERY. tion or crackling on pressure; there is no appearance of surround- ing 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 de- stroyed and the fangs filled with metal. They form sometimes very rapidly. I have treated them where the cyst has enlarged to the si7.e of a hickory-nut in a single week. This rapid growth is par- ticularly diagnostic. The easiest treatment is of course the extraction of the offending tooth ; but they may also be readily cured by opening them trans- versely and stuffing the cyst with lint, saturated with tinct. of iodine, or some other stimulant; the cyst is thus obliterated, and the sac at the end of the fang destroyed, through the healthy inflammar tion which the treatment excites. These tumors are not to be confounded with other encysted tumors, of which mention will hereafter be made. 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 pomum 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 THE TEETH AND THEIR DISEASES. 145 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, and got well. Mr. Fleischman {British Medical Journal) relates the following example : " Miss Rose S , a little girl, aged five years, had been 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 see that his case is simply one of alveolar abscess, — but offers it as " a good illustration of re- flected 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 evei'y case in which I have seen it, where the sinus passed in such direction, was associated with the central incisor teeth. 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 chapter on Trismus.) Abscesses from this cause generally discharge about the neck of the tooth ; they may, however, void themselves 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, 10 146 ORAL DISEASES AND SURGERY. and, in defiance of all treatment, ran on to abscess, which abscess discharfred upon the cheek. The pus voided, of course relief 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 exam- ined 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. (See chapter on Odontalgia.) CHAPTER VIII. THE TEETH AND THEIR DISEASES. TEISMUS. In the chapter on Dental Anomalies, I alluded to the process of maxillary enlargement, and exhibited how that process was, in part, counterbalanced by an untimely extraction of the deciduous teeth. I further showed 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, referred to the impossibility of a natural and healthy evolution of the wisdom teeth, and to the conditions favoring periodontal inflammation. In this chapter we are to consider lock-jaw entirely, as it has a local signification, and even, so far at least as a few paragraphs are concerned, more exclusively than this, as it has alone a surgico- dental signification. Such surgico-dental signification, however, will, I apprehend, outside of tetanic conditions, be found 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 has, 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 we have now 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, most 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- (HY) 148 ORAL DISEASES AND SURGERY. common resistance— jou 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 periosteum enters into the subinflammatory state, and becomes as ready to put on acute disease as is the tinder to take the spark. If, then, interference with the elongatory process has been such as to yield these troubles, when only twenty-eight teeth have erupted, is it not plain to infer that the development of the four dentes sapientiae must proportionably add to these difficulties ? Of course it is very plain, and only by appreciating the character of such trouble can we fit ourselves to abort its lesions. These lesions are periostitis, alveolar abscess, stomatitis, ostitis, necrosis, trismus, etc. In the chapter on Anomalies, I remarked that all dental troubles arising from retraction and diminution of the maxillary arch could be provided against by a timely extraction of certain of the perma- nent teeth ; and from this we might infer that trouble arising from an advancing wisdom tooth might also be provided for on the same principle, namely, by extracting the second molar, thus providing 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- looked, however, is too evident, from their many secondary lesions which the surgeon finds himself constantly called upon to treat. I advanced the view that the majority of the cases of trismus would be found having, as the primary lesion, some periodontal 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 the result of the inodular tissue, which would close up the break in the continuity. Anchylosis might exist, the sequence to articular disease. Traumatic tetanus, affecting the muscles of the jaw, would have a primary lesion combined with peculiar nerv- ous 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 alone a local significa- tion; that signification not being always very evident, or other- wise associated with so many complications as not to seem di&-j tinguishable. We read in reports of case after case of local trismus,— of the THE TEETH AND THEIR DISEASES. 149 lesion being referred to this cause and the other cause, — the treat- ments being as various as the diagnoses. Many of the inferences thus presented are, without doubt, just and reliable ; but I would give it as my 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, page 191, vol. ii., 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 should have expected, had I seen the case with him, to have been able to have pointed out that the ulcerated sore throat, to which he alludes, had its primary 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' C asy,.— Acupuncture in Protracted Lock-jaw. — 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 of matter. In 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 effect. 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. 150 ORAL DISEASES AND SURGERY. 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 effect 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 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 con- vulsions was greater, and lasted longer, while the spontaneous convulsion recurred several times in the evenings after each of the first trials. As leeching did not succeed in mitigating the con- vulsion, 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 convulsion 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 I referred to, as from my own experience, occurred in THE TEETH AND THEIR DISEASES. 151 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 tempero- maxillary articulation, which overbalanced the influence of the de- pressor muscles, holding of course the parts 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 further on, the stick was turned on its axis, the adhesions yielding before the strain. Thus the mouth was opened at least an inch, and we were enabled to explore this cavity for the lesion upon which the trouble depended. So far this case will be seen closely to similate that of Dr. Sellers — sore throat, aphonia, hysteria. 152 ORAL DISEASES AND SURGERY. 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. We dis- missed the patient for the day, after directing a sorbefacient 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 Mall 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, I 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 I have alluded to as being found in the preceding case. This patient, 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. Antiphlogistics in every form had been resorted to. The patient came to me under the anticipation that nothing could save him from necrosis of the angle of the bone. 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, by 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 strike you to associate disease with the parts ; but this tooth, a single cusp of which only 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- THE TEETH AND THEIR DISEASES. 153 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 of their reaction 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 practi- tioner 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 the tooth, in nine cases out of twelve he will find caries. Such a lesion will at once be recognized to have important surgi- cal relations. For example, I have b&en 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, 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 alway respond to the stroke of an instrument. Its periosteum being inflamed, common sense would direct that a tooth so diseased should, be at once extracted ; but such extraction is oc- casionally among the almost impossible things. A tooth so affected will not unfrequently 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 unfrequently the only external evidence yielded by the inflammatory attack. The jaw stiffens and relaxes, as an odontalgia will come and go. In such ephemeral cases it is not at all unlikely that the trismus is exclu- sively a nervous action, or reflected irritation to the motor branch of the trifacial, — slight local inflammatory action being the irritant. 154 ORAL DISEASES AND SURGERY. Wisdom teeth erupt from the seventeenth to the thirty-fifth year ; generally, however, at about the twentieth year. Some years ago I treated a case of trismus, the history of which is as follows : The patient, David B., a farmer, after doing a hard day's work, and getting himself much overheated, threw himself, just at early evening, down 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 superior 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 his cheek. 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 have resulted in abscess ; abscess of the alveolo-dental membrane, or 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 effort 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. 1 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 periosteum. Again, it is through the alveolus of the palatine fang of this tooth that we find THE TEETH AND THEIR DISEASES. 155 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 entirely free from pain, his only trouble being the trismus, 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 was of sufficient extent to have bound the jaw from the glenoid cavity to the anterior border of the masseter muscle ; passive motion was re- sorted to, but employed very gently. Leeches, blisters, and sorbe- facients 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, questions 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 which 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 the 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 many 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 inflammation, 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. 156 ORAL DISEASES AND SURGERY. A person will not unfrequently be attacked with trismus after the dental operation of inserting a pivot tooth. Here the lesion is in- flammation, and the treatment is to be directed accordingly; the root of the tooth is in a state of periodontitis. A person will sometimes be attacked with trismus after the opera- tion of plugging a tooth with metal; the attack comes on suddenly; it is a reflex nervous action. The conducting facility of the metal irritates the nerve periphery in the pulp ; this irritation is referred 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, advise 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 obscure, may result from the employ- ment of two different metals in the operation of tooth plugging: galvanic action is the consequence, and the nerve is subjected to a 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 pulp into a state of excitement, and is an admirable search warrant for obscure lesions of the 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 : I suggest that most of the cases of so-called idiopathic or obscure trismus will be found to depend on conditions 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 extraction 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- THE TEETH AND THEIR DISEASES. 157 pies, 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 meehanico-dental lesions are not to be overlooked, but to be searched for, and discovered secundum artem. Trismus, it also must be very evident, not unfrequently exists as a result of various traumatic conditions. Thus, anchylosis has been known to result in an articulation, too long denied motion, where the jaw has been unduly kept fixed in fracture. The ordinary false anchylosis is frequently associated with such fractures, a pa- tient being sometimes months in recovering the normal motions of the parts. Trismus from cicatricial bands, resulting from deep burns, is perhaps the most intractable form of the condition. Ulcerations, the result either of ptyalism or the cancroid affections, have some- times resulted in a closure of the jaw entirely beyond remedy. Exos- tosis is occasionally a source of trismus, the articular condyle being rendered incapable of free motion. To describe any particular treatment applicable to the various causes would be to consider such causes in detail. This, it will be found, has been done in various parts of this work, as special cases have presented themselves ; such conditions will be seen to demand and employ the ingenuity and learning of the surgeon. In this connection, as an example of such an application of skill to the overcoming of difficulties, I may present the somewhat celebrated case of Dr. S. P. Hullihen, of Virginia. I think it would be difficult to find a better study : " Miss Mary S., aged twenty, daughter of the Hon. William S., of Ohio, came to Wheeling, in the spring of 1848, to obtain relief from the effects of a very severe burn, which she had received fifteen years before. The burn was principally confined to the neck and lower part of the face, and its cicatrix produced a deformity of the most dreadful character. Her head was drawn downward and forward, the chin was confined within an inch of the sternum, the under lip was so pulled down that the mucous membrane of the left side came far below the chin, the under jaw was bowed slightly downward, and elongated, particularly its upper portion, which made it project about one inch and three-eighths beyond the upper jaw. In front there was scarcely any appearance of either chin or neck. She was unable to turn her head to either side, the cheeks and upper lip were dragged considerably downward ; she could not close her eyelids ; 158 ORAL DISEASES AND SURGERY. she could not close her jaws but for an instant, and then only by bowin"- her head forward. She could not retain her saliva for a single instant ; and, as might be expected, her articulation was very indistinct. " She had been taken to the City of New York, some years before, for the purpose of being relieved from this deformity, and was placed under the care of two of the most distinguished surgeons in that city, who performed an operation by dissecting up the cicatrix on the neck, then raising the head and sliding up the cicatrix from its original position, leaving a raw surface below to heal up by granu- lation. I need scarcely add that the operation was entirely unsuc- cessful. "After a careful observation of the case, it became evident that such a complicated deformity could be best remedied by performing three separate operations: one upon the jaw, another upon the neck, and a third upon the under lip. " To remove the projection of the under jaw seemed to require the first attention. Unless that could be done the other operations, however successful, would add but little, if any, to the personal ap- pearance of the patient. This lengthening of the jaw had taken place entirely between the cuspidatus and first bicuspid tooth of the right side, and between the first and second bicuspids of the left. By the elongation, the teeth just described were separated on both sides about three-fourths of an inch. " To saw out the upper edge of these elongated portions of the jaw, and then to divide that part of the jaw in front of the spaces thus made, by sawing it through in a horizontal manner, so as to permit the upper and detached portion to be set back in its original position, appeared to be the only possible way of remedying the deformity. This plan I therefore adopted, and performed the opera- tion on the 12th day of June, in the manner now to be described. " The operation was commenced by sawing out, in a V-shape, the elongated portions, together with the first bicuspid on the left side, each section extending about three-fourths ©f the way through the jaw. I then introduced a bistoury at the lower point of the space from which the section was removed on the right side, and pushed it through the soft parts close to and in front of the jaw, until it came out at the lower point of the space on the left side. The bistoury was then withdrawn, and a slender saw introduced in the same place, and the upper three-fourths of the jaw, containing the six front teeth, was sawed off on a horizontal line, ending at the bottom THE TEETH AND THEIR DISEASES. 159 of the spaces before named, the detached portion being still connected, on the outer and inner sides, to the jaw below, by the soft parts. "After having with the bone nippers removed from the detached portion the corners which were created by the horizontal and per- pendicular cuts of the saw, it was set back, so that the edges from which the Y-shaped sections were removed came together. " Thus it will be perceived that this portion of jaw and teeth, which before projected and inclined outward, now stood back and inclined inward, and in its proper and original place. " In this position the jaw was secured by passing ligatures around the cuspidati in the detached portion and the now adjoining bicuspids in the sound portion ; then taking an impression of the jaw in very soft wax, a cast was procured, and a silver plate struck up and fitted over the teeth and gum, in such a manner as to maintain the parts in that same relation, beyond the possibility of movement. " The patient declared that the operation gave her little or no pain. There was a little swelling about the chin during the first three days after the operation, but not the slightest uneasiness. In this way the case progressed ; the gum healed in a few days, the jaw united strongly, and in the time bones usually unite, and the wearing of the plate was discontinued within six weeks after the operation was performed. " The deformity of the jaw being now removed, the next thing to be done was to relieve the confined condition of the head, and the distortion of the face and neck resulting therefrom. This I de- termined to accomplish, if possible, after the manner of Professor Miitter in similar cases, and I accordingly performed the operation on the 31st day of July, assisted by Dr. Wissell. " I began by dividing the skin immediately in front of the neck, about half an inch above the sternum, and then carried the incision back about three inches on each side. I then commenced a careful division of the strictures, which were s© thickened in front as to ex- tend to the trachea, and on the sides as not only to involve the platysma myeides, but a portion of the sterno-cleido-mastoid muscle also. After dividing everything that interfered with the raising of the head and the closing of the mouth, as far as the incision was now made, it became evident that, to give free motion to the head, the incision on the neck must be extended back through the remain- ing cicatrix, which was at least two inches wide on one side, and about an inch and a half on the other. 160 ORAL DISEASES AND SURGERY. " This was accordingly done, the whole presenting a wound up- wards of nine inches in length and nearly five in width. A thin piece of leather was now cut in shape of the wound, but somewhat larger, and placing it upon the shoulder and arm, immediately over the deltoid muscle, a flap nearly ten inches in length and five in breadth, having an attachment or neck two inches wide, was marked out, and then dissected up as thick as the parts below would permit. This flap was now brought around and secured in the wound on the neck by the twisted suture, the sutures being placed about an inch and a half apart. Between each of these sutures, one, two, and sometimes three small stitches were inserted, depending entirely upon the number necessary to bring the edges neatly together. These stitches were of fine thread, had a very superficial hold, pro- duced little or no irritation, and served to keep the parts in better apposition than any other means I could have devised. The wound of the shoulder was next drawn together about one-half of its entire extent; the remainder was covered with lint. @ne long, narrow strip of adhesive plaster applied around the neck to support the flap, and over this a cravat tied in the usual way, constituted all the dressing deemed advisable at this time. " The patient bore this tedious and very painful operation with great fortitude, and uttered scarcely a murmur. She was somewhat exhausted, but not from the loss of blood. There was no vessel divided of sufficient importance to require a ligature. "August 1st. During the fore part of last night the patient was somewhat distressed, was very unmanageable, would talk inces- santly, and occasionally sat up in bed. An anodyne was adminis- tered at twelve o'clock, after which she rested much better and slept some. Complains of sickness of the stomach this morning; has vomited three or four times ; flap very pale ; pulse rather weak. Directed to refrain from all kinds of drinks. " 2d. Complains only of pain in the shoulder ; was much dis- tressed the latter part of last night, on account of a retention of urine. The catheter was employed, and about three pints of urine drawn ofi", after which she rested well. Pulse somewhat excited ; flap better color. " 3d. The patient rested well last night ; the use of the catheter still necessary. All eff"orts to keep the patient from talking and moving unavailing ; color of the flap rather pale, save at the ex- treme point and about two inches along the lower edge, which is assuming rather a dark-blue color. Pulse about the same as yester- THE TEETH AND THEIR DISEASES. 161 day; removed a pin from near the point of the flap, and enveloped the neck in cotton batting. Patient complains of hunger ; chicken broth ordered. "4th. Patient rested well ; the use of the catheter yet necessary; complains of slight headache ; the color of the flap nearly natural, and even the point is assuming a healthy hue, and appears to be uniting ; pulse almost natural. " 5th. Urinates without difiiculty ; bowels moved by injections ; patient entirely free from pain ; pulse natural. "6th. Dressing removed ; the flap is uniting by the first intention along both sides, throughout its entire extent ; the greater part of the pins and stitches removed. " 7th. The remainder of the pins and stitches removed ; patient perfectly comfortable and cheerful. " 10th. Sat up all day by the window. " 16th. Walked out to take an airing. " During the whole progress of the cure, there was not the slight- est swelling or undue inflammation in the flap or about the neck. The patient was slightly hysterical for the first few days, but never complained of anything but pain in the shoulder, a slight headache of a few hours' duration, and the uneasiness occasioned by the re- tention of urine. The wound on the shoulder granulated rapidly and skinned over in about six weeks after the operation. It was curious to observe that upon touching the flap after it had healed in the neck, the patient would always refer the sensation to the shoulder or arm from which the flap was taken. " The confinement of the head and the distortion of the face occa- sioned by the strictures being now removed, the next step was to relieve, as far as possible, the very great deformity of the under lip. " The under lip, from being dragged down and greatly stretched by the former projection of the under jaw, was rendered greatly too large, so that it pouted out an inch or more farther than the upper lip. This, together with a turning out of the mucous membrane on the left side, which extended nearly down to the lower edge of the chin, making the lip too short on that side, was the nature of the deformity yet to be relieved. " To remove this unseemly appearance of the lip, the inverted portion was cut out in a Y-shape, extending down to the flap in the neck, and sufficiently large to reduce the lip to its proper size. The edges were then brought together, and secured after the manner of a single hare-lip. The wound healed in the most beautiful manner, 11 162 ORAL DISEASES AND SURGERY. aud the appearance of the lip was greatly improved ; but there yet remained a deep depression or notch in the edge, sufficiently large to keep exposed the tops of two or three teeth, besides preventing the coming together of the lips on that side. " I now determined to raise, if possible, this depressed portion of the lip, aud for this purpose I passed a bistoury through the lip, about two lines from the free edge, first on one side of the depres- sion, and then on the other, and then carried the incisions down- ward to meet at a point on the lower edge of the chin. " The depressed portion of lip now lying between the two inci- sions was next dissected loose from the jaw, and then raised to a level with the remainder of the lip, and there retained by pins, after the manner of dressing a double hare-lip, the line of union forming a letter \. " This operation was as successful as the others, and the original deformity being now removed, the young lady, though still bearing evidences of the burn, has the free use of her head, eyelids, jaws, and lips, and may mingle in society without particular note or remark." This case, although not one, strictly speaking, for the cure of trismus, is yet, however, so analogous to certain traumatic con- ditions of this kind, that no special case with which I am acquainted contains as much of just that particular order and kind of operative proceeding required in this direction of surgery, and necessary to be understood and appreciated by the surgeon. CHAPTER IX. THE DISEASES OF THE TEETH. CARIES. Caries of the teeth is a chemico-vital action, and most markedly a trouble of hereditary transmission and predisposition. So true is this, that it may be prognosed that the ofifspring of parents afflicted in this way will be in like afflicted, and that on the other band the children of parents possessing good teeth will be in like favored. So marked, indeed, is this analogy in the teeth of parent and child, that in most instances it extends to the very shapes and arrangement of the organs, thus deformity insuring deformity, and regularity, regularity. One parent alone may thus influence for good or evil. Caries of the teeth, allowing for differences in structure, and con- sequently in impressibility, is to be viewed as most analogous to caries of the bone proper, and, consequently, is most scientifically treated as caries in bone is treated — in other words, dental caries is more a vital or constitutional, than a local or chemical trouble, or it is chemico-vital, as syphilitic caries of bone is chemico-vital, or as scrofulous caries is chemico-vital. In syphilitic, scrofulous, mercurial, or other commonly recognized dyscrasiac caries, the prac- titioner feels that three distinct requirements are to be met : 1. The natural forces are to be increased. 2. The specific condition is to be conquered. 3. The local indications, or the caries, are to receive local attention. In common dyscrasiac caries of the teeth, or in caries not of peculiar or special hereditary transmission, these prin- ciples of treatment are to apply, and if justly appreciated, and the constitutional condition discovered and understood, the prac- titioner must find that he can cure the one caries as he cures the other. In the caries of peculiar hereditary transmission, that is, of that special something which exhibits itself alone in the direction of the teeth without any evident constitutional dyscrasia, we are to treat and hope, just as we treat and hope in the phthisis of trans- (163) 164 ORAL DISEASES AND SURGERY. mission. It is to be a treatment on general principles, and is com- pelled, too often, to be experimental. It can certainly only be dif- ferential. Unfortunately, in the one case, as in the other, medication seems to stand us to no very satisfactory end, — the lung will break down, and the tooth will break down, — it is only a matter of time, or, might I better say, a matter of an inability on our part to appre- ciate cause and treatment. In connection with an inability on the part of the teeth — as the vital force is concerned — to resist deteriorating acute tendencies, we have, not unfrequently, to contend with certain direct physical im- perfections, which, like the wooden horse of Troy, gives ingress to the enemy, which otherwise might have been resisted. Examina- tion of the teeth, particularly the pre- and posterior molars, ex- hibits, quite too frequently, irregularities in the protecting covering of enamel, breaks in the continuity, as it were, particularly in the various sulci. In these depressions lodge and decompose the various ingesta of diet, acting, of course, as irritants, and producing, as I believe, just the same character of eflfect as would be produced in any bone ; that is, inflammation, yet modified, of course, by differences which exist between the tooth bone and ordinary bone ; it is, however, inflammation in the one case, and inflammation in the other ; the matter of acids and alkalies have little to do with the matter, except as they are agents of irritation. If proof is needed of these asser- tions, it seems fully enough found in the resistive ability of common healthy dentine, from which the enamel has been so cut as to make the surface a self-cleansing one. Witness the filed teeth of the South Sea Islander ; or, to come directly home, witness the everyday re- sults of ordinary dental operations. One practitioner files the teeth so that the surfaces shall always present inclined planes, another wedges teeth apart, files off the enamel, in the process of getting ready a carious cavity for filling, and the operation completed, re- moves his wedge, and allows the exposed faces of the dentine to fall together; the one, a self-cleansing surface, remains healthy, the second, non-cleansing, soon again takes on ulcerative action or decay. A tooth, then, may, in its vital relations, be just strong enough to resist external forces brought to bear upon it, if in its construc- tion there is no mechanical imperfection. It may again, even with such imperfections, be able to resist injurious impressions, as is often enough witnessed. Integrity of the teeth we shall assume to depend on two con- DISEASES OF THE TEETH. 165 ditions: inherent vital resistive power, and the absence of irritating influences. The vitality of a tooth can be elevated as the vitality of a lung is increased Irritating influences, both internal and ex- ternal, can be met and combated, in the one case as in the other. The study of the vitality of a tooth, and the study of its adverse influences is the study of vitality anywhere. The treatment is, of course, constitutional, and is to be appreciated by the practitioner if he would be successful in his efforts. In viewing, from a systemic stand-point, the composition of the teeth, we have primarily to remark, that the component parts are formed from and preserved by that chemico-vital relationship ex- isting between blood and parts to be nourished. We recognize, and know, that in that fluid which we denominate blood resides the element of nutrition, and that as this material is well or illy adapted to meet the requirements of the different tissues, so are these tissues found to be in varying states of health. We infer that blood, rich in the elements of tooth-structure, is capable of yielding good teeth, provided the process of similation resides to a proper extent in the part to be built up and nourished, so that the study of caries, from the constitutional stand-point, 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. Dentine. Enamel. Organic matter 29-27 28-70 3-59 Inorganic matter 70-73 71-30 96 41 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: Water 780-15 Fibrin 2-10 Albumen 6809 Coloring matter 133-00 Cystallizable fat 2-43 Fluid fat 1-31 Extractive matter 1-79 Albumen, in combination with soda 1-26 166 ORAL DISEASES AND SURGERY. Chloride of sodium and potassium ; carbonates, phosphates, and sulphates of potash and soda 8-37 Carbonates of lime and magnesia ; phosjjhates of lime, mag- nesia, and iron ; peroxide of iron 4-60 1000 00 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 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 has been interfered with, and that we may look at the sub- ject from the most comprehensive stand-point, we begin with that period of dental evolution in which the primary impressions are pro- duced. 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 re- ceive 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 somewhat now remote, the celebrated naturalist, Buffon, alluding to the animals of this continent, advanced the fol- lowing opinions : " 1st. That the animals common both to the Old and New Worlds are smaller in the latter. " 2d. That those belonging to the New are on a smaller scale. " 3d. That those which have been domesticated in both, have de- generated in America. " 4th. 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, DISEASES OF THE TEETH. 167 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 this 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 different 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 devel- oped — the countenance, rather elongated, relieved 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-twenty summers pass, this 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 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 wrong in our sys- 168 ORAL DISEASES AND SURGERY. tern 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 success- ful 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 in- vestigation 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 natm'al 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 Mundingoes, 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 mind of many, attributed to the great and sudden changes of temperature experienced on this continent — the thermometer rising and falling 20, 30, and even 40 degrees in twelve hours. But if attributable to these sudden changes, we know that sudden expansion by means of heat, or sud- den 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 sometimes 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 DISEASES OF THE TEETH. 169 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 fibers 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 different 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 composed of three different substances, ^and these three are disposed according to the purposes required of them ; they are cementum or crusta petrosa, dentine (known as ivory in the tusk of the elephant), and enamel. The cementum or crusta pe- trosa corresponds in all especial particulars with bone ; possessing its characteristic lacunae or small cavities, and being traversed by vascular medullary canals, whenever it occurs of suflScient thickness ; it is the first covering of the young teeth, 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 inor- ganic or mineral matter predominates, though to a less degree than in enamel. It is traversed by a vast number of very fine cylindri- cal, branching, wavy tubuli, which commence at the pulpy cavity, and radiate toward the surface. The diameter of these tubuli, at " 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. 170 ORAL DISEASES AND SURGERY. their largest part, average about 1-10, 000th of an inch; their smallest are iinineasurably fine ; so much so, that they cannot pos- sibly 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 fibers, about the l-5600th of an inch in diameter, ar- ranged side by side, and closely adherent to each other ; their length corresponds with the thickness of the layer which they form ; and the two surfaces 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 quanity of animal matter. In the center of the tooth is the soft pulpy cavity, which affords a bed for the blood-vessels and nerves which supply it with life and sen- sibility. " 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 70-73 71-30 96-41 100- 100- 100- " These proportions will occasionally differ; in some individuals 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 DISEASES OF THE TEETH. 171 molar or grinding teeth of man, and of the bones of the arm and leg of a man of forty, show the following proportions : Inorganic matter : Phosphate of lime, with traces of fluate Dentine. Enamel. Bone. of lime 66-72 89-82 54-61 Carbonate of lime 3-36 4-37 9-41 Phosphate of magnesia 1-08 1-34 1-07 Salts, etc -83 -88 2-35 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 bone 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 4-3Y; 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 compo- sition. 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 2 oz. 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 caliber of which is so small as 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 neces- sary 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 : 172 ORAL DISEASES AND SURGERY. "Water 780-15 785-58 Fibrin.. 2-10 3-57 Albumen 6509 69'41 Coloring matter 13300 119-63 Crystallizable fat 2-43 4-30 Fluid fat 1-31 2-27 Extractive matter, uncertain 1-79 192 Albumen in combination with soda 1-26 2 01 Chlorides of sodium and potassium ; carbonates, phosphates, and sulphates of potash and soda. 8-37 7-30 Carbonates of lime and magnesia ; phosphates of lime, magnesia, andiron; 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 780 parts, and the coloring matter amounting to 138, we shall 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 1. " 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 in- teresting 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- 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 struggle 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 con- stituents required for this important undertaking. And this nourish- DISEASES OF THE TEETH. I73 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 bt 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- Woman's Milk by Simon. Water 883-6 Butter 25-3 Casein 34-3 Milk sugar and extractive matter 48-2 Pixed salts 2-3 1000- Maximum of Minimum of 1-i observations. 14 observations. Butter 540 8-0 Casein 45-2 10-6 Sugar and extractive matter 62-4 392 Salts 2-7 1-6 174 ORAL DISEASES AND SURGERY. " Now, although these amounts will no doubt vary, under every variety of circumstances, according to the health, exercise, jjassio7is, and /oo(/ 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 i some of the constituents, it abounds more in butter, but particularly , in casein, or cheese ; and on the other hand, human milk abounds ' more in tbe 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 i 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. " Xow, 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. " 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 lohite 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 suga7- in the process of diges- tion. This principle is, therefore, called saccharine. DISEASES OF THE TEETH. 175 "3(1. All the fat, butter, oil, etc. which, when deprived of the other substances, is left in the state of oil, and thei'efore called ole- aginous. " Now, of these three the albuminous is the nutrient, and the saccharine and oleaginous the calorifacient, or heat-giving; and chemicial analysis shows that they vary in composition. ALBUMEX. OLEAGINOUS. Eggs. Wheat. Mutton fat. Carbon 55000 5501 78996 Hydrogen 7073 723 11-700 Nitrogen 15-920 15-92 Oxygen ^ 9-304 Sulphur [ 22-007 21-84 Phosphorus J SACCHARIDE. 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 oiygen 49-42 55-87 52-93 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. " 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 body 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 176 ORAL DISEASES AND SURGERY. butter, cheese, and sugar ; consequently we can understand how an infant can thrive so well 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 body,— 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 were 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 Avhich the 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 specter 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. * Analysis of Albuminous substances found casein from in whey after coagulation fresh milk. with an acid. Carbon 5-1-825 54-96 Hydrogen 71,53 715 Nitrogen 15-628 15-89 Oxygen ■» 21-73 Sulphur J 22-394 0-36 DISEASES OF THE TEETH. 177 "We now advance from infancy to childhood — and this is a period when the greatest attention is required in supplj'ing 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 entirely 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 temperature ; 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 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 nourishment 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 of 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 compos- ing the spine, instead of forming a column, allowing the body to be erect and dignified, are zigzag in their course, causing one shoulder 12 178 ORAL DISEASES AND SURGERY. 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 individual. " 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 people of those countries 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 potatoes. We have heard a great deal of the fam- ishing 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, allow- ing all this — allowing, in the best seasons, the chief article of sub- sistence has been potatoes for breakfast, dinner, and supper ; glad indeed many of them to get a little animal food once a week to din- ner, 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 dis- ease and suffering, and in the last stage of debility ; but let them recover from that state, and the robust frame and healthy constitu- tion will be again developed ; the bones are strong, the teeth unde- cayed, and the muscular energy only wanting opportunity to dis- play itself; — in fact, when we wish to denote strength in woman, we use the familiar phrase, ' strong as an Irish woman,' and all this from being reared on potatoes* But then, if we examine the * 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. NrXRITIVE ELEMENTS. 100 lbs. wheat bread contains 30 lbs. " flesh " 21 lbs. " fresh beans " 80 lbs. ^ " peas " 83 lbs. i casein and starch. " lentils " 94 lbs. J " potatoes " 2.5 lbs., albumen, starch, and sugar. " carrots •' 14 lbs. -, '• beets " 8 lbs f ^Ihumen with sugar. DISEASES OF THE TEETH. 179 analysis of the potatoes, we shall find contained in 100 parts of dry- potatoes, — Carbon 41-1 Hydrogen 58 Nitrogen \ 45.I 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 Scotland 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 break- fast, at least, of oatmeal — that is, porridge and milk ; and milk, po- tatoes, 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- land) is coarse, and contains much of the bran which invests the oat — containing, as it does, a large proportion of the earthy constit- uents required for the production of bone. Analysis of 100 parts of dried oats gives, — Carbon 50-7 Hydrogen 64 Oxygen 36-7 Nitrogen 22 Ashes 4-6 "I may here casually remark, that the advantage to be derived from this wholesome food has not escaped the observation of her Majesty, Queen Victoria, who appears in the 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 peas- ant child in Scotland. " I rather doubt if parents generally have given to this subject the 180 ORAL DISEASES AND SURGERY. attention to which it is entitled. I trust, however, that those who have followed me thus far, may be impressed with its importance. We cannot shut our eyes to the complaint which so generally prevails, of decayed teeth and a moment's reflection will call to mind the num- ber 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 regai'ds 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 I 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 children more beautiful or more lovely — healthy 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 four- teen years, and even to a more advanced age — there is a con- tinued 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. 1 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 nourishment from the mother, she ought to partake of good whole- some, 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, the stalwart frame of man, or the enduring, firmly-knit, compact, and healthy physical constitution in woman, the organic and inorganic or earthy com- * Dr. Jackson, of Philadelphia. DISEASES OF THE TEETH. 181 pounds of which that frame is composed must not be denied — nature must be supplied, 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-breadj, 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 abundantly, in most arti- cles generally used as food; and where they are deficient, the animal suifers 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. Iroit 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 as food by man — such as potatoes, cabbage, peas, cucumbers, mustard, etc. Lime is one of the most universally difl"used 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; 182 ORAL DISEASES AND SURGERY. "Of the inorganic constituents contained in wheat (and the same may be said of the other cereal grains) I have already 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 remaining, and superfine flour, or that in general use throughout this country, and on which Prof Johnston has made the followiug 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 diff"erent 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, — 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 TOO out of a thousand parts, or a little more than tico-thirds of the whole. Now, by reference to the same work, we find, in a com- munication from a Mr. Bentz, the difl'erence in weight of a barrel of flour without the bran, and when only the outer coating of the wheat is taken of. He says, ' The weight of the bran or outer coating would, therefore, in the common superfine flour, constitute the offal, weighing only 5j lbs. to the barrel of flour, while the ordinary weight of offal is from 65 to TO 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 oflfal or bran, we must consider that there is an actual loss of these im- 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." * Patent Office Report, 1847, p. 116. DISEASES OF THE TEETH. 183 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 aunually 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 lbs. 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. 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 may 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 Indian corn (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 of 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 Agricultu- ral Society for 1849: Whole kernel. Starch 50-64 Sugar and extractive 746 Sugar 1-50 Piber 6-28 Matter separated from fiber 0'05 Albumen 8-64 Casein 1-70 Gluten 4-56 Oil 400 Dextrine or gum 4-84 Water 10-22 99-89 184 ORAL DISEASES AND SURGERY. Ash of the kernel constituting about two per cent. Carbonic acid a trace. Silicic " 1'450 Sulphuric" 0206 Phosphoric acid o0-955 Phosphate of iron 4-355 Lime 0150 Magnesia lG-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 was 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 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 lime 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 heatrsustaining purposes only, and DISEASES OF THE TEETH. 185 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 provi- sions 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 — horses, hogs, sheep, etc.? I have already shown that the overplus of the calorifacient food, after what may be required for sustaining the temp^ature, 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 analysis that grass or hay contains not only the nutrient principle, but the inorganic constitu- ents 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 9-0 100- " 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 same quantity is given to a horse at rest, it overloads him with fat, which, in his case, accumulates more internally, or around the in- ternal organs, and will, in course of time, induce disease ; while in * Fifteen pounds of such hay, containing oz. 3-095 of nitrogen, f These ashes having a good proportion of lime. 186 ORAL DISEASES AND SURGERY. 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 1 "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 hearty. It is not 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 of bone and muscle, cannot be transformed either into the inorganic constituents of bone or teeth, or into mus- cular fiber ; 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 consitution, that the food, in the first 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 ornament 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- * Analysis of mare's milk. Water 896-3 Butter traces. Casein 16-2 Sugar of milk, extractive matters, and fixed salts 87-5 1000- DISEASES OF THE TEETH. 187 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." We pass here from the consideration of primary impressions to the treatment of caries, as met with in the growing child or adult. And, first, we may spend a few moments in considering the direct local attention demanded, and from which our investigations should carry us to other constitutional relations than the primary impres- sions just considered. Caries of a tooth differs from caries of common bone only in the fact of an inability to repair by any secondary material the injury done through the destructive influences of the disease, — requiring for the restoration of harmony to the parts, and for the protection of the exposed susceptible dentine, a mechanical treatment. The opera- tion demanded, being one of everyday performance, and withal one urging man to the attainment of skill, through the pecuniary reward its successful accomplishment offers, has given to this department of operative surgery a degree of skill and perfection attained by few others; and yet, is this class of operations embraced within a few such simple principles, that any practitioner, with an ordinary amount of ingenuity, has only to practice to become skillful. The local treatment of carious teeth consists in cutting from the cavity of decay all dead and dying matter, and after well cleans- ing and disinfecting the part, replacing that removed, with some unirritating and indestructible material. 188 ORAL DISEASES AND SURGERY. The first step in the operation consists in getting at the disease. This in many eases is quite easy enough, the cavity lying so exposed that it is only necessary to have the patient open the mouth to see it. In other instances, and these much the most numerous, the decay lies in such position that much cutting and filing, and it may be wedging, are necessary to the exposure. This matter, to be prop- erly appreciated, must be studied in connection with the individual cavities. Teeth are filled or stopped with various materials, — gold, tin foil, amalgam, and tooth-bone being the principal agents employed. Fig. 34. — Porms of Chisels used in Dentistry. Of these, by far the best is gold, and after this the tin ; the two latter agents being not at all reliable, and only perhaps allowable where, from the extent and character of the decay, a tooth must be filled with a plastic material or otherwise sacrificed. It is as easy DISEASES OF THE TEETH. 189 to fill a tooth with amalgam or with tooth-bone as it would be to fill it with putty. The instruments employed for filling teeth are very numerous and ; varied, each operator possessing certain favorite styles ; but the 1 instruments absolutely necessary to the performance of the opera- I tion are really — as in all other operations — very few and very ; simple. In the first place, it being necessary to expose the cavity, chisels and files are required. Chisels are made straight, curved, and at right angles. An accurate idea of what they are may be derived by an examination of the drawing. Files. — Files are of every coneeivable form. Fig. 35. — File, with Carrier. Fig. 35 represents a carrier having in it a straight file, such as is used for the separation of the first six anterior teeth. A modifica- tion of such a straight file, much used, is one with a curved and convex face. Files, cut on long shanks, with a curve to clear the lips, are used for the back teeth ; these are made rights and lefts. The straight file is seldom used in a carrier, the fingers being found the more convenient means. A cavity exposed, its excavation or cleansing is the next step ; for the accomplishment of this operation in.struments called exca- vators are necessary. These, like the chisels and files, are various in pattern ; yet, whatever the peculiarity, they are only modifica- tions of two elementary styles, which two styles are used principally .by every dentist, and are known as the hoe and hatchet excavators, the one cutting, when pulled toward the operator, hoe-like ; the second represented by the cutting edge of the ordinary hatchet. Drills. — The rose drill is a favorite instrument with the dentist. These are of various sizes, and when sharp, will cut out a cavity on the grinding face of a tooth very perfectly and very rapidly. The spear-shape, a modification of the rose, is much used. A tooth, to be properly excavated, must not only have every particle of diseased matter removed, but the cavity must be made of such form that it will retain the material to be impacted, and not 190 ORAL DISEASES AND SURGERY. Fig. 36. — Hoe Excavators and Modifications. «= ==) ^ _)L==Jt==J (l^ -^ ^L=. =J 11= J f^.Sr^h n n n n r Fig. 37. — Hatchet Excavators and Modifications. O Q DISEASES OF THE TEETH. 191 Fig. 38. — Rose Drills and Spear Drills. 192 ORAL DISEASES AND SURGERY. only this, but it must retain it, while being of a shape that every portion of the walls can be gotten at with equal facility. In other words, the cavity should not be larger than its inlet or margin; should it be so shaped, and should the material employed to fill it be either of the foils, such filling is most apt to be imperfect. Ir- regular or ragged edges are not to be allowed. Good joints, or union between the metal and teeth, cannot possibly be effected under such circumstances ; hence, an operation, otherwise good, becomes of little avail. Also, it is important that no sulci or sharp angles should exist within the cavity, but every part, if possible, is to be rounded and regular. FILLING. Gold, the best material to be employed, is used in two different forms ; prepared either as a leaf or as a spongy mass. Gold Foil or Leaf Gold. — The manufacture of leaf gold, or foil, must be an exceedingly nice manipulation, seeing that so many have undertaken it, and yet so few have succeeded in satisfying the dentist. Some gold foil is exceedingly adhesive, so much so indeed that with serrated instruments it can readily enough be stuck piece to piece, or welded. In this form it is now most commonly used, and may be quite as easily attached and built upon the plane sur- face of a metal dollar as within the cavity of a tooth. To effect such result, it is only necessary to keep the parts and metal per- fectly dry, and to use instruments with sharply-serrated points. A fault, however, not unfrequently attached to this adhesive gold, is its want of softness or ductility. Unadhesive gold foil, employed entirely by some operators, is made to support itself within a cavity by a process of wedging ; in this form it is used, either rolled up as cylinder, or otherwise as pellets. Gold foil comes into the market done up in books — these books being numbered from 4 to 35. The number signifying the weight by grains of each leaf. Of these different numbers, some prefer one, some another; it is perhaps a matter of choice rather than dif- ference. Sponge Gold. — This preparation, as implied in its name, comes in the form of a sponge or porous mass. It is most adhesive, and if kept perfectly dry during the process of manipulation, can be at- tached particle to particle, until a tooth, however broken and imper- fect, can have its outlines perfectly restored. To use it, instruments, as employed with foil, sharply serrated, are necessary; and the DISEASES OF THE TEETH. 193 portion 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 much more tedious preparation to work than the foil, and, for a perfect operation, demands much more skill, and infinitely more patience. Gold, as a preparation for filling teeth, while the most perfect article employed, is yet not without its objections. It is, unhappily for this purpose, an admirable conductor of thermal changes, and when used in close proximity to the pulp of a tooth, not unfrequently so irritates it as to result in its inflammation and death. Another objection is its color. Tin Foil. — This is simply purified tin beaten into thin leaves. 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 ob- jectionable in color than gold, but possesses an advantage over it in being a less sensitive thermal medium. It is also comparatively inexpensive. 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 four parts of silver to six of the tin — different persons having different formula — and, when thus united, is comminuted by the file, and put aside for use when needed. To make an amalgam, or paste filling, as it is as frequently called, take a portion of these filings, enough to correspond with the size 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 13 194 ORAL DISEASES AXD SURGERY. cavity with bibulous paper or other absorbing material — supposing the cavity to have been previously prepared — and with any conven- ient instrument press the paste into place. 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. Osteoplastic or Tooth-bone. — This is a preparation 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, and in the form of a paste, thus produced, it is plastered 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 days. This can be accomplished, — first, by protecting and shielding the mass placed in the tooth while in the act of setting or hardening, through the careful employment of nap- kins 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 several days, or quite as long as is necessary. Gutta-percha. — This agent is not unfrequently used as a tem- porary stopping. It is introduced precisely as the amalgam, being, however, first warmed in the flame of an alcohol-lamp. In its place it is often found quite useful ; I have seen these temporary fillings preserve a tooth for years, — it is not well, however, to so trust them. A preparation, much used as a temporary filling, consists of gutta-percha, quicklime, quartz, and feldspar ; it is known as Hill's stopping. It can be purchased at any of the depots at a very reas- onable price. The process of filling a tooth, whatever may be the material em- ployed, is, unless when complications exist, a matter merely of mechanical skill. As- before remarked, it requires only practice to become a proficient, that is, taking it for granted the manipulator has mechanical ability. Complications, associated with the sy.stem at large, are, however, so frequent in occurrence that it has now be- come a recognized fact that a general medical education is as neces- sary for the proper appreciation and understanding of this depart- ment of practice as for that of any other. Hence the great progress which all writers are called on to chronicle, and which has in its results been of such great gain to the public at large. For a continued consideration of this matter, the treating and DISEASES OF THE TEETH. 195 filling of individual cavities, the preparation of artificial teeth, etc., the reader is referred to the various text-books on dental surgery. Fig. 39. — Instruments employed in Introducing, Condensing, and Polishing Gold and Tin Fillings. 196 OBAL DISEASES AND SURGERY. As caries of the teeth is seen to have a strong exciting cause in the influence of local irritants, it naturally occurs that such sources of trouble are to receive a proper degree of attention; hence the em- ployment and use of dentifrices and washes. 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 condition; of the constitutional causes, all aS"ect the integrity of the teeth which are deteriorative to the system at large. Unhappily for the dental organism, primary unhealthy impressions made upon the teeth, Avhile 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 such period, is so apt to impress permanent pittings upon the enamel. Unhealthy parents cannot by possibility beget perfectly healthy" oflPspring. Here is a great primary antagonist. The teeth, how- ever, are living, and consequently changing bodies : particularly 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, when considering the rela- tive low vitality of these organs, than treatment directed to the pro- duction 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 must, to a greater or less extent, be felt. A first indication calls for the consideration of causes interfering with the proper vitality of any denture coming under observation. DISEASES OF THE TEETH. I97 Hereditarily, or how otherwise deteriorated, 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, either of organic functional irregularity, or of animal habits common to the parent, and which is to be esteemed of deteriorating import, our first attention 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 molec- ular impression. Here a predisposing cause would have come from and would be still residing in a syphilitic condition. Granting, then, that such molecules, still living, are impressible, would judgment not direct a primary 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 an hereditary venereal transmission, and I never thought of directing medication otherwise than in recog- nition of such a transmission; and satisfied, as every medical man must be, that the circulatory fluid permeates tooth structure, I treat venereally deteriorated teeth on the same common principle, and have found in the result that measure of success which has justified the conclusions. In other words, I have prolonged the life and health of such organs, just as is prolonged the life and health of the patient upon whose molecules are impressed the fiat of the tubercles of phthisis. Such a treatment consists, however, not in administering 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 is most important to recognize. A child may have its molecules deteriorated 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 nourish- ing 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 enough trace constitutional variations, for just as at difi'erent periods the functions of organic life were healthily or un- healthily performed, so we find the disturbances written in the char- 198 ORAL DISEASES AND SURGERY. acter of the teeth belonging to the period. More expressive even than this is the fact that the deciduous teeth mark, in the periods of their solidification, 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 now admit. But here, unfortunately, the matter has been left, most practitioners acting on the premises 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 ? That would be very true, but certain of the fillings came out years ago and have never been replaced, yet are the teeth quite as good as those in which the operations remained. 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 stand-point should the diseases of both be viewed. It is not of course every case of a carious bone that demands a constitutional 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 that practitioner have who has not the inclination to look for a primary lesion outside of things strictly local in sig- nification. A principal exciting cause of decay in the teeth is found in a lack of cleanliness ; most persons, without recognizing it, are careless in their attention to these organs. Another exciting cause lies in injury done by an improper use of them, — the biting of hard substances, as rock-candy, cracking of nuts, etc., breaking in this way the enamel, and thus exposing to irritation the higher organized and suscep- tible dentine. A lack of proper exercise for the organs is another prolific source of disease ; witness the expression of this in the teeth of swill-fed cows. Children and adults should use, in part at least, food which requires mastication for its comminution. The lodgment of decomposing particles in the sulci, and between the teeth, should be strictly guarded against. To this end the quill or pick of wood or brush should be frequently and freely employed. Certain irritative conditions of the oral fluids should receive atten- tion ; thus, whether this fluid be too acid or too alkaline, it is alike DISEASES OF THE TEETH. 199 injurious, and should receive correction. A piece of common litmus paper is always at command for these analyses, and the conditions of the fluid can be ascertained at any time in a single moment. An inspissated mucus is another source of offense to the teeth. In some mouths this is so persistent and offensive in character as plainly enough to point to its constitutional origin. To correct it I have always placed most reliance on the exhibition of the mineral acids, assisted by a free course of salt bathing. As a local antago- nist there is nothing better than an astringent acidulated wash, con- joined with the permanganate of potass. A very good formula is as follows : B. — Decoct, quercus (fort), ^vi; Acid, sulph. aromat. 5i ; Potass, permang. gr. xx. M. This may be used in full strength, or it may be diluted, pro re nata. Conjoined with this treatment, the aqua chlorinat. of Watson may be used ; fifteen drops given once a day for a few days will correct all disagreeable odor, and render the breath sweet and pleasant. In an acid condition of the oral fluids, where local medication seems necessary, a very pleasant formula is as follows: B. — Tinct. capsici, 5ijj Tinct. pyrethri, ^i ; Tinct. cinchonse, Tinct. quillai, aa ^ij ; Aqua calcis, §iv ; 01. gaultherise, q. s. M. This may be used on the brush as an ordinary wash, and will be found quite agreeable. An alkaline local indication may very well be met by a prescrip- tion like the following: B. — Tinct. capsici comp. 5i; Acid, sulph. aromat. Aquai cologn. aa ^ij ; Spts. vin. Gal. ^iij ; Tinct. quillai, 5ij ; 01. lim. vel verbena vel gaultherise, q s. M. Sig. Use pure or dilute, as most agreeable. 200 ORAL DISEASES AND SURGERY. Tooth powders are necessary to proper cleanliness. A very good combination for everyday use may be prepared as follows : B. — Os sopiae pulv. ^i; Carbo ligni pulv. 5i I Coral pulv. Jss ; Lap. pumic. pulv. Cretae prep, aa 5i ; Iridis flor. pulv. ^i ; 01. limon. q. s. M. The objection to such a combination, that certain of its ingredi- ents are insoluble in the fluids of the mouth, does not, in my ob- servation, hold good. It will keep the teeth very clean, and, like all powders, should have the frequency of its use modified by the end to be accomplished. Of course, like all other good things, it could easily enough be abused. Castile soap is an excellent article for occasional use. Its too continuous employment, however, is apt to induce a spongy, relaxed condition in the gums. Floss silk, well waxed, should be used daily between the teeth, or where there is much tendency to the collection and retention of particles, it may be employed unwaxed, and being wet, enveloped in pumice or cuttle-fish powder. Thus prepared, it can be made to keep the approximal surface very clean. Common lamp-wick is even a better material than silk, if the spaces are open enough to permit its use ; it is not nearly so apt to irritate the gums. Caries of a tooth has, as its sequelae, sensibility of the irritated and inflamed dentine ; exposure of the dental pulp, accompanied by the pains of irritation and inflammation ; periodontitis not unfre- quently ; reflex neuralgic pains ; and, in occasional instances, epulo- fungoid excrescences from the exposed pulp. The prophylaxis to these conditions consists in checking and controlling the caries on its earliest appearance. CHAPTER X. DISEASES OF THE TEETH. ODONTALGIA. Under this common head we shall consider all the various pains in the teeth, however induced. The term comes from the two Greek roots, odous, a tooth, and algos, pain — odontalgia, toothache, or pain in a tooth. The causes of toothache may be classed under the following heads : 1. Sensitive dentine. 2. Direct or indirect exposure of the pulp to sources of irritation, 3. A diseased state of the periodonteum. 4. Confinement of pus and gas in the pulp cavity. 5. Granules of osteo-dentine in the pulp. 6. Sympathy. 1. Recession and absorption of the gum and alveolus. 1st. Sensitive Dentine. — Some teeth, immediately upon the break- ing down of the enamel and the consequent exposure of the dentine, become exceeding sensitive, or, in other words, exhibit themselves as peculiarly susceptible to the influence of irritating agents. This impressibility is caused in some instances by the exposure of the enamel membrane, in others by an excess in the organic elements of the tooth ; from the endosteum, and perhaps periosteum, nerve fila- ments permeate more or less completely all the intertubular spaces of such teeth, and thus in proportion to the surface presented is the existing irritability. The pain, under these circumstances, is seldom, perhaps never, unless the irritation is carried to the pulp, at all acute, but rather dull and annoying, and influenced almost wholly by the contact of irritating substances. Thus sweets, taken into the mouth, or cold or hot drinks, or acids, will at once create pain. Sometimes the discomfort arising from sensitive dentine is con- tinuous. In these cases the cause must be looked for in some irrita- (201) 202 ORAL DISEASES AND SURGERY. tive condition existing in the oral fluids. These may be too acid, or otherwise too alkaline. Test Avith the litmus, and prescribe accordingly. Medicinal obtunders are by some highly recommended as direct applications to teeth thus sensitive, but their employment must always be made with much caution. Cobalt, arsenious acid, chloride of zinc, chromic acid, acid nitrate of mercury, are preparations em- ployed. The danger arising from their use is the too common ill effect upon the dental pulp, this organ being very apt to be irritated and inflamed by absorption of the obtunding agent. My own im- pression is that such agents as are cscharotic in their qualities should seldom, if ever, be employed. In place, it is much better to apply chloroform, aconite, or preparations of kindred character. Better still, avoid the use of the irritating agent ; or, if this is not practicable, antagonize its irritative quality through an adapted pre- scription. A permanent cure for sensitive dentine is to be found in plugging the cavity, and this is, without doubt, the proper treatment. Bur- nishing down the tubules is another remedy proposed ; this fre- quently answers, temporarily, a very good purpose. The excavation of a sensitive cavity is sometimes most unbeara- ble. It is better, however, that the patient should endure the suffering than risk destroying the vitality of the tooth ; or, if such endurance is impossible, it is better that he should be etherized. A very few cuts of a sharp excavator will generally be sufficient to clear out the debris, and if the instrument is used with boldness and skill, the pain is very quickly over. Etherization needs not, of course, be car- ried to any very profound extent. To distinguish between the common sensibility of exposed den- tinal structure and sensibility arising from exposure of the dental pulp, it is only necessary to use an instrument in examination of the cavity. If the trouble pertains alone to the dentine, all parts touched will be found alike sensitive. If the nerve or pulp is exposed, the pain to touch increases as the instrument approaches the deepest part of the cavity, or the seat of the exposure, such seat being not unfrequently in cornua, which may run quite near to the surface. 2d. Direct or Indirect Exposure of the Pul]:) to Sources of Irri- tation. — Reference to the anatomy and relations of the dental pulp, exhibits it as a body composed of the most delicate connective tissue, in which ramify nerves, arteries, and veins. This body is lodged DISEASES OF THE TEETH. 203 in a bony cavity, sufficient only in size for its comfortable accommo- dation, and for the halitus or fluid which surrounds it. Any undue congestion will therefore at once be perceived to result in a pressure, and^vhich, from the presence of nerve matter, must yield acute pain. This appreciated, the pains resulting from an irritated pulp must be felt to be alike in general character. A pulp need not, as suggested in connection with applications employed to obtund sensitive dentine, of necessity, be fairly exposed to be the subject of irritation. Cases not unfrequently occur where the plate or floor of a cavity is so thin and so altered in structure that it will yield or bend. In these instances the agencies of mastication may and do readily enough force this plate down upon the pulp. Asa consequence of such pressure we have irritation, and, it may be, inflammation. Irritation of a pulp is much more apt, however, to be associated with its exposure. Here everything entering into the cavity is a source of offense, and the lesion is always plainly enough discovera- ble; foreign particles coming in contact with such an exposed pulp give instant and perhaps excessive pain. This pain may quickly subside, or it may continue for hours or days ; in the latter case, inflammation will be found to have established itself. A free and open break into the pulp cavity is attended with much less pain in inflammation of the organ than more limited exposure. In the first case, the swelling pulp has plenty of room, and conse- quently less pressure is exerted on the nerve filaments. In the second, the protruding congested organ becomes quickly strangu- lated, and thus pain of the most acute and severe character is induced. The treatment of an exposed pulp is of a twofold character,— palli- ative and radical. The first consists in the employment of soothing and quieting applications, and is principally employed for the relief of children. The second implies the destruction of the pulp ; this being generally effected through the instrumentality of escharotic applications. To quiet an irritated pulp, a first attention is to be directed to the removal of any and all sources of offease. If the fluids of the mouth are irritative, the character of the condition must be sought for and corrected. If foreign particles have found their way into the cavity of decay, they are to be carefully syringed away with warm water. Such attention may be all that is sufficient. If not, and the excitability continues, recourse should be had to sooth- ing applications,— chloroform, aconite, and laudanum, in equal parts. 204 ORAL DISEASES AXD SURGERY. sometimes act very happily, particularly in such cases as depend upon excitation unattended with inflammation. Where evidence of congestion or vascular excitement of any grade exist, lead-water and laudanum will frequently act like magic. Persulphate of iron and tinct. iodine, in similar conditions, are found sometimes to act very happily, constringing the vessels, and thus breaking up, or aborting, as it were, the congestion. In the odontalgia of first dentition, it i is well that the parent should be provided with a general prescrip- ; tion. A very good one is as follows, to be applied by saturating a small piece of cotton and laying it loosely in the cavity: R. — Creasotum, gtt. vi ; Tinct. iodinii, 5i ; Aqua plumbi, 5ss ; Chloroform, Tinct. opii, aa 5i- M. Such a prescription is suggested on the principle of Dewees' car- minative, and meets, in some one or another of its ingredients, the single or various indications that may be present. In a severe inflammation of the pulp, it may be necessary to re- sort to more indirect medication : blisters upon the nape of the neck will frequently result in speedy relief; hot pediluvia; saline cathar- tic medicines, as the sulphate of magnesia ; diaphoretics, as the spirits of Mindererus; or diuretics, as the niter preparations. An inflamma- tion of the dental pulp, if not too far advanced, may almost invari- ably be broken up by the administration of from ten to forty grains of bromide of potassium, the application of a mustard poultice to the back of the neck, and a hot foot bath, continued from twenty minutes to half an hour. To destroy a pulp, a small portion of the following maybe laid in the cavity, and loosely covered with wax, or cotton saturated in sandarac varnish : R. — Acid, arsenicum, Morph. acet. vel morph. sulph. aa grs. x; Creasotum, q. s. for a thick paste. M. Of this a piece the size of a common pin-head will be found quite enough for the purpose. In the application of this arsenical paste, means should be taken to insure its action as speedily and thoroughly as possible. If too little is used, it produces not the death of the pulp, but an inflammatory action, which is apt to involve DISEASES OF THE TEETH. 205 the whole tooth, making it tender and irritable, resulting, not un- likely, in chronic periosteal trouble. To insure a speedy action, it is well to somewhat freely expose the pulp before making the ap- plication. A very admirable plan, if convenience permits, is to prick the paste into the organ with a needle-pointed instrument ; a pulp so treated in my own mouth was thus rendered capable of a painless removal after a very few minutes, and without the slightest apparent inflammatory action being provoked. Arsenic applied to a pulp for its destruction had better be re- moved after twelve or fifteen hours. I do not recognize this, how- ever, as absolutely necessary, particularly in the fully developed adult tooth ; but such practice is not at all amiss, as thus the possi- bility of its effects on parts beyond the foramen is guarded against. In referring to the physiological changes constantly in progress in young teeth, and particularly the deciduous set, the inadvisability of arsenic as an application is at once made evident. Here the for- amina are in various conditions of enlargement; and applications of such character would of course pass at once through these to the parts beyond. If the destruction of the pulp in this class of teeth becomes a necessity, the object may be effected by the continuous and daily employment of creasote, to which has been added equal measure of Monsel's solution of the perchloride of iron. A permanent tooth, after the destruction of its pulp, can have the cavity filled, and be made, in the majority of instances perhaps, quite as useful as ever. (See works on Dental Surgery.) A cause of odontalgia from an irritated pulp frequently exists in the case of plugged teeth, from proximity to the organ of the mate- rial used in the filling. In these instances a constant irritation is kept up by thermal impression, induced by the pi'esence of the metal. If inflammation supervenes, the pain, because of the perfectly in- closed condition of the pulp, becomes of the most acute and unbear- able character ; relief will generally be obtained by the removal of the filling ; or, if this should not succeed, the pulp may be treated as above described. Where several teeth are in a state of irritation from such a cause, and confusion of distinct location is thereby in- duced, as is not unfrequently witnessed, the affected teeth can be made clearly to designate themselves by holding in the mouth cold water; or, what is even better, touch each particular filling with some steel instrument. The increase in sensation will be thus made very marked. The dental operator frequently cures such teeth by introducing 206 ORAL DISEASES AND SURGERY. between the filling and floor of the cavity some non-conducting sub- stance, a piece of ordinary quill, a particle of asbestos, a layer of gutta-percha, or a portion of the Hill stopping. Still another source of irritation to the dental pulp is found in the wearing down of the teeth. This is particularly observed in persons who use large quantities of tobacco,- or in such as have the upper and lower teeth directly articulating. Happily, however, in the generality of such cases, nature antagonizes the external influ- ence by depositing, in quantities as needed, secondary or osteo-den- tine within the pulp cavity, contracting at the same time this organ, so that, in proportion as the tooth wears away on its cutting face, the pulp recedes, and casts out, as its protection, this secondary material. It is a beautiful and wonderful process of ofi"ense and de- fense, and commands our admiration. In some cases, however, and these not a few, this reparative or protective power does not seem to exist ; where this happens, the pulp becomes, of course, soon the subject of irritation. I have seen, from such a cause, some of the severest cases of odontalgia. The only cure is to be found in the destruction of the pulp. To apply arsenical paste under such circumstances, there being no cavity of decay, it may be sufficient to lay it in the cup-shaped depression commonly existing on the cutting faces of such teeth (the result of the more rapid wearing of the inner dental structure over the outer enamel wall), keeping it in place with a covering of wax. When pos- sible, however, it is much better, and more speedy practice, to care- fully drill an opening into the pulp cavity, and with a delicate needle pick the arsenic directly into the pulp. The death of the organ se- cured, it is to be removed from its cavity by a barb, and its place supplied with gold. Improper union of metals in the filling of a tooth is another not unfrequent source of irritation to the dental pulp. Tin foil is some- times placed in the bottom of a cavity, and the operation finished with gold. In many, not in all instances, this composition produces a galvanic action, which, if not removed, will quickly enough destroy the pulp. Still another source of irritation is the employment, in cavities more or less in proximity to the pulp, of the preparation described as tooth-bone : the chloride of zinc used in the compound will not unfrequently, within a very few hours after its application, produce an inflammation in the parts almost, if not entirely, uncontrollable; few preparations require to be used with more judgment. DISEASES OF THE TEE TIT. 207 A tooth so irritated is to have the filling removed, and pei'haps it will always be found the best practice to finish the death of the pulp as speedily as possible. As a reverse to this, it is undeniable that the use of this material will sometimes prove just provocative of sufficient irritation to excite the secretion of secondary dentine, thus proving the best practice that could have been pursued. A pulp may give every evidence of being in an irritated condition where the osseous integrity of the tooth is perfect, or seemingly so. Here the cause may be still strictly local, or it may be constitutional. Blows received by a tooth often result in such irritation. Atmos- pheric changes will sometimes account for the condition. Pieces of ice brought and retained in contact with teeth of loose structure are frequent sources of such trouble. Cracks in the enamel, induced from whatever cause, and permitting the impression upon the den- tine of external influences, are other explanations. In a constitu- tional direction, rheumatism is, perhaps, the most frequent source; after this, gout. Reflex or radiated irritability is a frequent manifes- tation. This is, perhaps, most observable in the hysterical female. In these cases no special rules are required. It is only necessary to discover the cause of offense, wherever and however situated, and to remove it if possible. In the odontalgia of gout, dependence must be placed upon the exhibition of colchicum ; twenty drops, three or four times a day, according to the urgency of the symptoms, may be given. In rheumatism, I know few better combinations than the following. Its administration to be preceded by a free purging with a saline cathartic. R. — Ext. belladonna, grs. vi ; Vin colch. rad. §ss ; Tinct. guaiac. ammoniat. svi; Potass, iod. ^ss ; Aqua cinnamomi, ^vi. M. Sig. To the adult give a tablespoonful three times a day in a little water ; if it act too freely on the bowels, add opium q. s. Functional derangements of the stomach might perhaps deserve special attention, as the reflex or radiated odontalgia is concerned. Any one who has ever observed the relationship existing be- tween the pneumogastric and third nerve, as manifesting functional stomachic derangement in the enlargement of the pupil of the eye, will be at no loss to associate the fifth and ninth nerve. Pure neu- ralgia, as the term has common signification, is, I am satisfied, a 208 ORAL DISEASES AND SURGERY. very rare affection; an aching nerve will generally be found to have some lesion outside of a so-esteemed idiopathic condition, and the lesion can generally be discovered by closely looking after it. 3d. A Diseased Slate of the Periodonteum. — To the existence of this condition I have before had occasion to allude. Its most com- mon and precedent lesion is inflammation of the pulp. When this inflammation extends through the foramen of the tooth, it involves, by continuity of relationship, the enveloping membrane. As a first indication of such extension of the trouble, a slight soreness on the occlusion of the teeth is felt, or when the affected one is struck. A few hours later and this soreness has increased to a marked extent. The tooth is now elongated in its socket, or thrust outward, the re- suit of the congestion. So decided is this elongation that the teeth cannot be brought properly together. Pain is heavy, but intense, the whole jaw sympathizing. If the case is allowed to run its course, the acute condition will continue from three to six days, terminating, most likely, in suppuration. Pus will collect at the apex and about the root or roots of the tooth. Finally, after almost unbearable agony, it will induce, by the pressure from its presence, absorption of the confining bone. The pus will now escape into the soft parts, and, after provoking absorption here, will discharge itself as a parulis, or gum-boil, and thus will end for the time the trouble. Treatment by resolution is always in these cases to be attempted. The inflamed pulp should receive an immediate attention ; or, if it be dead, it should be syringed from its cavity. Periodontitis is not unfrequently provoked by the presence of a dead pulp in a closed cavity. In these cases, the very first indication is the opening of such cavity. This very frequently Avill of itself yield a cure. Con- tinued treatment consists, as suggested, in free scarification of the gum, and, after such depletion, the application of astringents. Leeches to the part act sometimes very happily. Hot foot baths, saline cathartics, and counter-irritants are also beneficial. Rest to the part is to be secured by heating a small piece of gutta-percha, and moulding it in the form of a cap over certain of the healthy teeth. A mouth- ful of cold water at once hardens this, and thus occlusion of the sound with the diseased tooth is prevented. If matter forms, absorption of the bone and soft parts is to be anticipated by drilling, with a spear-shaped instrument, into the socket of the tooth. By this little operation days of suffering may frequently be saved. Where, in ordinary cases, it is seen that resolutions cannot be DISEASES OF THE TEETH. 209 effected, and a patient will not submit to the operation of opening into the socket, abscess may be hastened by heat-retaining applica- tions made directly to the part ; of such applications there is nothing better perhaps than a split fig, roasted ; warm fluids may be held in the mouth, etc. The treatment is to be conducted on general princi- ples. Fever may be treated with the ordinary neutral mixture. A very good general febrifuge is that prescribed on a former page: R. — Liq. potassae citrat. §iij ; Spts. seth. nit. ^ss ; Ant. et potass, tart. gr. i ; Morphia acet. gr. ij. M. Sig. Take in dessertspoonful-doses, pro re nata. Periodontitis running into abscess is most apt to become chronic. A proper treatment is the daily injection of the sinus with some stimu- lant, than which there is nothing better than the tinct. of iodine, in varying strength, to suit the conditions. A very happy treatment in bad cases consists in keeping a tent stuffed into the tract, medicated with two parts of iodine and one part creasote. Constitutional tonic treatment is also commonly indicated. In my own practice I ordinarily direct a daily salt-bath, and fifteen drops, three or four times a day, of the following combination : B. — Tinct. ferri chl. 5iij ; Quinise sulph. gr. xxv. M. The ferrated elixir of cinchona is another very admirable prepara- tion. It may be, however, that a patient does not require iron. In such cases the quinia alone, or its equivalent of the bark, may be prescribed. (See chapter on Alveolar Abscess.) 4th. Confinement of Pus and Gas in the Pulp Cavity. — When the dental pulp dies, decomposition follows. As the result of such lesion we have two sequences: either the decomposed matter is gradually absorbed into the dentinal tubuli, and thus gotten clear of, as exhibited in the opacity of the tooth, or otherwise it becomes a source of great irritation and offense to the surrounding healthy structures. Periodontitis is very apt to be provoked, the evolution of gases forcing the matter unduly into, and in many cases entirely through the foramen. If inflammation of the alveolo-dental mem- brane does not result, then the trouble induced becomes of the ordi- nary neuralgic character. The living nerve filament at the foramen, still more or less associated with its continuation ramifying in the 14 210 ORAL DISEASES AND SURGERY. dead pulp, takes on inflammation, and thus irritability not only of this special filament results, but the whole trifacial tract is apt to sympa- thize. Some of the most severe and unbearable neuralgias I have ever treated, situated about the various parts of the head, have been quickly cured by discovering, and treating the cause in a confined dead pulj). I just now recall a marked example,— a patient of the late Dr. Elisha Townsend, treated by me for that gentleman during the sickness which destroyed his valuable life. The patient was a pro- fessional man, and completely lost to all self-control, or reason, for a period of three days, from the effect of neuralgic pain running between the orl)it and the dura mater of the anterior portion of the cranial cavity. In this case not the slightest complaint was made of any of the teeth. Examining the mouth, however, in the search for a cause, I discovered a half carious, and evidently dead lower bicuspid tooth, but with no connection between the cavity of decay and the pulp cavity. With a spear-shaped drill I effected this communica- tion, and in a single instant the patient expressed himself as cured. Relieved of the pain, he fell into a sound sleep, which continued some fifteen hours ; the next morning he went about his duties as usual. Any and every portion of the head and throat, supplied by the fifth nerve, or, indeed, by its associate relations, may be the seat of reflex trouble from a dead nerve. Thus we may have odonto-gas- tralgia, odonto-cephalalgia, odonto-cardialgia, etc. — even sciatica has been cured by the extraction of a diseased tooth. The common treatment of all such cases is to remove the tooth, or otherwise drill an opening into the pulp cavity. The relief ex- perienced is generally almost instantaneous. A tooth containing a dead pulp is distinguished by its loss of translucency when compared with its fellows, or in its opacity, ex- hibited by reflecting, through the means of a hand-mirror, the rays of the sun upon it. 5th. Granules of Odeo-denline in the Pulp. — In rare cases there is found to exist an irritability of the dental pulp which exhausts itself in the formation of isolated granules of semi-bonelike char- acter, which obtain lodgment in some portion or other of the organ, and become, in turn, the source of great offense to the parts, re- sulting indeed frequently in an odontalgia than which there are few severer forms. To diagnose this condition is an exceedingly diffi- cult matter, and it can, perhaps, be best done by exclusion. The teeth in these cases present every appearance of the highest health ; DISEASES OF THE TEETH. 211 no discoloration, no soreness on pressure, and not unfrequently are without the slightest local pain ; this manifestation being situated in some distant part, as the ear, the eye, the scalp, etc. Whether, however, the pain may be localized or dififused, it is always ex- pressed by the patient as being entirely unbearable, and is commonly more or less paroxysmal in character, thus being mistaken for idio- pathic neuralgia, and frequently so treated. A case illustrative just comes to ray mind. During a late session of the University of Penn- sylvania, a student in the medical department applied to me, suf- fering from neuralgia, so severe as to have entirely incapacitated him for study for a period of some three weeks. During this time he had tried all the ordinary remedies which had suggested them- selves, without finding the slightest relief The pain varied between the tuberosity of the superior maxilla and the ear. The teeth, about the tuberosity, were as sound and as healthy looking as any I have ever seen ; there was apparently no local lesion, while, on the other hand, the physique of the gentleman was not at all of the neuralgic type. I was perfectly at sea with the case, until, after a day or two, there came to my mind an instance of innodular calcification of the dental pulp I had once seen, where the patient had suffered in about a like manner. Now I was not prepared positively to affirm that here was a second case of calcification ; but so well satisfied was I of the existence of such a condition that I requested and obtained the consent of the gentleman to be allowed to pass an exploratory drill into the pulp cavity of the wisdom tooth. The result was the find- ing of the pulp filled with osseous granules — granules of osteo-den- tine, as they are technically termed. The extraction of the tooth was followed by the immediate cessation of all pain, and the pa- tient was able to go from my office direct to lectures. A marked case, where the lesion gives direct local manifestation, the pain being seated directly in the affected tooth, exists in the per- son of a professional friend. The gentleman may be said to be affected with a diathesis in this direction. More beautiful teeth than he possesses, or, rather, did possess, I have never seen ; and yet, one by one, they take on this condition, exciting such madden- ing pain that, regardless of everything, he flies to extraction for relief In this way, within the past few years, he has lost all his upper teeth. The treatment of this form of odontalgia consists in drilling into the body of the affected tooth, and securing thus a cavity of reten- tion ; apply the arsenious paste as directed. There are, however, 212 ORAL DISEASES AND SURGERY. cases in which, under these circumstances, it seems impossible to effect the destruction of the organ. Here there is nothing to be done but to extract the tooth or teeth. 6th. Sympathy. — Sympathetic toothache is most frequently found to be associated with teeth having a common period of eruption. Thus, if attention is called to an aching bicuspid, and examination discovers it to be in healthy condition, we will commonly find the primary lesion in either of the three fellow-teeth. If it is the first or third molar, or any particular tooth, that may be aching, the real seat of pain may be found in the associate organs. This is the first and most common relation of sympathy. Other and indirect causes exist in various directions, the most constant of such associations being, first, with the ear, second, with the uterus. (See Neuralgia.) 7th. Recession and Absorption of the Gtim and Alveolus. — When, for any reason, the gum falls below the enamel cap, the periosteum and cementum of the tooth becomes exposed to the various sources of irritation. The odontalgia thus provoked is seldom, however, acute or severe in its character, but dull and annoying. The practice in these cases is generally most unsatisfactory, resulting, sooner or later, in the necessity for extraction. If the recession is associated with acute conditions, treatment directed to meet the indications may result very well ; but commonly such recession is slow and chronic, and admits of no remedy. Medicaments to neutralize or correct irritative conditions in the oral fluid sometimes are demanded, and answer a very good end. Of such neutralizing agents, acids or ant- acids are employed, according to the indications yielded to the test by litmus paper. I myself generally use lime-water in the one direction, or very dilute citric acid in the other. CHAPTER XL DISEASES OF THE TEETH. SALIVAEY CALCULUS. Salivary Calculus or tartar is that limelike material so often seen collected about the necks of the teeth. Observation elicits the fact that the primary seat of deposit is about the posterior or lingual faces of the inferior central teeth and the buccal aspect of the supe- rior molars ; as in these situations exist the outlets of the salivary- secretions, the inference is made for us that from such secretions comes, in part at least, the deposit. Analysis of Saliva. Analysis of Salivary Calculus. Water. Carbonate of lime. Ptyalin. Phosphate of lime. Fat. Fat. Chloride of sodium. Mucus. Chloride of potassium. Accidental matter. Phosphate of lime. Sulph-cyanide of potassium. When the salivary secretions are sluggish, the inorganic material, not being held in solution until fairly ejected into the mouth, becomes deposited about the roughened and inviting surfaces of immediately neighboring teeth. A nucleus once fairly formed, the secretion goes on until serious secondary lesions are apt to result. The first and most marked effect of salivary calculus is upon the teeth ; beginning upon one face, it soon involves the whole tooth, and, if undisturbed, envelops, sooner or later, in an imperfect sheath, the whole denture. A mouth so filled with tartar is not only one of the most disgusting, but, as well, one of the most unhealthy conditions presented in that cavity. Salivary calculus soon destroys the integrity of the teeth. It does this by its eff'ects on the secretory crypts about their necks and by compelling the diminution of the periosteal supply ; this membrane dying little by little as the foreign body encroaches on it. As a result of such abstraction of nutrition, (213) 214 ORAL DISEASES AND SURGERY. the tooth soon dies, and is exfoliated as any other sequestrum ; tooth after tooth dies, and each week or each month one or more drops from its socket. Not unfreqnently there may be seen standing, isolated and alone, on some portion of the dental arch, most frequently, however, either on the anterior portion of the inferior arch, or the posterior portion of the superior, a yellowish-looking tumor, which might not in- aptly he compared to a shellbark, covered with inspissated mucus. Sometimes this tumor will be found quite firm in its position, seem- ing, indeed, as if it might have sprung from the socket of some long ago extracted tooth ; at other times you will be able to move it quite freely, as if it had a fleshy peduncle. These tumors give to the patient a most disgusting appearance, are insufferably oifeusive, and so detrimental to health that five or six grains of their substance, given to a small animal, will not unfreqnently cause its death. The comi)osition of such tumors consists of phosphate and carbonate of lime, epithelial scales, inspissated mucus, and the various debris of a cavity devoted to mastication. In other words, they are salivary calculi. The nucleus of such a growth is of course a tooth. The manner of formation is too evident to need description. I have re- moved these calculi, where the nucleus had become so encysted, from crown to apex, that no trace of it was to be discovered without dividing the mass. Where, however, the encystment has advanced to this extent, the tumor is about ready to drop from the mouth of its own accord. I have seen a calculus of this kind encyst the six lower front teeth, making as strange a looking tumor as could be well im- agined. Similar calculi develop, as may be inferred, in other parts of the mouth. Thus, just within the orifice of the duct of Steno they may occasionally be found ; the tumor, in such a case, bulging out from the cheek against the second molar tooth of the upper jaw. The formation of such tumors, in these situations, does not necessarily imply the closure of the orifice of the duct: they form when the gland is sluggish; the secretion not being in sufiicient abundance to hold the lime of the saliva in solution until it is ejected from the duct, it falls on the floor of the duct, and, lodging, makes the nucleus. I remember, on one occasion, to have been called by a fellow- practitioner to see a case where a mass of this calcareous matter, quite the size of the largest almond, seemed to be growing from all DISEASES OF THE TEETH. 215 that portion of the sublingual region anterior to the gland of that name ; one-half the tumor looked as if it might be below the level of the floor of the mouth, the mucous membrane enveloping the mass with ragged and ulcerated edges. It certainly presented a very strange and threatening look. My friend was deceived as to its char- acter, because there was no apparent direct association between the tumor and the neighboring teeth ; and because it was as firmly fixed as though it might have been a growth springing from neigh- boring bone. Yet this was a salivary calculus and nothing else, the only question being as to its cause and fixedness. Looking about the mouth, I perceived that the patient had certain artificial teeth on the left side of the arch ; these teeth were all coated with tartar, and so associated thereby with the natural teeth as to be only distinguishable by that difference in the translucency so immediately noticeable by any one experienced in such direction. Knowing well that it is a plan with many dentists to secure such teeth by passing a strong gold wire across the mouth, and which wire not unfrcquently buries itself within the mucous membrane, thereby occasionally quite concealing it, I inferred at once that this would be found the nucleus of the calculus, and accordingly so di- rected an examination. This was commenced by cutting away the calculus from about the artificial teeth, and, as anticipated, the band was revealed ; next was sought the concealed attachment of the op- posite side, and this being discovered and exposed, the two ends were forced from the teeth which they clasped, and thus the artificial teeth, wire, and calculus were lifted from the mouth in a body. The site of the calculus, as may be inferred, presented a cup- shaped ulcerated depression, and was quite angry-looking. The only after-treatment consisted in the use of an astringent wash. The ulceration healed kindly in a very few days. I may suggest that the existence of such calculi is not an unfre- quent cause of dyspeptic and other alimentary troubles. I have just now, in my mind, the memory of a case of dyspeptic con- sumption very illustrative. In her mouth, the patient, a lady, had but a single tooth, and this for years had been so imbedded in salivary calculus as much more to resemble a half-rotted shellbark than a tooth — her breath was made insufferable by it. I removed the offensive mass, and the recovery of the patient was really magical in its rapidity. Such calculi are to be removed in any convenient manner ; they may be pulled away, broken away, or, when loose, may be cut from 216 ORAL DISEASES AND SURGERY. the fum ; tlie operation being entire)}- a mechanical one, and of course very simple. I forget, however, in such advice, my reference to calculi situated in the duct of Steno. These are to be removed, either by enlarging the duct and crushing the stone, or otherwise by cutting down upon it at the most convenient point. When so cut upon, the wound will not commonly require any after-attention. Mrs. Boyd, a lady, sixty-nine years of age, residing on Sansom Street, West Philadelphia, applied to me, being directed by some unknown professional friend, concerning a tumor of the mouth, from an inflamed condition of which she was at the time enduring much suffering. Ocular inspection revealed the following condition : a tumor, very scirrhus-like, hard, lobulated, and angry-looking, occupied all that portion of the floor of the mouth, to the right of the mesial line ; general inflammation of the whole oral cavity, to such extent as to make mastication too painful to be practiced, and to render degluti- tion very difficult. All the teeth in the neighborhood loose, and occupying irregular positions, the result, evidently, of a hyperplastic condition of the alveolo-dental membranes. The superficial cervical glands, especially those of the submaxillary region, sympathizing to a considerable extent ; while the submaxillary gland itself was so enlarged as to render it sufficiently prominent to be easily mapped out. The patient seeming unable to talk of anything except her pres- ent great pain, which she described as cutting, tearing, burning. I dismissed the case for the day, after prescribing for her immediate relief, namely, the ordering of leeches, aperients combined with Dover's powder, astringent local applications, etc. Two days after, I again visited the case. The general inflamma- tion was resolving very rapidly, while the mental equilibrium of the patient was quite restored. The disease had been pronounced cancer by several gentlemen, and advice given that no application of any kind should be made to the tumor ; that the patient should not even permit it to be handled for any further examination. Under this impression as to its character, the lady had given up all hope of any permanent relief, and was awaiting the end she expected. The history of the case is as follows : Eighteen years before, while engaged in milking an intractable cow, the patient received under the chin a kick so severe in char- DISEASES OF THE TEETH. 217 acter as to confine her to bed for over two weeks. This trouble gotten through, the parts soon recovered their natural tone, and seemed as well as ever. A little over nine months had passed, however, before she was made conscious of occasional slight inflammatory attacks about the region of the sublingual gland. These attacks continued to grow in frequency and extent, terminating, to use her own language, " by a something which looked like a whitish worm, coming from some- wheres, into her mouth." This worm, she said, " was always the assurance to her of immediate relief" The trouble continued to recur for over a year, when a tumor began to develop in the parts. The inflammatory attacks now de- creased in number, but increased in severity — the patient noticing that after each inflammation the size of the original tumor was augmented. So the case ran on for a period of several years. It was re- marked, however, nearly ten years back, that the tumor had ceased to enlarge from the inflammatory attacks, having at that time gained the size of a pullet's e^g, and neither increasing nor decreasing up to the time of my examination. Understand me to refer to the tumor in a quiescent state, for each succeeding inflammation swelled all the parts, tumor included, temporarily, more than the one which had preceded it. The patient's general health was quite good ; there was no con- stitutional evidence to be perceived of the cancerous cachexia. Kow, while the history of this tumor, in its local features, was in many points the history of cancer, yet, considering its location, con- sidering the affection of the gland duct, which, as indicated by the story of the worm, evidently had association with the tumor ; con- sidering the inflammatory attacks to which the parts had been so frequently subjected, and which had resolved harmlessly; consider- ing the length of time the tumor had existed, without passing or apparently tending to pass to the ulcerative stage ; considering these features in a diagnostic point of view, I decided, and felt firm in the decision, that the tumor was benign, and not a cancer. What then was it ? The trouble commenced evidently with in- spissated ranula. My conviction, founded on the history, was, that it was still a ranula. Not ranula, as derivatively we under- stand the meaning of that word, but ranula, as pathologically the term has association with the salivary ducts. What the contents 218 ORAL DISEASES AND SURGERY. of such cyst, if cyst there was, might be, I did not feel prepared to decide. Acting on the strength of this conclusion, I suggested to the patient my impressions, and requested to be allowed to pass a scalpel through the parts. This, however, met with a most de- ^ cided negative,— the refusal not being, perhaps, so very strange, | considering the assurance that Mrs. B. had so often received, that any attempt to operate would be her death-warrant. Failing in several other attempts at persuasion, I became, at length, annoyed at the obstinacy of the patient, and dismissed the case. About a month after, however, prompted by curiosity, I called again on Mrs. Boyd. There was now not the slightest evidence of inflammation about the parts. The tumor was about the size of a pullet's v^