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<neral floor of these wings is concave, and marked with elevations
and depressions for the accommodation of neighboring convolutions.
Turning the bone, these wings are seen to be made up of three
surfaces: the encranial face, as just described; an external surface,
nccupying, when in articulation, a place in the base of the skull; and
an orbital surface.
The external surface is irregularly convex, and is separated into
two portions by a ridge called the pterygoid. The superior of these
two faces is seen entering into the composition of the temporal fossa
for lodgment of temporal muscle. The inferior face lies beneath the
zygoma, and forms part of the fossa of this name, giving attachment
to the external pterygoid muscle. Running from the postero-lateral
angle of the surface is seen a prolonged spine : to this is attached the
laxator tympani muscle and the internal lateral ligament of the
lower jaw.
The orbital face of the wing assists in forming the outer boundary
of the orbit ; it is quadrilateral in form, smooth, and concave. Be-
low, it has a somewhat rounded border, and enters into the forma-
tion of the spheno-maxillary fissure ; internally, it assists in forming
the sphenoidal fissure. At the lower edge of the inner border is a
delicate spine, giving origin to one head of the external rectus mus-
cle. The foramina generally seen on this face are called orbitar
foramina : they transmit small arteries.
The lesser wings, frequently described as the processes of In-
grassias, are seen on the encranial surface extending outward, over-
lying at their apices the great wings. These wings are triangular
in shape, having their bases associated with the body of the bone.
In articulation they complete the posterior boundary of the anterior
fossae of the cranium, and are lodged in the fissure of Sylvius. The
fissure or slit which separates them from the great wings is called
the lacerated foramen. It transmits the first or ophthalmic branch
of the fifth nerve, the third, fourth, and sixth nerves, and the ophthal-
mic vein. The lesser wings are connected with the body by two
footstalks, inclosing within them and assisting in forming the optic
foramina. A process seen jutting backward from the foramen is
called the anterior clinoid process ; to it is attached the common
tendon of the recti muscles.
The legs or pterygoid processes, seen falling from the point of union
of the great wings with the body, consist of two plates, separated
behind by a deep notch, but united almost fully in front. The ex-
40
ORAL DISEASES AND SURGERY.
ternal plate is broad and curved, and forms part of the zygomatic
fossa ; to it is attached the external pterygoid muscle. The internal
face forms part of the pterygoid fossa, and gives origin to the inter-
nal pterygoid. The internal plate has a particular interest; it ends
in a tubercle or hook-like process, which is felt in the mouth just back
of the maxillary tuberosity. The hamular process around it turns the
tendon of the tensor palati muscle — a tendon divided in the operation
for cleft palate. The base of this internal plate forms a fossa, the
scaphoid, from which originates the tensor muscle just alluded to.
The outer surface of this plate forms the pterygoid fossa; the inner
surface assists in forming the outer posterior boundary of the nares.
The base of the pterj^goid process is quite broad, and in front gives
support to Meckel's ganglion. The vidian canal passes through it.
The sphenoid articulates with all the bones of the cranium, with
the two malar, the vomer, and two palate bones of the face.
The muscles to which it gives origin are the temporal, external,
and internal pterygoid, tensor palati, laxator tympani, levator pal-
pebras, the recti of the eye, and superior oblique of eye.
THE NASAL BONE. '
ElG.
13.— Nasal
BOJTE.
The figure exhibits the faces of a left nasal bone articulating with
its fellow, which is its counterpart ; the two occupy the quadrilateral
space existing between the two maxillary bones
and the frontal, and form the prominence known
as the nasal bridge. That these bones must vary
considerably in shape would be inferred from va-
riations in the shape of the bridge so frequently
seen. Looked at from above downward, each
bone is observed to be concave, while viewed
from side to side, it is convex; several light
' HiUSc grooves are commonly noticed on the surface
\jj V?i^l for the accommodation of vessels ; the foramen
seen about the center transmits a small vein.
The inner surface reverses relations with the
outer — being convex from above below, concave
from side to side. Its only feature of interest is
a groove for the lodgment of the nasal nerve.
The borders of the bone are three articular and
one free. The superior, serrated and somewhat
narrow, fits in the frontal notch, forming the fronto-nasal artic-
Anterior view of
the left nasal bone-
1, frontal border ; 2,
nasal border ; 3, maxil.
lary border ; 4, lower
border ; 5, nasal fora-
men.
ANAT03tY OF THE MOUTH AND FACE.
41
ulation. The lateral border is beveled, at the expense, above, of
the internal plate, below, of the external, and fits with correspond-
ing bevelings of the nasal processes of the maxillary bone. Intern-
ally, or mesially, the bone articulates with its fellow of the opposite
side, being- prolonged below into a crest, which forms a part of the
nasal septum, and articulates with the nasal spine of the frontal
above, and the ethmoidal perpendicular plate below. The lower border
is free, at least so far as any bony articulation is concerned, giving
attachment by a thin, sharp edge to the lateral cartilage of the nose.
A notch, seen at the center of this border, transmits the nerve occu-
pying the groove on the inner surface.
Fig. 14.
-The Malar Bone.
3
THE MALAK BONE.
The malar, or cheek bones, may be likened to two bony pads laid
on either lateral aspect of the face for the purpose of influencing a
general convexity. Each bone is ir-
regularly quadrilateral, supported
above by articulation with the frontal,
sphenoid, and superior maxillary
bones ; in front by the malar process
of the maxillary ; posteriorly by the
zygomatic process of the temporal.
The bone presents two surfaces,
four processes, and four borders. The
external surface, convex and smooth,
presents little of interest ; the fora-
men, seen upon this face, has its
place sometimes occupied by two or
more ; they ai*e simply the orifices
of canals, transmitting unimportant
vessels. The surface, in relationship,
is mostly covered by the orbicularis palpebrarum muscle, while the
zygomatic! have origin from the lower and inner aspect.
The internal face is concave, and assists in forming, above, the
temporal fossa, below, the zygomatic. It yields partial origin to both
the temporal and masseter muscles.
Of the four processes, the orbital is the most interesting ; turning
at right angles with the external face of the body, it assists in form-
ing a portion of the outer wall of the orbit and orbital ridge. The
frontal is thick and serrated, and articulates with the external angu-
OUTER VIEW OF THE RIGHT MALAR BONE. 1,
external or facial surface ; 2, malar fora-
men; 3, frontal process; 4, 5, orbital bor-
der; 6, maxillary border; 7, zygomatic
process ; 8, temporal border ; 9, inferior
border.
42
ORAL DISEASES AND SURGERY.
lar process of the frontal bone. The maxillary is rough, and trian-
gular in shape, and attaches the bone in front. The zygomatic is
sharp and flat, and forms part of the yoke overlying the ridge sep.
arating the zygomatic from the temporal fossa.
The four borders are the orbital, the maxillary, zygomatic, and
temporal. These borders correspond with the relations named, but
have no interest apart from the processes.
Fig. 15. — The Lach-
rymal Bone.
THE LACHRYMAL BONE.
Looking at the view, or, much better, at the articulated skull, the
lachrymal bone is seen to occupy a position of some prominence in
the composition of the orbit. A ridge on its
anterior surface divides it into two parts: one
part, called its orbital face (bounded above by
the orbital face of the horizontal plate of the
frontal bone ; laterally, by the os planum of the
ethnoid ; below, by the orbital surface of the
maxillary bone), enters into the composition
of the orbital cavity. The face, to the inner
side of the ridge, is smooth and concave, and
articulates with the nasal process of the max-
illary bone, internally, and with the lachrymal
process of the turbinated, below ; these three
bones in their union form the ductus ad nasum,
or lachrymal canal, transmitting the tears to
the inferior meatus.
The bone, by its internal or nasal surface,
enters into the composition of the middle me-
atus, and assists in filling in the anterior eth-
moidal cells. Like the external surface, it is divided into two faces,
the line of division being a depression corresponding with the ridge
on the opposite surface.
One muscle has its attachment to this bone — the tensor tarsi.
EXTERSAL VIEW OF THE
EIGHT LACHRYMAL BONE. 1,
orbital surface ; 2, lachry-
mal fossa ; 3, small process
bounding the latter infe-
riorly ; 4, frontal border ;
5, ethmoidal border; 6,
maxillary border ; 7, pro-
cess articulating with the
turbinated bone.
THE HYOID BOXE.
The OS hyoides is the bone situated on the anterior part of the
neck t)etween the chin and sternum. In shape it somewhat resem-
bles the ordinary horseshoe, and is held in place entirely by a
series of antagonizing muscles, of which it gives attachment to
ANATOMY OF THE MOUTH AND FACE.
43
Fig. 16. — The Hyoid Bone.
1, body
greater horn ; 3, lesser
horn.
some ten pairs. A glance at the bone naturally divides it into a
body and four processes or horns ; the greater of these cornua extend
quite widely over the lateral aspect of
the neck, giving attachment to the hyo-
glossus, middle constrictor of the pha-
rynx, and thyro-hyoid muscles, and by
a bulb, constituting its extremity, to the
thyro-hyoid ligament ; it also serves as
our best guide to the position of the
lingualis artery. The lesser cornua are
simply two conical eminences, more or
less prominent on different specimens. Starting out at the point of
junction of the great horns with the body, they look upward toward
the chin, and serve to afford attachment to the stylo-hyoid liga-
ments.
The body is irregularly quadrilateral in shape, convex in front,
concave behind. A crucial ridge, the intermuscular, divides the
front face into four fossae. This surface is exclusively devoted to the
attachment of muscles ; above, to the genio-hyoid and the genio-hyo-
glossus ; below, to the stylo-hyoid, mylo-hyoid, and digastricus. The
posterior surface is smooth and concave, and occupies a position just
in front of the epiglottis, being separated from it, above, by some
cellular tissue and a membrane called, from its relationship, the
thyro-hyoid.
CHAPTER II.
THE MOUTH.
Studying the mouth from the living subject, we remark, first, an
entrance of two fleshy folds, the lips ; separating these, we are met
by a second portal, the teeth ; the space existing between these two
entrances is called the hall or vestibule ; opening this inner gateway,
by depressing the lower jaw, we are introduced into the oral cavity
proper.
The mouth is the commencement of the alimentary canal. It has
as offices, the reception of food, gustation, mastication, and insaliva-
tion ; eonsequentl}' must possess organs and agencies pertinent to
these ends.
Looking into the mouth, we observe that it is an oval cavity,
bounded posteriorly by a veil or curtain. This falls obliquely to-
ward the fauces, having a central pendulum, terminating laterally in
arched curves. We can see beneath this veil, or between it and the
base, and thereby recognize the cavity we are viewing to be simply
the commencement of a canal. Every part of the cavity we remark
to be covered by a common membrane, which membrane we find
to associate externally on the lips with the common skin ; internally
we see it passing back of the veil down the throat, — this is a mucous
membrane, and examination reveals it to be continuous from this
cavity to the outlet of the rectum. The teeth, thirty-two in number
in the adult, are placed in two harmonizing or articulating arches or
curves, and are, in shape and character, correspondent with omniv-
orous habits. Thus certain of their number, the incisors, as they
are called, are so arranged as to cut or incise. Certain others, the
cuspidati or canines, are spear-shaped, and tear or lacerate. Still
others, the bieuspidati and molars, have broad and roughened sur-
faces, acting the part of grinders. The tongue, a muscular body,
rests within the lower dental arch ; it evidently is fitted and suited
to preside over the labor of the teeth, receives or rejects articles to
be comminuted, places and retains such articles in position to be
(44)
THE MOUTH. ^ 45
masticated, and, when ready to be swallowed, rolls up masses into
boluses, and passes them into the pharynx.
The roof of the cavity, beginning with the palatine faces of the
teeth, is made up evidently of hard and soft tissues. The hard por-
tion we discover to be the flesh-covered alveolar and palatine pro-
cesses of the superior maxillary bones and the palate processes of
the palate bone. The soft portion dissection reveals to be a simple
attached basement tissue covered with the common membrane.
Continuing to look for a short period into the mouth, we observe
that jets of fluid are occasionally sent up from the anterior floor just
back of the lower central teeth. We also see drops constantly issuing
from an orifice situated on the cheek by the side of the superior
second molar tooth. This fluid is the salivary secretion, and comes
from glands situated in the immediate neighborhood. Besides this
salivary fluid, pearly drops are seen, more or less plainly, over the
surface of the common mucous membrane. This is mucus, and is
the product of the follicles, crypts, or glands of the common mem-
brane.
The mouth, then, we may say is made up of, and invites a study
of, the lips, cheeks, gums, teeth, mucous membrane, tongue, hard
and soft palate, and salivary glands ; and if we accept, as indeed
surgically we must, that the cavity begins with the lips and ends
at the posterior wall of the pharynx, then we include in the study
all the relations which belong to the posterior entrance.
The lips and cheeks are alike in their composition, and are truly a
part and parcel of each other. First, in the dissection, we have a
layer of skin on the outside and a layer of mucous membrane on
the inside. Removing the skin, we expose a layer of cellular fascia,
in which is more or less fatty tissue. This superficial fascia, as it
is called, differs from other fasciae of the same signification, in not
being a distinct or laminated tissue. It is intimately connected with
the skin, and more intimately associated wuth the muscles. Re-
moving this, a complex grouping of muscles is exposed, — the muscles
of expression.
The view (Fig. 17) expresses so fully the position and signification of
these muscles that it scarcely seems necessary to enter on any descrip-
tion of them. The orbicular, or sphincter of the lips, may, however, be
specially noted, as its influence is concerned in retracting wounds of
the part. In studying the muscles of the face, it will be observed
that they naturally arrange themselves into groups. Thus we have
46
ORAL DISEASES AND SURGERY.
a group that are elevators, another that are depressors. Then
groups that pertain to particular regions, as the nasal, superior
maxillary, inferior maxillary, intermaxillary, etc. Surgically, how-
ever, the information they possess is sufficiently elicited in com-
prehending their general plan and arrangement.
Situated upon, and running among these muscles, we have the
Fig. 17. — Muscles of the Face.
Muscles of the head and neck. 1, 2, occipito-frontal muscle: 1, its frontal belly; 2, its
occipital belly; 3, nasal pyramidal muscle; 4, superior, and 5, posterior auricular mus-
cles; 7, labio-nasal elevator; 8, elevator of the upper lip; 9, nasal compressor; 10, 11,
zygomatic muscles ; 12, masscter muscle ; 13, buccinator ; 14, depressor of the oral angle ;
15, oral orbicular muscle ; 16, elevator of the oral angle ; 17, 18, depressor of the lower
lip ; 19, sterno-mastoid muscle ; 20, trapezius ; 21, posterior belly of the digastric and the
stylo-hyoid muscle ; 22, anterior belly of the former ; 23, loop of fibrous tissue attach-
ing the tendon of the digastric muscle to the hyoid bone; 24, omo-hyoid nmscle; 25,
sterno-hyoid ; 26, sterno-thyroid, seen to the outer side and behind the anterior belly of
the omo-hyoid; 27, mylo-hyoid ; 28, splenius; 29, elevator of the scapular angle; 30,31,
middle and anterior scalene muscles; 32, clavicle.
arteries of the face. These are all branches of the external divi-
THE MOUTH.
47
sion of the common carotid, and will be found in the dissections
distributed exactly as seen in the view. The facial, the third
branch of the carotid externus, is observed to cross over the lower
jaw just in front of the masseter muscle; and, in the subject, is seen
to emerge from or beneath the submaxillary gland, generally pass-
ing through its substance. Its branches are ten in number; four
are offshoots from its cervical portion; six are facial. The facial
Fig. 18. — Arteries of the Face.
The EXTERNAL CAROTID ARTERY AND ITS BRANCHES. 1, right coiiiuion Carotid; 2, internal
carotid; 3, external carotid; 4, superior thyroid; 5, lingual ; 6, facial; 7, submental ; 8,
inferior coronary; 9, superior coronary; 10, muscular branches; 11, lateral nasal artery ;
12, angular artery; 13, occipital artery; 14, descending cervical; 15, muscular branch;
16, posterior auricular artery ; 17, parotid branches ; 18, internal maxillary ; 19, temporal ;
20, tranverse facial ; 21, anterior auricular ; 22, supraorbital ; 23, middle temporal ; 24,
anterior temporal ; 25, posterior temporal artery.
branches are, first, the inferior labial, which passes forward under the
depressor anguli oris, and supplies the lower part of the lip, anasto-
mosing with all the subjacent vessels, the submental, inferior coro-
nary, and inferior dental arteries. The coronaries — the second and
third of these branches — penetrate the substance of the underlying-
muscles, and pass around the lips immediately beneath the mucous
48
ORAL DISEASES AND SURGERY.
membrane ; their pulsations may be very plainly felt ; in many per-
sons these vessels are of such large size as to render hemorrhage
from them a matter of some trouble to control.
The lateralis nasi, the fourth of the branches, ascends along the
side of the nose, supplying its aloe and dorsum. The fifth, the
angular, passes between the inner canthus and nasal bridge. It
gives off sub-branches to the orbicularis muscle, to the lachrymal
sac, and to the integument of the suborbital region, and finally
loses itself in an anastomosis with the ophthalmic artery. A point
Fig. 19. — The Common Carotid, with its Divisions.
;::v4isi:iiiM'*^^
Left COMMON carotid dividixg into the external and internal carotid arteries. 1,
common carotid artery ; 2, internal carotid ; 3, external carotid ; 4, superior thyroid ; 5,
lingual ; 6, pharyngeal artery ; 7, facial ; 8, inferior palatine and tonsillar arteries ; 9, sub-
maxillary; 10, sulimental ; 11, occipital; 12, posterior auricular; 13, parotid branches;
14, internal maxillary; 1.5, temporal artery; 16, subclavian artery; 17, axillary; 18, ver-
tebral artery ; 19, thyroid axis ; 20, inferior thyroid giving off the ascending cervical ; 21,
transverse cervical; 22, suprascapular; 23, internal mammary artery.
in the view to observe is, that the inferior and all the mesial line of
the face are supplied by branches of a common trunk, and that this
trunk is compressible on the lower jaw just in front of the masseter
muscle, facial hemorrhage being thus perfectly under control by com-
pression.
THE 310 UTH.
49
THE NEPvYES OF THE FACE.
This view beautifully exhibits the distribution of the branches of
the facial nerve. The main trunk, seen emerging just below the lobe
Fig. 20. — Nerves of the Face.
1, trunk of the nerve emerging at tlio stvlo-mastoid foramen; 2, its deep auric-
ular branch ; .3, anastomosis of the latter with the great auricular nerve of the cer-
vical plexus ; 4, 5, 6, branches to the contiguous muscles ; 7, 8, branches of the facial
to the digastric and stylo-hyoid muscles; 9, temporo-facial division of the nerve; 10,
branch to the temple, anastomosing with the auriculo-temporal nerve; 11, temporal
branches; 12, zygomatic branches; 13, infraorbital branches; 14, 15, cervico-facial divi-
sion of the facial nerve ; 14, buccal branches ; 16, inferior maxillary branches ; 17, cervical
branches; 18, auriculo-temporal nerve; 19,20, terminal branches of the frontal nerve;
21, terminal branch of the lachrymal nerve ; 22, external nasal nei-ve ; 23, branch of the
temporo-malar nerve ; 24, terminal branch of the internal nasal nerve ; 2.5, infraorbital
nerves ; 26, anastomosis between the buccal branch of the inferior maxillary nerve and
the buccal branches of the facial nerve ; 27, terminal branches of the inferior dental nerve ;
28, great occipital nerve ; 29, 31, branches of the great auricular nerve ; 30, small occipital
nerve ; 32, superficial cervical nerve, anastomosing with the facial nerve.
50 ORAL DISEASES A. YD SURGERY.
of the car, in front of the anterior border of the stcrno-eleido-mas-
toideus, is the portia dura, or hard portion of the seventh nerve, the
motor nerve acting on the muscles of expression. The nerve arises
from the medulla oblongata, passes outward over the crus cerebelli,
and enters the auditory meatus with the soft or auditory portion ;
passing to the bottom of this meatus, it enters the Fallopian aque-
duct, follows the serpentine course of this canal until it arrives
at the stylo-mastoid foramen, whence it emerges, as seen upon the
outside of the face. While, however, in the temporal bone, the
nerve connects with several others, and forms a ganglion, the intu-
mescentia gangliformis, as it is called.
Issuing from the stylo-mastoid foramen, the facial associates with
the pneumogastric, glosso-pharyngeal, carotid plexus, auricularis
magnus, and auriculo-temporal. Passing to the face, it unites with
the three divisions of the fifth nerve.
In front of the ear the nerve is seen to divide into two primary
divisions or trunks, the temporo-facial and cervico-facial. The tem-
poral, the larger of the two, passes through the parotid gland,
crosses the neck of the lower jaw, and divides into three sets of
branches, distributed to the temporal, malar, and infraorbital regions.
The cervico-facial passes downward and forward through the gland,
and divides into buccal, supra- and inframaxillary branches. The
manner of distribution and anastomoses is perfectly shown in the
dissection.
THE VEIXS OF THE FACE.
The veins of the face will be seen to correspond quite closely
with the arterial distribution. Surgically they are, however, of
little import, as it is seldom that wounds of them are of sufficient
consequence to command any direct attention ; they pass their blood
into one or another of the three jugulars, being not by any means
constant in the selection. Between them all, however, the most
thorough anastomosis is always found to exist, thus rendering it
really of little consequence what may be the direct downward course
of the current. The veins of the antero-exterior head are the facial,
the temporal, the internal maxillary, and temporo-maxillary.
The facial, commencing at the inner angle of the orbit, is formed
by the confluence of the supraorbital, palpebral, nasal, and angular
veins. It commences its course downward and outward, passing
beneath the zygomatic muscles, receiving the superior and inferior
labial veins, the buccal, and masseteric ; passes to the base of the
THE MOUTH. 51
jaw, receiving just below it the submental, the inferior palatine, the
submaxillary, and ranine veins, and, finally, with a great branch, re-
FiG. 21. — Veins of the Face.
Veins of the head and neck. 1, frontal vein ; 2, nasal vein ; 3, 4, labial veins ; 5, facial
vein ; 6, lingual vein ; 7, internal jugular vein ; 8, 9, posterior and anterior temporal veins ;
10, transverse facial vein; 11, internal maxillary vein; 12, posterior auricular vein ; 13,
external jugular vein ; 14, posterior, 15 anterior jugular veins, a, external carotid artery;
6, eterno-mastoid muscle; c, trapezius; d, pectoral muscle; e, deltoid muscle.
ceived from the temporo-maxillary, loses itself in the deep jugular.
The temporal commences by a plexus on the side of the head and
52 ORAL DISEASES AXD SURGERY.
vertex, passes downward in front of the ear, receives the transverse
facial, posterior, auricular, occipital, and deep maxillary veins, enters
the substances of the parotid gland, and, finally, being enlarged by
these various branches, becomes the external jugular.
The internal or deep maxillary is, in its origin, a series of veins
collecting the blood from the parts supplied by the internal maxil-
lary artery and adjacent parts. These various veins, the middle
meningeal, deep temporal, pterygoid, masseteric, buccal, and inferior
dental, forming the common trunk, empty into the temporal.
The temporo-maxillary is simply the name given to that part of
the temporal vein below the point of entrance of the maxillary —
either name is used with equal propriety.
SECTIOXAL EXPRESSION OF MOUTH.
The view (Fig. 22) represents a section directly through the center
of the skull from before backward, and perfectly exhibits the char-
acter of the mouth and its associations. Below is seen the tongue
in its relations, in front, to the genial turbercles ; behind, to the epi-
glottis. A fossa between the root of this organ and the epiglottis,
one each side of a common center, the fraenum epiglottis, is particu-
larly worthy of note, as it is a frequent receptacle for fish bones and
other foreign bodies, giving sometimes much trouble in their re-
moval. The free surface of the tongue is seen to be convex, while
the section reveals its common body to be triangular with the apex,
looking forward.
The roof of the mouth, seen above, is remarked to be a quite thin
plane, forming as well the floor of the nose. Its relation to the oral
cavity is concave, but differing widely in various persons, being in
some almost flat, in others very deep. The anterior portion, bony,
will be recognized as being formed by the palatine processes of the
maxillary and palate bones ; the posterior portion, soft, veil-like, and
movable, is the velum, terminating in the uvula in the center, just
above and in front of the tip of the epiglottis ; laterally, in two
pillars or half arches, called respectively the anterior and posterior
pillars. The first of these — the one seen in the view as associating
itself with the tongue — is formed by the projection of the palato-
glossus muscle ; the second, or posterior, is the projection likewise
of a muscle, the palato-pharyngeus, passing from the veil to the
pharynx; the fossa existing between these pillars lodges the tonsil
gland. The hard portion of the palate or oral roof is frequently the
THE MOUTH. 53
seat of necrosis ; it will be remarked that only the smallest loss of
substance is required to associate the two cavities. The isthmus of
Fig. 22. — Sectional View of the Nose, ]\[oitth, Pharynx.
Vertical section of the face and neck, through the median line antero-posteriorly,
EXPOSING TO VIEW THE NOSE, MOUTH, PHARYNX, AND LARYNX. 1, OVal cartilage of the left
nostril; 2, triangular cartilage; 3, line of separation between the two; 4, prolongation of
the oval cartilage along the column of the nose ; 5, superior meatus of the nose ; 6, middle
meatus ; 7, inferior meatus ; 8, sphenoidal sinus ; 9, posterior i)art of the left nasal cavity,
communicating with tlie pharynx ; 10, orifice of the Eustachian tube ; 11, upper extremity
of the pharynx ; 12, soft palate, ending below in the uvula ; 13, interval of the mouth be-
tween the lips and jaws ; 14, roof of the mouth, or hard palate ; 15, communication of the
cavity of the mouth with the interval between the jaws and cheek ; 16, tongue ; 17, fibrous
partition in the median line of the latter; 18, genio-glossal muscle; 19, genio-hyoid
muscle ; 20, niylo-hyoid muscle ; 21, anterior half arch of the palate ; 22, posterior half
arch of the palate ; 23, tonsil ; 24, 25, floor of the fauces ; 26, 27, pharynx ; 28, cavity of
the larynx; 29, ventricle of the larynx; 30, epiglottis; 31, hyoid bone; 32, 33, thyroid
cartilage; 34, thyro-hyoid membrane; 35, 36, cricoid cartilage; 37, vocal membrane.
the fauces, the space between the two arches, is bounded, above, by
the margin of the palate ; below, by the base of the tongue ; laterally,
by the half arches and amygdalae.
54 ORAL DISEASES AND SURGERY.
The Tonsils— The tonsils are glandular organs, situated one on
cither side of the isthmus. These bodies are made up of many lob-
ules, having many sulci lined by involutions of the common mucous
membrane. They arc not unfrequcntly the seat of such hypertrophy
as to make necessary their amputation, while in their sulci may lodge
debris, which, in its retention and decomposition, becomes one of the
sources of an unpleasant breath. Externally these bodies are in
very close relation with the internal carotid arteries, a point neces-
sary to be kept in remembrance in performing operations on them.
The relationship of a bolus of food Avith the pharynx, and its
direction, over the chink of the glottis into the oesophagus, by the
epiglottis, is clearly exhibited by the drawing.
The Tongue. — Dissection of the tongue reveals it to be a some-
what complex body, although made up in the great mass of its bulk
by muscular substance. Attached to the inferior maxillary bone in
front, and to the hyoid behind, it yet moves with the greatest free-
dom and latitude in either direction, giving us the idea that if it is
muscular substance, it must be free muscle set upon fixed muscles,
and this is practically the case as is understood by studying a dis-
section.
The muscular structure of the tongue is made up of five distinct
pairs and certain non-attached fasciculi. The body, as its surface is
concerned, is seen with a base looking backward into the fauces,
and a tip, which represents the apex of a pyramid. Beginning
the study of the organ with its relations to the hyoid bone, we
remark, first, that from this bone arises a muscle, the hyoglossus,
which, passing almost directly upward, enters, with the stylo-glossus,
the root of the body, and expands itself laterally and forward.
Passing toward the center of the bone, we remark a second muscle,
the genio-hyoglossus, which, having apparent origin from the genial
tubercles, radiates downward and upward, attaching one of its
wings to the os hyoides, the other spreading out to assist in the
formation of the tongue. The stylo-glossus, the third muscle, arises
from the styloid process of the temporal bone, passes downward
and forward, and occupies or makes up either lateral aspect from
the tip to the bone. The fourth, the lingualis, seen between the
stylo-glossus and genio-hyoglossus, passes from the tip to the base,
having, indeed, some few of its fibers continued to the os hyoides.
The fifth, the palato-glossus, is the muscle of the anterior half arch;
it assists in forming the base and side. The unattached fibers are
certain longitudinal and transverse bands running through the sub-
THE MOUTH.
55
stance of the organ. The tongue, as an organ of nutrition, is
adapted most happily, through its muscular character, to preside
over the acts of mastication, and, this process completed, to transfer
the comminuted mass back into the grasp of the pharyngeal con-
FiG 23 — Upper Surface of the Tongue.
1, 2, V-like row of the circumviillatc papillas 3, capitate papillaj ; 4, 5, conical i)a-
pillse ; 6, G, floor of the fauces, with numerous simple follicular glands ; 7, tonsils ; 8,
summitjof the epiglottis ; 9, the middle glosso-epiglottic frsenum, with depressions on each
side bounded externally by the lateral frseua.
strictors. Its ability and variety of action is comprehended by a
single moment's observation of the study exhibited in a dissection.
Fig. 23, exhibiting the magnified upper surface of the organ, dis-
56
ORAL DISEASES AND SURGERY
covers it covered with mucous membrane, clotted here and there with
more or less regularly located papillae, of varying size and character.
The mucous membrane envelops the tongue wherever the body
has free surface. Above, it is dense, and affords support to numerous
papillffi; below, it is exceedingly delicate, and is traceable through
the ducts of the submaxillary and sublingual glands.
The papillae, seen upon the dorsum, are cone-shaped projections of
homogeneous tissue, holding arteries, veins, and nerves in plexiform
arrangement ; they are located in three distinct sets, each having
distinctive features.
The most posterior are the largest, and occupy a position which
very much resembles the letter V ; they may be likened to inverted
cones, the apices resting in cup-shaped depressions of the mucous
membrane, hence surrounded each by a valley. They are various])^
Figs. 24 axd 25. — Papillae of Tongue.
Diagram of the papill.5 of the tongue, modPi-attly iiiagiilfiod. 1, capitato papilla; ; 2,
conical papilla;; 3, epithelium; 4, the same structure forming bunches of hair-like pro-
cesses; 5, connective tissue.
Papill* of the tongue, highly magnified. 1, conical papillae ; 2, capitate papilla; ; 3,
simple papillae, occupying the intervals of the compound papilla; ; 4, epithelium ascending
from the conical papillaj in hair-like processes ; 5, isolated epithelial scales from the
latter.
named the maximce or circumvallatffi. Of this class there are some
fifteen ; the elevated margins of the fossa surrounding these papillae
THE MOUTH. 57
are studded with secondary papillae. The structure of these bodies
is accurately exhibited in the magnified drawing.
The papillifi fungiformes or mediae are scattered somewhat irreg-
ularly over the sides and apex of the organ ; they are exceedingly
vascular, and closely covered with secondary papillae ; are broad and
rounded on their free surfaces, narrow and pointed at their attach-
ment to the tongue ; their middle size and red color easily dis-
tinguish them. The magnified fungiform papillae are seen in the
drawing.
The smallest or filiform papillae follow somewhat in their arrange-
ment the order of the maximse, being interspersed among the fungi-
formes. They are very minute, and covered so deeply with epithe-
lium as to appear quite white ; they are enveloped with secondary
papillae, as exhibited in the figure.
In the tongue, beside these papillae are found also numerous mu-
cous glands ; these bodies, scattered over the whole surface, secrete
the ordinary mucus ; they differ in no respect from mucous glands
wherever situated. In the valleys surrounding the maxima papillae
these glands are found in larger number than in any other portion
of the organ.
A transverse section exhilMts the tongue as composed of two sym-
metrical halves, separated from each other by a fibrous septum, each
half consisting, as we have seen, of muscular structure, supplied with
vessels and nerves, and having, in most cases, much interposed fat.
The tongue, being an organ of both special and common sense, is
furnished with nerves of both signification. Thus the papillae, at the
apex and sides, are supplied with the gustatory filaments from the
third branch of the fifth nerve ; the great papillae and base of the
organ, from filaments of the glosso-pharyngeal ; the muscular struc-
ture, from the hypoglossal.
The arteries of the tongue are the lingual, branches of the facial,
and ascending pharyngeal. The one of most signification is the first.
Each vessel anastomoses with its fellow, just above the fr»num,
on the under surface of the organ, and is liable to be opened in the
operation for tongue-tie. This artery is the second branch from the
external carotid ; it pursues a course parallel, for a short distance,
with the great horn of the hyoid bone lying between it and the hypo-
glossal nerve. "Wounds of the tongue occasionally make the vessel
at this point the seat of ligation.
The epiglottis, seen by depressing the dorsum, forms, practi-
cally, the base of the organ, being supported in the center by a bridle,
58 ORAL DISEASES AND SURGERY.
the frtenum epiglottis, and at either side by two duplications of the
lingual mucous membrane, the glosso-epiglottic ligaments or folds.
as they are called ; these boundaries form two lateral depressions or
fossae, fossae lingualis, noticed as being so frequently the seat of the
lodgment of foreign particles.
The Gums. — See Diseases of the Gums.
The Mucous Membrane. — Practically considered, the oral
mucous membrane is to be viewed as commencing at the lips and
terminating at the anus, so much is it in sympathy part with part.
Anatomically, we view this membrane as consisting of a plane of
homogeneous tissue, underlaid by its vascular supply, the vessel
being supported b}' and in cellular tissue. This basement mem-
brane gives support to a covering of squamae or scales, known as
the epithelium, and covers in tissues or organs which have offices
of a recrementitial nature.
The tissues, beside the vascular, which underlie the mucous mem-
brane, are the nerves, lymphatics, and the papillary structure. The
epithelium, the enveloping tissue, is singularly various in its char-
acter, being sometimes columnar, again squamous, again ciliated.
Commencing at the alveolar margin of the lower jaw, this mem-
brane passes over the floor of the mouth, envelops the tongue on
all its free surface, forming beneath, by its duplications, the frsenum
lingua ; from the back of the organ it is so reflected as to form the
three glosso-cpiglottidial folds ; from this it lines the pharynx and
larynx, and is then continued over the digestive and respiratory
tracks, lining, in the latter, the very terminal vesicles.
The mucous cysts or follicles, so plentifully scattered over the
oral mucous surface, have, as their office, the secretion of a limpid
fluid, which is commonly to be seen standing over the membrane as
drops of cold sweat are observed on the forehead in typhoid condi-
tions, the two, indeed, looking very similar. The constituents of
mucus are water, the peculiar organic principle called mucosiu, and
alkaline salts. Mucous glands are variously named, according to
their location, as glandulae labiales, buccales, etc.
Columnar epithelium consists of rod-like particles, bulged near
the center by a nucleus, crowded closely together ; this variety is
found in the air-passages, on the intestinal villi, in the bile duct, and
elsewhere. The scaly is found in the alimentary tract as low as the
stomach. The glandular seems a constituent of all the glands,
being made up of particles bulky and globular. Ciliated epithelium
is the columnar variety clothed with secondary particles.
THE MOUTH. 59
THE SALIVARY GLAXDS.
The salivary glands are of the conglomerate order, and are very
well represented by an ordinary bunch of grapes. There is, first, a
great number of lobules, each lobule being a miniature gland ; from
these come ducts, or channels of outlet, representing the grape-
stems ; these all are associated with a common branch or duct,
which is the channel of outlet into the mouth.
The parotid, the largest of the salivary glands, is situated in the
hollow between the external ear and ramus of the inferior maxillary
bone. Its weight varies considerably in different individuals, the
mean, however, being in the neighborhood of an ounce. The bound-
ary of the gland above is the zygoma ; below, a line carried directly
across from the angle of the jaw to the sterno-mastoid muscle. Dis-
sected from its bed, the organ is found quite deeply seated ; it ex-
tends above into the glenoid fossa of the os temporis, and below
rests upon the styloid process and muscles, extending forward to the
space between the two pterygoid muscles. The gland is exceedingly
vascular, having imbedded in it the external carotid artery, which,
in its substance, divides into the temporal, internal maxillary, trans-
verse facial, and posterior auricular. The temporo-maxillary vein
also traverses the structure, while the deep jugular and the internal
carotid artery lie very close to its deep surface; it is also pierced by
the facial and great auricular nerves. Externally, the gland is
smooth, and has its lobes protected by a covering, very similar in
appearance to the pia mater of the brain. Upon this covering lie
two lymphatic ganglia, the enlargement of which is often mistaken
for disease of the gland itself. Covering the gland is the parotid
fascia, a reflection simply of the common deep fascia of the neck,
the platysma myoides, fascia superficialis, and skin. The gland
empties its secretion into the mouth through a duct known as that
of Steno. This passes across the face between the superficial fascia
and muscles, perforating the buccinator opposite the second molar of
the upper jaw. A line, designating the position of the duct, and
which is most important to be remembered, is drawn from the lobe
of the ear to the middle of the upper lip. This duct is quite dense,
is about the diameter of a crow-quill, and is some two inches in
length ; it consists of three coats — an external or fibro-muscular, an
internal or mucous, lined with ciliated epithelial scales, and a mid-
dle or cellular coat.
The submaxillary, the second in size of the salivary glands, is
60 ORAL DISEASES AND SURGERY.
situated beneath the lower jaw in the superior cervical triangle,
resting, in part, in the submaxillary fossa. The gland is some-
what of the size and shape of an almond-hull, and has a weight of
two or three drachms ; it is completely enveloped by a triangular
envelope, made by two leaves of the deep fascia attached below to
the digastric tendon. Directly upon the gland, and within the envel-
ope, are two lymphatic ganglia, which are quite liable to take on in-
flammatory enlargement ; these glands I take to be pretty constant,
as I have examined many subjects for them, and mostly with the
common result of seeing them. The so-called extirpation of the
submaxillary gland is, most generally, the removal of one of these
bodies enlarged from inflammatory action; these ganglia may be
surgically viewed as being strictly non-vascular, a ligature being
seldom needed in operations upon them. The gland itself, on the
contrary, is very vascular, the facial artery passing frequently
directly through its substance, or so closely connected with the lower
surface as to compel the division of it, or some of its large vessels,
before the body can be raised from its bed; the lingualis also sends
branches to it, while its veins correspond with the arteries. The
gland is closely in relation with the parotid, behind, and the lingual,
in front, being separated from the first by the stylo-maxillary liga-
ment, and from the latter by the mylo-hyoid muscle. The duct
by which the gland conveys its secretion to the mouth is some two
inches in length ; it passes between the mylo-hyoid and genio-hyoid
muscles, and opens by the side of the fraenum lingua. It is the most
common seat of ranula. The duct is called Wharton's duct.
The sublingual is the smallest of the three glands ; it lies directly
beneath the mucous membrane, being between it and the m34o-hyoid
muscle ; its weight is about one drachm The exact position of the
gland, as it lies at the lateral aspect of the symphysis, can be seen
by raising the tip of the tongue ; its bulk will be noticed by elevating
the mucous membrane, upon which its excretory ducts, some twenty
in number, open ; these ducts are called ductus Riviniani, and are dis-
tinguished from one or more, called the Bartholin, opening into or
near Wharton's duct. The lingual gland, when diseased, may fre-
quentl}' be removed with very little hemorrhage. I have extirpated
it without using a ligature.
THE MOUTH.
61
TEMPORO-MAXILLAEY ARTICULATION".
The inferior maxillary bone articulates with the anterior portion
of the glenoid cavity of the temporal, forming what is known as an
arthrodial or gliding joint. The direct composition of this joint
consists of the convex condyloid head of the maxillary bone, the
concave surface of the glenoid fossa, interarticular fibro-cartilage, a
double synovial membrane, and a loose capsular ligament. (See
engraving.)
Figs. 26 and 27. — Vertical Section of Temporo-Maxillary Artic-
ulation.
Vertical section of the aeticdla-
TION OF THE LOWER JAW. 1, is placed
above the glenoid cavity ; 2, glenoid
cavity ; 3, iuterarticnlar cartilage di-
viding the joint into two cavities, 4 and
5; 6, an interarticular cartilage sepa-
rated from a joint, to exhibit its form.
External view op the temporo-maxillart
articulation. 1, zygoma ; 2, glenoid tulierelc ;
3, ramus of the inferior maxillary bone ; 4,
mastoid process ; 5, external lateral liga-
ment; 6, stylo-maxillary ligament, a process
of the cervical fascia.
The double character of the glenoid fossa, with its fissure of
division, its articulating eminence in front, and the cartilage-cov-
ered condyle of the maxillary bone, must be understood by looking
at the bones. The view represents the parts in position and physi-
ological relation. Above is seen the glenoid cavity ; below, the con-
dyle of the inferior maxilla; between, the interarticular fibro-carti-
lage, with a synovial or lubricating membrane lining each aspect of
the joint: the back part of a common capsular ligament is also seen,
which, when complete, would be exhibited as enveloping the whole
joint. Back of the section, as shown in the view, is that portion of
the cavity which lodges the upper part of the parotid gland.
The capsular ligament is an exceedingly loose sac, very much,
indeed, like the capsule of the humero-scapular articulation ; it is
62 ORAL DISEASES AND SURGERY.
attached above to the circumference of the glenoid cavity, and in
front to the articular root of the zj'goma ; below, it clasps the neck
of the bone just beneath the head.
The interarticular fibro-cartilage is an ovoid plate placed between
the two bones ; it is supported in its position by a more or less per-
fect circumferential attachment to the common capsule, the external
lateral ligament, and to the tendon of the external pterygoid muscle :
below, its face is concave, corresponding with the convexity of the
condyle ; above, it is concave in front, convex behind, corresponding
with the glenoid cavity proper, and the eminentia articularis. In
composition the circumference is markedly fibrous, shading off to a
cartilaginous center, frequently quite soft, and sometimes perforated.
The synovial membranes, placed, as seen in the view, one above,
the other below the interarticular fibro-cartilage, are the ordinary
lubricating membranes of closed cavities ; they may very well be
likened to two simple bags, with parietal attached faces. These
bags secrete the synovia, a fluid which looks not unlike the white
of an e^^, but which is much more oily and resistive in its nature.
From the spinous process, seen on the great wing of the sphenoid
bone, a ligament, the internal lateral, descends to be attached to the
inner face of the ramus. Behind, from the styloid process of the
OS temporis, a second, the stylo-maxillary, passes to be inserted just
above the angle.
The external lateral ligament is a short, somewhat triangular-
shaped band of fibrous tissue, having origin from the zygoma; pass-
ing obliquely downward and backward, and inserted about the neck
of the condyle, just below the head, it lies in contact with the lateral
aspect of the interarticular fibro-cartilage, and really assists in form-
ing, or at least thickening, the common capsule. Externally, it is
quite superficial, being only covered by the integuments, except in
instances where the upper border of the parotid gland spreads over
it. The importance of the character of this articulation renders
necessary its careful study by personal dissection.
CHAPTER III.
FIFTH PAIR OP NERVES.
The fifth is an encephalic nerve — that is, coming off from that por-
tion of the cerebro-spinal center lying within the cranium. Called the
fifth, because this is the order of its emergence; called also trifa-
cial, because, while within the cranium, it divides into three portions,
which portions, in their divisions and subdivisions, are distributed
respectively to the superior, middle, and inferior portions of the
facial region ; called also " trigeminus," a name derived from tri,
three, and geminus, twin, or double, signifying literally three double,
triple, referring to its threefold divisions.
The fifth, trifacial or trigeminus, is first discovered as a number of
filaments, of which there are two distinct sets, coming off from the
sides of the pons Varolii ; this is called its superficial origin. The
deep, or true origin, can be traced into the substance of the pons as
far as the lateral tract of the medulla oblongata. These filaments of
origin are called the roots of the nerve, and, being twofold, afford the
likeness which exists between this particular encephalic nerve and
those of the spinal cord.
The fifth nerve is peculiar in being both compound and special :
that is to say, it supplies parts with filaments of sensation, fila-
ments of motion ; and through one of its branches, called the "gusta-
tory," with filaments which pertain to the sense of taste. It is the
great sensitive nerve of the head and face ; the nerve of motion to
the muscles of mastication ; the nerve of the sense of taste to the
anterior part of the tongue. (See Function of Nerve.)
Immediately on the emergence of the roots from the points of their
superficial origin, they pass through a slit-like opening in the dura
mater at the apex of the petrous portion of the temporal bone. Here
the larger root, called the sensor, enters a ganglion, lying in a
fossa on the anterior face of this triangular apex, the Gasserian or
semilunar.
The ganglion of Gasser is a small, reddish-gray semilunar knot
enveloping apparently the great or posterior root of the fifth nerve
(63)
64
ORAL DISEASES AND SURGERY
as it passes over the temporal apex ; its size is equal perhaps to
that of an ordinary buckshot, although from its flattened and cres-
centic form, the measurement from tip to tip of its horns would sur-
pass somewhat the diameter of such a shot. The convex face of
the ganglion looks forward.
Fig
Trifacial Division and Ganglia.
Trifacial ner^i, tin un ' 1 " ' ' '""^ ' rtmoved. 1, semilunar
ganglion; 2, oplitliilniit ntnt , 3, l.itliijm<tl ni.i\t., 4, liont.il nei\e , 5, 6, its two princi-
pal branches ; 7, a branch passing from the orbital above tne pmiey of tne superior oblique
muscle ; 8, nasal ner\'e ; 9, its external nasal branch ; 10, course of the internal nasal nerve
from the orbit into the cranium, and nose ; 11, 12, 13, temporal branches of the inferior max-
illary nerve ; 14, commencement of the auriculo-tomporal nerve ; 15, greater petrosal uervo.
I. olfiictory nerve ; II, optic nerves ; III, oculo-niotor nerve ; IV, pathetic nerve to the
superior oblique muscle of the eye ; V, trifacial nerve ; Its small root visible beneath the
cut end of the large root, wliich forms the semilunar ganglion dividing into the ophthal-
mic, superior and inferior maxillary nerves ; VI, abducent nerve ; Vll, facial, included in
a groove of the auditory nerve, VIII, both entering the auditory meatus ; IX, glosso-
pharyngeal, X,pneumogastric, and XI, accessory nerves emerging at the jugular foramen;
XII. hypoglossal nerve.
On emerging from this ganglion, the posterior root is found di-
vided into three cords — the three primarj' divisions of the sensitive
portion. The first of these cords constitutes what is called the
ophthalmic nerve, or the ophthalmic portion or division of the fifth
nerve. The second cord, the superior maxillary nerve, or superior
THE FIFTH PAIR OF NERVES. 65
roaxillaiy division of the fifth. The third, the inferior maxinary
nerve.
The first of these nerves has its distribution over the orbito-frontal
region.
The second has its distribution over the superior maxillary
region.
The third associates with the lesser or motor root, which root
first connects with it at the base of the skull, and has its distribution
over the inferior maxillary region.
Ophthalmic Nerve.
This division of the fifth passes from the Gasserian ganglion along
the outer wall of the cavernous sinus, and enters the orbit through
the sphenoidal fissure ; before entering which, however, it breaks
up into three branches. These branches supply the eyeball, the
lachrymal gland, the mucous lining of the nose, and the muscles
and the integument of the forehead. They are called frontal, lachry-
mal, nasal. The ophthalmic is the smallest of the three divisions
of the fifth. It is a flattened band not more than an inch in length,
receiving, before breaking up into its terminal branches, filaments
from the carotid plexus of the sympathetic, and giving off two or
more filaments, which, with a branch from the fourth nerve, pass
between the layers of the tentorium.
The Frontal Bi^anchia the largest of the divisions of the ophthalmic,
and is commonly regarded as the continuation of the nerve. In the
orbit it lies above the levator palpebrse muscle, between it and the
periosteum, dividing about midway of the cavity into two branches —
supratrochlear and supraorbital.
The supratrochlear branch passes inward to the pulley of the
superior oblique muscle, giving off here descending filaments which
anastomose with similar trochlear filaments from the nasal nerve.
A second or terminal branch passes from the orbit between the
superior oblique and supraorbital foramen, ascends behind the cor-
rugator supercilii and occipito-frontalis muscles, to both of which it
distributes filaments, and is finally lost in the integument of the
forehead.
The su]3raorbital branch or division of the frontal passes forward
until it reaches the supraorbital foramen, when it passes out unto
the forehead. In this situation it gives off a number of filaments to
the upper eyelid, called palpebral. In its distribution over the fore-
5
66 ORAL DISEASES AND SURGERY.
head, it sends branches to the orbicularis palpebrarum, occipito-
frontalis, and corrugator supercilii muscles, anastomosing in the
first named muscles with filaments of the facial nerve. Other two
sets of terminal filaments supply, the first, the periosteum covering
the frontal and parietal bones ; the second, the integument, as far
back as the occiput.
The Lachrymal. — This is the smallest of the three divisions of
the ophthalmic. It is almost always accompanied by filaments from
the fourth nerve. In the orbit it connects itself with the orbital
branch of the second or superior maxillary division of the fifth
nerve. Its distribution is to the lachrymal gland, the conjunctiva,
and the integument of the upper eyelid, in which last situation it
joins with filaments of the facial nerve.
The Nasal. — This division is intermediate in size between the
frontal and lachrymal. Entering the cavity of the orbit between
the two heads of the external rectus, it passes directly across the
optic nerve to the anterior of the ethmoidal foramina; through this
foramen it passes into the cavity of the cranium, where it traverses
the shallow groove on the front of the cribriform plate of the eth-
moidal bone, until arriving at the nasal slit it passes directly down-
ward into the nose, terminating in two branches. Of these two
branches, the external descends on the inner surface of the nasal
bone, supplying the mucous membrane of its neighborhood ; leaving
the cavity at the juncture of the bone wnth the lateral cartilage, it
passes on the external part of the nose down to supply the integu-
ment of the lips, and join with the facial nerve. The second branch,
the internal, supplies the mucous membrane about the front of the
septum.
In the orbital cavity are given oif three branches from the nasal —
the ganglionic, ciliary, and infratrochlear.
The ganglionic is a slender cord, about half an inch in length,
which is the sensor filament to the orbital or ophthalmic ganglion.
(See Ganglia.) i
The ciliary, called long ciliary, to distinguish them from certain
shorter branches, called also ciliary, given off from the ophthalmic
ganglion, are two or three in number, and, in association with the
short ciliary, pierces the posterior face of the sclerotic, and, passing
between this coat and the choroid, are distributed to the ciliary
muscle and iris.
The infratrochlear branch is given off just as the main portion
passes into the ethmoid foramen, joining beneath the pulley of the
THE FIFTH PAIR OF NERVES.
67
superior oblique muscle, with a filament of the supratrochlear nerve ;
this branch continues to the inner angle of the eye, where it is dis-
tributed to the orbicular muscle, the integument of the eyelid, and
side of the nose, to the conjunctiva, caruncula lachrymal is and
lachrymal sac.
Recapitulation. — The ophthalmic or first division of the fifth
nerve supplies the tentorium, lachrymal gland, caruncula lachry-
malis, lachrymal sac, ciliary muscle and iris, muscles of eyelid and
forehead, integument of forehead and nose, mucous membrane of
eye and nose, and pericranium of frontal and parietal regions.
Fig. 29. — Superior Maxillary Nerve.
The external wall of the left orbit and op the superior maxillary bone removed.
I, superior maxillary nerve iu its course througli the infraorbital canal ; 2, 3, posterior
dental nerves ; 4, anterior dental nerve ; 5, anastomosis between the dental nerves ; 6,
spheno-palatine ganglion; the branch from the superior maxillary nerve above is the
commencement of the temporo-malar nerve ; 7, pterygoid nerve ; 8, greater petrosal
nerve joining the facial nerve ; 9, deep petrous nerve joining the carotid plexus of the
sympathetic ; 10, abducent nerve with its communicating branches of the latter jjlexus ;
II, superior cervical ganglion ; 12, ascending branches to the carotid plexus ; 13, facial
nerve ; 14, glosso-pharyngeal nerve ; 15, the tympanic nerve ; 16, branch to the carotid
plexus ; 17, 18, 19, branches to the round and oval windows and Eustachian tube ; 20,
branch to the smaller petrosal nerve, 21.
This nerve or division arises, as a flattened band, from the middle
of the Gasserian ganglion. It passes forward over the greater wing
of the sphenoid bone, until, reaching the foramen rotundum, it leaves
the cranium, and presents itself in the spheno-m axillary fossa; from
this fossa it passes to the orbital cavity, through the spheno-maxil-
lary fissure, where, being lodged in the infraorbital canal, it con-
tinues forward to the points of its ultimate distribution.
68 ORAL DISEASES AND SURGERY.
Branches of Distribution— 1. In the spheno-maxillary fossa—
three in number— orbital, ganglionic, posterior dental.
The orbital enters, with the main branch of the nerve, the orbital
cavity, and divides into two branches, temporal and malar. The
temporal branch passes from the orbit through a foramen in the
malar bone, and enters the temporal fossa ; it here perforates the
temporal muscle and fascia, and is distributed to the integument
covering the side of the head, and associates with the facial nerve,
and an ascending branch, auriculo-temporal, of the inferior max-
illary. The malar branch leaves the orbit also through a foramen
in the malar bone, perforates the orbicularis palpebrarum muscle,
and joins with a branch of the facial.
Ganglionic, two in number. — They drop directly down into the
spheno-palatine, or Meckel's ganglion; hence are commonly known
as the spheno-palatine branches.
Posterior Dental. — This branch arises from the trunk just as it
enters the orbit ; it instantly breaks up into an anterior and posterior
portion. The first supplies the gums and buccinator muscle; the
second pierces the tuberosity of the maxillary bone, and, after form-
ing a minute plexus above the alveolus, distributes filaments to each
of the posterior teeth ; its termination is lost in a union with the
anterior dental nerve.
2. In the Infraorbital Canal. — One. The anterior dental. This
branch is given off about midway of the canal. It enters a second
canal existing on the anterior face of the maxillary sinus, and curv-
ing backward, associates itself, as above alluded to, with the pos-
terior dental ; from the curve are given off filaments to the anterior
teeth — incisors, canines, and bicuspidati.
3. On the Face. — Three. Palpebral, nasal, labial. These are the
terminal filaments, the division occurring as the nerve issues from
the infraorbital foramen. The palpebral filaments pass up to the
supply of the orbicularis palpebrarum muscle and the integument
and conjunctiva of the lower eyelid ; at the outer angle of the orbit
they associate with the malar branch of the orbital and filaments of
the facial nerve. The nasal filaments pass across the nose, supply-
ing the muscles and integument of this region; they usually join at
the tip with the nasal branch of the ophthalmic. The labial fila-
ments pass downward beneath the levator labii superioris, and are
distributed to the muscles and integument of the upper lip, to the
mucous membrane of the mouth, and to the labial glands. The
intricate plexus situated in the canine fossa is formed of filaments
THE FIFTH PAIR OF NERVES.
69
from the facial nerve associating with twigs of the trimaxiUary
division.
Recapitulation. — The superior maxillary nerve, or second division
of the fifth, supplies the integument on the side of the head, Meckel's
ganglion with its sensor filaments, the teeth, the antrum, orbicularis
palpebrarum muscle, integument and conjunctiva of lower eyelid,
muscle and integument of nose, muscles, integument, and mucous
membrane of superior lip and labial glands.
Fig. 30.— Inferior Ma.xiillary Nkrve.
Distribution of the inferior maxillary nerve. 1, muscular branch to the masseter
muscle ; 2, 5, 7, branches to the temporal muscle ; 3, branch to the buccinator, anasto-
mosing with one from the facial at 4 ; 6, external pterygoid muscle ; 8, auriculo-temporal
nerve ; 9, branches to the temple ; 10, branches to the ear ; 11, its anastomosis with the
facial ; 12. lingual nerve ; 1-3, branch to the mylo-hyoid muscle from the inferior dental
nerve, 14 ; 15, branches to the teeth ; 16, terminal branches to the lower lip and chin.
This nerve or division is the largest of the three, and constitutes,
justly speaking, the only portion of the fifth nerve compound in
character. The sensor portion is the third of the cords emerging
70 ORAL DISEASES AND SURGERY.
from the Gassorian gan^^liou; the motor portion is that lesser root
alluded to as coming off from the pons Varolii ; the sensor cord falls
quickly into the oval foramen of the sphenoid bone, through which
it passes from the cranium. The motor cord, which has passed
forward beneath the Gasserian ganglion, unites with the sensor just
as it emerges from this foramen. Here then is made, b}^ this union,
a single cord, the perfected or compound inferior maxillary nerve — a
nerve made up of filaments of motion and filaments of sensation.
At the point of juncture of these two cords is found a little ganglion,
the otic. (See Ganglia.)
Immediately beneath the base of the skull, this compound inferior
maxillary nerve divides into two branches — anterior and posterior.
Into the anterior branch passes most of the motor filaments.
The anterior branch breaks up into five divisions, and is dis-
tributed to the muscles of mastication. These divisions or branches
receive names from the parts supplied by them; they are the mas-
seteric, buccal, deep temporal, and pterygoid.
The posterior branch is the larger of the two divisions ; it sub-
divides into three parts. These supply the inferior teeth, tongue,
and auriculo-tcmporal region. Hence the branches are named in-
ferior dental, lingual, and auriculo-tcmporal.
Divisions of Anterior Branch. — 3Iasseteric. — This branch
runs across the sigmoid notch of the inferior maxillary bone, enters
the substance of the masseter muscle, and is distributed in it. In
crossing the notch it occasionally gives off a filament to the artic-
ulation.
Deep Temporal Branches. — They are two in number. They pass
under the temporal muscle, and supply its deep surface.
Buccal. — This branch pierces the external pterygoid muscles,
passes down beneath the coronoid process of the jaw, pierces the
fibers of the temporal muscle, and, reaching the buccinator, divides
upon it into a superior and inferior branch. The superior supplies
the upper part of the muscle and the integument ; the inferior sup-
plies the lower part of the muscle and its lining mucous membrane.
Pterygoid Branches. — Two in number. One supplying each
pterygoid muscle.
Divisions op Posterior Branch. — Auriculo- Temporal. — This
branch passes out to the inner side of the temporo-maxillary articu-
lation, turns upward in company with the temporal artery ; and on
emerging with this vessel from beneath the parotid gland, divides
into two branches. The posterior of the two supplies the attrahens
THE FIFTH PAIR OF NERVES. 71
auren, the pinna, and the neighboring integument. The anterior
passes upward with the terminal branches of the artery, and is dis-
tributed to the temporal integument. Branches of communication
exist between the auriculo-temporal nerve, the facial, and the otic
ganglion. The articulation, the parotid gland, and the external
auditory meatus receive nerve endowment from the auriculo-tem-
poral.
Lingual or Gustatory. — This branch is a nerve of special sense,
presiding in part over the action of taste ; its terminal filaments, as
might be inferred, are distributed extensively to the papillae and
mucous membrane of the tongue. Of the three sets of papillas, the
filiform and fungiform, or those situated on the anterior, two-thirds
of the organ receive the principal supply, the posterior or great
papillae being supplied from the glosso-pharyngeal. On this account
it was deduced that the gustatory presided over taste only as the
anterior two-thirds of the tongue was concerned; and which in-
ference has been abundantly borne out by vivisection. (See Todd
and Bowman, pa^es 385, 86, 87, 88, 89, and 90.) In the dissection,
the gustatory branch is seen coming off just opposite the sigmoid
notch. In company with the inferior dental nerve, or branch, it
passes down along the inner side of the ramus, until, leaving the
dental somewhat above the posterior dental canal, it crosses obliquely
to the side of the tongue, along which it pursues its way to its points
of final termination, anastomosing at the tip of the organ with fila-
ments of the hypoglossal. In its course it lies first beneath the
external pterygoid muscle, crosses the internal pterygoid, rests upon
the superior constrictor of the pharynx, runs over Wharton's duct,
where it reaches the apex of the tongue. In its course, branches of
communication are given off to the submaxillary ganglion and the
hypoglossal nerve.
Inferior Dental Nerve or Branch. — This is the largest of the
three divisions of the inferior maxillary nerve. Between its point
of origin and entrance into the dental canal, it gives off a branch,
the mylo-hyoid, distributed to the mjdo-hyoid and anterior belly of
the digastric muscles. The main portion, after entering the poste-
rior foramen of the dental canal, pursues its way beneath the teeth,
giving, in its course, filaments to all these organs, terminating finally
in a branch, the mental, which passes from the canal at the mental
foramen, and has its distribution in the muscular and cutaneous sub-
stance of the inferior lip.
Recapitulation. — The inferior maxillary nerve, or third division of
72
ORAL DISEASES AND SURGERY.
the fifth, supplies the muscles of mastication, the auriculo-temporal
region, the anterior two-thirds of the tongue, the mylo-hyoid and di-
gastric muscles, the inferior teeth, and the muscles and skin of the
lower lip.
Ganglia of the Fifth Pair of Nerves.
Associated with the fifth nerve are six ganglia : they are called
Gasserian; ophthalmic, lenticular or ciliary; Meckel's or spheno-
palatine ; naso-palatine or ganglion of Cloquet ; otic ; submaxillary.
Ganglion of Gasser. — This ganglion, called as frequently the
semilunar, from its shape, is found lying in a slight depression on
the anterior face, near the apex of the petrous portion of the tem-
poral bone. It receives the posterior or sensor cord of the fifth
nerve, and transmits it divided into three parts. The ganglion re-
ceives filaments from the carotid plexus of the sympathetic, and
gives ofi" filaments to the tentorium cerebelli, and to the dura mater
of the middle fossa of the cranium.
Fig. 31. — Ophthalmic Gaxgliox — the Outer Part of the Eight Orbit
Eemoved.
1, optic nerve; 2, ocnio-motor nerve; 3, branch to the superior straight and oWiqne
muscles; 4, branch to the inferior oblique muscle; 5, abducent nerve to the external
straight muscle; 6, trifacial nerve, its ganglion and three principal branches ; 7, ophthal-
mic nerve; 8, nasal nerve ; 9, ophthalmic ganglion; 10, its communicating branch with
the oculo-motor nei-ve ; 11, do. with the ophthalmic nerve ; 12, do. with the carotid plexus
of the sympathetic ; 13, the ciliarj' nerves ; 14, frontal nerve.
Ophthalmic, Lenticular or Ciliary Ganglion. — This ganglion, as
implied in its name, is found in the cavity of the orbit. It is a small,
quadrangular, flattened body, not larger, generally, than the ordinary
pin head; it is situated between the external rectus muscle and optic
nerve, well enveloped in the mass of fat found occupying this portion
THE FIFTH PAIR OF NERVES.
73
of the cavity. Its branches of communication are derived, the first,
or sensor, from the nasal ; the second, or motor, from the third nerve ;
the third, or sympathetic, from the cavernous plexus. Its branches
of distribution are the short ciliary nerves. These nerves, ten or
twelve in number, arise from the anterior face of the ganglion, being
connected, as two sets of filaments, with the superior and inferior
angles. The two sets pass forward, one being above, the other below
the optic nerve, until, reaching the sclerotic coat of the eye, they
penetrate this organ, and are distributed to the ciliary muscle and iris
Fig. 32. — Vie"w of tue Spheno-Palatine Ganglion, the Outer Wall
or THE Left Nasal Cavity, and the Olfactory Nerve.
\\
1, olfactory nerve; 2, nasal branch of the ophthalmic nerve; 3, spheno-palatine gan-
glion ; 4, 5, 6, palatine nerves ; 7, branch to the nose ; 8, nasal nei've to the outer wall of
the nose ; 9, do. to the inner wall ; 10, pterygoid nerve ; 11, facial nerve ; 12, deep petrous
nerve joining the carotid plexus; 13, the other branch of the pterygoid is the larger pe-
trosal nerve, which joins the facial.
MeckeVs Ganglion — Spheno-Palatine. — This is the largest and
most extensively connected of the cranial ganglia. Its position is
in the spheno-maxillary fossa, immediately in front of the vidian
foramen. In shape it is triangular, and in color reddish-gray. Its
branches of communication are derived, the first, or sensor, from the
superior maxillary nerve, which, as has been seen, gives to it two
filaments while crossing the fossa. The second, or motor, from the
facial nerve, or rather from the intumescentia gangliformis of that
nerve. This branch is known as the great petrosal nerve ; it emerges
from the Fallopian canal through the hiatus Fallopii, passes along the
74 ORAL DISEASES AND SURGERY.
groove loading from this foramen, until, reaching the foramen lace-
rum basis cranii, it pierces the cartilaginous substance, filling up this
osseous break, and entering the vidian canal, associated with the
carotid nerve, passes forward under the name of vidian to the gan-
glion. The third, or sympathetic, is derived from the carotid plexus
through the vidian.
The branches of distribution from this ganglion are numerous,
and supply a portion of the orbital periosteum, the nares, the hard
and soft palates, the half arches, the tonsil, the pharynx, etc.
The ascending branches, two or three in number, enter the orbit
through the spheno-maxillary fissure, and supply the periosteum.
The descending, called palatine branches, are three in number;
the anterior of these, or large palatine nerve, descends through the
posterior palatine canal, passes along the groove on the hard palate,
and is distributed to the gums, the mucous membrane, and palatine
glands, anastomosing back of the incisor teeth with the naso-pala-
tine nerve ; while in the palatine canal, filaments are given off which
pass to the middle and inferior turbinated bones.
The middle branch, called external palatine nerve, descends through
the same canal as the preceding ; it distributes its filaments to the
soft palate, to the uvula, and the tonsil.
The posterior, called small palatine nerve, descends through the
accessory palatine canal, and emerges back of the posterior palatine
foramen. It is distributed to the levator palati muscles, the soft
palate, tonsil, and uvula.
There are two sets of branches coming off from the internal sur-
face ; these are called superior nasal and naso-palatine.
The superior nasal, four or five in number, enter the nasal fossa by
the spheno-palatine foramen ; they supply the mucous membrane of
the superior portion of the fossa.
The naso-palatine enters the fossa with the other nasal nerves,
passes across the roof of the nose, until, reaching the septum, it de-
scends between the periosteum and mucous membrane to the ante-
rior palatine foramen ; passing through this canal, it unites with its
fellow of the opposite side, and distributes its filaments to the mu-
cous membrane about the incisive fossa.
Naso-Palaline Ganglion or Ganglion of Cloquet. — This is simply
the small swelling situated in the incisive fossa, the result appar-
ently of the union of the naso-palatine nerves. The very name of
ganglion is denied it by most writers.
Otic Ganglion.— This is an oval flattened body, of small size,
THE FIFTH PAIR OF NERVES. 75
lying on the sensor portion of the inferior maxillary nerve, imme-
diately beneath the oval foramen. Its branches of communication
are, by sensor filaments with the auriculo-temporal nerve, by motor
Avith the inferior maxillary nerve, and with the sympathetic by the
plexus surrounding the middle meningeal artery. Branches of com-
munication also exist with the glosso-pharyngeal, and through the
medium of the lesser petrosal with the facial nerve.
The branches of distribution are two in number : one to the ten-
sor tympani, and one to the tensor palati muscles.
Submaxillary Ganglion. — This is a small sized circular ganglion,
situated upon the submaxillary gland. It is connected, through
communicating branches, with the gustatory nerve, sensor ; with the
facial, through the medium of the chorda tympani, motor ; and with
the sympathetic by filaments from the plexus of the nervi molles.
The branches of distribution are five or six in number ; they arise
from the lower part of the ganglion, and supply the duct of the gland
and mucous membrane of the floor of the mouth.
FUNCTION OF THE FIFTH NEKVE.*
" The determination of the functions of the roots of spinal nerves
has afforded the clew to that of the functions of the roots of the fifth
nerve. The analogy of the smaller root of the fifth with the ante-
rior spinal root, and of the larger one with the posterior spinal root
has long been admitted by anatomists. Hence an analogy of func-
tion must be admitted, and the former must be viewed as consisting
of motor fibers, the latter of sensitive ones ; and by tracing each of
the three great divisions of the nerve, we may determine its func-
tion by its constitution, according as it derives its fibers from either
root or from both. The ophthalmic and superior maxillary are com-
posed of fibers derived exclusively from the larger root ; they are,
therefore, sensitive nerves. The inferior maxillary consists of fibers
derived from both roots, and consequently is both motor and sensi-
tive. Sir C. Bell, in his original exposition of the functions of this
nerve, fell into error from having neglected to avail himself of this
method of analyzing the constitution of each of its three divisions,
from which he would have seen that it is the inferior maxillary alone
which derives its fibers from both roots, and which perfectly resem-
bles a spinal nerve in constitution.
* See Todd and Bowman.
76 ORAL DISEASES AND SURGERY.
■ " The distribution of the three divisions of the fifth nerve confirms
most amply the view of its physiology suggested by the anatomy of
its origin. The ophthalmic and superior maxillary are distributed
entirely to sentient surfaces, or anastomose with motor nerves (the
facial). They supply the skin of the forehead, of the eyelids, the
conjunctiva, the eyeball, the mucous membrane of the nostrils, the
integuments of the face, the upper lip, the nose, the beard on the
upper lip, the integument of the ear, the temple, and the whiskers ;
they are the sensitive nerves to these regions. The inferior maxil-
lary has two distinct sets of branches — the one by which the muscles
of mastication are supplied ; the other, which go to the integuments
of the lower lip and chin, and the beard, and the mucous membrane
of the mouth and tongue. This nerve is, therefore, the nerve of mas-
tication, and of sensation to the surfaces above named.
" Repeated experiments in the hands of various physiologists,
none of which, however, were more conclusive than those of Mayo,
indicate the same views of function. Division of the ophthalmic or
of the superior maxillary induced loss of sensibility without muscu-
lar paralysis, leaving only such an impairment of the motor power
as destruction of the sensitive nerves invariably produces, by im-
pairing the power of exact adjustment, for which a high degree of
sensibility is necessary. But when the inferior maxillary nerve was
cut, then both the power of mastication Avas destroyed on the same
side, and the sensibility of the lower part of the face and tongue was
lost. If the nerve were divided in the cranium, the whole side of
the face and forehead, with the eyeball and nose, became insensible,
and the muscles of mastication were paralyzed. Irritants might
then be applied to the eyeball, without exciting winking, or causing
pain, and strong stimulants might be introduced into the nostrils
without creating the least irritation. When the trunk of the nerve
within the cranium of an ass was irritated, the jaws closed with a
snap from the excitation of the motor fibers, which are distributed to
the muscles of mastication.
" The conclusions which we draw from anatomy and from experi-
ment are confirmed by the histories of cases in which the fifth nerve
had been diseased. In such instances we may observe the most
marked separation of the motor and sensitive power, when the
larger portion only or the two superior divisions of the nerve are
affected, and we find both motion and sensation destroyed when the
whole trunk of the nerve is involved in the disease. It is not
uncommon in such cases to find the eyeball totally insensible to
THE FIFTH PAIR OF NERVES. 77
every kind of stimulus, the nose quite unexcitable by the fumes of
ammonia, or the most pungent vapors, and the mucous membrane of
the mouth so insensible to the contact of foreign matters that a mor-
sel of food will sometimes remain between the gum and the cheek
until it has become decomposed. The insensibility of the eyeball
exposes it to the permanent contact of irritating particles of dust,
etc., which excite destructive inflammation of its textures. The
whiskers may be pulled forcibly without sensation. The muscles
of mastication become wasted and inert, as shown by the distinct
depression in the regions of the masseter and temporal muscles, but
the superficial muscles, on which the play of the features depends,
preserve their natural condition.
" The fifth nerve may, therefore, be regarded as the motor nerve
in mastication, and the sensitive nerve to that great surface, both
internal and external, which belongs to the face and anterior part of
the cranium. From its great size, and the large portion of the me-
dulla oblongata with which it is connected, it may excite other
nerves which are implanted in that center near to it. Thus it may
be an exciter to the portio dura, as in winking ; or to the respiratory
nerves, as in dashing cold water in the face, or in sneezing. Its lin-
gual portion distributed to the mucous membrane of the tongue is
at once a nerve of taste, touch, and common sensibility, and its con-
nection with the papillary structure of the red parts of the lips con-
stitutes it a pre-eminently sensitive nerve of touch in those regions.
" The study of the pathological conditions of this nerve illustrates
its physiology in a highly interesting manner. In the dentition of
children, whether primary or secondary, it is always affected, more
or less : and in excitable states of the nervous centers, the irritation
of it consequent upon the pressure of the teeth often gives rise to
convulsions, the brain and spinal cord being irritated ; and we can
often trace to such irritation, whether in infancy or in childhood, the
foundation of epileptic seizures in subsequent years. Painful affec-
tions of the face {neuralgia) have their seat in this nerve; tic dou-
loureux, for example. Many of the instances of painful affection of
this nerve or of branches of it, which come under our observation,
are well-marked examples of reflected sensation, the primary irrita-
tion being conveyed to the center by the vagus or the sympathetic
from the stomach or intestinal canal. No one of these is so common
as the pain over the brow, which so often follows derangement of
stomach digestion ; and which may frequently be instantaneously re-
moved by taking away the source of irritation, as by neutralizing free
78
OEAL DISEASES AND SURGERY.
acid in the stomach. Frequently also the branches of this nerve, in
greater or less number, on one or both sides, may, according to the
humoral view, form a focus of attraction for a morbific matter gen-
erated in the blood, in persons exposed to the paludal poison, or in
persons of rheumatic or gouty constitution ; in these cases, as in
most others of similar pathology, the neuralgia occurs in paroxysms
of greater or less severity, each paroxysm being followed by a pe-
riod of convalescence, which lasts, it may be supposed, until the
morbid matter has been again accumulated in quantity sufficient to
induce a hiffh de2:ree of irritation of the nerves."
CHAPTER IT.
DENTITION.
The direct and associative lesions of the teeth being so common
and so many, the study of the diseases of the mouth will naturally
commence Avith these organs.
In the foetus of six weeks is to be observed, at the border of the
palate, a groove occupying the position of the future teeth. This
groove is called the primitive dental ; scattered along the bottom of
it are certain fine papillae, which, in their development, are found
gradually to assume the shape of the crowns of teeth. As these
papillfe grow, the groove is converted into a series of distinct folli-
cles for their accommodation by the growth of septi between each
papilla, which septi soon begin to ossify, to assist in forming the
bony sac or alveolus common to the perfected teeth. It is seen,
however, that the septi complete only a circumferential boundary,
the summit of the papilla being exposed. Before, however, the
papilla has assumed the form of the tooth, the upper soft margin of
the pit enlarges and falls over, forming an operculum or lid.
The tooth thus forming is generally regarded as a cutaneous
production, and would seem to be a modification of the hair or nail.
If such inference is an error, and this body is not entirely a cutaneous
production, it is plainly enough seen that the papillae, being sub-
mucous, enveloped, or overlain by the mucous membrane lining
the primitive groove, must, in its development, either rupture this
envelope, or assume and modify it. Now, what is the state of the
case ? According to the observations of Goodsir, and the opinion
of Todd and Bowman, "the tooth papillae must be regarded as
homologous with, or answering to the tactile and hair papillae of the
skin, and it would therefore be expected that its main part would
consist of a peculiar submucous tissue, covered by a homogeneous
basement membrane, and surmounted by a tissue answering to the
epithelium. The substance of the papillae is, at first, a congeries of
granular nuclei, dispersed irregularly through a firm, homogeneous,
subgranular matrix or blastema, in which vessels and nerves are
(79)
80 ORAL DISEASES AND SURGERY.
by degrees developed. This is bounded by a definite transparent
membrane, on which rests a reflection of the epithelium lining the
sac, modified in structure so as to present a series of columnar,
nucleated particles, the matrix of the future enamel." It would ap-
pear, according to these observers, that the lining and reflected
layers of the epithelium become blended together, and constitute but
one, Avhich is more adherent to the sac than to the papilla ; so that on
opening the sac its walls generally seem unattached to the surface
of the papilla, and the latter to be limited to what has been regarded
as the basement membrane.
The growth of the papilla, thus circumstanced, is considered by
these authors as follows : " Between the columnar epithelium lining
the sac and the surface of the alveolar cavity, that is, apparently in
the wall of the sac itself, is found a thick, semi-transparent, pulpy
tissue, which has been termed the enamel pulp. It presents toward
the pulp of the tooth — that is, toward the original papilla — a series
of elevations and depressions precisely the reverse of those of the
dentinal pulp on w^hich they rest, and answering mutually to these,
with only the columnar epithelium intervening. The structure of
this pulpy tissue is elastic, spongy, loaded with fluid albumen, but
destitute of vessels.
" In a vertical section of these parts, the enamel pulp is seen
covered with columnar epithelium, the enamel matrix on the surface
toward the dentinal or tooth pulp; while on the opposite surface
the blood-vessels of the membrane lining the alveolus are seen
coming up to and forming loops immediately under the enamel
pulp, without penetrating it. It is further remarkable that short
tubes, filled with glandular epithelium, descend among these vessels
from the enamel pulp, and end by blind extremities. How these
tubes, which are evidently glandular, can discbarge their contents,
it is difiScult to understand, seeing they appear to open into the sub- i
stance of the enamel pulp. J
" The next stage* is that of ossification ; and the earthy matter is
first deposited in the homogeneous membrane forming the dentina
pulp. The most prominent portions of the crown are the first t(
harden ; and the ossification proceeds inward by the gradual conver
sion of the pulp into the dentine or ivory. The nucleated particles o
the pulp nearest the ossifying surface are found arranging themselves
in series vertical to that surface ; and it appears that, in order t(
* Goodsir, Todd and Bowman, observations continued.
DENTITION. 81
form these vertical series, they multiply by transverse division,
much as those of bone cartilage are found to do. The earthy matters
are then deposited in the indistinct cells surrounding the nuclei, so
as to form the hard and dense walls of the dentinal tubes, as well
as the intercellular substance, so as to form the intertubular tissue of
the perfect tooth. The cells unite endwise, and their nuclei elongate
and coalesce in a manner to constitute the cavities of the tubes, and
so as often to retain this mode of origin in their permanent form.
" The calcification of the enamel commences on the surface of the
dentine in contact with that primary osseous sheet formed from the
basement membrane of the dentinal pulp. On this primary layer
are minute shallow cups, closely aggregated, answering to the ends
of the enamel columns and receiving them in a firmly cemented
union, as the consolidation of the elementary cells proceeds. The
enamel columns at a very early stage seem to consist only of a single
series of nucleated particles, intervening between the dentine and
enamel pulp. Those of the new row arrange themselves endwise
on the others, which they resemble in all respects, so that the enamel
attains its proper thickness rather by the superposition of particle or
particles successively deposited, and by the subsequent calcification
of each in its turn, than by the development of its parts by an in-
terstitial increase ; and thus it appears to differ from the dentinal
pulp and to resemble the epithelium, to which it is allied.
" It is from that surface of the enamel pulp which looks toward
the tooth that this successive development of new enamel columns
proceeds ; as they form, this tissue wastes ; but it is not probable
that the pulp is converted into the columns, as the dentinal pulp is
converted into dentine, because the anatomical characters of the
pulp are so dissimilar from those of the columns. When first calci-
fied, the enamel rods are loosely aggregated, and easily separate
from one another under pressure ; but they gradually become so
consolidated by the advance of the calcifying process in their inter-
stices, as to make the finished enamel the most hard and inde-
structible of all the products of organization.
"The development of the layer containing the ordinary lucunae
of bone, and which in the human teeth covers the fang, and is con-
tinued a little way within the cavity of the root, does not seem to
have been as accurately studied as that of the dentine and enamel.
There can be little doubt that a membranous matrix, probably like
that of the cranial bones, is laid down as the fang is developed,
in which the usual steps of ossification precede the lacuuse and
6
82 ORAL DISEASES AND SURGERY.
their canaliculi, being formed from the corpuscles of the temporary
matrix.
" When the ossification of the dentine is so far advanced that the
tooth can sustain with impunity the pressure to which it is destined,
and when the enamel is densely calcified, the eruptive stage occurs,
in which the tooth makes its way through the gum. This is due
to the same law of development which governs the form and position
of other organs. The gum over the sac is absorbed, and the crown
of the tooth is forced upward against it, chiefly by the increasing
size of the fang below.
" As the development of the teeth proceeds, so does that of the
alveoli : so that by the time the teeth break through the gums, their
walls are sufficiently strong, and embrace the necks of the teeth with
firmness enough to furnish a solid basis of support. Their vascular
canals are developed, and especially those which convey to each
tooth its interior supply of vessels and nerves. The gums and
alveoli are likewise provided with vessels which play their part in
the development and subsequent nutrition of the organs."
These are the views of development entertained by the authors
above quoted. Investigations which I myself have made in the
direction have seemed to simplify the matter very much, and, in-
deed, to deprive it of a very great share of its obscurity. Whether
these views may be nearer right than the various others held, the
reader may for himself determine.
At a certain period of foetal life a groove is observed, the pro-
gressive development of which proves it to be the primitive dental
groove. This groove is lined by a delicate membrane continuous
with the mucous membrane, and perhaps a part of it — modified, but
still a part of it, just as the conjunctival cells which pass over the
cornea are really part and parcel of the common ocular conjunctiva.
This membrane, at points corresponding with the position of future
teeth, is elevated into papillae or little hills. A section through the
membrane, over any of the bulbs, exposes a papilla. This papilla
or body, closely examined, is found to be made up of a congeries of
granular nuclei, dispersed irregularly through a firm homogeneous
blastema. This papilla is the rudiment of the future tooth, as obser-
vation of its development proves. It is not inclosed in a cell wall or
membrane of its own, but is a kind of hyaloid structure or substance.
The papilla, thus understood, is seen to lie beneath the mucous
membrane ; and in this membrane resides a certain amount of elas-
ticity. As the papilla enlarges and projects itself, it becomes in-
DENTITION. 83
closed to all the extent possible with this mucous membrane con-
tracted about the body so as to constitute a sac or cell wall, just
precisely as the parietal peritoneum contracts about and makes a sac
to the projected intestine in hernia. This sac enveloping the papilla
has its continuation, as is seen, necessarily over the sides of the
groove ; as then this groove enlarges and deepens, and finally en-
velops the papilla, it is seen that the body or tooth germ gets a
second sac. It is as though one should envelop his head in a
double night-cap, and then bind over this a handkerchief — the sub-
mucous structure of the lateral walls and operculum representing
the handkerchief.
At this period, the pulp or original papilla having attained the
size of the tooth it represents, commences the process of the forma-
tion of dentine. Before the attainment to full size of the papilla,
there existed between it and its sac proper a halitus or fluid. This
halitus, now that the congeries of cytoblasts or nucleated granules
have obtained their full growth and secretive power, is replaced by a
more highly endowed secretion, the work of these matured cells.
This secretion, deposited against the inner sac, or between it and
the pulp, contains the elements of the dentinal structure, is, indeed,
the dentine, and deposits layer after layer, supported by and moulded
into form by the sac.
As this deposit intrudes on the pulp, so this body contracts within
itself, until, finally, by some law of nature, it stops at that certain
point which maintains within the tooth a canal or cavity, and a
vascular and nervous pulp to occupy it, — this pulp being the con-
tracted original papilla ; the vessels of this papilla being vessels
entirely analogous to any one of the ordinary papilla of touch, so
supplied and so maintained.
Why this secretion, in its organization, should assume the position
of the elongated tubular cells which pertains to the structure of
dentine, 1 have of course no idea, and it is quite enough for our
purpose to say that it is a law of life perhaps never to be compre-
hended this side of eternity, and the discovery of which would, at
any rate, have but little practical signification to us.
The formation of the dentine completed, the covering of it with
enamel begins, or rather this deposit is, to a degree, coincident
with the dentinal formation. Secreted by the same pulp which
formed the dentine, the same secretion, some portion of it finds its
way into and through the primary sac. As it passes through this
sac it is modified, receives new elements, perhaps, which, as it is
84 ORAL DISEASES AND SURGERY.
received into the second space, or the space between the first and
second caps, and its calcification commences, impresses upon it the
arrangement of its particles after the hexagonal order of the enamel.
Between the enamel thus formed and the dentine exists the primary
sac; simply the originally modified mucous membrane, which we
first saw as overlying the papilla. This membrane continues its
existence between these two hard bodies, and receives and modi-
fies, for the support of the enamel, the liquor sanguinis sucked out
from the dentinal tubules and intertubular structure. It may be
called the enamel membrane. It has of course been much modified,
and it is from it that we receive the impressions of pain when it is
exposed by a break in the continuity of enamel.
The growth of the root of the tooth, as its dentine is concerned,
has precisely the history of the body. It is associated with the
pyramidal elongation of the papilla or pulp, which, pushing up-
ward the crown, elongates upon itself the enamel membrane. This
elongation, with a greater vascularity and vitality assumed by the
membrane as it approaches the basement vessels, modifies again the
result obtained by the secretion passing through it from the dentinal
pulp, the result being a nearer approach to true bone in the produc-
tion of cementum. The periodonteum is simply the modified external
sac, lost of course above the neck as the tooth has emerged through it.
This is a very simple and easily understood explanation of tooth
growth. The observations leading to the conclusions were some-
what extensive, and, to my mind, the phenomena are indorsed by
general physiological analog)^
We may pass here to what infinitely more concerns us as prac-
titioners — namely, the relations of the first and second dentitions.
The teeth are divided into two sets or dentitions. The first is
called the deciduous, milk or temporary, and consists of twenty
teeth, — ten to each jaw. The second is called the permanent set,
and consists of thirty-two teeth, — sixteen to each jaw. These
various teeth, in size, density, and general character, are relative
to the jaws containing them. The first set consists of eight incisors,
four canines, and eight molars. The second set consists of eight
incisors, four canines, eight premolars, and twelve molars.
Of the first set, the papillae of the anterior molar appear first, the
canine and incisors next, and the posterior molars last. About the
fourth month these papillae are all in their sacular envelopes, and
forming behind the lids of the sacs are little crescentic depressions,
called cavities of reserve, lined with mucous membrane, and con-
DENTITION. 85
taining the germs of the papillae of the second set of teeth, — one to
each deciduous germ. The first molar of the permanent set is
markedly related to the deciduous set, by having a common origin
from and in the primitive dental groove ; and from sacs, secondary
to the capsule of this tooth, spring the reserve cavities of the second
and third molars of the second set.
The eruption of the temporary set, although more or less irregular,
ensues, as a rule, in the following order and time : the lower teeth
erupt first — the four central incisors about the seventh month, the
lateral incisors about the eighth month, the anterior molars about
the thirteenth month, the canines about the sixteenth month, and the
posterior molars about the twenty-fourth month. The period inter-
vening between the first and last eruption is considered the critical
period in infantile existence. (See chapter on Associated Lesions of
First Dentition.)
The ossification of the permanent teeth commences, just before
birth, with the anterior molars, proceeding forward, but terminating
with the premolar at about the third year ; the posterior molars are
the last to ossify.
The position of the permanent papillae, which at first are situated
between the sacs of the deciduous and the gum, gradually recedes
behind, falling deeper and deeper, at least, relatively so, as the
milk set elongates, until, on the completion of growth in the decidu-
ous, the germs of the permanent set are found in a common alveolus
at the apices of these cavities, occupying, indeed, almost the position
and physiological relations of the original papillae.
At this point, whenever it may be, and it varies of course with
different individuals, commences a process of antagonism, — it is
intended that the new shall advance and increase, that the old shall
decline and diminish. The relative position of the two bodies is as
follows : extending to the apices of the alveoli, and receiving at these
apices the principal vessels of nutrition, are the perfected roots of
the first teeth. Crowding down into these alveoli, with nutritious
vessels of their own, possessed with the high vitality of growing
bodies, are the pulps of the second teeth, — it is the story repeated of
the rootlet lifting the stone. As these pulps enlarge, so is there a
corresponding enlargement in the alveoli containing them, until,
finally, through such process of absorption they have fallen directly
beneath the roots of the first set. Of course a pressure has been
equally exerted upon these roots, and, as a result, the nutritious
vessels passing into the pulp cavities, through the foramina at the
86
ORAL DISEASES AND SURGERY
apices, have been gradually obliterated. But do the pulps of the
milk teeth die? Not at all; or at least not necessarily. The neigh-
boring vascularity is very great, the requirements of the organ very
small ; a sufficient supply is received from the circulation in the
dentine, as well as from the periosteum, which, to the last, con-
tinues to close in the enlarging foramina. But this does occur : the
absorbent or destructive system has been given the mastery, and
little by little, day by day, and month by month, the roots of the
first teeth disappear, while the crowns of the second advance, and
occupy the space gained, until at length, as is witnessed every day,
the milk tooth drops out of the cavity, minus a root, while the crown
of the permanent is seen in its cavity.
If here we take up this thrown off tooth, we shall find that the
pulp chamber, or what remains of it, instead of having an almost
complete bony envelope, as is the case in the perfect organ, has
communicated more and more largely, for a varying period, with
the soft parts, guarding us, in such knowledge, against a treat-
ment in aching milk teeth, at certain periods, which would be most
applicable at others.
Fig. 33. — General Appearance of the First Set ok Milk Teeth.
1. 2. 3. 4. 5.
6. 7. 8. 9.
Temporary teeth of one side. 1, 2, upper and lower incisors ; 3, upper and lower
canine ; 4, 5, upper and lower molars ; 6, 7, triturating surface of the lower molars ; 8, 9,
triturating Burfaco of the upper molars.
To judge of the condition of the foramina of the first teeth, we
compare them with periods of eruption of the second, recognizing
that the enlargement or absorption corresponds with such advance in
the permanent.
DENTITION. 87
The first teeth of the second set erupt entirely back of the tem-
porary, and in no way interfei'e with them. These are the anterior
or first molars, and appear commonly at about the sixth year,
seldom earlier, but not unfrequently from one to several months
later; the sixth year, however, is the rule. The second teeth to
appear are the central incisors, the lower a little in advance of
the upper — about the seventh year ; the third, the lateral incisors,
at the eighth year ; the fourth, the anterior premolars, at the ninth
year ; the fifth, the posterior premolars, at the tenth year ; the sixth,
the canine or cuspidati, at the eleventh year ; the seventh, the
second molars, at the twelfth year; and the last, the third molars or
wisdom teeth, at a period varying from the seventeenth to the twenty-
fifth year — more commonly, however, about the eighteenth year.
CHAPTER V.
ASSOCIATIVE LESIONS OF FIRST DENTITION. I
Although it comes not strictly within the province of a work on
surgery to treat of the associative lesions of the first dentition, yet
it would seem that such a work could not be at all complete without,
at least, reasonable reference to such conditions. 1
When one considers the delicate and susceptible organism of an
infant human being, and the fact of its usherance into a world where
active causes of disease are in constant antagonism to it, he is very I
well i)repared to understand that in the influences of the process of
dentition must necessarily exist a powerful predisposing cause in-
viting to attack, and, indeed, opening the portals, as it Avere, to
enemies that otherwise might have passed harmlessly by.
The calculations of Dr. Arbuthnot that, at this period, one in
every ten children has its life destroyed through the associative
and influenced lesions of the age, may, perhaps, not be strictly in
accordance with statistics at large ; but the mortality is so alarm-
ingly great that, to the general practitioner, no subject offers in its
study more important and vital interests.
In the first place, we have to remark that the process of dentition,
while a physiological one, is yet, like that of utero-gestation, one of
continuous irritation. Of the meaning of this word irritation, every
surgeon and every physician has in his mind full quite enough 1
reminiscences. Irritation, then, is the matter of consideration in all *
and every of these associative lesions ; if happily, in such cases, we
could exactly appreciate and exactly control such irritations, we
should of course abort or resolve the results.
It is not, however, by any means to be esteemed that all infantile
diseases are influenced by, or indeed even remotely associated with,
dentition : mistakes of such nature are quite too frequently made,
and infants are tortured, and iu many cases have the existing dis-
ease aggravated, by the lancing and cutting which follow. It is
very true that irritation from this cause has not always an associ-
ated external local manifestation; but such manifestation is, I think,
(88)
ASSOCIATIVE LESIONS OF FIRST DENTITION. 89
much more frequently to be found present than absent, — at any rate,
it should always have its full share in the diagnosis. It will of course
be taken for granted that dental irritation is influenced to a most
marked extent, all things being equal, by the slowness or rapidity
of the evolution of the teeth. Thus, such equality existing, we would
not anticipate from the eruption of a single tooth the trouble of five
or six, and such a difference in evolution is so marked that it may be
said of some children that they cut their teeth in mass, while with
others it is a process of the greatest regularity and harmony.
Again, the physical condition and age of the child are matters not
without much significance. A delicate infant suffers more, as a gen-
eral thing, than a robust one, while premature dentitions are attended
with more danger than late ones. In taking into consideration the
influences of this process, we are not to forget either the varying
degrees of susceptibility, as manifested in different individuals, as
thus we are led to appreciate the fact that judgment is not to be
founded alone upon the extent or degree of local manifestation. Some
children are preternaturally susceptible to stimuli, and these are
not at all necessarily of the weak and feeble class ; others, on the
contrary, are so obtuse, even from earliest age, as to be very little
influenced by any ordinary or common cause of irritation.
To the experienced physician, the appreciation of associated or
abstract dental irritation should not be a matter of difficulty. He sees
and he does what is to be done, what only can be done ; if the treatment
fails, the fault resides not in the practice. In the first place, to under-
stand dental irritation, one must be familiar with dental evolution;
this of course is the understanding of the physiology of the subject.
We know the varying periods of eruption, and we are thus at once
led very dii'ect in our researches. If we find a source of offense, as
manifested by a tumid, congested gum, we have only to pass a lancet
down to the confined tooth, and having done this, we may expect
and hope for relief from any general trouble which has been en-
gendered by the just liberated organ. If we look into the mouth,
and see no manifestations of offense, it is generally the case that
dentition has nothing to do with a trouble which may have in-
fluenced the search, — not always, however, for I have inferred
that dentition may be a source of reflected trouble, while itself pre-
senting no local signs. Still, such cases are very rare, and when
existing depend on great rapidity in evolution, either as a single
tooth is concerned or the simultaneous advancement of a number.
Many teeth, rapidly advancing at the same time, could very well
90 ORAL DISEASES AND SURGERY.
be esteemed as a source of constitutional offense, not only as di-
verting in such direction an excess of the vital force, but also in
local irritations induced in neighboring structures, and which might
not at all be evident by any external signs. In these latter cases,
the physician can do nothing but increase, by indicated means, the
ability of the system to endure the irritation ; such means being
more frequently found in tonics than in sedatives. In the weak,
strict attention is to be given to diet, to exercise, and cleanliness.
The character of the clothing is also of much consequence. If the
milk of the mother is not properly nutritious, other means are to be
taken to nourish the child.
In cases where there seems simply an excess of irritability, such
susceptibility is to be lowered by the withdrawal of any and every-
thing capable of fostering it; this will pertain to the lodgment of
the child, food, drink, clothing, exercise, etc., matters which would
at once strike the observing practitioner.
Disturbance provoked in the alimentary canal, and fever induced
through the process of teething, when existing conjointly with acute
disease, of whatever character, necessarily aggravate such disease,
and increase by just that much the attending discomfort or danger;
hence the recognized increased mortality in the exanthemata occur-
ring at this period.
The diseases, if they may be so called, directly associated with
and dependent on abnormal dentition, and having therefore neces-
sarily their cure more or less intimately associated with the correc-
tion of the primary lesion, are —
1st. Localized Stomatitis.
2d. Irritative Fever.
3d. Diarrhoea.
4:th. Spasms.
5th. Eruptions on the Skin, especially the Scalp and Face.
1. Localized Stomatitis. — The first indication in this condition,
dependent on advancing tooth eruption, consists, most likeh', in a
sense of titillation or itching, — as, before any local sign is visible,
the child is found irritating the parts with anything coming into its
hands, seeming most comfortable when biting upon hard substances.
Slavering is also associated with this stage. After a time tume-
faction of the gums is observed, and this inflammatory action circum-
scribes or extends itself on the same principle as the vaccine disease
— that is, as influenced by constitutional or local circumstances. If
several teeth are attempting eruption at the same time, and these
ASSOCIATIVE LESIONS OF FIRST DENTITION. 91
are situated at opposite sides of the cavity, then the probability is
that the inflammation will be a diffused one. If, on the contrary,
the irritation is confined to a single tooth, and there is in the habits
of the child no particular inflammatory tendency, then it may reason-
ably be anticipated that the area of congestion will be very circum-
scribed. The shape and extent of face in the erupting tooth have
not seemed to me to have as much to do with the amount of irrita-
tion as one would naturally infer to be the case. I have certainly
seen quite as much trouble from an erupting incisor as in the case
of a four-cusped molar. Bad and degenerating inflammations are
always associated with constitutional conditions. Thus in scrofulous
children, it is sometimes the case that a semi-gangrenous ulceration
is the result of cutting a tooth which it is quite troublesome enough
to manage ; while in children of a syphilitic cachexia such a condi-
tion will be even aggravated, the gums and continuity of mucous
membrane looking as if it was impossible to keep the parts from
breaking down into general ulceration. When tumefaction of the
gum is dependent on tooth eruption, and the child is of healthy con-
dition, a certain evidence is found in the glistening character of the
swelling : the part immediately over the tooth or teeth looks stretched
and feverish. This tense look is nearly always present, and may,
under all circumstances, be esteemed an indication demanding the
use of the lancet. In unhealthy conditions, this glistening is not
commonly present, its absence being dependent on the flaccid, re-
laxed condition of the gum tissue. Here, as implied, the congestion
is of more diffused character; the part and associate parts are turgid
and soft looking. You esteem, in looking into the mouth, that scari-
fication would be of service, but that it is demanded for a sense of
general relief, rather than for a strictly acute local condition. Lanc-
ing in the first of these cases, if properly performed, yields an almost
instantaneously good result ; in the second, such relief is gradual,
and most likely inconsiderable. In the first, it is all-sufficient to the
cure ; in the second, the constitutional indications are soon felt to be
of much more consequence than any local requirements.
To lance the gums of a child, let the surgeon seat himself directly
in front of the nurse, the height of the knees of the two parties cor-
responding. Let the nurse now take the child on her lap, support-
ing its whole body, excepting the shoulders and head, which are to
rest upon the knees of the operator. In this position the nurse con-
trols perfectly the legs and arms of the infant, while the surgeon has
complete command of its head, and can examine and operate upon
92 ORAL DISEASES AND SURGERY.
its mouth at his convenience. The face of the child should look
toward the window, or if night is the time of operation, a candle or
lamp will be found all-sufficient.
A tooth should be lanced in consideration of its shape. Thus, if
it be any of the anterior six teeth, either of the upper or lower jaw,
a single incision made sufficiently deep to feel the lancet strike upon
the enamel is all that is required. This incision should be made
across the mouth, or on the line of the cutting edge of these teeth, as
we find them in our own mouth. With the posterior teeth, the
crucial form of incision is demanded: such form will alone relieve the
advancing cusps, and affords the result desired.
Concerning hemorrhage, it has not been my experience that any
special danger is to be apprehended. I certainly never hesitated to
lance the gums of a child on this score, and never met with a case
that gave me any particular trouble. In ordinary cases, the loss of
a little blood is rather to be desired than otherwise, while if a hemor-
rhagic diathesis exists, the local application of strong alum-water or
of bayberry powder will generally be found all-sufficient for its con-
trol. A little cobweb, as found in the cellar, wet with borax-water,
and then dipped in the bayberry powder, will in ninety cases out of
the hundred not fail to control the bleeding, when laid over the in-
cision, — the application to be secured by passing over it, if necessary,
one layer of a delicate roller.
A constitutional medicament, of great effect in these cases, will be
found in the Erigeron Canadense. One drop of the tincture to be
given in a little water, each minute, until the bleeding ceases, or
until twenty or thirty drops are taken. Opium and lead act very
happily in combination. The dose of each must of course be small.
A very good formula would be as follows:
B. — Pulv. opii, gr. :^;
Plumbi acet. gr. i;
Aqua, giij. M.
Sig. Teaspoonful to be taken each half hour, p. r. n.
Touching a bleeding gum with Monsel's solutions, or with ni-
trate of silver, is, in my experience, dangerous practice. The only
alarming cases of hemorrhages I have ever seen have been the re-
sults of such applications. It is true that such effects may rest
rather with the operator than with the agents ; but it is seldom
that one seems to succeed in using them with sufficient cleverness
and localization. They are certainly much more apt to do a great
ASSOCIATIVE LESIONS OF FIRST DENTITION. 93
deal of harm than any reliable good ; secondary hemorrhages are
common to them, and which are always of a character much more
difficult to manage than the primary trouble.
Another matter in this connection particularly worthy of note, is
the influence on the hemorrhage through the sucking propensity of
the child. This is to be obviated by passing a, roll of rubber or
other convenient material across the mouth, and so confining it as
while it shall not fret the little patient, it will destroy the ability to
make a vacuum This manipulation is very simple and easy of
accomplishment. The ordinary soft india-rubber ring may be cut
in the middle; tie a piece of string or tape to either end, pass the
rubber across the mouth, and fix the tapes on the back of the neck ;
an hour or two will be found quite sufficient to retain the apparatus
in the mouth.
Cases of localized stomatitis, having association with the strumous,
scorbutic, or syphilitic cachexia, require, as suggested, a treatment
external to the cause exciting it; the child must be built up; the in-
flammation passing quickly into an adynamic type demands for its
cure stimulation rather than depression ; or, to express the require-
ments more justly and explicitly, a local treatment must be quieting
and perhaps refrigerating, while tonics, combined with the mineral
acids, will be required constitutionally.
A child eight years of age, of marked scrofulous condition, tissues
relaxed, abdomen pendant, was presented at one of my clinics, suf-
fering with trouble in the oral cavity. Making an examination, the
mucous membrane of the palatine aspect of the superior jaw was
found angry and uncomfortable looking, no tension at any point, but
the whole membrane turgid, and yet flaccid looking. In searching
for the cause of trouble, the age of the patient directed a first atten-
tion to the position of the first bicuspid teeth, the lateral incisors
being erupted and in position ; exploration with the lancet — the
deciduous molars had been removed long before — revealed these
teeth on either side, with the second bicuspid of the right side
nearly ready to erupt. The ordinary crucial incisions were then
made. In the case of a healthy child, this would have been all-
sufficient; with such a child, however, not so. Eelief from the
incision will certainly, to some extent, be obtained; but the conges-
tion will continue, and it may be will grow worse, the parts seem-
ing to lack that energy necessary to the restoration. In this par-
ticular case, and which is here noted merely as a type, the mouth
was ordered to be washed three times each day with very dilute
94 ORAL DISEASES AND SURGERY.
brandy and aromatic sulphuric acid. Internally, lemonade was given
each two hours, five drops of brandy to each wineglassful. Aro-
matic sulphuric acid acts very happily in these and similar cases,
or the nitromuriatic acid may be administered in from two- to five-
drop doses, three or four times a day. Iron, combined with an acid,
as in the Tinctura Ferri Chloridi, is a most admirable medicine, given
in from five- to eight-drop doses, three times a day. It is found
also not unfrequently necessary in these cases to bring the acid, in a
more concentrated form, directly to bear upon some obstinate point
of ulceration ; this is done very readily by means of a pine stick.
Dip the point into the acid u.sed, and employ concentrated or dilute
according to the seeming requirements of the case. The acid nitrate
of mercury so applied is found sometimes to act very happily, or the
deliquesced chloride of zinc may be used. The zinc, followed by a
brush of the ofiicinal tincture of iodine, will sometimes induce granu-
lation as if by magic ; or the iodine combined with creasote may be
employed with every hope of success.
In syphilitic stomatitis, specific treatment must be conjoined with
the supporting. A combination that I use with the most satisfactory
effect is as follows :
B. — Hydrarg. bichl. gr. 1 ;
Potass, iod. 5i ;
Sj-rupus ferri pyrophos. ^iv. M.
Sig. From a quarter to half teaspoonful, according to age, three
times a day.
It not unfrequently happens, however, that a treatment which has
preceded ours has been too free in the exhibition of the mercurials;
here the medicine is not to be longer used, but, conjoined with the
supporting treatment, we are to employ the chlorate of potash.
R. — Potassae chloras, ^ss ;
Aqua, Iviii. M.
S. Teaspoonful, internally, four to six times a day, and the mouth
to be washed with the same, ad libitum.
In all adynamic conditions of childhood, it is, I presume, a com-
mon experience that no better treatment is to be found than lies
in the observance of general hygienic laws. The food must be
nourishing, and not given to repletion. Fresh air and exercise are
necessities. The child should sleep by itself, or, what, as it is con-
ASSOCIATIVE LESION^S OF FIRST DENTITION. 95
cerned, is even better, it might sleep with some young person of
more robust and healthy condition. The daily use of the salt-sheet
bath, with the water tepid or cold, according to the ability of the
patient to bear. This is an invaluable adjunct to restoration. Throw
the wet sheet quickly about the person of the child, and rub until a
fine glowing reaction sets in. In the use of this means, however,
close attention is to be given to the daily result. If reaction is not
secured, but the child seems cold, and the cutaneous capillaries con-
tract, then such bath is to be discontinued ; or if the cold water has
been used, it must be modified, even perhaps to absolute warmness.
A good plan to adopt with this bath, is to commence with milk-
warm water, and advance with gradations to cold.
All the functions of a child of scrofulous or syphilitic condition
are to be carefully attended to. If the bowels are habitually cos-
tive, as is very frequently the case, olive oil of good quality may
be administered q. s. This oil not only obviates such a condition,
but acts as a most desirable article of nutrition. If given alone, a
teaspoonful or dessertspoonful, each day, administered at any con-
venient period, -will generally be found sufficient, — and, indeed, in
many cases, too laxative. If the child is of an age to take the oil
mixed with other food, much attention to the quantity employed
will not be found of special consequence. In cases where the
kidneys fail to eliminate with sufficient rapidity, small doses of
sweet spirits of nitre may be exhibited. Buchu, where there is
undue irritability of the urinary apparatus, will be found to apply
very happily. A prescription which I very frequently make, is as
follows :
R. — Take of buchu one ounce ; add one and one-half pints of hot
water, and simmer down to one pint; when cold, strain, and give in
teaspoonful doses, four or six times a day, p. r. n.
Particular attention is also demanded to the state of the skin. It
should feel soft, not relaxed, moist, and reasonably oily ; it must be
kept very clean, but not washed too frequently with soap. Whisky
or brandy, where stimulation seems indicated, may be added to the
water with which a child is bathed ; but a healthy skin is to be made
rather from within outward, than from without inward — that is to
say, a skin which does not perform properly its offices, indicates, as
a general thing, some derangement ulterior to itself, so that the local
attention implied is never to be esteemed but as adjunct treatment.
It has not unfrequently happened to me to observe that a stomatitis,
having apparently a local signification, has immediately disappeared
96 ORAL DISEASES AND SURGERY.
upon the correction of a trouble existing in the skin. This is mark-
edly seen in the retrograde exanthems.
Angina simplex, a simple inflammation of the fauces, is not un-
frequently dependent on irritations existing or having origin in the
oral cavity. Here the trouble is simply one of continuity, and its
cure is found of course in the cure of the oral trouble. Angina
simplex, or the extension of the oral inflammation, is generally first
made evident in difficulty of swallowing. Examination reveals the
throat red and engorged, the degree being influenced by the con-
dition of the patient. Sometimes this congestion is so great as to
make the act of deglutition an impossibility ; even fluids taken into
the throat will be ejected through the nostrils. The uvula oc-
casionally will be enlarged to an extent, as the result of effusion into
its cellular structure, which seriously endangers the respiration of
the patient, compelling, indeed, in many cases, the amputation of
the organ. In some instances aphthous patches appear upon various
parts of the mucous membrane ; these denote that the inflammation
is adynamic in its type, and are, I think, always a matter for con-
cern, just, indeed, as a phagedenic chancre is a cause for more alarm
than a simple sore, implying absence of vital force and degenerative
tendency. An aphthous ulcer is a patch of yellow exudate, frequently
excavated, but not necessarily so. It is the form of ulceration and
exudation so frequently seen in weakly, broken-down women. The
microscope exhibits the aphthous exudate as a fungous growth ; it
has, however, as yet failed in designating its specific. Angina sim-
plex, it has been remarked, when dependent on any oral trouble,
may be expected to retire upon the removal of the immediate cause.
This, however, is not always the case, as witnessed in the ady-
namic types, or in children of very full or sanguine temperaments.
In these cases, a treatment must be pursued as implied in the indi-
cations. If the continuance of the inflammation depends upon the
surcharged conditions of the vessels, a general or local depletion
will be found demanded. Three or four Swedish, or twice as many
American leeches, may be put upon the upper part of the neck ; the
number to be graduated to the strength of the patient and the
urgency of the case. A treatment preliminary to this, and one
which in my own practice I always employ, when the case is not
especially urgent, consists in reducing the volume of blood, either
by the administration of diaphoretics or the saline cathartics.
Epsom salts, a tcaspoonful in a wineglass of water, will carry
much fluid from the blood of a young child; or the spirits of Min-
ASSOCIATIVE LESIONS OF FIRST DENTITION. 97
dererus — covering the patient warmly until diaphoresis is produced
— given in teaspoonful doses, every ten minutes, will be found to
sometimes very quickly break up such inflammations Hot pedi-
luvia are not to be neglected ; the feet and legs of the little patient,
kept in hot water for the space of a quarter of an hour, will, in very
many cases, be all-sufficient for a cure. A less speedy, but fre-
quently very successful way of treating angina, consists in divert-
ing, as it were, the seat of irritation; thus, by the administration of
nitre we may send it to the kidneys, or with tarter emetic we can
throw it upon the skin.
B. — Spts. ammoniae aromat.
Spts. seth. nit. aa ^ss. M.
S. Give from five drops to a teaspoonful, according to age, every
three or four hours.
The ammonia in the above prescription drives the congested
blood forward, while the nitre directs it toward the kidneys.
In cases in which the circulation is deficient in the cutaneous
capillaries, as indicated by their diminished caliber, small doses of
antimony answer an admirable end. This treatment may be con-
joined with one of the salts of morphia, or the two together may
be given in the Hoffmann's anodyne mixture.
An emetic will not unfrequently break up a sthenic sore throat.
In the case of children syrup of ipecacuanha answers every purpose.
It may be given in doses varying from a half to a full teaspoonful,
according to age, every ten or fifteen minutes, until the desired
result of emesis is obtained.
If, conjoined with the local inflammation, we have a sympathizing
by the system at large, as manifested in fever, febrifuges are to be
employed. The following combination will be found happily adapted
to such indications:
R. — Liq. potassEe citrat. §iij ;
Spts, seth. nit. ^ss ;
Ant. et potass, tart.
Morph. acet. aa gr. i. M.
Of this mixture the dose for an adult would be a dessertspoonful
every two hours ; for an infant, one year of age, from five to eight
drops might be given, being diminished or increased according to
effect. Overdoses produce sick stomach.
1
08 ORAL DISEASES AND SURGERY.
l)[et. This should of course be light, as in all sthenic inflamma-
tions. The child may be limited to the breast alone ; or if age or
circumstances will not permit of this, gum-water, or other light and
unstimulating food, should be alone employed — that is to say,
should be alone employed while the grade of the inflammation is
running upward. Ice-cream is an admirable food, particularly when
eaten slowly, and, I may say, continuously. By continuously, how-
ever, I do not mean that great quantities are to be taken, but a
reasonable portion be made to last as long as possible. Eaten in
this way, it is refrigerant not only to the inflamed part over which
it necessarily passes, but to the system at large, lowering the heat
of the whole body, and thus quieting the disturbed circulation.
Chronic Angina. — Inflammation of the fauces, running into a
chronic condition in children, may perhaps always be esteemed as
depending on some constitutional predisposition. In these cases
the glandular bodies seem to be mo.st markedly the seat of trouble.
Granulations are generally prominent over the mucous membrane,
this tissue being covered with a mucoid or muco-purulent secretion.
Ulcers are very common, and not unfrequently are of such degener-
ative tendency as to threaten the continuity of the parts. A dis-
agreeable association, connected nearly always with a neglected
angina, is the chronic enlargement of the tonsil glands. I have
been compelled to operate in these cases, as every slight cold would
so swell up these bodies as to render respiration almost as difficult
as in asthma. I have just now under treatment a little girl, in
whom, from this cause, these glands are so enlarged that respiration
during sleep is accomplished only by an effort that it is absolutely
painful to listen to. Of course the case is curable by excision ;
but to this neither parent nor child can be brought to submit. The
sense of tickling and rawness in the throat, in chronic angina, is
another source of discomfort ; the patient is constantly kept cough-
ing and hawking. This is induced not unfrequently through the
dryness of the membrane, and again as a result of the irritating
nature of the secretions, or it may be dependent on ulceration. From
whatever cause induced, however, I have never found anything
better adapted to its temporary relief than gum arable held in the
mouth and allowed slowly to dissolve. Difficulty in hearing is
another frequent association of chronic angina, — the explanation
being found in the inflammatory thickening of the Eustachian tube.
Pain in the act of swallowing is the result of a lymph exudate
n the submucous cellular tissue. This it is which e-ives the
ASSOCIATIVE LESIONS OF FIRST DENTITION. 99
irregular thickening so observable about the posterior wall of the
pharynx.
Chronic angina, if not dependent on any specific constitutional
conditions, would be most rationally treated by stimulation, local or
general, or both, as would seem to be indicated. The ordinary
domestic remedy of a red-pepper gargle, if judiciously used, would
not unfrequently produce a speedy cure. Unhappily, however,
domestic medication is too apt to be carried to excess, and thus adds
to, in place of subverting, a disease. If a true, uncomplicated chronic
angina presents in a child, and it will not do to deny but what such
cases may exist, let the patient first be treated with a wash com-
pounded as follows :
B. — Tinct. capsicum comp. 5ss;
Aqua, iviij. M.
If a few applications of this gargle should not effect a change, let
nitrate of silver be added, in proportion of one-half a grain to the
ounce. If even this should not result in the desired change, then it
will be well to esteem that a general medication is indicated. First
we may set about to correct any functional disturbances that may
be present, and follow such corrections with tonics. Muriated
tincture of iron is an admirable medicine, where the system seems
to require building up; quinine, in the majority of cases, may be
given in addition, with a very happy effect.
R. — Tinct. ferri chl. Jiij ;
Quinias sulph. gr. x. M.
S. To be taken in from three- to ten-drop doses, three times a
day.
Where treatment, as just indicated, shall fail, alterative medica-
ments of the various classes may be tried, — alum-water, tinct.
iodinii, weak dilutions of creasote, acid nitrate of mercury, chloride
of zinc, solutions of lead, etc. Constitutional vices must receive
full share of attention. I have presumed to imply that in children
affected with chronic angina the cause is always found to exist in
this direction. Scrofula is by far the most common of these vices.
A scrofulous child is liable to almost any description of physical de-
generation. Now scrofulous degeneration is rather a difficult thing
to describe, the conditions are so diversified and varied. A child
descended from consumptive parents is degenerate, — it is not amiss
to say scrofulous. A scrofulous child has not necessarily a special
100 ORAL DISEASES AND SURGERY.
distinctive type. It may, for example, have white, delicate skin,
tumid abdomen, non-compact, pouting lip, and the languid, listless
gait. It may have every belonging of the most marked lymphatic
temperament ; or, on the other hand, a scrofulous patient may look
as if possessed of all the characters of a vigorous constitution. I
do not know what l)etter to do, in cases of this kind, than to make
a general observation of antecedent and present conditions, and
found a treatment accordingly. Syphilis, it has been inferred by
some writers, lies closely, or away back in the distance, as the root
of such conditions ; but if such should be the case, a treatment anti-
syphilitic is not necessarily implied. This peculiar vice may have
lost itself in a general degenerative condition, just as an injury,
which has of itself gotten well, may yet be the cause of broken
health and physical adversity,— just, indeed, as phthisis may suc-
ceed syphilis, long since inferred to have been cured. In all such
cases we can only hope, in the correction of ill conditions recognized
as existing, to find the good we require. We may philosophize and
reason, but if nothing functionally wrong is perceived, we must
have recourse to a somewhat empirical treatment, building, as we
say, the patient up. In other words, there are no specific means of
cure; therefore we resort to such general tonics as experience has
demonstrated to be useful. Cod-liver oil, administered daily, cream,
mixtures of spermaceti and milk, preparations of iron, infusions or
tinctures of the bitter barks, as the Peruvian, serpentaria, etc., are
medicines to be employed in these cases.
2. Irritative Fever. — Irritative fever, or fever from the irritation
of teething, is a direction of infantile trouble very frequently de-
manding the attention of the physician. It may not be amiss, for
the benefit of the student, to remark that by irritative fever we
mean fever the result of something that produces overexcitement.
This, it is true, would also be a definition of inflammatory fever,
the two conditions being really one and the same, except in degree.
Now the irritative fever of dentition is, as a rule, a rapid fever — that
is, it appears and disappears quickly, the lancing of a gum causing
it very frequently almost instantly to vanish: not always, however,
for it can readily be understood that such a disturbance of the func-
tional conditions could be excited as to make a return to an equilib-
rium much less probable than production of some organic change.
All febrile conditions in children of a sthenic type are attended
with much restlessness ; but the fever of dentition is markedly so.
Muscular excitability is a prominent association ; the sleep is broken ;
ASSOCIATIVE LESIONS OP FIRST DENTITION. 101
thirst is very great; appetite impaired and irregular, the child taking
the breast rather for the relief obtained from the moisture of the
milk than from desire for food ; the pulse is not unfrequently driven
to an incredible rapidity; the face is flushed and burning; the eyes
congested and protruded. Convulsions, and not unfrequently death,
mark the climax.
The disturbance effected in the sj^stem, as has been remarked,
will be found, most likely, in proportion to the local irritation, and
the age, constitution, and general condition of the patient. The
marked mobility existing in the nervous structure of infants renders
the brain peculiarly susceptible ; it is therefore a most common
association to find the feverish infant flighty, and perhaps entirely
out of its head ; while if febrile disturbance, consequent upon denti-
tion, supervenes, when other diseases are in progress, such diseases
will be commonly much intensified.
The diagnosis of dental irritative fever is not always an easy
matter, and simply because the fever is irritative, and not inva-
riably inflammatory — that is to say, the local disturbance is con-
fined to the nervous structures, and does not involve, to a perceptible
extent, the local vascular. We look into the mouth, but we see no
swelling of the gums, no evidences of inflammation; yet the trouble
is there, and it may be that it is only by incision that the fever is
to be controlled; the diagnosis must therefore necessarily not unfre-
quently be of a differential character, or by exclusion. To aid us
in this, we not only consider the absence of other causes of irrita-
tion, but we have a marked assistance in our knowledge of the
varying periods of tooth eruption, and of the causes advancing or
retarding such evolution.
Where dental evolution is inferred to be the cause of a febrile
manifestation, and incisions do not seem demanded, we are to
resort to ordinary general treatment. Lemonade, made with pounded
ice, is a most grateful and refrigerating febrifuge ; the neutral mix-
ture, made fresh, by simply adding the carbonate or bicarbonate of
potassa to lemon-juice, is another excellent medicine. This addition
may be made to a full saturation.
Or a refrigerating mixture, made as follows, may be prescribed,
and administered pro re nata in teaspoonful doses :
R. — Liq. potassae citrat. siij ;
Spts. seth. nit. ^ss ;
Ant. et potass, tart.
Morph. acet. aa gr. \. M.
102 ORAL DISEASES AND SURGERY.
Much relief is given b}^ sponging the skin when it is very hot,
using water and alcohol, or water and cologne, or water and vine-
gar. Bathing the wrists in cold water is another source of great
comfort. Bromide of potassium is an admirable preparation to
administer in febrile conditions. To children it may be given,
dissolved in strong, ice-cold lemonade, in doses of two grains or
more to the tcaspoonful.
Tartar emetic, added to these doses in the proportion of the for-
tieth of a grain to each, assists its quieting influence. Where the
pulse is much excited, and the infant is of sthenic condition, tinct.
of verat. viride may also be added, one drop to each dose ; in the
use of this last agent, however, the effect is to be watched with
care. Emetics are highly valued by some. Cathartics may also
be used to good purpose, the sulphate or carbonate of magnesia
being employed, as preferred.
"When, in defiance of treatment, a fever of irritation continues, our
efiForts are to be directed to effects that may be produced outside of
the ordinary functional disturbances. The extension of inflammation
by continuity, where, for example, severe and unyielding inflamma-
tion resulting from dentition exists, may produce pharyngitis, paro-
titis, bronchitis, pneumonitis, gastritis, or it may excite to take
an morbid action the brain, the heart, the liver, or, indeed, any
organ of the body. When such sequela occur, we are to treat the
parts involved as in any common inflammation, just, indeed, as we
have been treating the unyielding fever, except that we may feel
the necessity to make such treatment more vigorous ; it may be
that under such circumstances we will find the local or general
abstraction of blood an absolute necessity, while derivation, by
counter-irritation, will commend itself as all-important.
In these cases it is not to be forgotten, however, by the prac-
titioner, that, conjoined Avith the original cause of inflammation,
some other may exist ; thus, a malarial influence may have been
lying in abeyance, and needed but the depression, the result of the
dental trouble, to allow of its asserting itself; or some half-corrected
tendency to congestion is, by the excitation, entirely undone. Such
associations are constantly to be considered if treatment is to be suc-
cessful. This excitation of morbid action is well demonstrated in
the association, with dentition, of diarrhoea and the cutaneous erup-
tions ; while the treatment, wherever the secondary irritation shall
exhibit itself, is recognized to have a common character.
3. Diarrhoea. — The alimentary mucous membrane being con-
ASSOCIATIVE LESIONS OF FIRST DENTITION. 103
tinuoiis from the mouth to the anus, it will be at once recognized
that a localized inflammation could render irritable the whole tract.
It is thus that diarrhoea, or, indeed, more commonly all the symp-
toms of cholera infantum, associate wnth difficult tooth eruption, and
it is thus that to cure a diarrhoea or an attack of cholera infantum
we have so frequently only to cut down upon a certain confined
tooth or teeth. I am led, however, to infer that it is quite too
common a practice, during the period of dentition, to ascribe to this
process not only every diarrhoea, but the numberless other functional
irregularities which may happen to occur at such period. Diar-
rhoea, or this combined with vomiting, has many causes external to
the influences of tooth eruption.
The stomach of an infant may be likened to an enlarged portion
of a common tube, and not only this, but it is a vertical or almost
vertical tube ; hence a child overfed needs only to be inverted to
have the milk run from the orifice of the tube.
Again, the mucous membrane of the intestines of an infant is
tender and susceptible ; excess of food, or food not easy of digestion,
irritates this membrane, and, by the relationship of tissue, excites to
action the middle coat of the tube, yielding discharge or diarrhoea.
Crapulous diarrhoea may thus be somewhat continuous, for the rea-
son that, unassisted, the contractions may fail to relieve the canal
of the source of offense, and thus their continued efforts keep up
the continued discharges. Worms irritating the canal are not the
infrequent cause of diarrhoea. In hot weather we generally have
an increase in diarrhoea cases ; and not only is the irritation thus
induced not limited to the intestinal tract proper, but the liver as
markedly sympathizes ; hence the frequency in these months of
cholera infantum, the excess of bile being thrown both ways. En-
teritis, from follicular ulceration in typhoid conditions, may induce
and keep up a diarrhoea in a child as it does in an adult. Tabes
mesenterica is a cause of diarrhoea in the scrofulous infant. Syphilis
may ulcerate and irritate the intestinal tract, just as we so frequently
see such irritation in the mouth. These allusions are sufficient to
remind us that diarrhoea is not a disease but only a symptom, and
that, whether occurring in the dentitional or any other period, it
may have, as its provocative, a great variety of sources or lesions.
When a diarrhoea depends on a dental origin it is, perhaps, always
a condition of vascular perversion, and is entirely direct in its
nature ; the erupting tooth or teeth inflames the mucous membrane
of the mouth, and, by the continuity of tissue, the irritability ex-
104 ORAL DISEASES AXD SURGERY.
pends itself over the intestinal portion of the structure. It is well
to say that in diarrhoea of this character there is much or little
mucin, according to the state of the inflammation, and much casting
off of epithelial scales ; but there is, of course, nothing diagnostic
in such phenomena, because of not being peculiar to a particular
form or character of inflammation. We are to look at the mouth,
and we are to look at the throat ; if there is a local condition of
irritation and inflammation, and if the vascular derangement ex-
tends as far as we can follow it, we have reasonable grounds for
inferring that in the teeth resides the origin of the trouble, particu-
larly if, having examined the system at large, we fail in discovering
other lesions. I desire not, however, to be understood as asserting
that it is only in this way we have dental diarrhoea, for I too well
know there is another way, and that is through the second of the
legs of Bichat's tripod. I very well know that there is an influ-
enced innervation, and that if the bowels of an infant are weaker
than its lungs or its brain, that deranged innervation will there ex-
pend itself I have seen the diarrhoea of such deranged innervation
relieved almost instantly by an incision into a tooth-cyst, and yet
there was no redness, no swelling, or other evidences of local ex-
citability. These cases are, however, rare, and have their analogues
in the reflex spinal irritations. The diagnosis must necessarily be
somewhat differential in character ; yet, where a case is at all ob-
scure and the circumstances urgent, it is commendable practice to
make incisions over the positions of teeth whose periods of eruption
correspond most nearly with the time of operation.
It is very well, however, and indeed necessary, to remember that
a mucous membrane may be inflamed, in varying localities, without
having intermediate sanguineous disturbance. Thus a stomatitis
and an enteritis might be present at the same moment ; the one de-
pending on local dental disturbance, the other upon a cause or
causes of entirely dissimilar nature. Now in a case of this kind,
having associative diarrhoea, it will plainly enough be seen that
any treatment directed to the stomatitis would not (except as a
similarity in practice might pertain to both troubles) affect the
enteritis. To recognize these cases, antecedent conditions must be
inquired into. Colds or atmospheric vicissitudes will, most fre-
quently perhaps, be found an explanation of the disturbances. The
cutaneous circulation, as a result of some inadvised exposure, has
been depressed, and thus the enteritis has been forced upon a part
having the least ability to resist the inrolling wave. In some in-
ASSOCIATIVE LESIONS OF FIRST DENTITION. 105
fants, restless and nervous in their natures, a predisposition to enteric
irritation or inflammation seems to be inborn ; the slightest disturb-
ance reacts in this way. It may not be that diarrhoea is the result,
but the irritation exhibits itself in some evident way.
The milk of a nurse is occasionally the source of a diarrhoea.
Infusoria and crystalline substances will be found frequently, on ex-
amination, in such milk. Here a cure would only be obtained by a
change from such diet to one which would be healthy or normal, —
good cow's milk, diluted or pure, according to the age of the infant,
being the best substitute. Other causes of diarrhoea, to be con-
sidered in connection with a supposed but doubtful dental source,
are debility; hepatic derangements, interfering with the venous cir-
culation ; an increased peristaltic motion through mental emotions,
as anger or fright; a rheumatic or scrofulous diathesis; malarial
influence, etc.
Diarrhoea from dental irritation, if inflammatory by the continuity
of relationship in the membrane, generally demands the lancet alone
for its cure; the operator should free the advancing tooth or teeth.
If, however, on the removal of such cause, the effect does not sub-
side, the invoked and persistent irritability is to be treated on such
principles as commend themselves. Sweet oil and paregoric I have
found act very happily. To each teaspoonful of the oil add from
five to twenty drops of the opiate, according to the age of the little
patient. Heating applications to the abdomen are most useful ; for
example, a poultice made as follows :
Flour, ^ss;
Mustard, 5i ;
Ginger, 5ij ;
Black pepper, 5ss.
Mix these together with a little vinegar, and keep to the skin until
it is well reddened. It is not at all necessary to blister the surface.
Another, and perhaps a more comfortable mode of treatment, is to
give small doses of Dover's powder, or, what I prefer, the liq. potassse
citratis, in conjunction with minute doses of tartar emetic.
R. — Spts. seth. nit. ^ss ;
Liq. potassse citrat. ^ij ;
Ant. et potass, tart. gr. ^. M.
Give in ten- to fifteen-drop doses each two hours.
If the inflammation has anything of a sluggish or passive char-
106 ORAL DISEASES AND SURGERY.
actcr, the spts. Mindereri will act happily. Half teaspoonful doses
each two or three hours to be given.
Diarrhoea from dental irritation, not inflammatory in character, is
to be treated in consideration of its nervous relation ; and just here
is a condition in which the bromide of potassium acts most satis-
factorily. It may be given in five-grain doses, dissolved in water ;
or, if the practitioner does not like to commence in the infant with
such a dose, he may try if less will answer his purpose, and in-
crea.se pro re nata. Less than five grains, however, I do not think
will do much good, unless, indeed, the child is very young. Spts.
Mindereri, sweet spirits of nitre, and the camphorated tincture of
opium also act most satisfactorily in these cases. They may be
given in such proportions as indicated. An ordinary prescription
would be about the following :
B, — Spts. Mindereri, ^ij;
Spts. seth. nit. |ss ;
Tinct. opii camph. 5ij- M.
Sig. Twenty-five drops each two to four hours.
The following combination is a valuable one, when other sources
of irritation, not perhaps thoroughly appreciated, exist in conjunc-
tion with the dental trouble :
B. — Hydrarg. chl. mite, gr. ij ;
Pulv. opii,
Pulv. ipecac, aa gr. i ;
Mag. carb. gr. xii. M.
Ft. chart. No. xii.
Sig. Dissolve, or mix with any convenient vehicle, one of these
powders, and administer after each operation, if profuse, or other-
wise each two, three, four, or five hours, according to judgment.
4. Spasvis. — To appreciate the cause and condition of spasms and
convulsions in early childhood, whether influenced or not by the
excitement of dentition, one has but to consider the restless mobility
of the cerebro-spinal system at such age. If, at an early period of
life, we examine the gray matter of the spinal cord, we are struck
with its development when compared with the similar substance in
the cereliral portion of the encephalic mass. To express ourselves
diflFcrently, the ganglion of excito-motor or reflex action we find to
be much in excess in its development, and not only so, but sensitive
and susceptible, as its ofiBces are concerned, to the last degree,— a
ASSOCIATIVE LESIONS OF FIRST DENTITION. 107
result most likely of the necessity for the motiou of growth and
development existing in the members of a child ; such a system
may be compared to a tensely strung instrument, responding to the
slightest touch.
The difference between a regular and irregular motion is the dif-
ference between mx ability or disability of the cerebellar gray matter
to perform its functions of co-ordination ; the difference between a
co-ordinated and an irregular motion is the difference of spasm, and
if we carry it to the disability of the cerebral mass to influence, it
is the difference of convulsion.
Spasm, then, may be defined to be irritation, direct or indirect, of
the spinal cord or its terminal outshoots or nerves. This founda-
tional principle appreciated, the further consideration of the subject
is not at all diflScult. Yery true it is, that there may be causes of
disturbance that we cannot discover ; but the results, and the mean-
ing of them, are not thereby rendered any the less obscure : it would
be only the cure that would be delayed or denied.
We are prepared, then, to recognize in what way dental evolution
is a cause of spasm : it is precisely as it is a cause of diarrhoea, as it
is a cause of fever ; but the reflected irritation in the latter case
expends itself on the muscular system rather than upon the mucous
or vascular. The cure or the mode of cure suggests itself: first,
we are to remove the condition of irritation ; second, if the parts do
not quickly soothe and quiet themselves, we are to help them. To
meet the first indication we simply lance the gums. I do not think
that in these cases we are to be influenced too entirely by local
manifestations of congestion — cut freely down upon teeth whose
periods of eruption suggest them as being the source of offense.
Take a pledget of cotton, and, saturating it with solution of mor-
phia, thrust it, by means of some delicate instrument, into the cut
you have made. This is quite equal to the more fashionable subcu-
taneous injection, and tends to soothe and quiet the disturbed nerve
filaments. If yet the spasms should persist, some general effect on
the nervous system at large must be secured. Tincture of valerian
and gentian in equal parts, given in ten-drop doses, repeated pro re
nata, will sometimes act most satisfactorily. If this should not
answer, the bromide of potassium may be employed. The bromide,
cantharides, and camphor, as recommended by Dr. Chambers in
epilepsy, constitute an admirable combination.
108 ORAL DISEASES AND SURGERV.
B. — rotass. brom. gr. iij ;
Tinct. cantharid. gtt. iij ;
Mist, camphorae, gtt. x. M.
Sig. Give this in a little water three or four times a day.
If, after proper trial of the above — say a few days— the irritability
fails to be subdued, the inference will be that our diagnosis has
been a mistake, and that dentition is not wholly, at least, in fault.
At this point we see the necessity of glancing at other causes
of irritation which may exist. Many children incline to nervous
derangements from anaemia; this we know to be a quite common
cause of such derangements. An anemic condition might not
of itself, in a special case, induce spasm, but assisted by conjunc-
tion with a second irritant, the two together could excite to the
condition ; and one removed, the other could very well resist a cura-
tive agent. A glance here shows us why the sedative has not
effected the cure ; let us add iron to our prescription, and a very few
more days will give us a different result. Perhaps, on the contrary,
the condition of a child is just the reverse ; instead of being anemic
it is plethoric. Give to this child repeated do.ses of some suitable
saline mixture, and conjoin with the potassium quarter-grain doses
of calomel ; or, if you do not wish thus to medicate, starve it for
a few days, give it nothing but the breast, and this only in the
daytin)e; or, if the period is that of second dentition, deprive it
of all but vegetable food, with water for drink ; a cm"e would most
likely follow such treatment. Lack of good, fresh, pure air, un-
wholesome food, deficient or improper clothing, sleeping with de-
bilitated persons, the milk of the nurse, articles of food not easy of
digestion, hepatic derangements, worms in the alimentary canal,
influences passed from mother to infant, and numberless similar
conditions, are exciting and predisposing causes of spasm and con-
vulsions ; and all demand, in every case, their share of consideration,
if we are to be successful in treatment.
Spasm resulting from the congestion of nerve centers, however
induced, is not unfrequently tonic in its character ; the child may
lose all consciousness; it passes into the state that we call con-
vulsion. In these cases results must be obtained immediately; we
must relieve the overburdened part. How? By derivation. Try
first a hot foot-bath ; let it be as hot as the skin will bear it. Inclose
the steam of the water so that it shall envelop all of the child but
its head ; compel it, if possible, to take teaspoonful doses of the spirits
ASSOCIATIVE LESIONS OF FIRST DENTITION. 109
Mindereri. The steam, or the steam and mixture in conjunction,
will soon compel profuse perspiration, and thus secure a double de-
riv^ation. Such treatment will, most likely, relieve the congested
part ; at least it has generally proved most reliable in my hands. If
it should not answer the intention, then a vein may be opened, or
leeches may be applied. The opening of a vein in such cases I
have never had occasion to resort to, but it is good practice, and
is recommended by the best writers. The pediluvia and deriva-
tion by perspiration, I think, however, will be found reliable.
If, after consciousness is restored, the pulse continues rapid, with
fullness, give one-drop doses of the tinct. verat. vir., or relax the
system generally by doses of tinct. lobelia or ipecacuanha. Ten
drops of either of these medicines will very well answer the pur-
pose. Keep the child now cool, and guard against every source of
discomfort.
Passive congestions are sometimes a cause of infantile spasms ;
these are not difficult to distinguish from the acute or active con-
ditions, the languor and sluggishness markedly contrasting with
the turgidity and fullness. Again, it is distinguished from the
active condition in its results, these being not immediate, but
mediate. Passive congestions depend on some obstruction in the
circulatory apparatus, and are, perhaps, more frequently associated
with the chylopoetic than with any other system. Stagnations
occur as a result of some interference with the respiratory office, or
they may be the result of the action of some directly sedative poison.
Wherever, and however they exist, they are to be removed, if pos-
.sible, by meeting and combating the cause, which, of course, is the
only philosophy of cure.
"In cases of pure irritation," sa3"S Dr. Wood, "besides removing
the 'Cause, it is proper to diminish the nervous susceptibility and to
control the cerebral irritation by diffusing the excitement over the
whole system. To meet the first indication, narcotics may be em-
ployed ; and none is more efficacious than opium, which, to di-
minish its stimulant influence, may be combined in some instances
with ipecacuanha. Hyoscyamus, lactucarium, or conium may be
substituted, if on any account thought preferable. But before re-
sorting to these remedies, the practitioner must be very sure of his
grounds. He must be quite convinced that it is nervous irritation,
and not active congestion of the brain, that he has to encounter.
The second indication, above alluded to, is to be fulfilled by antispas-
modics, administered by the mouth, the rectum, or the skin, and by
110 ORAL DISEASES AND SURGERY.
the use of tonics, of which the metallics are deemed most efficient.
Of these the oxide of zinc has perhaps enjoyed most reputation,
thoug'h the chalybeates shouhl be preferred in anemic cases. Should
the digestion be impaired, and the system at large feeble, the simple
bitters or quinia might be preferable to the metallic tonics. These
remedies may often be combined in the same prescription. Thus,
opium or hyoscyamus, assafetida, and either oxide of zinc, carbonate
of iron, sulphate of quinia, or extract of gentian or quassia, may
very properly go together. The cold or shower-bath, cautiously
used, may also serve to strengthen the nervous system. Fresh air
and nutritious diet of easy digestion are important. Any derange-
ment in the hepatic secretions should be carefully observed, and
treated with minute doses of calomel, blue pill, or mercury with
chalk. When the disease depends on intestinal spasm, great ad-
vantage will often accrue from the use of laudanum, with assafetida
or spirits of ammonia by the mouth, the injection of musk into the
rectum, the application of a mustard cataplasm, or blister over the
abdomen ; and if, as often happens, the bowels are distended with
flatus, from the Introduction of a catheter into the colon, and draw-
ing off the air by means of a syringe. Should the disappearance of
an eruption have preceded the convulsions, efforts should be made
to restore it by friction with croton oil or other active irritant. In
urgent cases a blister might be produced, by means of a strong
solution of ammonia, on the surface previously affected.
" In frequently recurring convulsions, resisting other measures,
and threatening life, the practitioner would be justified in resorting
to the inhalation of chloroform, which will often quickly quiet the
spasms; and if reapplied with each return, may obviate the danger
until the tendency is past. It has the advantage, moreover, over
other narcotics, of not congesting the cerebral centers, though^the
danger of fatal prostration from its use must not be forgotten.
" Even when asphyxia or apparent death may have resulted from
the convulsions, hope should not be abandoned ; but efforts should
be made by artificial respiration to restore the functions of the lungs,
and consequently that of the heart."
Finally, on this subject, I may direct attention to the connection
between the troubles we are considering and the predispositions of
an hereditary nature, so often found in association. When these
deteriorative conditions exist, it is a necessity for success in treat-
ment that we consider and combat them.
5. EruiMons.— That the skin of childhood should be the subject
ASSOCIATIVE LESIONS OF FIRST DENTITION. HI
of irritative changes is certainly only what is to be expected, and
that variations in condition do most frequently occur is as true as
that they are thus expected.
Certain general considerations of the subject give us, I think, the
kej^-note. Thus, in the beginning, a momentary thought directed
to the great change v^^hich must result in the passage from intra- to
extra-uterine life, would naturally lead to the anticipation of a
cutaneous hyperemic condition at once to be developed. In intra-
uterine life we not only have the delicate and susceptible skin lubri-
cated with the soft, bland smegma, but pressure on any and every
part is jealously guarded against by the surrounding amniotic fluid.
A single minute, frequently, and the most irritative changes occur :
the waters pass away, the uterus crowds and passes upon every
part of the child, while the outside world, still less considerate, re-
ceives it on its birth, its atmosphere stimulating and irritating, its
rough points jagging and abrading, while unnecessary, and too fre-
quently ill-advised, appliances and applications add to the common
discomfort.
Cutaneous hyperismia — erythema, as it is generally called — is a
child's primary skin trouble. Such an erythema is certainly nothing
more nor less than the variegated blush of an overstimulated circula-
tion. Perhaps if the smegma were left undisturbed for a few hours,
just as nature smeared it over the body, or until the skin had be-
come somewhat accustomed to its new atmosphere, such hypersemia
would be avoided ; but as such excitability seems to do no im-
mediate harm to the child, neither nurse nor mother, I imagine,
would be found satisfied with such an arrangement. But does this
hypersemia do no harm ? Does it not provoke an excitability in the
skin which would be better absent ? Certainly children are most
susceptible to cutaneous impressions, as witnessed not only in colds
so easily taken, but by the variety of local manifestations, to the
relief of which the practitioner is so frequently called. Dental irri-
tations pertain to these troubles only as they act as excitants to
the pre-existing predisposition, or as they keep up an excitability
which overmasters the corrective force natural to the vis vitse.
Hyperemia running into an excess is inflammation. Inflamma-
tion of the skin finds a primary expression in the term dermatitis.
A dermatitis has secondary signification, as it presents peculiarities
which lead us to look for reasons for such expressions Thus, one
inflammation in the skin is a simple sthenic increased vascularity,
having the phenomena of redness, heat, pain, and swelling. A
112 ORAL DISEASES AND SURGERY.
second is not regular and honest in its expressions, but throws out
claw-like expansions, and looks dusky and threatening, throwing to
the surface, here and there, blebs of serum. We distinguish this
second from the first by the subterm erysipelas, or erysipelatous in-
flammation. Then we have an inflammation which presents the
peculiarity of studding the face of the skin with pustules, and this
derangement we distinguish by the term pustulae or pustular inflam-
mation. Another form which covers the inflamed surface with
vesicles; another which throws out groups of nodules — papular;
another which circumscribes its redness to patches — rashes; an-
other which presents raised or elevated patches — urticaria, etc. All
having alike the primary signification of a perverted circulation, but
diS"cring in presenting each distinctive phenomena, which mark dif-
ferences in local or constitutional circumstances.
That dental irritation develops or creates the distinctive features
in a skin disease is sheer nonsense. All that such irritation can
have to do with the matter is that it exhausts the system, just as
any pain exhausts and tires us, and reduces, as remarked, the
ability of the vital force to guard or protect itself against an enemy
or enemies in waiting at the threshold. It does not make the
enemy, it only lets him in b}^ weakening the bars.
That a skin disease is thus introduced, and continued in an ability
to resist applied medication, is true beyond the shadow of a doubt;
and it is for such a reason that the consideration of dental irritation,
in connection with infantile skin diseases, is most important ; and
yet this study, as the evolution of the teeth are concerned, difl"ers in
no wise from its study in relation to stomatitis, diarrhoea, or spasm, as
certainly any intelligent mind must at once appreciate. It does differ,
however, as far as a collateral treatment is concerned, and such treat-
ment implies the study of skin diseases, as in works on dermatology
the subject is presented. It comes within our province here, however,
simply to state some generalizations in such a direction, — an idea, if
the reader pleases, as to the mode which such an investigation might
be entered upon to compel it more readily to yield to us its secrets.
A thousand complex scientific terms would scarcely exhaust the
vocabulary of the dermatologist of the signification he has for the
varieties and modifications of pathological skin phases. These
thousands of conditions, however, are found to revolve around eight
centers, as radii from a star. The center of each is the nucleus or
pith of the divisions, and the subdivisions are but radii of the com-
mon substance.
ASSOCIATIVE LESIOXS OF FIRST DENTITION. 113
All skin diseases belong to one of eight orders :
1st. Pimples.
2d. Scales.
3d. Rashes.
4th. Bullffi.
5th. Pustules.
6th. Vesicles.
"Zth. Tubercles.
8th. Spots.
1. Pimples — Papulse. — Small and pointed elevations of the cuticle,
with an inflamed base — very seldom containing fluid, seldom sup-
purating, and commonly resolving as scurf.
Three primary divisions of papules are made: strophulus, lichen,
and prurigo.
Secondary divisioiis. — Strophulus intertunctus.
S. albidus, S. confertus, S. volaticus, S. candidus.
Lichen simplex, L. pilaris, L. circumscriptus.
L. agrius, L. lividus, L. tropicus.
Prurigo mitis, P. formicans, P. senilis,
P. pudendi muliebris.
2. Scales — Scaly Diseases — Squamae. — Scales or lamina form
upon the skin. Scales are of various forms. In some cases, as in
pityriasis, resembling a scurf; in other cases, as in ichthyosis, being
broad and flattened, and bearing likeness to fish scales. To mark
the various prominent differences, four varieties are enumerated:
Psoriasis, Lepra, Pityriasis, Ichthyosis.
Subdivisions. — Lepra vulgaris, L. alphoides, L. nigricans.
Psoriasis guttata, P. diffusa, P. gyrata.
P. inveterata.
Pityriasis capitis, P. rubra, P. versicolor, P. nigra.
Ichthyosis simplex, I. cornea.
3 Ba.'ihes — Exanthemata. — Irregular, variously figured patches,
appearing on various parts of the body, leaving interstices of a
natural color, and terminating in exfoliations of the cuticle. The
designation is generally limited to efflorescences, originating in fevers,
as for example measles and scarlet fever.
Bateman, however, includes, and perhaps more philosophically,
Erythema, Urticaria, and Purpura in the division.
The first division is, then, according to Bateman, Rubeola, Scarla-
tina, Urticaria, Purpura, Erythema.
114 ORAL DISEASES AXD SURGERY.
Subdivisions.— llnhco]a vulgaris, Scarlatina simplex.
S. anginosa, S. maligna, Urticaria febrilis, TJ. evanida.
TJ. persistans, U. conferta, U. subcutanea.
U. tuberosa, Purpura simplex, P. hsemorrhagica.
P. urticans, P. senilis, P. contagiosa, Erythema Iseve.
E. papulatum, E. tuberculatum, E. nodosum,
4. JiuUee. A condition in which effusion occurs on the true skin,
separating the cuticle in the form of blebs or blisters. An effusion
developed by a blister comes justly in its consideration under this
head, for it is surely not less a bleb that have produced it — the dif-
ference between such a bleb and one produced by an erysipelatous
inflammation is that one has strictly a local signification, while the
second is a systemic condition. Blebs or bullae have three primary
classifications: Erysipelas, Pemphigus, Pompbolyx.
The subdivisions are into J^rj^sipelas phlegmonodes, E. oedema-
todes, E. gangrenosum, E. crraticum, Pompholyx benignus, P. dinu-
turus, P. solitarius.
5. Pustules — Pustulse. — An inflammation of the skin, resulting in
the formation of purulent matter, which accommodates itself by
throwing up little circumscribed tumors. Whether one or many of
these pustules rise on a common inflamed base depends on the
fundamental or exciting cause ; and because the conditions which
produce pustular inflammation vary, so have we various names by
which to distinguish and appreciate these causes. Five primary
pustular inflammations exist: Impetigo, Porrigo, Ecthyma, Yariola,
Scabies.
The subdivisions are numerous, depending on peculiarity of fea-
tures. Impetigo figurata, I. sparsa, I. erysipelatodes, I. scabida, I.
rodens, Porrigo larvalis, P. furfurans, P. lupinosa, P. scutulata, P.
decalvans, P. favosa. Ecthyma vulgare, E. luridum, E. cachecticum,
Yariola, Scabies papuliformes, S. lymphatica, S. purulenta, S.
cachectica.
6. Vesiculse — Vesicles. — Yesicles differ from pustules in con-
taining lymph— they look like little water pimples, although it is
very frequently the case that the contained lymph is quite opaque:
the end of a vesicle is by scurf or scab. There are seven primary
varieties: Yaricella, Yaccinia, Herpes, Rupia, Miliaria, Eczema,
Aphtha.
The subdivisions are Yaricella lenticulus, Y. conoidaj, Y. globate.
Herpes phlyctaenodes, H. zoster, H. circinatus, H. labialis, H. pra-
putialis, H. iris, Rupia simplex, R. prominens, R. escharotica.
ASSOCIATIVE LESIONS OF FIRST DENTITION. 115
Eczema solare, E. impetiginodes, E. rubrum, Aphtha lactantiuni, A.
actultorum, A. anginosa.
7. Tubercula — Tubercles. — These are small, hard, circumscribed
tumors — they may be fixed in a state of integrity, or they may be
degenerative. There are eight kinds of these tumors — or, to express
it differently, there are eight distinctive differences: Phyma, Ver-
ruca, Molluscum, Vitiligo, Acne, Sycosis, Lupus, Elephantiasis,
Framboesia.
Among these, subdivisions seem only necessary with acne and
sycosis. Thus, there are three peculiarities in acne, which are
marked by the terms Simplex, Indurata, Rosacea. In sycosis,
Sycosis menti, and S. capillitii, designating the location of the
tubercules.
8. Macula — Spot — Mother-Mark — Freckles or Ejjhelis — Neevus.
These eight classifications, after Bateman, with his subdivisions,
make out of skin diseases all that they deserve. It is for the student
to comprehend the primary divisions, as their pathological differ-
ences are concerned ; the radii, or subdivisions, will be found to take
care of themselves. Without an understanding of the general sub-
ject one could scarcely expect to appreciate any accidental or positive
dental relations. The subdivisions will be remarked, on examina-
tion, to be simply as family surnames distinguishing one child from
another ; it is true, of course, that there are peculiarities of char-
acter, just as each child is peculiar, and, by such peculiarities, are
these modifications on the primary condition named. Now, it is not
by any means common to associate all these conditions with dental
irritations ; yet it is certainly true that any one of them may have
such association : therefore, if the student would understand one he
must understand all.
CHAPTER VI.
ANOMALIES OF SECOND DENTITION AND THEIR SURGICAL RELATIONS.
Anomalies in second dentition may be classed under seven heads:
1st. Tci'th common to the age, but erupting external or internal
to the arch.
2d. Teeth denied space in the arch, because of natural or surgical
interference with the process of maxillary enlargement.
3d. Germs, developing in positions where their product must
remain encysted.
4th. The production of supernumerary teeth.
5th. Third dentitions.
6th. Teeth, the periodonteum of whose fangs is in association
with the periosteum of the sinus maxillare.
7th. Germs, with heterogeneous development.
These seven conditions, then, because they differ from a just or
normal dental evolution, we call anomalies.
Anomaly First. — A tooth external or internal to the alveolar
arch not unfrequently gives origin to an ulcer or locates epithelioma.
Yet close as is this primary to the secondary lesion, and evident as
such relationship would seem to be, I have known ulcers of the
tongue, lips, and cheeks treated for months — of course, without suc-
cess — where it has never seemed to strike the practitioner that the
tooth could have any association with the disease ; indeed, in one
case, where the patient was remotely connected to myself, a horrible
death was the result of a cancer located in the cheek from this very
anomaly.
Note. — Even where there is excess of room, the permanent teeth
not unfrequently erupt irregularly ; indeed, this applies so directly
to the inferior incisors, that it may almost be said to be the rule
rather than the exception. Unless, however, specially indicated, it
is the best practice to leave them to nature ; they will almost always
be found to come right of themselves. I would be understood as
classing them with the anomalies only as the derangement is marked
and permanent.
(116)
ANOMALIES OF SECOND DENTITION. 117
Anomaly Second. — Teeth denied space in the arch. This anomaly
has perhaps the largest associative pathological connection.
I remarked that this lesion, if we may term it such, is more fre-
quently the fault of the surgeon than of nature. If, for one moment,
we refer to certain physiological relations existing between the first
and second dentures, we may find that it is within our power to
prevent the many ills that follow so frequently in this train, and
simply by doing little, or, more commonly, nothing.
The deciduous dental arch is filled, as we are all aware, com-
pletely by its ten teeth. The second or permanent set is to comprise
in number sixteen, and each tooth certainly quite as large again as
its predecessor. This increase in number and size of the teeth, it is
evident, must be provided for in an enlargement of the alveolar
arch. This provision is always attempted by nature in the process
described by the physiologist as the elongatory.
I will illustrate this process of maxillary enlargement by con-
sidering the ten milk teeth as so many wedges placed in a springy
arch. This arch it is designed to lengthen by additions to either
end. If, now, these wedges should be removed before others were
ready to take their place, it is evident that the elongation, being-
made at the ends, would, to a greater or less extent, be counter-
balanced by the springing together of the parts at the sites of the
removed wedges. The process of maxillary or rather alveolar ab-
sorption, is truly represented by this retraction of an arch * In pro-
portion to the number of deciduous teeth removed prematurely, will
be the curtailment in size of that arch, at least of its alveolar face.
Let us, then, look at the results of such abridgment — approximal
caries of the teeth, periosteal troubles, trismus, odontocele, necrosis,
the violent inflammations attendant on the development of the dentes
sapientiae, etc.
Note. — If there is a pathological Pandora's box, it is certainly the
lesion of an overcrowded maxillary arch.
Such condition is made evident to the practitioner the moment he
looks into the mouth of his patient: the teeth are jammed into
the most uncomfortable-looking positions ; the deformity, however,
mostly existing in the front of the mouth, — either the central incisors
override, or the laterals are thrown back, or otherwise the cuspidati
*Prof. Gross, and Mr. Tomes also, in his last book, denies this position;
why, I know not. With the greatest possible respect for the opinion of these
gentlemen, it is my experience that they are wrong.
118 ORAL DISEASES AND SURGERY.
take the tu^=k position, standing out prominently from the arch, the
bicuspids occupying too anterior a location, approximating, indeed,
not unfrcquontly with the lateral incisors.
2Vcalmcn(.— To abort the ill consequences of such a contracted
arch, extract at as early a period as possible the bicuspids of either
side.' This very simple operation will frequently not only secure
against secondary lesions, but will occasionally correct the most an-
noying deformities. But let it be remembered by the practitioner
who prefers prophylactic to operative surgery, that on his treatment
of the deciduous mouth depends, in a measure, the health and com-
fort of the adult.
If I am asked what is to be done with the deciduous aching tooth,
I may answer that the tooth should have been filled on the first ap-
pearance of decay; the dentist has in his armamentum plastic ma-
terials which he can employ in such cases, and which will be found
to answer admirably the purpose of their intention.
Equal parts of chloroform and tinct. aconite applied to the nerve
on a delicate pellet of cotton, will sometimes instantaneously cure
this form of toothache. Arsenical applications are not unfrcquently
employed, but unless the practitioner is very conversant with the
physiological change that occurs in the fangs of these teeth he had
better not use it ; if, however, he feels prepared to employ escha-
rotics, he can prepare no formula better than the following :
R. — Acidum arsenicum,
Morphias sulph. aa gr. x;
Creasote, q. s. to make a thick paste.
This is the paste so universally employed by the bettor class of
dentists for destroying the pulps of adult teeth. To apply it, take a
piece not larger than a pin's head, and dropping it lightly into the
cavity, cover loosely with cotton ; the cavity is washed out with
warm water after ten or twenty hours. I would not leave it in a
deciduous tooth over ten hours ; and if absorption of the fang had
advanced to any extent, even one might be too long. Employ it
fearlessly in the adult mouth, only remembering you deal with
arsenic, but with the child be careful. Equal parts of tinct. of
iodine and Monsel's solution of the perchloride of iron is also an
admirable application. I have stopped a raging odontalgia instan-
taneously with this combination. Give the mother a prescription
for this last, or some sedative formula, but do not pull out the teeth.
The central incisors of the deciduous set should last until the
ANOMALIES OF SECOND DENTITION. ng
seventh year; the laterals until the eighth; the first deciduous molar
until the ninth year ; the second until the tenth ; the deciduous
cuspid until the eleventh ; and let it be remembered that the most
posterior molar teeth that are in the mouth at the sixth year are
the first permanent molars, and that these teeth get their place in
the jaw, without displacing any of the deciduous.
For an account of some of these secondary lesions, together with
treatment, see a future page.
Anomaly Third. — This anomaly is remarked by examination of
the classes of teeth erupted. Teeth all erupt in pairs, so that one is
not likely to be deceived. The anomaly is not unfrequently the re-
sult of interference with the development of the germ of the perma-
nent through non-absorption of the root or roots of the deciduous
teeth.
Example. — A deciduous central incisor erupts — as the rule — about
the seventh month, and is succeeded by the permanent at the seventh
year. Now the physiological relation existing between the two
teeth is as follows : at the time when the deciduous has attained
its fullest development the germ of the permanent is at its apex.
Retrograde metamorphosis now commences in the fang of the de-
ciduous, while, in an inverse ratio, the development of the perma-
nent advances. Now, it sometimes happens that no process is set
up for the taking away of these deciduous fangs, and, as a conse-
quence, the permanent are compelled to make alveoli for themselves ;
this they generally do by emerging posterior to the deciduous ; but,
as can readily be imagined, odoytocele or encystment is not unfre-
quently a result.
Note. — Sometimes, long after the period at which the second
dentition is usually completed, the incisors, as would seem to be
natural, may be remarked, each occupying its respective alveolus.
Yet here we may have odontocele. One of the incisors that we see
is a milk tooth. This anomaly could, however, deceive only the
very superficial observer, the difference in the classes of teeth being
sufficiently marked.
Because of this non-absorption of deciduous fangs, arrest in the
development of the permanent sometimes occurs. It is really quite
a nice point in practice to give advice in such cases ; if you direct
the extraction, and no tooth comes to replace the one lost, you will
be sure to get a good deal more censure than you could possibly
deem yourself deserving.
There are a number of conditions to take into the consideration
120 ORAL DISEASES AND SURGERY.
of such a case— the most pronunent one of which is, the existence
or non-existence of the anomaly in a hereditary point of view. I
am acquainted with a family where continued integrity on the part
of certain front teeth, conjoined with the non-appearance of the per-
manent, has been a striking peculiarity as far back as the ancestors
can be remembered. Ability to advise, in such cases, can only be
gained by a careful study of the laws of dentition.
Surgical Relations.— In an examination of any obscure tumor of
the maxillary bones, examine the dental arch ; if a deciduous tooth
occupy the place of a permanent, the existence of odontocele may be
rea-onably inferred.
Anomaly Fourth. — Supernumerary Teeth. — These teeth differ
from all others in being doul)ly conoidal ; this is the rule. It is, how-
ever, to be remembered that we meet with exceptions. Harris men-
tions having seen them so resembling the natural teeth as "to make
it impossible to distinguish which should be called the super-
numerary;" as for myself I have never met with such decided
exceptions.
An encysted condition of these teeth obscures very much the
recognition of their existence. In diagnosing diseases of the mouth,
we must bear in mind that we have such odontoceles. The study
of their evolution is very interesting ; but, of course, concerns the
physiological rather than the surgical author. We may remark,
however, that they are not necessarily a dermatic production, and
the appearance of them in the mouth is as unaccountable as their
association with ovarian and other remote tumors.
Surgical Relations. — With the exception of their relation to
tumors, we have only to deal with them as they so strangely
present themselves in the mouth. Let me give an example of such
practice. A patient presents himself and tells you that there is a
piece of bone working out through his mouth ; and, truly, an exam-
ination will seem to verify his assertion. But there is one point
which, if observed, will never mislead. Necrosis is always pre-
ceded by, and is associated with, inflammation. The eruption of a
supernumerary tooth is very gradual, and, so far as my experience
goes, is never associated with inflammation. To extract such teeth,
wait until they have emerged to the base of the cone ; or, if such
waiting does not seem desirable, carefully force sharp-pointed forceps
through the bone until you may be able to grasp this cone, then
with a rotary motion you may easily pull them aw^ay. Their alveoli
need no attention.
ANOMALIES OF SECOND DENTITION. 121
Anomaly Fifth. — Third Dentitions. — I would not be understood
as referring here to that extra development sometimes occurring in
young adult life, and yet the mention of the existence of such an
anomaly is, perhaps, desirable. Thus Columbus reports that one of
his children had three sets of teeth. Valerius Maximus and Pliny
relate similar facts. A son of Mithridates is said to have had two,
and Hercules three. I myself have seldom seen this anomaly, and
incline to think that its existence, in these modern times, is not co-
extensive with the ancient period I have certainly had quite five
hundred persons tell me that such and such tooth or teeth were the
third of the class, but examination, in almost every individual case,
has satisfied me they were mistaken ; this anomaly has, however,
surgically, little or no signification.
Third dentitions, as here referred to, are those which are asso-
ciated with advanced age. The student will recognize their phys-
iology when I classify them with second sight, etc. The lesions
of this anomaly are what might be termed associative — that is,
we are occasionally so deceived by them as to be led falsely to in-
terpret engorgements, congestions, etc.
A single case will illustrate the anomaly: an individual, aged
sixty-five, applied to Dr. Harris, suffering with pain in the gums
and jaws. No local lesion was at all discoverable. A tentative
treatment was resorted to. The apparent disease went on, however,
entirely uninfluenced by the experimental medication, until, at last,
it attained an intensity positively excruciating. In twenty-one days
the mystery was explained by the eruption of a third set of teeth.
Anomaly Sixth. — Association of the odonto-periosteum with the
membrane of the antrum of Highmore.
It will be remembered that the most easy entrance to the max-
illary sinus is through the palatine fang either of the second or first
molar tooth. It is, indeed, as I well know from experience, a very
common thing to find the roots of these teeth perforating the cavity.
Remembering this association of parts, it will be seen that many
conditions, which may have been deemed obscure, are thus made
very plain. Dr. Harris, who was a close observer in diseases of
the mouth, went so far as to say that two cases, mentioned by Bell
and Bordenave, were the only authenticated exceptions where ab-
scess had formed in this cavity at any other point than that at which
it had been penetrated by the root of a tooth.
A case mentioned in Braithwaite, from the practice of a Mr. Louis
Oxley, of London, illustrates most happily the relations of this
122 ORAL DISEASES AND SURGERY.
lesion : A young woman, of rather strumous habits, complained of
a (hill, aching pain under the orbit. The pain lasted from three to
four months, attended by a gradual elevation of the orbital surface
of the maxilla. The eye above this surface became at length so
aCFccted as entirely to lose its functions. At this stage of the
case the young woman was directed to use leeches and blisters be-
hind the ears, and to employ drastic purges. After three months'
blindness, the patient first perceived a discharge, from the right nasal
fossa, of a thick, purulent fluid. This discharge had existed, he says,
ei"-hteen months, when he first saw the case. An examination of
the mouth at once revealed the cause of so much misery, and the
removal of three roots, in a state of periostitis, was the simple
means by which two most important organs regained their proper
functions.
The nasal opening of the maxillary sinus, it is known, is, in a
healthy condition, almost closed by the duplicature of membrane
lining the turbinated and neighboring bones ; congestion of this
membrane not unfrequently closes it entirely. Thus secretions ac-
cumulate, giving alarming and threatening disfigurements to the
face. The weakest points in the osseous boundaries of this cavity
are, the floor of the orbit, the hard palate, the tuberosity of the
bone, and the canine fossa. Any accumulation would necessarily
be most apt to vent itself at one of these four points, unless atresia
of the duplicated membrane alluded to should occur, and which is
not commonly the case.
Note. — My own experience regarding abscess of the antrum is,
that in the great majority of cases the pus seeks to vent itself
through the floor of the cavity. After the inflammatory action has
passed to the suppurative stage, you will notice a swelling in the
roof of the mouth at the side of the mesial line, corresponding to the
diseased cavity : this is the abscess pointing, and, if left to itself,
will be sure to make an ugly opening. Such a result will be found
particularly undesirable if there should be any specific virus linger-
ing in the system. But wherever this abscess should tend to point,
it is of course desirable to abort it.
If the assertion of Harris is true, concerning the almost invariable
dental origin of this abscess (and certainly my own experience, so
far as it goes, confirms him ; for, while I have seen several cases of
this kind, I have yet to meet with one w^here the treatment indi-
cated was not of a surgico-dental character), we turn naturally to
the alveolar arch, seeking there the source of offense and defense.
ANOMALIES OF SECOND DENTITION. 123
For a single momeut, then, let me direct attention to a few dental
lesions of the most practical character, and without the ability to
recognize which, the practitioner will assuredly find himself at sea.
Because, when you turn to this dental arch, you find it entirely
clear of teeth, and healthy-looking, you are not hastily to conclude
that the primary lesion is not in such direction. You are to re-
member that fangs of teeth are not unfrequently broken oif in an
attempted extraction, and that when so broken, particularly deep in
the socket, the dentist is not unapt to leave such pieces alone. Now
it is easy to understand that a fang so situated may be the source of
extensive disease, and yet the gum over it be without bi'eak in its
continuity, and perfectly healthy-looking. The rehition, in such a
case, of the fang is with the antrum — it need necessarily have no
external sinus. Make here an explorative incision along the gum
down to the bone. If, happily, you come to a cavity, you will have
hit on the origin of the trouble ; but if you find nothing, you have
made only a simple incised wound, which left to itself will generally
heal in a few hours.
Again, because the part may have its usual complement of teeth,
and each tooth should seem perfectly healthy, you are not to turn
hastily away. There may be in one of these teeth a dead pulp. To
satisfy yourself on this point, take up a delicate steel instrument,
and strike with it each tooth separately, directing your patient to
note any difference in the sensations ; if he should start when you
strike a particular tooth, my veracity for it, you have found the
primary lesion. But still again, the lesion may be here, and yet the
patient not express the anticipated pain. Take now a hand-mirror,
and placing your patient full in the sunlight, reflect the rays over
the teeth, — if there is a dead tooth, you will remark an opacity in it
not belonging to its neighbors : this is the tooth ; extract it.
If a tooth has a plug of metal in it, take the filling out, — the
cavity will, not unlikely, be found to communicate with the pulp
chamber.
If, now, for a few moments, we study periodontitis, the student
will be prepared to make the most of the cases which we shall have
to consider under various heads associated with such lesions.
Periodontitis means inflammation of the periosteum which sur-
rounds the fang of the tooth. Its causes are manifold : scurvy,
syphilis, ptyalism, a dead pulp, direct injury to the part. It is
sometimes an idiopathic affection, — stomatitis from any cause may
provoke it, simply by continuity of structure ; it is very common
124 ORAL DISEASES AND SURGERY.
after the dentist has destroyed the pulp of a tooth and filled the
fano-s with gold or other metal. A common cause, as remarked,
is an overcrowded condition of the alveolar arch.
Periodontitis commences with a dull, heavy, gnawing pain : this
is the state of simple vascular excitement in the part. As the grade
of inflammation advances, the pain increases with it, the tooth seems
to project beyond its fellows, and really does so ; occlusion of the
jaws gives agonizing pain ; finally, if not arrested, the action goes
on to the suppurative condition, yielding alveolar abscess. Now,
it is to be borne in mind that gum-boil is alveolar abscess, and this J
is the way in which the pus formed commonly vents itself; but, "
from cases hereafter mentioned, it will be seen that so simple a
thing as alveolar abscess may utterly confound and deceive even
very experienced men.
Alveolar abscess almost invariably runs into a chronic condition.
When discharging on the gum, it may run through the features of
gum-boil once a week, or once a month, for years; it will dischai'ge
from a single drop to a spoonful of pus per day ; will be one day
apparently well, and the next in full discharge. The excruciating
pain referred to, pertains almost exclusively to the original inflam-
matory attack, although the tooth continues more or less sore until
a complete cure is eftected. The inflamed periosteum of one tooth
will not unfrequently so affect surrounding parts that a patient can-
not possibly locate the seat of pain. (See chapter on Trismus.)
Diagnosis and Treatment. — The afl"ected tooth will always re-
spond to a stroke from a steel instrument, whether the attack is
of the acute or chronic form. No such response is made so mark-
edly in any other form of odontalgia.
A periosteal inflammation may, in nine out of twelve cases, be
aborted as follows : pass a lancet several times through the gum
down to the alveolus ; let the patient hold water in the mouth so as
to prevent the formation of clot, and provoke free bleeding. As
soon as the vessels and capillaries have disgorged themselves, paint
the parts heavily with tinct. of iodine, the officinal strength. The
philosophy of this treatment is sufficiently evident not to need ex-
planation.
Chronic periosteal inflammation is most certainly cured by extract-
ing the offending tooth ; when this, however, seems undesirable,
inject through the sinus, which passes from the gum into the cyst,
at the root of the tooth, the tinct. of iodine ; do this for three or four
days, and tnen force through the sinus a tent of cotton. Leave this
ANOMALIES OF SECOND DENTITION. 125
tent to nature ; its ejection will most generally be found to be the
result of the healthy granulations which will have obliterated the
cyst.
Anomaly Seventh. — Germs of Heterogeneous Development. — It
occasionally, indeed frequently, happens that the dental germ, instead
of arranging its parts according to the ordinary laws of its nature,
assumes the most fantastic and heterogeneous shapes, giving such a
variety of appearances that only a close attention could appreciate
its dental character. Tumors of complex kinds are thus occasionally
produced, and, unless appreciated, are necessarily the source of much
anxiety both to surgeon and patient. In the admirable memoir of
M. Forget, crowned at the Academy of Sciences, Paris, in 1859, are
illustrations of cases both of this seventh and the ordinary anomalies.
I present them to my readers as being quite as satisfactory studies
as perhaps could be selected.
126 ORAL DISEASES AND SURGERY.
PLATE I.
Fig. 1.— ft. Osseous tumor united to a molar tooth (a).
Fig. 2.— a, b. Section of the tooth and of the tumor.
Fig. 3.— a, b. Dental tumor formed by the anomalous development of the
first two molars,
fl. Summit of the tumor, b. The root of the tumor.
Fio. 4.— a. Cyst of the right branch of the inferior maxillary bone, the
cavity of which is made visible by the circumferential resec-
tion of its external wall.
b. A molar tooth inclosed in the osseous tissue, and e?i relief upon
the bottom of the cyst.
c. External wall of the cyst, inverted.
d. Condyle and neck of the jaw.
e. Summit of the coronoid apophysis, with the insertion of the tem-
poral muscle.
Fig. 5. — Upper jaw of a horse; view of half of the palatine face.
a. Osseous cyst developed in the interior and right side of the jaw;
it includes the tumor represented by Fig. 6.
b. Eight canine, thrust backward and inward toward the medio-
palatine line.
d. Alveolus of the left canine tooth.
e. Osseous perforation, conducting to the interior of the cyst.
Fig. 6. — Intramaxillary osseous tumor (natural size); it was contained in the
cyst represented in Fig. 5.
Fig. 7 (300 diameters). — Kepresents a part of the section of the tumor shown
in Fig. 6. This tumor appears to be formed entirely of the
cement or osseous substance surrounding the dental root. It is
an exostosis of the dental cement. This exhibits the structure
described in the explanation of Fig. 4, Plate I.
a. Vascular canaliculi of the osseous substance of the tumor (Havers'
glands). The tumor traversed by these as in the normal osse-
ous substance — only they are more rare, more scattered, and
more irregularly distributed.
b. Osteoplasts disposed circularly, or nearlj' so, in a concentric man-
ner around the Haversian canal, but less exact and evident than
in the normal condition.
c. The osseous substance, properly so called, in which the osteoplasts,
or characteristic cavities of the osseous tissue, are excavated.
IFXiJ^TIB I.
F^i
Us- 2
(127)
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(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^<f, hard almost as stone, and distinctly divisible into three
lobes. The patient assured me that, with the exception of an occa-
sional sharp pain, she felt little or no inconvenience.
At this visit, more than ever satisfied with my diagnosis, I re-
urged an operation, but which was as decidedly refused as before.
On a Saturday morning I was again called to see the patient.
She was suffering from another of the inflammatory attacks : the
most severe she had ever experienced.
Examination discovered the tumor swollen to such an extent as
to throw the tongue over into the left cheek. Mastication had been
impossible for three or four days, while the ability to swallow was
being very rapidly lost ; yet with all this inflammation, there seemed
no tendency to the formation of abscess.
Placing the old lady in an arm-chair, before the window, with-
out asking permission or offering any suggestion, I managed to get
the mouth under my control, and, before she was aware of the in-
tention, I passed a bistoury directly through the body of the tumor
— the knife grated over some hard substance.
After a time spent in making peace, in which I was greatly as-
sisted by the assurance I was enabled to give of the dicovery which
would result in her immediate cure, I proceeded to the dissecting
out of the foreign body. This, as anticipated, proved to be a salivary
calculus. The specimen is now in possession of my friend. Dr. D. H.
Agnew, to whom I presented it for the pathological museum of the
Philadelphia Hospital, and is, perhaps, one of the largest on
record.
The pathology of such a lesion is at once appreciated, the forma-
DISEASES OF THE TEETH.
219
tion of the calculus in this region was merely secondary to the occlu-
sion of the mouth of a gland duct.
Dr. J. J. Woodward, who made an analysis of a portion of the
calculus, informed me that he found it composed almost exclusively
of the phosphate of lime, only a very small trace of the carbonate
being perceptible.
Saw Mrs. Boyd, for the last time, one month later. All induration
had so completely disappeared that I think it would be difficult for
any one who had not seen the case to say which side of the mouth
the tumor had been removed from ; not the slightest perceptible
tendency to ranula being visible.
The treatment of the ordinary collections of tartar is very simple,
and may be made very effectual. Various cutting and scraping in-
struments, very well understood by glancing at the engravings, are
used in the process of removal. The operation consists simply in
scraping away the mass, being careful not to scratch the enamel,
and afterward polishing the teeth ; using for the purpose, first, pul-
verized pumice, afterward an ordinary burnishing instrument.
Fig. 40. — Instruments employed in removing Tartar from Teeth.
To prevent re-collection, the action of the glands is to be increased,
either by local or constitutional sialagogues, as seems indicated. Or
if the practitioner doubts, in any individual case, the advisability of
such prescriptions, then pumice-stone, finely pulverized, may be used
with a good stiff brush ; or, what I think will be found a still better
plan, the patient may, each few days, standing before a mirror, use
the pumice on a piece of soft pine or orange stick.
220 OFAL DISEASES AND SURGERY.
Salivary calculus has been thought to produce caries and necrosis
of the alveolar processes. I do not, however, remember in my own
practice ever to have seen such a result. As the teeth drop out the
calculus falls away with them, and thus its power for evil ends. A
sponfry and scorbutic character of gum tissue, and consequent hem-
orrhage, are very common associations; but the practitioner at once
sees that the cure is in bis own hands.
CHAPTER XI I.
DISEASES OF THE TEETH.
DENUDATION.
This affection, at once appreciated by referring to the drawings,
is, without doubt, one of the most deforming conditions to which the
dental organs are subject. It is sometimes seen attacking every in-
dividual tooth, at others, confining its ravages to a very few. A
very common seat of the affection is where the gum festoons. Here
may be seen a sulcus or groove passing from tooth to tooth, involv-
ing all those situated in the anterior part of the arch. Another
form of the affection involves the cutting edges alone, while in still
other cases the depressions are situated promiscuously over every
portion of the teeth.
The disease, commencing as a slight gutter or break in the
enamel, progresses with a varying degree of rapidity, sometimes
Figs. 41 and 42. — Denudation.
moving with such slow pace as scarcely to be observed from
year to year; in other instances, and these, unfortunately, much
the most frequent, making constant attention necessary to the pre-
servation of the organs. Occasionally the process begins at a num-
ber of points, and these enlarging, finally coalesce, to the destruction
not unfrequently of all the anterior enamel wall.
Concerning the cause or causes inducing this condition much
diversity of opinion exists. My own conviction is that it is mark-
edly a disease of predisposition, the result of impressions made on
the enamel at the period of its formation, and which predisposition
has never by accident or design been corrected. Why some of these
teeth should denude rapidly and others slowly must depend on both
intrinsic and extrinsic circumstances. That these circumstances,
(221)
ooo ORAL DISEASES AND SURGERY.
however, arc not appreciated from that practical stand-point which i
should enable us to use them for the benefit of the patient, is un- I
fortunatolv too true. Except as a mechanical treatment is concerned i
we can only look on, and trust for a speedy and limited line of de- {
markation. I am in the habit, however, of prescribing freely of the 1
lime tonics ; but whether such treatment does any good I do not
feel myself able to say.
Another source of dental trouble in this direction arises from spon- |
taneous or mechanical abrasion of the cutting edges of the teeth. '
Spontaneous abrasion is a most infrequent aflfection, and where not \
traceable to mechanical action is too obscure to permit the venturing
of an opinion. The supposition that the parts are chemically de-
stroyed by the secretion of an acid secreting gland, which it is claimed
has been discovered in the apex of the tongue, is akin to many simi-
lar suppositions.
Abrasion of the teeth from mechanical causes is a very common
affection, and a very unfortunate one. The articulation of the two
dentures has much to do with the production of such a condition ;
indeed, everything, if w^e would except an abnormal softness of enamel
as found in certain teeth. Teeth that articulate scissor-fashion, the
one set over or in front of the other, seldom suffer from this trouble.
It is most markedly an affliction of direct articulation.
Per.sons having jaws thus articulated find their teeth year by
year wearing shorter ; and was it not that, as this abrasion goes on,
nature offsets the waste by internal repairs, throwing out layer after
layer of osteo-dentine, the dental pulps would be quickly enough
exposed.
The character of food used, w^hile perhaps it would never yield
this condition, yet the predisposition in the articulation existing,
without doubt assists in the destruction. Thus it is remarked, that
sailors eating constantly of hard bread, and chewers of tobacco, are
most subject to abrasions ; but this is only true strictly as it applies
to such as have this peculiarity of articulation, and wnth such the
progress of the abrasion is very rapid.
A means of relief, which, wiiile fairly successful, is associated
with much discomfort, consists in the adaptation to the posterior
teeth of caps of metal ; these caps take the strain off mastication,
and thus protect the teeth. Another mode, but which is apt to
excite odontitis, consists in cutting out cavities from the abrading
faces of the teeth, and supplying the place of the removed dentine
with plugs of gold. This latter plan has many advocates, and is
highly commended by practitioners of experience and judgment.
CHAPTER XII I.
THE EXTRACTION OF TEETH.
The extraction of a tooth is an easy or difficult matter, according
as the principles involved in the operation are clearly or obscurely
comprehended. In the adult mouth there are thirty-two teeth, and
these, as the study of their extraction is concerned, are compre-
hended under six classes.
Fig. 4o. — Diagram of Teeth.
Fig.
44.
Q
1
PI
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P
^B(
111
iffl
[ M
H^_/J|^H
■Hirlj
Bfi' ""i^H
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H 1^1
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^Ki
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w
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i'lg. 4ii, permanent teeth of upper jaw. Fig. 44, of lower jaw. 1, 2, incisors; 3, canine;
4, 5, bicuspids or small molars ; 6, 7, 8, largo molars or grinders.
The first of these classes embraces the eight central and lateral
incisors; teeth with cone-like roots, and accommodated in alveoli
representing hollow cones.
The second class embraces the cuspidati, and are represented by
the partly flattened cone.
(223)
224 ORAL DISEASES AND SURGERY.
The third class embraces the bicuspidati, and are represented by
the flattpnod cone.
The fourth class embraces the superior first and second molars,
teeth having three roots, two external cone roots, situated antero-
postoriorly, with the interspaces looking toward the cheek; the
third, gonerally a flattened root, looking toward the palatine arch.
The fifth class embraces the inferior first and second molars, teeth
having two roots, one looking anteriorly, the other posteriorly ; the
interspace looking outward and inward.
The sixth class embraces the four wisdom teeth. These are single-
rooted as a rule, with a curve looking backward.
To extract a tooth of the first class, the application of the force is
required in a twofold direction, rotatory and downward, or upward,
as the case may be.
To extract a tooth of the second class, the force is required in a
threefold direction, downward or upward, lateral, and rotatory.
To extract a tooth of the third class, upward or downward, and
lateral, or inward and outward, as one loosens a nail.
To extract a tooth of the fourth class, the same application of the
force; one-half of such a tooth is, however, to be extracted at a
time — that is, we first break the attachment of either the inner or
outer roots, and feeling these yield, the force is instantly brought to
bear upon the other. In extracting 4:eeth of this class in this man-
ner, much care is necessary in guarding against a too great extent
of lateral motion ; otherwise the roots, instead of yielding, will be
found to break, thus complicating matters very seriously.
Teeth of the fifth class require the lateral and direct application
of the force ; they are to be gently rocked inward and outward until
felt to yield, when they are at once to be lifted from their sockets.
Teeth of the sixth class are to be carried backward and upward,
or downward, in the line of the axis of their single curved root ;
such applications will make easy an extraction which might other-
wise be attended with much risk.
INSTRUMENTS.
Instruments are now made in consideration of the anatomical pe-
culiarities of the teeth for which they are intended.
Figs. 45 and 46 represent instruments adapted to the formation of
the incisors, both of the superior and inferior jaws.
Fig. 45 represents, when closed, a hollow cone, the least circum-
EXTRACTION OF TEETH.
225
ference of which is at the free edge. Reference to the incisor teeth
exhibits them as double cones, the base abutting just external to the
alveolar process. This instrument, if thrust beyond the bases of
Fig. 45. — Incisor Forceps for Sitertor Jaw.
Fig. 46. — Incisor Forceps for Inferior Jaw.
the cones, is found to have the firmest possible hold of the tooth,
and to fit it perfectly in its various diameters. To apply it, if the
tooth is situated in the superior jaw, the operator stands to the right
Fig. 47. — The Matnarc Forceps— Eight and Left.
of his patient. If the lower jaw is the seat of operation, I think it
will be found most convenient to seat the patient upon a low chair,
15
226 ORAL DISEASES AND SURGERY.
and stand directly back of bim, using the curved forceps, and lean-
ing over his head to make the extraction.
The same instruments apply equally well to teeth of the second
and third classes; the straight forceps for the superior jaw, the
curved for the inferior. The applications imply the same positions.
Than the Maynard forceps (Fig. 41) nothing, I think, could be de-
vised more happily meeting the anatomical requirements of class four.
The outer beak, horn-shaped, is designed to slip in the interspace
between the two buccal roots. The inner beak, flat and grooved,
fits accurately and firmly against the palatine fang. These forceps
are, of course, in pairs, and apply, the one to the right side, the
other to the left.
Other forceps are also in use for the extraction of these teeth, and
it might be desirable to have one set at least beside the Maynard.
Fio. 48.— The Ordinary Molar Forceps— Right and Left.
To apply these forceps the operator stands to the right of his pa-
tient, precisely as in the case of teeth of the first three classes, the
left arm passing around the head, the fingers of the left hand holding
the lip out of place. In using the Maynard forceps care must be
taken to thrust the point of the horn directly into the interspace,
otherwise the operator would have no hold on the tooth ; this being
in position, the flat blade is carried along the palatine fang as high
as possible. A few rocks of the tooth inward and outward, com-
bined with a direct force in the line of its long axis, and it will be
found to give way.
Fig. 49 represents a forceps, invented by the same gentleman, for
the extraction of class five. This consists of two hornlike beaks,
which, as is seen by reference to class five, are admirably adapted to
EXTRACTION OF TEETH.
227
the interspace looking outward and inward. To apply this forceps,
which is equally adapted to either side of the mouth, the patient is
to be seated upon a low chair, while the operator stands behind and
leans forward over the head. The gum being well lanced, the beaks
of the forceps are thrust down until they are felt entering the inter-
spaces, the exact center line of the tooth corresponding to this space.
Fig. 49. — Maynarb Forceps for Inferior Molars.
So direct and happy is the application of force with this instrument
that it is not unfrequently the case that the simple closing of the
handles will cause the tooth to start from its socket. A few rocks,
however, inward and outward, will always easily effect the extrac-
tion. The great advantage of the instrument over such as are or-
dinarily used, is markedly evident where a tooth is much decayed
about its crown ; the instrument lifting from beneath rather than
exerting pressure upon the crown. These instruments of Dr. May-
nard cannot be too highly applauded.
Fig. 50. — The Phtsick Forceps.
Fig. 50 represents a forceps, designed by the late Dr. Physick, for
the extraction of the wisdom teeth. This instrument, as is seen, is
a double inclined plane, and, in consideration of the necessity of
throwing these teeth backward, is designed to be applied between
the tooth to be extracted and the one directly anterior to it. The
closure of the handles is expected to throw the tooth from its
socket.
It sometimes occurs, however, that these teeth, as is seen in the
228 ORAL DISEASES AND SURGERY.
superior tooth in the drawing, have more than a single root; and
these roots, instead of being inclined in a common axis, are fre-
quently spread out in various directions. In cases of this kind
it is plain that the instrument would not apply. Another objection
to its use lies in the injury apt to be inflicted on the anterior or ful-
crum tooth; this not unfrequently having the enamel so crushed and
broken as to expose the more susceptible dentine, and thus lead to
caries. Still another oVijection lies in the contusion inflicted on the
periosteum, this membrane being occasionally so injured as to result
in its severe inflammation.
Fig. 51.— Forceps for Wisdom Teeth.
Fig. 51 is an instrument, a modification of Maynard's cow-horn,
employed by myself in the extraction of this class of teeth, and
which I find to answer the end very satisfactorily.
With this instrument, bent, as is seen, at nearly right angles, one
has little difficulty in getting at either upper or lower teeth, and the
inclination backward is not at all difficult to be given. Two pairs,
right and left, are required. The ordinary key instrument, if lightly
and delicately made, answers a very admirable purpose with this
class. The roots being generally quite short, there is none of the
common danger of alveolar fracture, and being but lightly set in
their sockets, and easily yielding, the application of but very little
force is required.
In using the key, the fulcrum should be placed on the inner face
and well back upon the tooth, the claw being upon the opposite face
and well in front ; this application allows of the proper direction of
the force, and admits of the easy and natural removal of the organ.
Another instrument employed in the extraction of these teeth is
the elevator.
To apply this instrument, the grooved face is laid against the
antero-lateral aspect of the tooth, and being carried down to the pro-
cess, the hand is depressed so that the free edge alone impinges; the
tooth is then pushed outward from its socket, and backward. When
wisdom teeth are not too firmly adherent, this is an admirable in-
EXTRACTION OF TEETH.
229
strumcnt for their removal ; care, however, is necessary that it
shall not slip from the tooth and inflict injury on the neighboring
soft parts.
Fig. 52. — The Elevator — Yakious Forms.
Extraction of Fractured Teeth and Roots of Teeth. — It not
unfrequently happens that in attempts to extract teeth, fractures re-
sult ; and such fractures must, of course, present the greatest variety
of aspect, and require various resources for the removal of the parts
left.
Teeth of the first, second, and third classes present the same com-
mon features of fracture, and may claim a first attention. Fig. 53
represents the alveolar line, and the various relations held to this
line, or free laorder, by fractured teeth or roots.
A fractured tooth, as represented by Subfig. 1 (the first root to
the left), is placed in no worse condition for easy extraction than
230 ORAL DISEASES AND SURGERY.
before the occurrence of the accident. The same forceps and the
same manner of its application still apply to it.
Subfi". 2 represents a slight modification of the same condition.
The one forceps and the one application still, however, apply. It
is advisable, if the tooth is at all brittle, to work the blades of the
instrument well beneath the alveolus. This affords greater support
and yields increased security.
Fig. 53. — Relation of Fractured Roots to Alveolar Line.
1. 2. 3. i. 5. 6. 7.
Subfig. 3 may represent a bicuspid tooth with the crown half
broken away. In such a case, if the remaining portion is not at all
brittle, and if the process is soft and spongy, the forceps, as de-
scribed, having well-sharpened blades, may again be tried, working
them well beneath the process, and securing all the hold possible on
the root. If fracture again occurs, which, indeed, is very likely,
simulating figures 4 and 5, the cutting forceps is to be employed.
To use a cutting forceps, make, with a scalpel or other blade, an J
incision on either side of the root through the soft parts directly
down to the process; these cuts must correspond with the exact
center line of the root. The forceps is now to be applied scissors-
fashion, cutting directly through the bone. Being thus brought in
contact with the root, and grasping it perhaps full half its length,
the removal is, of course, a perfectly simple matter.
Some operators prefer to precede the cutting forceps with the
elevator, and this instrument, in many cases, certainly effects the end
very well.
In the application of the cutting forceps, it not unfrequently hap-
pens that, from want of care, the blades, instead of coming directly
upon the root, slip to the back or front of it. In these cases the
fang may generally be easily enough picked out with the ordinary
root forceps. A form of cutting forceps used by many, consisting of a
double curved blade, avoids this accident, but it is to be objected
to on account of the wound it makes.
Roots, represented in 4, 5, 6, and 7, are removed on a common
EXTRACTION OF TEETH. 231
principle. The first attempt is to be made with the elevator : lay-
ing the groove of this instrument closely against the root, its
sharpened knifelike edge is insinuated between the fang and pro-
cess, being worked down as far as possible. The handle is now
carried obliquely to the line of the root, and thus, with careful yet
oscillatory motion, the piece is forced from its bed. It is very well
known, however, that with a dense, heavy, alveolar process, this
instrument cannot be made to operate so happily, it being next to
impossible to insinuate it between the bone and tooth. Under these
circumstances, another instrument, the screw, may be brought into
requisition. See Fig. 54.
Fig. 54. — The Screw.
The screw is designed to operate upon the tooth root as the spiral
operates upon the cork. Well tempered, and very sharp, it is intro-
duced into the pulp canal, and quietly and gently turned until it has
taken a firm hold. A simple direct movement, and the root is brought
away.
It may happen, however, that no hold suflSciently firm for the
extraction can be obtained with this instrument. When this is the
case it may be laid aside, and the always reliable cutting forceps
brought into requisition. If preferred, however, the screw can be
bored into the tooth until fracture is produced, and this will some-
times enable us quite easily to pick away the splinters: particularly
will this be found to be the case when the line of the fracture divides
the root in its length.
Roots of the molar and wisdom teeth, superior and inferior, are
removed on a common principle. In the use of the elevator, a very
happy result is not unfrequently secured by applying the blade to
the inner face of the root, carrying the shank across the mouth, and
making a fulcrum of some convenient opposite tooth.
Where the roots of a molar tooth are so firmly fixed as to seem
incapable of removal with the application of an ordinary amount of
force, it is better to divide them. This is easily done with the
232 ORAL DISEASES AND SURGERY.
cutting forceps, and, after the separation, each root may be picked
out sinffly, and generally with comparative ease.
Deformed or Anomalous Teeth.— Understanding the principles
on which teeth of ordinary character are extracted, the practitioner
needs little instruction so far as anomalies are concerned.
Subfigures 1, 2, 3, 4, and 5 represent five anomalies, and they may
very well stand for the class. In removing such teeth from the
mouth, the matter of greatest importance is to recognize them. Now,
while this cannot in all cases be done so as to appreciate exactly
the condition of the roots, yet we can always say that some impedi-
ment to the removal exists ; and this, after all, is the most important
matter, as it influences us in the amount of force exhibited, and
which, too freely rendered, might result in fracture of the bone, or
still greater injury to surrounding parts.
A tooth, as represented in Subfig. 1 (the first to the left), will
generally yield in its roots so as to pass the intermediate piece of
process. If it does not so yield, then this wedge of bone will frac-
ture and be brought away. Such fracture, however, results in no
harm, and is to be esteemed of little consequence.
Subfig. 2, by the great curve in the root, is made incapable of
passage, unless, after being loosened, it is carried outward in the
direction of the axis of the curve. In this way it is easily removed.
The character of the curve is recognized by the resistance offered
when the tooth is carried in certain positions, and the absence of such
resistance when carried in the proper line. The attempt to remove
such a tooth by simple force would result either in fracture at the
curve, in lifting out a neighboring tooth, or in fracture more or less
extensive of the alveolar process.
Subfig. 3 represents exostosis of a root. A tooth fang so enlarged
will not pass through the process unless the bone is very open in its
structure. Such a tooth may be made quite loose, but while it
moves freely enough in its socket, it is felt to be held by something
abnormal. To free such a tooth, it is only necessary to use the
cutting forceps, or, what I prefer, take the ordinary small surgical
chisel, and cut away sufficient of the process to admit of the passage.
EXTRACTION OF TEETH. 233
This little operation is easy of accomplishment, and must prove
adequate to the end.
Subfig. 4 represents one form of twin teeth. The two must be
extracted together, which may be difficult or the reverse, accord-
ing to the character of the process. It is well, before making the
effort to extract, to free the process from the teeth as thoroughly as
possible ; this is done by a sharp and flat elevator or the chisel.
Subfig. 5 represents a second form of twin growth, the result of
original germ union. If the offshooting bulb is situated within,
and covered by the process, it is to be treated as if it were a case of
exostosis of the fang. These germ unions are exceedingly rare, and
one might not be met with in a lifetime.
CHAPTER XIV.
GENERAL REMARKS ON EXTRACTION,
The relationship of the teeth with the jaws is through the medium
of a cellular process known as the alveolar. Each tooth has pits or
alveoli corresponding to the number and character of its roots ; thus,
the central and lateral incisors, the cuspidati, and the bicuspidati,
having each but one root, have each but one alveolus.
The molar teeth of the superior jaw have three roots, conse-
quently a threefold relation to the alveolar process.
The molar teeth of the inferior jaw have two roots and two al-
veoli.
The wisdom teeth, as a rule, have a single short curved and
stumpy root, consequently a similar alveolus.
The association of the teeth with their alveoli is through the
medium of periosteal tissue ; this membrane is coarse and fibrous
about the free edge of the bone, loose and cellular as it gets deeper.
A proper-shaped lancet may be made to excise the coarse fibers ;
consequently, the operation of extraction should always be preceded
by that of thorough lancing. In this way much of the strength of
the relationship of the tooth with its socket is to be overcome.
A tooth extracts difficultly or easily as influenced by the character
of its periodenteum, and the loose or firm character of its alveolus,
A limited fracture of the alveolar process is generally not to be
considered a matter of much consequence. If an extensive fracture
should associate with an extraction, the tooth and bone may be laid
carefully back in place, and treated as any common fracture ; or, if
this does not seem desirable, the fractured piece may be dissected
from the soft parts, and the wound treated on general principles.
Sometimes, when too much force is injudiciously used, a fracture
may occur, including several teeth. In such accident, the circum-
stances of each peculiar case must direct the practitioner ; they are
ugly and generally unnecessary troubles, and not apt to occur where
proper care is exercised. If I myself should meet with such an acci-
dent, I should certainly make a first effort to reunite the parts ; failing
(234)
GENERAL REMARKS ON EXTRACTION. 235
in which, I would have, of course, no resource but to dissect away
the piece, or otherwise wait on nature for a process of exfoliation.
Laceration of the gums is an accident frequently associated with
the careless extraction of teeth. Such laceration may be trifling or
it may be serious, and is, perhaps, always to be guarded against by
careful attention to lancing. A small piece of gum torn by a tooth
as it comes away, had better always be removed ; left in the mouth,
it is a source of annoyance, and reflects, in the mind of the patient,
on the practitioner. Large strips are to be carefully laid back in
place, and secured by one or more stitches, or other convenient
means of retention.
Hemorrhage. — Hemorrhage after extraction is influenced by two
circumstances : the state of the parts and the predisposition of the
patient. An ordinary tooth extraction is followed by hemorrhage
lasting but a very few minutes. In extraction for periosteal trouble
the bleeding is more profuse ; but such hemorrhage, if at all reason-
able, should not be interfered with ; it expedites the cure of the case
wonderfully, relieving the general congestion of the parts.
In cases, however, where a hemorrhagic diathesis exists, alveolar
hemorrhage is not unfrequently of the most profuse character,
making necessary the most judicious and energetic treatment for its
arrestation. Two cases, occurring in the persons of father and son,
will illustrate this direction of practice.
Mr. B., aged 19, applied to his dentist for the removal of the
second superior molar of the right side. The operation over, the
bleeding seemed not excessive, and the patient was dismissed as
usual. On the same day, in the latter part of the afternoon, bleed-
ing recommenced ; Monsel's solution of the persulphate of iron was
employed, and the patient again dismissed. During the night hem-
orrhage again recurred, and the family physician was sent for ; the
solution of iron was again employed, and a temporary arrest again
secured. The next day it reappeared, and nitrate of silver was
applied in the alveolus. This controlled the hemorrhage until
the succeeding day, when it again appeared ; and so off and on over
a period of eight days. At this time I first saw the case in consulta-
tion, the patient being unable to swallow any other than liquid food,
owing to the swelling of the fauces and oesophagus from the effects
of the nitrate of silver.
In now treating the case we first took from the cavity the half-
coagulated clot it contained, and, washing the parts thoroughly, dis-
covered that the bleeding came not alone from the socket of the tooth,
236 ORAL DISEASES AND SURGERY.
but from about the margins which had been ulcerated by the various
applications. The next step was to secure an impression of the roof
of the mouth, which was obtained without difficulty through the
employment of the common impression wax and cup. To this impres-
sion a silver plate was struck. The cavity was now carefully packed
with lint saturated with a solution of alum, and over the bleeding
gum was laid a thin piece of cotton stuff, saturated in like manner.
The plate was now placed in position and firmly secured. Tincture
of Erigerou Cauadense was given in one-drop doses, repeated every
few minutes, and the feet were placed in hot water, the patient sit-
ting up. Hemorrhage ceased entirely in the course of an hour, and
did not recur.
JVIr. B., the father of this young gentleman, aged perhaps 50, suf-
fered five days from hemorrhage, under the following circumstances.
A wisdom tooth of the left upper jaw troubling him, because of its
great looseness, he applied to his dentist for its removal. Not deem-
ing it necessary or desirable to wound the gum, the practitioner ex-
tracted it without the preliminary step of lancing, and in the act
was so unfortunate as to tear away a small strip. Hemorrhage
was immediate, and more or less continuous. Monsel's solution
being pi-escribed by his physician, it was employed, but w^ith some-
what of the same result as in the son's case. On the evening of
the fifth day I first saw this case ; the patient was much weakened
from the excessive discharge, and exceedingly frightened and nerv-
ous. "Washing away the clots, I discovered the blood oozing from
the torn gum, and not at all from the tooth socket. Commenced im-
mediately to give the erigeron in drop doses, repeated every minute,
and ligatcd against the wound a tuft of cotton saturated in the alum-
water ; the hemorrhage ceased entirely within ten minutes, and did
not recur. As an assurance, prescribed the wine of iron, which the
patient continued to take to the amount of four ounces.
Tinct. Erigeron Canadense, in cases of this character, seems to be
a quite reliable haemostatic; not entirely so, however, as I have
prescribed it where it certainly failed to exert the slightest in-
fluence.
Opium and lead are valuable agents in hemorrhagic conditions —
a pill composed of one grain of opium and two grains of acetate of
lead will generally, if repeated each few hours, be found entirely
reliable.
A hot pediluvium is an invaluable adjunct, being not unfrequently
alone sufficient to the control of severe local hemorrhage.
GENERAL REMARKS ON EXTRACTION. 237
The ordinary cobweb of the cellar is an excellent local hasmostatic ;
particularly reliable is it if saturated in water and mingled with
bayberry powder. As a local application to large bleeding surfaces
I know of nothing to surpass it. I used this once in the case of an
infant laboring under profuse hemorrhage from lanced gums, and it
controlled the bleeding almost immediately, although almost every
conceivable thing had been previously applied without benefit.
Monsel's solutions cannot, I feel, be too strongly objected to as
an application in oral, and, indeed, I think, in any other kind of
hemorrhage. Or, if they must be used, the practitioner should never
trust them in unskillful hands. They certainly will check a hemor-
rhage, but generally only temporarily. With the coming away of
the clot the bleeding is almost sure to reappear, while hemor-
rhage, secondary to the use of the solution, is always more difficult
to control than when no such preparations have been used ; the
application certainly lowers the vitality of parts. The best effects
of the Monsel's solutions are secured by simply touching the
bleeding part: to do more is to do harm. The common mode of
saturating a tuft of cotton and packing it pell-mell into or against a
part, is most reprehensible, and should never be practiced.
Of the haemostatic effect of alum-water I feel I could scarcely
say too much. I always employ it in the various operations about
the mouth, and it seldom fails. In any ordinary venous or capillary
hemorrhage, if assisted by proper adjuncts, it may commonly be
depended on.
In persons of known hemorrhagic tendencies, the extraction of
teeth, as well as the performance of any surgical operation, should
be preceded, when possible, by a few days or weeks of preparatory
treatment. Tinct. of the chloride of iron, in doses varying from 10
to 20 drops, should be given three times a day for one or more
weeks. Conjoined with this the patient may take at the same
hours as much Peruvian bark, the red variety, as will lie upon a
silver half dime. On the day of operation three pills should be
given, at intervals of one or two hours, each containing one grain of
pulverized opium and two grains of acetate of lead. With such pre-
liminary treatment little trouble need be apprehended from hemor-
rhage.
Eest is a valuable haemostatic. A bleeding part should remain
as quiet as possible, and, if possible, be kept well elevated. Com-
pression of a bleeding alveolus or a bleeding gum can very well be
effected by the use of a common bottle-cork ; plugging the socket, or
238 ORAL DISEASES AND SURGERY.
laying the cloth over the gum, cut a concavity into one face of the
cork and fit it over the parts ; it is solidly retained in place simply
by closure of the teeth ; or, if the patient be a child, the head bandage
may be thrown about the jaws.
Compression should be moderate and not severe, and once made,
and the hemorrhage thereby controlled, should not be too hastily
removed
Luxation of the Inferior Maxilla. — Occasionally, as the re-
sult of a sudden movement, or an abnormal laxity of the ligaments
of the temporo-maxillary articulation, the condyloid process falls
forward over the glenoid boundary. The patient is thus rendered
unable to close the mouth, and is said to labor under luxation. (See
chapter on Luxation.)
Local Anesthetics in the Extraction of Teeth. — The em-
ployment of various local agents to secure exemption from pain in
the operation of extraction, has of late commanded so much atten-
tion that no chapter on the subject of such operations would be
complete without reference to the subject.
The most simple and, we may say, elementary application in this
direction, consists in inclosing in a piece of bladder, or other conve-
nient skin, a small portion of pounded ice and salt, and enveloping,
for a few moments, the part to be operated on. To secure most
conveniently the effect of such a process of refrigeration, various
instruments have been devised, but none, so far as the application of
the ice and salt is concerned, have been found to answer any better
purpose than the bladder or skin inclosure. Such skins should consist
of two little bags, one to rest upon the outer, the other upon the inner,
side of the gum. To prevent pain from the application of the cold,
the bags should be brought gradually in contact with the gums ; or,
what will answer a similar purpose, the application may be pre-
ceded by ice-cold water held in the mouth for a few moments.
An apparatus designed and manufactured by Messrs. Home &
Thornwaite, of London, is said to answer a very good purpose, and
is thus described : " A required amount of water is cooled down, by
means of ice and salt, to about zero, in a vessel called a refrigerator.
To this vessel is attached another, called a graduator, containing
warm water at about 100°, and so constructed as to allow the slow
admixture of its contents with the chilled water in the refrigerator,
and thus produce a gradually diminishing temperature, for the pur-
pose of preventing sudden shock and pain to the teeth, which a
direct application of cold would inevitably cause. A tube conveys
GENERAL REMARKS ON EXTRACTION. 239
this graduated current into a terminal portion constructed of very-
fine membrane, which adapts itself to the form of the gums, and
wholly surrounds the tooth to be extracted. The fluid then passes
away through an exit tube. In this manner a constant current of
cold, at a decreasing temperature, is made to pass over the part,
abstracting therefrom all heat, and consequently all feeling."
The concentrated tincture of aconite is a useful local anaesthetic, but
one that should be used with a considerable degree of caution. If a
portion of this tincture be applied to one-half the lip, sensibility will
be so interfered with that a goblet placed to the parts will appear
as if broken.
A mixture of chloroform and laudanum in equal parts is much
lauded by some. To apply this, it is only necessary to saturate a tuft
of cotton, and lay it against the tooth to be extracted.
Electro-galvanism claimed at one time a good share of attention.
Its application consists in applying one pole of a battery to the for-
ceps, while the other is held in the hand of the patient ; a gentle
current is then to be let on, during the passage of which the tooth is
extracted. This mode of effecting local antesthesia is still practiced
by very many ; but I must say that, in my hands and in the hands
of many experienced friends, it has proved a failure. Not that it is
attempted to deny that in certain cases it does not seem somewhat
to obtund sensibility, but in the majority of instances it either does
no good at all or adds the discomfort of the current to the pain of
the operation.
The application of the spray of ether and rhigolene is the latest,
and perhaps the most worthy and reliable, of the local anaesthetics ;
certainly one may say reliable when employed for operations of
limited extent about the soft parts, but as to its equal reliability in
tooth extraction, my experience has not so well satisfied me. With
these agents I have performed many operations as thus applied,
in the way of the removal of sebaceous and other superficial tumors,
the opening of abscesses, carbuncles, and similar operations, and
the result has been everything I could have desired ; but in its
application to the teeth, the obtunding of the sensibility has not by
any means been so marked ; particularly has this been the case
where rhigolene was used.
The process of freezing a part through the known refrigerant power
of evaporating ether seems first to have suggested itself to Dr.
Richardson, of London. An instrument, invented by this gentle-
man for the accomplishment of such an end, is here exhibited,
forms of bellows for both hand and foot being represented.
240
ORAL DISEASES AND SURGERY.
For the spraying of any plain surface the simple straight tube is
all that is necessary. For the teeth the double sprayer, as seen in the
drawin"-, is used; with this instrument a continuous vapor is cast
both upon the outer and the inner face of the gum, and congelation
is rapidly induced.
Fig. 55.— Sprat Apparatus — Hand Instrument.
In using this hand instrument, the operator himself should not
work the pump. A very few moments' compression of the ball
renders the hand shaky and unmanageable.
Upon this instrument of Dr. Richardson's, modifications have
already been made : of these, one by Messrs. Codman and Shurt-
leff, of Boston, has, perhaps, attracted most attention ; it certainly
seems to divide the ether more infinitesimally, thus insuring a more
complete vaporization ; but it has a weak point, in that the tube
seems frequently to freeze or choke up, an accident that does not
occur with Dr. Richardson's instrument.
An objection urged to the use of extreme cold as thus induced, is,
that injury is done to the soft parts, as it is thought will be mani-
fested in inability to unite wounds happily and easily. That such
objection is, however, not valid, I have satisfactorily proven, for, if
anything, parts thus operated on have united better and with less
inflammatory reaction than has obtained where the spray has not
been used.
GENERAL REMARKS ON EXTRACTION. 241
Fig. 56. — Spray Apparatus — Foot Instrument.
Rhigolene, or hydro-carbon, manufactured from coal oil, and much
vaunted by some, has not, in my hands, proven so satisfactory as
ether. It certainly freezes a part more quickly than this latter
agent, but this does not seem alone to be the object, as anaesthesia is
not nearly so complete.
16
CHAPTER XV.
GENERAL ANESTHESIA.
" So long as pain is an evil, and ease a good,— so long, in other
words, as man is man, — must any means be prized that is capable of
achieving the latter by the abolition of the former. As, then, the
pain of surgical operations is certainly of the most terrible of its
class, and it is no matter of doubt that agents exist which possess
the power of abolishing this pain, what remains for consideration is
not so much whether this means shall be hailed as a matchless and
priceless discovery and be cherished and adopted as a blessed thing, —
this appreciation has been made, this adoption has been consecrated
bv almost universal practice, — what remains for consideration is,
whether the good is a pure good, or is counterbalanced by evil.
" The obvious, open, palpable, glorious good of anaesthesia, and
particularly ether anaesthesia, is to deliver the wretched victim of
surgical disease from the additional torture of pain, while seeking
the goal of health through the portals of chirurgery. The evils
that have been said to follow or accompany this good have, how-
ever, been regarded by some as of so serious a character as not only
to induce them to reject general anaesthesia in their own practice, but
to denounce it publicly as a means that should not obtain with sci-
entific and conscientious men.
" We confess that we are surprised whenever we hear these ex-
pressions, and, strange as it may seem, there are even now enough
to give expression to them. Of the hundreds and thousands, we
might say hundreds of thousands, who have taken ether to insensi-
bility, we have been unable to discover, after the most extended in-
quiries, a single case which resulted in death, or left behind it conse-
quences of serious importance that were certainly attributable to it.
In a small proportion of cases there have, no doubt, been some un-
pleasant results, such as temporary depression of the vital powers ;
headache, more or less considerable, for some hours, or even days ;
hysterical excitement in women for a similar length of time ; slight
bronchial irritation, nausea, and sickness, and some other slight af-
(242)
GENERAL ANJESTHESIA. 243
fections ; but the proportion of patients suffering, even in this slight
manner, has been extremely small, indeed wonderfully small, when
we consider the indiscriminate manner in which the practice has
been had recourse to, with bad ether and bad manipulators. Indeed,
that so very few, and such trifling accidents have occurred in such a
state of things, is most convincing proof of the general safety of the
practice. For, in considering the entire incompetence of the many
who are in daily, fearless employment of the agent, so far from these
uniformly innocent results being anticipated, one might very natu-
rally look for others of a very different kind. We have ourselves
been constantly looking for ill consequences, and we are still prepared
to find them ; but when they arrive, if ever they now are to arrive,
we shall have to consider well, before condemning the agent, whether
the event was a necessary consequence of its use, or merely an acci-
dental result from its abuse."
The preceding very impartial and terse consideration of the gen-
eral question of anaesthesia, as reference is had to its production by
sulphuric ether, we find in a British exchange. The question, " To
what are accidents (if accidents there are) attributable?" is naturally
suggested, and would excite in the mind a desire to enter on the
consideration of a subject fraught with such importance, before
taking up its use or joining in the cry of those who abuse.
Such consideration I propose to make the subject of this chapter,
and trust that not a little personal experience enjoyed will enable
me to present it with some degree of clearness. We first consider
sulphuric ether.
An agent, refreshing in itself, may, in improper hands, become a
source of ill ; this truth embraces the whole Materia Medica.
What is sulphuric ether?
" When equal weights of rectified spirits and oil of vitriol are
mixed in a retort, the latter connected with a good condensing ar-
rangement, and the liquid heated to ebullition, a colorless and highly
volatile liquid, long known under the name of ether, or sulphuric
ether, distils over. The process must be stopped as soon as the
contents of the retort blacken and froth, otherwise the product will
be contaminated with other substances which then make their ap-
pearance. The ether obtained may be mixed with a little caustic
potash, and redistilled by a very gentle heat.
"Pure ether is a colorless, transparent, fragrant liquid, very thin
and mobile. Its sp. gr. at 60° is about 120 ; it boils at 96° under
the pressure of the atmosphere, and bears, without freezing, the
244 ORAL DISEASES AND SURGERY.
severest cold. When dropped on the hand it occasions a sharp
sensation of cold, from its rapid volatilization. Ether is very com-
bustible; it bm-ns with a white flame, generating water and carbonic
acid. Although the substance is among the lightest of liquids, its
vapor is very heavy, having a density of 2-586. Mixed with oxygen
gas and fired by the electric spark, or otherwise, it explodes with
the utmost violence. Preserved in an imperfectly-stopped vessel,
ether absorbs oxygen and becomes acid, from the production of acetic
acid. This attraction for oxygen is increased by elevation of tem-
perature." (Foumes.)
Dr. Jackson's formula for the preparation of ether for anaesthetic
purposes is, we believe, as follows: procuring the strongest and
purest rectified sulphuric ether — that just described — wash it well,
to get clear of any acids, then decant from the water, drying it with
chloride of calcium, to free it of any water that might otherwise
remain from the washing.
This, however, is but a single formula. Different chemists gain
the same ends through different processes. It is for the surgeon
to buy of a reliable druggist rather than attempt, himself, the
preparation.
This, then, is ether, an agent which experience demonstrates that,
breathed into the lungs, will produce insensibility. To exhibit ether
successfully, four essentials seem necessary:
1st. That the ether should be very pure.
2d. That the vehicle upon which, or with which, the agent is ex-
hibited, should be of such character that full volume of atmospheric
air is allowed to pass through the ether into the lungs.
3d. That the vapor of the ether be properly diluted, given for the
first few inspirations comparatively weak, and increased in strength
as the glottis, air-passages, and lungs can bear it.
4th. That insensibility be produced as quickly as the system will
bear, as evinced by obvious signs.
A cone-shaped, close sponge is the best means for administering
ether. This possesses every advantage, except economy in the ad-
ministration, without having any of the common faults. From two
to five minutes will be found the average time necessary to pro-
duce the full effect of perfect sleep, while cases will present them-
selves whei-e double this time will be required, and where, indeed,
it may be necessary to combine with the ether the more powerful
effect of chloroform, or even to employ the undiluted chloroform.
From an article emanating from a gentleman of snuch experience in
GENERAL ANESTHESIA. 245
anaesthetic agents, we have the following: "It is possible to in-
spire three, four, nay, ten times the quantity of ether capable of
producing sleep, without this state being produced, provided the
vapor be taken in a too diluted form ; and we believe this over-dilu-
tion and its consecpent protracted inhalation is a frequent cause of
the excitement which supervenes In the practice of many persons,
while it so rarely shows itself in that of others. In these cases the
patient may be made drunk ; drunk in the first degree, but not dead
drunk, the condition required for surgical purposes."
It will be remarked, let us notice in passing, that one of the most
common objections of the opponents of ether lies at this door — this
supervening state of excitement instead of the desired state of stupor ;
but does not the question again very pertinently apply. Is the fault
with the agent, or with the operator ?
The idea is to be conveyed that the effects of sulphuric ether and
the common alcoholic beverages are the same. The effects of alco-
holic liquids are too well known to require minute description. We
have, first, the state of exhilaration, which gradually changes to com-
plete stupefaction or narcotism. The last state, the result probably
of a narcotized state of the .brain. Just so acts ether, yet passing
through its various stages more quickly, the result of its being
poured in a continuous and undiluted stream upon the heart and
brain. The ether is no sooner absorbed than the blood charged with
it passes to the left side of the heart, and immediately thereafter is
circulated through the coronary vessels, the carotid and vertebral
arteries, and thus pervades the tissue of all parts of the heart, as
well as of every portion of the brain. A writer, in an influential
dissertation, presents an example in this wise :
" Suppose, to take an extreme illustration, that the blood was as
capable of absorbing as much ether as water can combine with, or
one-tenth its own weight. If, then, we suppose the blood in the
lungs was impregnated to this extent, it would be applied in that
state to the heart and brain ; whereas, if the blood in the stomachic
vessels was impregnated to the same extent with ether, before reach-
ing the liver it would have mingled with more than its own mass
of pure blood from the splenic and mesenteric veins. The tenth
would then become a twentieth, and, on the blood leaving the liver
and joining the larger current of the infei'ior cava, the twentieth
would become a fiftieth or sixtieth ; a further dilution would take
place at the confluence with the superior cava, so that the blood, on
reaching the heart and brain, instead of containing one-tenth part of
246 ORAL DISEASES AND SURG ERF.
absorbed ether, could not contain as much as one-hundredth. When,
therefore, the same quantity of ether, or any absorbable substance,
is taken up from the lungs and from the stomach, it must, in the
former case, be applied to the tissue of the heart and brain, in a state
of concentration at least ten times greater than the latter, and will
therefore act on these organs with more suddenness and energy."
The evanescence of the effect of ether, when compared with alco-
hol, is explained by a momentary consideration of the different man-
ner of absorption. During the inhalation of ether, as we have just
seen, the charged blood is applied to the heart and brain, while the
blood circulating in the lower parts of the body contains a much
smaller proportion of it. Now, on stopping the inhalation, the blood
in the heart and brain speedily passes off by the veins, and is suc-
ceeded by the comparatively pure blood coming from the lower
regions of the body, and so the narcotic symptoms disappear.
" It is far otherwise when alcohol is absorbed from the stomach,
for the whole mass of blood must be impregnated with it before a
highly charged blood can be applied to the heart and brain ; and
then the effect continues for many hours, till the alcohol has been
thrown out of the system by the lungs and skin. With respect to
ether, it must not be supposed that on the subsidence of the nar-
cotism it disappears from the body ; for it is merely weakened in its
effects by being diffused over the whole mass of blood. This is
obvious, from the smell of the breath for many hours, and from its
frequently causing copious perspiration."
Does not the question here suggest itself. If the effects of ether
and the common alcoholic beverages are so nearly alike, why the
great dread of the one and the entire fearlessness with the other?
Would not the answer seem to be something of this kind ? Men
when etherized are as dead drunk — our eyes are not well accustomed
to seeing them but partly drunk. In this state they excite amuse-
ment — in the state of profound drunkenness they have always
aroused our fears for their recovery. Associations have great
weight.
The immediate and obvious effects of etherization on the individ-
ual hardly require notice, as they must be familiar to all our readers,
if not from a personal experience, certainly from observation upon
others. "All the usual phenomena of the deepest sleep supervene,
gliding often into the profoundness of sopor and verging occasion-
ally upon, if not actually lapsing into, coma. The voluntary mus-
cles become suddenly relaxed, the jaw falls, the arms hang down,
GENERAL ANESTHESIA. 247
the eyes roll upward under the lid, the respiration becomes slow and
labored, and the face becomes either very pale or morbidly flushed ;
the aspect of things is truly such as can hardly be contemplated for
the first time without alarm : the individual seeming, to the com-
mon eye, to be sinking into the sleep of death."
It is impossible, says another observer, to see a single case of ether-
ization without being struck with its resemblance to asphyxia — and
experiments exhibit a real relation between the two. But in ordinary
asphyxia, the nervous system loses its power under the influence of
black blood, or blood deprived of its oxygen. But in etherization it
does so under the direction of this singular agent. This is really
all the difference, for in both there is the same loss of sensation and
voluntary motion, and the same, at least temporary, persistence of
the respiratory movements. In one word, there is the same survival
of the medulla oblongata over the spinalis.
"Etherization exhibits to us the entire mechanism of asphyxia — we
mean the successive deaths of the various nervous centers. It iso-
lates, just as mechanical experiments do, the intellectual powers,
the co-ordination of the movements, sensibility, motility, life. The
isolation of life — this point, this vital knot of the nervous system —
forms the most striking point of the experiments.
"In an etherized animal one point alone survives, and while it does
so, all others retain at least a latent life, and may resume their active
life ; this point once dying, all dies."
Throwing out of immediate consideration the idiosyncrasies, let
us for a few moments consider the question of the general safe ex-
hibition of the agent.
The safest agent may be made a source of ill : as the intruder on
the physical laws of' his organism must suffer the consequences of
his ignorance or temerity, so may an agent be made an injury by
its abuse. As the imbibition of alcoholic beverages may be carried
to a point beyond which the life principle reacts not, just so, and as
the warmest supporters of the anesthetics would have impressed,
may ether be made an instrument of irreparable injury, blasting and
destroying where it was designed to refresh and save.
To describe or lay down certain reliable rules, applicable in
all cases, of the process of etherization, is an impossibility. The
presentments of conditions in various individuals so materially
differ, that any but rules, the result of a general knowledge of the
agent, a comprehension of physiological laws and pathological alter-
nations, were charlatanism to act upon. One person, as Dr, Snow
248 ORAL DISEASES AND SURGERY.
remarks, "shall become impassable as the subject on the disseet-
ing-tablo ; another talks incoherently or mirthfully, replies to ques.
tions, or obeys directions ; others utter exclamations of pain, which
they afterward retain no reminiscence of having felt ; and others
ao-ain declare that they have suffered pain but felt themselves
powerless for its expression. Finally, in not a few, ungovernable,
violent or convulsive action takes place, quite adverse to the per-
formance of any delicate surgical operation. With some an utter
oblivion is induced ; while others, while undergoing all the apparent
torture of a prolonged dissection, are reveling in the realms of
memory and in the fields of imagination." M. Jobart and other ob-
servers have attempted to lay down three distinct stages in its
effects, according to the prolongation of the etherization. 1. That
of incoherence, agitation, or delirium, as the case may be. 2. Ac-
celeration of the pulse, with loss of sensibility and loss of power.
3. Exhaustion and coldness of the surface. As we remarked, the
matter cannot thus be methodically laid down, for it is quite certain
that any of these conditions may be induced, in different individuals,
by very various doses of ether ; while others, again, are susceptible
of only the first degrees, to appearances, and yet enjoy an immunity
from suffering during operations. Even the quickened condition of
the pulse and respiration, and that almost universally employed
criterion, the stationary condition of the pupil, may all deceive in
the supposed impression produced.
Various of the French Academicians some years back instituted
a series of experiments upon animals, for the purpose of determining
the mode and order in which the various portions of the cerebro-
spinal system were influenced during inhalation. The following are
some of the conclusions arrived at by the veteran vivisector, Baron
Flourens :
" The action of ether upon the nervous centers follows in a given
course. It acts, first, upon the cerebral lobes, disturbing the intellect.
It acts, secondly, upon the cerebellum, deranging the equilibrium of
the movements of the animal. Thirdly, it acts upon the medulla
spinalis, in which it extinguishes, successively, the sensory and mo-
tive principles ; and, lastly, it acts upon the medulla oblongata,
where arrived, life becomes extinct."
To produce the best effects of sulphuric ether, it is of the first
consequence that an entirely reliable article be employed. "For
myself," says Dr. Robinson, of London, "I feel convinced that many
of the failures that have occurred in its administration in some
GENERAL ANESTHESIA. 249
measure may be attributed to the imperfect preparation of the fluid.
I have myself obtained ether of various specific qualities from dif-
ferent chemists ; and on one occasion, requiring an extra quality for
a series of experiments, the gentleman supplying, being out of that
quality he had generally furnished, sent some of a different kind
which he had in his establishment, which was administered in
two cases. I found, however, I could only produce partial uncon-
sciousness, not insensibility to pain, and therefore deferred the
operations, which were upon the teeth. I afterward procured some
of the first quality ether, and employed it in the same case with
success."
The effect of a bad article of ether is not only the inability on
the part of the operator to produce more than a partial unconscious-
ness, but it is almost certain to produce nausea, giddiness, and
prostration. If a good article cannot be procured, better use none
at all.
The quantity of ether that may be given to an individual patient
is a matter for the practitioner ' to decide upon in connection with
each case. It is impossible to fix the dose of vapor that will be
required to produce given effects upon any patient, neither is it always
an easy matter to decide when just enough has been administered.
We cannot rely implicitly on the state of the pupil or pulse, or upon
what is considered by so many as the exact indication, namely, the
insusceptibility of the eyelids to impressions made by striking the
hairs. Perhaps the changes in the breathing are the most reliable
signs : these certainly influence me most ; so long as breathing con-
tinues easy and natural, little danger is to be anticipated, but the
moment it becomes labored, one is to precede or recede cautiously. In
etherizing a patient let the operator watch the pulse, the expression,
and the respiration. So long as these give no counter-indications,
the exhibition may be carried forward to the end desired.
As to a question of the continuance of a patient in the anaesthetic
condition, I think it will be found the proper rule to make the time
just as short as possible; that is to say, as the continuance of the
exhibition of the agent is concerned. If an operation to be per-
formed in the anaesthetic condition may be completed in five, ten, or
fifteen minutes, it is not good policy to prolong it, and with it the
continued administration of the ether to a half or a full hour. That
there is, however, any imperative or absolute necessity to hurry
through an ether case is not at all implied. I have known a patient
kept continuously under ether for forty-two hours ; and in obstetrical
250
ORAL DISEASES AXD SURGERY.
practice, ten or twelve hours of anesthesia is not at all unfrequent.
I only contend that it is neither necessary nor prudent to prolong,
without object, the condition. Where, however, such a prolonged
action is demanded, it is to be secured, not by keeping the saturated
sponge constantly applied over the air-passages, but only at such
intervening periods as is necessary to preserve the anaesthesia.
The condition of the temperature, as might be inferred, has much
to do in prolonging or shortening the time commonly considered
necessary to place a patient in a state of sleep. Dr. Snow procured,
from experiments, the following results :
One hundred cubic inches of air, saturated with the vapor of
ether, at a temperature of
44° would contain 27 cubic inches of vapor.
54 " 24-3
64 " 43-3
74 " 53-6
84 " 66-6
Being doubled by a rise of only thirty degrees ; or in other words,
we perceive that if, at a temperature of 84° Fahrenheit, we employed
two, or two and a half minutes in affecting a person to the state
desired, at a temperature thirty degrees less we would require
from four and a half to six minutes to have the same result.
Concerning the idiosyncrasies, I would speak my own experience
by saying that I have never yet met with a person who I thought
might not take ether, or ether in combination with chloroform. The
London Medical Gazette considers its use inadmissible where there
is a tendency to apoplexy, epilepsy, and also in plethoric individuals.
Another intelligent source says that persons presenting the slight-
est signs of being cataleptic should be viewed as idiocratical. Per-
sons while under the influence of liquor, it is generally esteemed,
should be viewed for the time as not fit subjects.
In a conversation with Dr. J. B. F. Flagg, had several years back,
that experienced man told me he believed in no idiosyncrasies, ex-
cept it might be a very high, nervous temperament ; remarked that
he had administered ether to the infant of thirty-six hours and to
persons in extreme old age ; had given it to the robust and the
weak, the plethoric and the consumptive ; had used it in all states
of pregnancy, except that stage known as quickening; would also
exhibit it here, but would feel called on to exercise more than ordi-
nary care. Seeming idiosyncrasies might generally, he thought,
be explained by an examination of the operator's ignorance of the
GENERAL ANESTHESIA. 251
agent. The faith of this gentleman in the perfect safety of the use
of ether is so great that he remarked he would not hesitate to use
it where there had been, or was, aneurism of the aorta. The
opinion of Di*. Flagg concerning the non-existence of idiosyncrasies
is to be taken before that of most persons either of this country or
Europe. His oppoi'tunities for observation have not been surpassed
by those of any other person, and perhaps equaled by few. The
work published by him in 1854, long before his retirement from
practice, has not, up to the present day, been advanced on, and is
an heirloom to be valued by those to whom his industry has left it.
CHAPTER XYI.
GENERAL ANESTHESIA.
From the consideration of sulphuric ether we may pass to an in-
vestigation of the character and merits of the perchloride of formyle,
or chloroform. This agent is, without any doubt, the most power-
ful and reliable of the anaesthetics; but, unfortunately, it possesses
qualities which render it not unfrequently fatal to life, and there-
fore make it of less value than the one we have been just con-
sidering. No person should employ chloroform who is not prepared
to meet many emergencies.
To procure chloroform, the chemist takes of chlorinated lime say
(to take a common formula), Ibsiv; rectified spirits, Oss; water, Ox;
chloride of calcium, broken in pieces, 5j- Put the lime, first mixed
with water, into a retort, and add the spirits, so that the mixture
may fill only the third part of the retort. Then heat them in a
sand-bath, and as soon as ebullition begins withdraw the heat as
quickly as possible, lest the retort should be broken by the sudden
increase of heat. Let the liquor distill into the receiver so long
as there is nothing which subsides, the heat being reapplied, if
necessary. To the distilled liquid add a quarter of the water, and
shake them all well together. Carefully separate the heavier por-
tion, which subsides, and add the chloride to it, and frequently
shake them for an hour. Lastly, let the liquid distill again from a
glass retort into a glass receiver.
In appearance chloroform resembles the freshest water of the
mountain-spring ; to the taste it is hot and very sweet ; to the
nostril it has much the odor of the common strawberry. When
dropped upon linen it evaporates most quickly, leaving, if pure, no
stain or sign behind. In weight it is quite one-half heavier than
water, and, as its vapor is concerned, is four times heavier than at-
mospheric air.
The smell of chloroform, says Dr. Snow, should be esteemed one
of the best tests of its purity and identity. When dropped on the
hand it should quickly evaporate, leaving not the least smell or
(252)
GENERAL ANESTHESIA. 253
moisture behind. If a disagreeable odor remains on the hand after
the evaporation, the chloroform has probably been made from im-
pure spirits, or even from wood or acetone, and is therefore unfit for
medicinal purposes. When chloroform becomes decomposed from
any cause, it acquires a greenish-yellow color, and gives off chlorine
and hydrochloric acid, so that the alteration is at once apparent.
When chloroform is pure, it has no reaction on test paper, but is
quite neutral. The best way, according to Dr. Snow, to detect a
small quantity of hydrochloric acid in it, is to moisten a slip of blue
litmus paper with distilled water, and hold it just within the neck
of the bottle exposed to the vapor. If sulphuric acid should be
present, it may be discovered by agitating the chloroform with dis-
tilled water and adding nitrate of baryta.
Chloroform maybe degraded by admixture with alcohol, and this
can be done without making any perceptible change in its appear-
ance: its specific gravity, however, is thereby lowered; and, accord-
ing to M. Mialhe, the foreign presence is most simply detected by
adding to the suspected fluid a small quantity of water, when a
milky opacity results.
Chloroform, as the heart's action is concerned, is a powerful seda-
tive. In nearly if not quite all the fatal cases resulting from the
administration of this agent, cardiac syncope has been the cause of
death ; and in a very small minority of the cases indeed has there
been any evident interference with the process of respiration. This
fact is always to be held in strictest remembrance when exhibiting
the agent.
In oral surgery, where it is desirable to produce the profoundest
and most prolonged primary impression, chloroform, if it were
without danger, is the anaesthetic most indicated and required. In-
deed, in my own practice I find many cases where I do not seem
to be able to get along without it, either using it alone or in asso-
ciation with the ether. Because its use is therefore so frequently
necessary, the oral surgeon should make himself as familiar as pos-
sible with all that concerns its defects as well as its virtues.
Experiments have demonstrated that eighteen minims of chloro-
form is the average quantity necessary to put an adult in a con-
dition insensible to surgical operations, — that is to say, that this
amount should be absorbed and carried to the nerve centers.
It has also been shown " that chloroform vapor has the effect of
suddenly arresting the action of the heart, when it is mixed with the
respired air to the extent of eight or ten per cent, or upward." With
254 ORAL DISEASES AND SURGERY.
these two lessons appreciated, it is seen that the manner and char-
acter of the exhibition of the agent have much to do with the result.
Not everything, however, as it is too truly a fact that fatal acci-
dents have occurred in the best and most skillful of hands, although
in these latter cases, the inference is to be drawn that the deaths
occurred from idiosyncrasies.
Eighteen minims, according to Dr. Snow, are to be absorbed from
thirty-six breathed; allowing thus that one-half is lost in expira-
tion. But temperature, as in the case of the ether, has much to do
with the taking up of such a quantity. The following table com-
prises the experiments of Dr. Snow in this direction. At a tempera-
ture of 40° Fahrenheit, 100 cubic inches of air will take up but seven
cubic inches of the vapor.
At 45° 8 cubic inches, At 70° 24 cubic inches.
50 9 " 75 29
65 11 " 80 36
60 14 " 85 44
65 19 " 90 55
This table readily exhibits the fact that anassthesia, by the use of
chloroform, must come on at varying periods, and that therefore no
judgment of its proper exhibition is to be derived in this direction.
Again, outside of these atmospheric associations, the manner of
the exhibition would have much to do with the minims inspired :
where, for example, it is exhibited poured over a single layer of
linen (as upon a handkerchief laid over the face), quite as much
would be lost in the surrounding atmosphere as would be inhaled
into the lungs.
Considering the danger as arising from the direction of cardiac
syncope, advantage is to be taken of all conditions antagonistic to
such depression. In blood-letting, it is known that such a condition
is much the most readily brought about when the operation is per-
formed on the patient standing, and when the primary impression
is made most marked through a large exit for the blood. In states
of depression, arising from whatever cause, either of physical or
mental disturbance, such tendency is increased. A surgeon always
hesitates to bleed a depressed patient ; or, if such bleeding seems a
necessity, supporting means are employed and continued in con-
junction with the blood-letting. Advantage is taken also of all col-
lateral indications, as for example, position, the patient lying down,
the head perhaps being placed on a lower plane than the body, the
GENERAL ANAESTHESIA. 255
orifice of exit being made very small ; intermissions in the flow of
the blood, stimulants, as the pre-exhibition of brandy or wine,
kind and encom-aging assurances, etc. The depressing effect of fear
on the heart's action is never to be lost sight of in the administration
of chloroform. How many patients faint even while preliminary
arrangements in anticipation of an operation are going forward ; and,
indeed, how many are the cases on record of death from such fright!
It would seem, then, that one would never be justified in adminis-
tering chloroform to a patient laboring under any marked depression,
at least such is my own conviction, and upon such conviction I have
always acted. All persons, or nearly all, approach an operation
with a certain amount of trepidation, but such fear may, in the ma-
jority of cases, be dispersed; or if this is impossible, then a prelimi-
nary artificial courage maybe given by the use of brandy, or cerebral
consciousness may be disturbed by the inhalation of a few drachms
of ether.
The objection, that chloroform should not be administered to a
patient in a sitting position, does not, however, seem to hold entirely
good. In oral surgery this is nearly always the necessary position-;
and I have thus administered it, in perhaps hundreds of cases, with-
out ever having had any ill result. A difference in the character of
cardiac syncope is here to be recognized. The paralysis may arise from
two sources, and exhibit, as far as the state of the heart is concerned,
quite different appearances, — that is, there is a syncope of anaemia
and a syncope of narcotism. Now while there are between these two
conditions much relationship, as the question of a vital propulsive
force is concerned, yet there are as well certain differences, of which,
as surgeons, we may take advantage. Paralysis of the heart occurs
when, from any reason, the organ is deprived of the effect of its natural
stimulus, the blood : this is the syncope or paralysis of ansemia. It
occurs again when, through the action of a common or specific
narcotic, its muscular fibers are relaxed and deadened. The two
causes may exist, and may act in conjunction. Chloroform is a specific
narcotic, as the heart is concerned ; at least this would seem to be
the deduction from post-mortems made in the fatal cases of its ex-
hibition. In ansemia, syncope is partly a mechanical production ;
the patient, in a standing position, faints, as the result of gravity
counterbalancing the natural distribution of the blood. In narcotic
syncope position is, perhaps, of little consequence, as far at least as
the action of the producing cause is, of itself, concerned. The ques-
tion then of sitting or lying, as the exhibition is concerned, resolves
256 ORAL DISEASES A^W SURGERY.
itself into a consideration of the state of the general health of a
patient : if there is deficiency, either in quality or amount of the
vital fluid, then the erect, or even semi-erect position, should never
obtain. If, on the contrary, a patient does not present such condi-
tions, then it would seem there is no special danger in such position.
Prefatory stimulation, if not contraindicated, is happily employed,
in conjunction with chloroform. A tablespoonful or more of brandy
given to a patient some five or ten minutes before the exhibition of
chloroform, will frequently support the natural action of the heart
through a prolonged operation, and thus dismiss the common source
of alarm.
In my own practice I never use chloroform but in conjunction
with ether — not mixing them, as in the common chloric ether, but
alternating, as the case seems to require or allow. Thus, employing
the cone of sponge, I commence the process by pouring within it a
quantity of ether, which is gradually, and yet as rapidly as possible,
brought to cover the mouth and nostrils. If now I find the pulse
rapidly increasing, or even remaining fixed and steady, and particu-
larly if undue cerebral excitability manifests itself, I drop into the
cone ten or twenty drops of chloroform ; this will generally be found
to almost instantly quiet the patient — from this point I proceed,
using principally the chloroform or ether, according to the result to
be secured. If an operation is one of simple character and of quick
performance, as the extraction of teeth, or the making of some
simple puncture or incision, then I think we had better not risk
anything with chloroform. If, on the contrary, it is some difficult and
tedious case about the mouth, where, after commencing, the surgeon
cannot well stop to readminister the anassthetic, then I take the risk
of the excess of chloroform for the prolonged effect it yields and
the greater profundity of the impression it secures.
The manner of the exhibition of the agent would have, as one
would infer, much influence, as the result is concerned. Thus, of
the various apparatus that have from time to time been devised
to assist in the use of chloroform, many are deserving of no better
name than life-traps; and in this connection one naturally finds
himself wondering at the character of contrivances which, par-
ticularly in the earlier history of chloroform, were employed, even
by the ablest men, in experiments directed to the testing of the
general safety and results of the agent. I can never read of the
white mice, and of the guinea-pigs, and cats, and bell-jars of these
experiments, without wondering that it should never have seemed
GENERAL ANESTHESIA. 257
to strike them that animals might as well die from lack of proper
respirable air as from chloroform.
In using pure chloroform, it is most desirable that there should
be the fullest admixture with air ; with this intention we use the
sponge, first softening it with warm water, which water is to be
well squeezed away. The respiration should be easy and natural,
and the patient fully en rapport with the operator. He should be
given to understand that anaesthesia is but a gentle and harmless
sleep, and that one should enter upon such a condition as he enters
upon natural slumber ; if such confidence can be secured, there will
not be found much trouble in producing narcotism. Another plan
of using the agent, and which has many advocates, is to let fall
drop after drop upon a napkin, laid loosely over the air-passages.
However employed, the principal indication is to have it in proper
dilution and combination with atmospheric air; this secured, any
mode of inhalation must be a proper one. Insensibility, as re-
marked by Dr. Snow, is not caused so much by giving a dose as by
performing a process. Nature, continues this gentleman, supplies
but one mixture of diluted oxygen, from which each creature draws
as much as it requires ; and so, in causing narcotism by inhalation,
if a proper mixture of vapor and air is supplied, each patient will
gradually inhale the requisite quantity of the former to cause in-
sensibility, according to his size and strength. It is desirable to
vary the proportions of vapor and air, but rather according to the
purpose one has in view, whether medicinal, obstetric, or surgical,
than on account of the age or strength of the patient ; for the respira-
tory process bears such a relation to the latter circumstances as to
cause each person to draw his own proper dose from a similar at-
mosphere in a suitable time.
The induction of insensibility varies with the individual, or
rather, one might better say, with classes of individuals. One class
will breathe quietly and slowly, until unconsciousness supervenes
as if by a natural sleep ; this belongs to the lymphatic temperament.
The nervo-sanguine or bilious class are apt to become restive and
frightened, and require a great amount of care and attention, being
the most difficult to impress. The true and full nervous class, while
timid and frightened, are apt to be impressed by a very few inhala-
tions. There is one question that here arises in regard to the exhi-
bition of timidity. When a patient becomes restive and excited,
shall the chloroformization go on ? Yes, I would answer, if such
exhibition is associated with mental disturbance produced by the
17
258 ORAL DISEASES AND SURGERY.
chloroform, for here it is not as the condition previously named, but
is rather an hallucination. These patients should be forced rapidly
beyond such states of excitement, and here is the point in which the
production of anaesthesia demands the greatest skill, courage, and
jud"-meut. I have over and again seen incompetent operators worry
a poor creature into a most wretched condition simply by fearing to
pass the Rubicon of excitement. If assured that all is right, and
such assurance is to be derived from the general aspect of the pa-
tient rather than from any special signs, we are to get over this in-
termediate excitable stage as quickly as possible, and get over it by
concentrating the chloroform. Patients laboring under this excita-
bility will, often enough, assure you that they feel that another inha-
lation will kill them ; that it is impossible to breathe ; that the heart
is laboring under a wonderful depression, and many complaints of
like character. Such speeches are mostly to be taken cum grano
salis, — the surgeon must judge for himself.
Before an operation of any magnitude is commenced, it becomes
the surgeon to assure himself that his patient is in the proper anaes-
thetic condition. Entire paralysis of the muscles of animal life is
commonly received as indicative of such a state, — this being mani-
fested in the lifeless falling of an arm when raised. But this is not
strictly reliable, as to obtund sensation we are aware the posterior
root of the spinal cord is to be affected, while loss of motion implies
only the anaesthesia of the anterior root. So c|uickly, however, does
the action of the agent pass from the one to the other, that this sign
is found to be one most convenient of acceptance. Dr. Snow, so far
as I am aware, was the first to call attention to indications as af-
forded by the eyelashes ; this test I have depended on for years, and
mostly find reliable. Just after unconsciousness is induced, remarks
this observer, the eyelashes are often closed very strongly when their
margins are touched, especially in females, and there seems to be a
positive hyperesthesia ; this, however, is only apparent, and arises
from the control of the will being removed while sensibility remains.
By continuing the chloroform the sensibility of the edges of the eye-
lids diminishes, until, at last, they may be touched without causing
winking. Under these circumstances, the most severe operation may,
in almost every case, be commenced without pain. Upon this indica-
tion of the eyelids, Dr. Snow thinks we may so entirely depend, as
ordinary cases are concerned, as to accept from them information as
to the exact extent of anaesthesia existing. When, for instance, he
says, touching the margins of the lids causes very slight and Ian-
GENERAL ANESTHESIA. 259
guid winking, the patient will commonly flinch a little if the knife is
used, but only in a manner that can be easily restrained, and will
not interfere with the majority of operations.
Three degrees of narcotism are described. " The first degree in-
cludes all the eflFects of chloroform that exist while a patient retains
a perfect consciousness of where he is and what is occurring. In
the second degree there is no longer correct consciousness. The
mental functions are impaired, but not necessarily suspended. In
the third degree there are no longer any voluntary motions."
The circumstances which influence or modify the effects of chloro-
form are thus considered by Dr. Snow, than whom, perhaps, there
is no one whose observations have been of a more extended or
thorough nature ; although it is not to be overlooked that he was so
sanguine in this direction that perhaps, in some instances at least,
his prejudices may have influenced somewhat his judgment.
" I arrived at the conclusion," says he, " after much careful obser-
vation, that chloroform might be given with safety and advantage
in every case in which the patient requires, and is in a condition to
undergo, a surgical operation. And having acted on this conclusion
for several years, I have found no reason to change it. It is desir-
able, however, to pay attention to every circumstance connected
with the health and constitution of the patient before exhibiting
chloroform, as many of these circumstances influence its effects."
Age. — " The age of a patient has considerable influence in modi-
fying the effects of chloroform. It acts very favorably on children.
They sometimes oppose the inhalation of it as long as they are con-
scious, but it does not occasion the rigidity and struggling, after loss
of unconsciousness, which are sometimes met with in the adult.
Anaesthesia is generally induced with a less amount of narcotism of
the nervous centers in children than in grown persons.
" The eff'ects of chloroform are more quickly produced, and also
subside more quickly in children than in adults, owing, no doubt, to
the quicker breathing and circulation. It often happens, however,
that when the insensibility has been kept up for some time, say
twenty minutes or half an hour, in a child, it is followed by a natu-
ral sleep of a few hours' duration, provided there is no painful
wound or other cause to prevent the sleep. I have given chloroform,
in a few cases, as early as the age of eight or ten days, and in a con-
siderable number of cases before the age of two months. And I
own memoranda of hundreds of cases under a year old to whom I
have administered this agent. There has been no ill effect from it
260 ORAL DISEASES AND SURGERY.
either in these cases or in those of children more advanced in life ;
and it is worthy of remark, that none of the accidents from chloro-
form which have been recorded have occm'red to young children." |
There is nothing peculiar in the effect of chloroform upon people!
advanced in years except that its influence subsides rather slowly'
on account of the slower breathing and circulation. I have given '
chloroform to many patients over seventy-five years of age, and to !
one as old as ninety years. ,
Strength or Debility. — "The comparative strength or debility j
of the patient has considerable influence on the way in which chloro-i
form acts. Usually the more feeble the patient is, whether from ill-i
ness or any other cause, the more quietly does he become insensible ; j
while if he is strong and robust, there is very likely to be mental '
excitement in the second degree, and rigidity of the muscles, and
})robably struggling in the third degree of narcotism. Patients in
a state of debility resemble children, not only in coming quietly and
easily under the influence of chloroform, but also in the circumstance,
that the common sensibility is suspended with less narcotism of the
nervous centers than is generally required in robust persons. Chil-
dren, and persons in a state of debility, have usually an acute sen-
sibility, which causes them to suffer pain from very slight injuries,
but this sensibility is more easily suspended by chloroform than the
less acute sensibility of robust persons."
Hysteria. — " Patients who are subject to hysteria sometimes
have symptoms of the complaint, such as sobbing, crying, or laugh-
ing, as soon as consciousness is suspended, or even impaired, by the
chloroform; but these symptoms can always be subdued by pro-
ceeding with the inhalation.*
" In some persons who are subject to hysteria the breathing be-
comes excessively deep and rapid while inhaling chloroform. f This
* Chloroform in hysteria is, I think, one of the most valuable medicines of
the Materia Medica, while, on the contrary, sulphuric ether is, so far as my
experience goes, most decidedly objectionable to such patients. I have treated
females atHicted in this way where ether had been used by the pound with no
other efiect seemingly than increasing, intensifying, and prolonging the par-
oxysm ; yet with a very few inhalations of chloroform, I have had the pleas-
ure of seeing these persons fall into the most natural slumber, and after rest-
ing quietly for hours, the slumber prolonged, perhaps, as sometimes has seemed
indicated, by occasional repetition of the inhalation, I have seen them, over
and again, awake perfectly recovered.
t Dr. Snow, in his paragraph, remarks the supervening of this condition
after the first few inhalations, but, according to my own experience, it is as
GENERAL ANESTHESIA. 261
usually occurs just as the patient is becoming unconscious, but in a
few cases even earlier, and the patient is aware of the impulse to
breathe in this manner. After this kind of hysterical breathing has
lasted a minute, the patient generally rests nearly a minute without
breathing at all, after which the respiration becomes generally very
natural. Chloroform is to be given very sparingly during the vio-
lent breathing, or else withdrawn altogether for a minute or two."
Pregnancy. — It is not generally esteemed that there is anything
in this condition objectionable to the use of chloroform.
The Menstrual Period. — This period is certainly not to be pre-
ferred or selected as an occasion of chloroform exhibition. Yet is
there nothing at all in the condition adverse to such exhibition.
The controlling effect of the agent over hysterical symptoms has just
been remarked, and such irritability of the system is the only pecu-
liarity of this state. Indeed, it is very common that the hysterically
inclined female is compelled to resort to chloroform, particularly in
conditions of dysmenorrhoea.
Diseases of the Lungs. — "Affections of the lungs sometimes
cause a little difficulty and delay in the administration of chloroform,
as the vapor is liable to excite coughing when the mucous membrane
of the air-passages is irritable. The inconvenience is, however, con-
fined to the time of inhalation, for the cough is generally relieved
afterward.*
"I have given," says Dr. Snow, " chloroform for surgical purposes
in many cases where phthisis was present, and in several patients
who had suffered from haemoptysis, and have not seen any ill effects
from its use in these cases. Chloroform has, indeed, often been in-
haled with advantage to relieve the cough in consumption. The
cases of chronic bronchitis in which chloroform is administered and
for surgical operations ai"e still more numerous."
Disease of the Heart. — "There is a very general impression
that the use of chloroform is unsafe when disease of the heart
uncommon when chloroform is used as it is common in the employment of
ether. When, in administering ether, I see the slightest signs of hysteria,
either in male or female, I always expect at once to control them by replacing
the ether with chloroform.
* This difficulty, as observed not only by Dr. Snow, but alluded to by
nearly all writers on anaesthesia, I have found to be almost, if indeed not en-
tirely, obviated by preceding the exhibition with a tablespoonful of thick
mucilage of gum acacia, the patient allowing it gradually to lose itself over
the mucous surfaces.
262 ORAL DISEASES AND SURGERY.
exists, more particularly fatty degeneration of that organ. This
belief has been encouraged by the circumstance that this affection ;
has been present in a few of both the real and alleged deaths from t
chloroform, and also by the fact that, in the accidents that have been
really due to chloroform, the heart has been the organ on which it
has exerted its fatal influence. When we come to investigate these
eases however, we shall find reason to conclude that the heart has
probably been diseased in quite as great a proportion of the patients i
who have taken chloroform without ill effects as those who have \
succumbed under its influence. As regards my own practice," says
this authority, "the only case in which death could in any degree be
attributed to the chloroform, was one in which there was extreme
fatty degeneration of the heart ; but, on the other hand, I have
o-iven chloroform in numerous cases without ill effect where the
symptoms of this, as well as of other affections of the heart, were
present in a marked degree. Indeed, I have never declined to give
chloroform to a patient requiring a surgical operation, whatever
might be his condition, as I early arrived at the conclusion that this
agent, when carefully administered, causes less disturbance of the
heart and circulation than does severe pain. Wherever," continues
Dr. Snow, " I have had an opportunity of seeing an operation per-
formed without chloroform, I have carefully examined the pulse,
and although none of these operations have been of a very severe
nature, I have found the circulation to be much more disturbed than
it would have been by chloroform carefully administered. The pulse,
in most of these cases, has been exceedingly frequent during the
operation, and in some instances it has intermitted to an unusual
extent.
"In one instance I had an opportunity of witnessing a similar
operation on the same patient, first without chloroform, and after-
ward under the influence of the agent. In the operation, which was
lithotrity, at the first operation I began to feel the pulse just when
the patient saw the lithotrite about to be introduced. It was 120 in
the minute. As soon as the instrument was introduced the pulse
increased to 144, and immediately afterward it became uneven, irreg-
ular, and intermitting. I could not count more than three or four
beats at a time ; and, occasionally, when the pain seemed greatest,
and the man was straining and holding his breath, the pulse was
altogether absent for four or five seconds. In order to ascertain
whether the absence of the pulse at the wrist might not depend on
the pressure of the muscles of the arms, caused by grasping the
GENERAL ANESTHESIA. 263
table, I applied my ear to the chest, and found that there was no
sound whatever to be heard during the intervals when the pulse was
imperceptible. It was evident that the patient held his breath till
the right cavities of the heart became so distended as to stop
the action of the organ till the respiration returned. The man did
not complain or cry out during the operation.
"A week afterward the lithotrity was repeated, but on this occa-
sion I administered chloroform. The pulse was 120 in the minute
when the patient began to inhale the chloroform, but it became
slower as he was made unconscious, and it was regular during the
operation. It was only toward the end of the operation, when the
effect of the agent was allowed to diminish, and when the man
began to strain a little, though not yet conscious, that the pulse in-
termitted slightly, passing over a single beat occasionally. There
were none of the long intermissions of the pulse observed on the
former occasion.
"It is very evident that if the above-mentioned patient had been
the subject of any affection of the heart which weakened or embar-
rassed its action, he would have run a much greater risk from the
pain of the first operation than from the inhalation of the chloroform
in the second one.
" In a few of the patients having the arcus senilis of the cornea,
a weak, intermitting, or irregular pulse, and other signs of fatty
degeneration of the heart, there have been a feeling of faintness and
a tendency to syncope as the effects of the chloroform were sub-
siding, especially when the operation had been performed in the sit-
ting position ; but these symptoms have soon subsided, in all cases
I have met with, on placing the patient horizontally, with, or with-
out, the help of a little ammonia to the nostrils."
Cerebral Diseases. — "Affections of the head offer no obstacle
to the administration of chloroform. I have given it to several
patients who had suffered previously from an attack of apoplexy;
some of them still retained the paralysis resulting from the attack,
but the chloroform has not been attended or followed by ill effects
in any of these cases."
The following interesting and most instructive case is mentioned
in this direction.
" The 31st of October was a day appointed by Mr. Fergusson to
perform lithotrity on a gentleman seventy-eight years of age, who
had a phosphatic calculus in his bladder. He was a patient of Mr.
Propert, and Mr. Fergusson had removed a similar calculus by litho-
2(34 ORAL DISEASES AND SURGERY.
trity, and I Lad given him chloroform at each of the operations, and
it was arran"-cd that he should have chloroform on the present occa-
sion. Mr. Propert informed Mr. Fergusson and myself on our arrival
that his patient had, the night before, an attack resembling apoplexy;
he had been insensible ; the breathing had been stertorous, the pupils
dilated, and the face very red and congested. Mr. Propert had
caused him to be cupped to fourteen ounces, and had given him
twenty grains of calomel in the course of the night, and in the
morning he was as usual, and remained so at the time of our visit.
We considered the case with Mr. Propert, and as there were reasons
for not postponing the operation, it was determined that he should
inhale the chloroform rather than be subjected to the pain. The
vapor acted very favorably, he recovered his consciousness a
few minutes after the operation, and expressed himself as feeling
quite well."
Insanity. — Chloroform acts on insane patients just as it does on
others : when the effects subside they are in the same state of mind
as before. Mr. Snow remarks the suspiciousness of the insane, but
gives his experience where teeth have been extracted and other
operations performed which it w^ould have been impossible to ac-
complish in the same individual without resorting to inhalation.
The employment of chloroform in the delirium of mania a potu has,
through the experiments of Dr. Ely McClellan, of the United States
Army, lately been revived, and commanded much attention, the suc-
cesses of this gentleman having been quite sufficiently verified by
practitioners in every part of the country : given in drachm doses,
jyt'o re nata, it seems completely to break the paroxysm, causing
the patient to fall into profound sleep, from which, after eight or
ten hours, he commonly awakes entirely relieved. In delirium,
however, the chloroform is to be taken into the stomach, and not
breathed.
I may close this consideration of chloroform by again remarking,
as alluded to in the commencement of the chapter, that the agent,
if one feels justified in using it, is far to be preferred in oral surgery
to the ether — a profound impression created through chloroform will
not unfrequently continue through quite a prolonged operation ; or
if it be necessary to renew the inhalation, the desired impression
is generally made with great rapidity. Operations about the mouth,
unlike most other surgical services, require to be executed with
great rapidity; therefore is it a necessity to be as little interfered
with as possible: an impression, apparently very profound, made
GENERAL ANESTHESIA. 265
with ether, is apt to be broken in the very first shock of an oral
operation. This first step may be of a character, starting, in some
instances, frightful hemorrhage, and which can only be combated
at the completion of the operation ; to have a patient start from con-
trol at such a moment, and under such circumstances, is sometimes
a matter of serious concern. If one has not used chloroform up to
this time, and the article is at all convenient, it is very apt to be
given to the patient in a quite free manner. I certainly do desire
heartily to recommend it, but prefer, as my own practice is con-
cerned, to combine it in varying proportions with sulphuric ether.
I have, in this chapter, used, in many instances, the strong authori-
tative experiences of Dr. Snow. I believe, and think I know for truth,
all that he maintains ; his experience with the agent has certainly
been of the most extensive nature, yet personally, however, I am
as yet afraid to use chloroform but in conjunction with ether ; and
while such fear may not at all be well grounded, yet as it exists, I
cannot do otherwise than give expression to it. At this day it is
certainly idle enough to attempt to deny that many deaths have
occurred in the use of chloroform, and these accidents have hap-
pened not alone in the hands of the charlatan, but the propor-
tion of accidents have occurred with most eminent and skillful
men, and where every care and scientific precaution possible were
taken.
Again, the accidents have seldom or never been traceable to an
overdose of the agent ; the deaths have never occurred from narco-
tism, but from direct, immediate, and unforeseeable paralysis of the
heart. I have not overlooked the fact, that fatal results happening
while chloroform was being used, might not be at all owing to this
agent. Certainly there are cases enough on record justifying such
a conclusion — cases with which every surgeon must be familiar
enough; but, on the other hand, there are, as well, instances in
such doubt, or perhaps I should rather say, of such certainty, that
one may rather err on the side of discretion.
NITKOUS OXIDE GAS.
Except as its use in dental surgery proper is concerned, I do not
think nitrous oxide will ever be found applicable to oral operations
(at least, as we at present know how to get the effects of this agent).
In this opinion, I am very well aware, others may not feel disposed
to agree with me, and it may very well be that I am wrong, as I
266 ORAL DISEASES AND SURGERY.
have had little experience with the agent. Be this as it may, how-
ever, ether and chloroform appear so satisfactory, and every way
reliable, and at the same time are so convenient of use compared
with the gas, that I imagine they will continue to hold the supre-
macy.*
* For a learned and exhaustive treatise on this subject, see a work by Dr.
Geo. J. Ziegler. Also an able monograph by Dr. Geo. T. Barker, published
in Philadelphia.
CHAPTER XVII.
SALIVARY FISTULE.
As a result of wounds, abscesses, ulcers, and other similar causes,
it sometimes happens that external communication is established
with the duct of Steno, in consequence of which the secretions of
the parotid gland, instead of passing into the oral cavity, subserv-
ing their recremental purpose, are poured out over the cheek, irri-
tating these parts, and proving the source of greatest discomfort,
not unfrequently, indeed, locating quite intractable excoriations. In
children, cancrum oris has frequently so sloughed away portions of
the cheek as to produce the most intractable of fistulas, necessitating,
indeed, plastic operations for their cure.
An ordinaiy fistule is very well represented by the accompanying
view.
Fig. 57. — Salivary Eistule — from Life.
In this particular case,* the fistule was the result of abscess
of the cheek, induced by caries of the tuberosity of the right
superior maxilla; the history of the case being as follows: the
* Added to this figure, which is from life, is exhibited a second form, that
of parotid fistule proper. The one cut has been made to subserve the two
illustrations.
(267)
268 ORAL DISEASES AND SURGERY.
patient, a gentleman of most excellent constitution and easy cir-
cumstances, suffering from a carious wisdom tooth, had sought
relief in its extraction. The dentist, however, to the misfortune
of the patient, broke the tooth, and was unable to remove the
fang. From the irritation thus induced, conjoined with that resid-
ing in the broken and inflamed root, a caries of the bone was in-
duced ; this, in its turn, inflaming the cheek, an abscess formed ;
this opened externally, involving the duct of Steno, thus producing
fistule. The ordinary condition of the patient was as follows : the
natural outlet of the gland continued patulous ; consequently, to the
comfort of the case, much of the secretion found its way into the
mouth. Through the artificial channel enough, however, escaped
to keep the cheek constantly bathed with saliva and pus, the orifice
being constantly covered with a large but soft and pasty imperfect
scab. Of course, so long as the saliva discharged through this
channel, it was impossible for nature to close it.
In this case, three weeks, lacking three days, were required for
the cure: first, examination was directed to the condition of the
underlying parts. The caries of the bone being found cured, the
depth and course of the fistule was discovered by the use of the
ordinary silver probe. This, for three days, was enlarged by the
introduction, each day, of a twisted tent of cotton. At the end of
this period a slender, straight-bladed bistouiy was passed directly
through the cheek into the mouth. An eyed probe was next
threaded with a cotton tent, large and thick at the part which was
to occupy the inner half of the thickness of the cheek, delicate, and
as threadlike as it could be made where it was to be lodged in the
track of the fistule. By the aid of the probe this tent was carried
through the cheek, and was then fixed in position by a little slip
of adhesive plaster, attaching it to the cheek. This tent, being kept
clean and disinfected by daily syringing, was retained in position
one week, the swelling of the inner bulky portion having by this
time resulted in the formation of quite a channel, with a correspond-
ing diminution in the diameter of the fistule. At this stage the
cotton was replaced with a wire seton, made by taking the most
delicate of ligature iron wire, doubling it upon itself a number of
times to half the thickness of the cheek, a single strand containing
the length designed to occupy the line of the fistule. To replace the
one Mith the other it was only necessary to attach them by an in-
termediate strand of silk: as one was withdrawn, the other occu-
pied its place. This wire seton was thus inserted, and was held
SALIVARY FISTULE. 269
in place by perforated, shot clamped on each extremity. In one
week the external or original fistule had closed so as to hug the
wire, the discharge being entirely into the mouth. The seton was
now withdrawn entirely, and on the next day complete closure was
found to have resulted. The case was thus dismissed cured, and
remained so.
A more common way to operate in salivary fistulas is to take a
strand of well-waxed ligature silk, threaded at each end to straight
or curved needles, as preferred ; seeking the bottom of the fistule,
the first needle is thrust through the cheek into the vestibule and
brought out at the mouth ; the second, needle is now passed to the
bottom of the fistule precisely as the first, and is also thrust through
into the mouth, but leaving some little tissue between its exit and
the line of the first. The two ends being out of the mouth, a single
knot is made, drawing it close up to the mucous surface of the cheek,
strangulating the contained tissue. This strangulation, however,
is not absolutely necessary, many surgeons, indeed, preferring the
knot loose, and to have the new passage resultant simply from the
presence of the silk. With such a new passage, the original fistule
will mostly tend to heal of itself, particularly will this be found the
case where the passage has been so made as to afford easier exit
for the fluid than the fistule. It is on such account that my own
experience prefers the operation first described.
Another form of salivary fistule, and one much more difficult to
treat, is where, from operations performed over the parotid region,
the gland has been exposed and some of its lobules opened. See
Fig. 57.
To treat such a case, attempt may first be made to close the opening
by means of a cauterant, either the actual or potential. Of the latter,
the crystals of the chloride of zinc should, I think, have the pref-
erence, being markedly provocative of healthy granulations. Ni-
trate of silver has been used by many with reported good success.
Cauterization, however, we are compelled to admit, is much more
frequently unsuccessful than otherwise, the more philosophical and
effectual mechanical measures being required.
A mode of operation, not unlikely to meet with success, consists
in the use of the strands of wire, made and employed precisely as
suggested in the more simple cases.
It has been recommended by many surgeons that in cases of
fistulae with induration of the part, such tissue be punched or cut
out : this was a favorite mode with the late Professor Horner. To
270 ORAL DISEASES AND SURG ERF.
accomplish this end, a blade or spatula of wood is placed against
the inside of the cheek, thus supporting it ; a slight longitudinal in-
cision is now made on the outside, through which the punch is
passed, cutting the section from the inside half of the thickness ; the
external wound is next approximated with a few stitches of the in-
terrupted suture, and if union should be secured, the cure will be
found complete. In this connection, too much praise cannot be
given to applications of alum-water, alternated, if it is thought de-
sirable, with very dilute tincture of capsicum. With these applica-
tions, I am certain that I have secured union in cases which, with-
out them, would have been utter failures. Upon Plate YI., taken
from Professor Smith's Principles and Practice of Surgery, Figs. 1, 2,
and 3, the surgical relations of fistule are exhibited ; also Horner's
operation.
PLATE VI.
A VIEW OF THE ANATOMY OF THE SIDE OF THE FACE, AND OF SOME'
OF THE OPERATIONS PRACTICED ON IT.
Fig. 1.— a side view of the Anatomy of the Face after the removal of the
integuments. 1. The shape and position of the parotid gland. 2.
The duct of Steno. 3. The sublingual gland. 4. The facial artery,
at the point where it passes on to the face. 5. The facial vein. 6.
The sterno-cleido-mastoid muscle. 7. The external jugular vein.
8. The zygomatic muscle. 9. Branches of the portio dura nerve
emerging from the upper edge of the parotid ; other branches are
seen on the face. — AJter Bernard and Huette.
Fig. 2. — The same Section after the removal of the Parotid Gland. 1. The
portio dura nerve at its exit from the stylo-mastoid foramen. 2.
The duct of Steno divided transversely. 3. The external carotid
artery when freed from the parotid. 4. The temporal artery. 5.
The facial artery after removal of the sublingual gland. 6. The
sterno-cleido muscle. 7. Main trunk of the external jugular
veiii. — After Bernard and Huette.
Fig. 3. — A three-quarter view of Horner's operation for the cure of Salivary
Fistula. A wooden spatula supports the inside of the cheek ; a
slight longitudinal incision is made at the external fistulous orifice,
and the hand of the surgeon is seen pressing the punch against the
spatula so as to cut out a piece through the cheek. The external
incision, being closed by a point of a suture, heals usually by the
first intention, leaving the orifice, made by the punch, open in the
mouth. — Drawn from Nature.
Fig. 4. — A view of the operation of Resection of the Upper Jaw, as practiced
by the incision of Warren. 1, 2, 3. The flaps everted, and turned
over the nose and eye so as to expose the bone. The left hand of
the surgeon is holding, 4, the bone at the moment of disarticu-
lation by the knife, 5, which is working at the pterygo-m axillary
fissure. Velpeau's operation is nearly the same as that of War-
ren. — After Bernard and Huette.
Fig. 6. — Represents the completion of the operation, the union of the wound
by the twisted suture, and the line of the cicatrix, which extends
from the malar bone to the mouth near, but not at, the angle. —
After Bernard and Huette.
Fig. 6. — A view of the termination of Gensoul's operation, showing the lines
of his incision. 1, 2. The first incision across the tumor. 3, 4.
The second incision. 1, 5. The third incision, forming flaps which
are to be turned up and down upon the face. The sutures are seen
as placed at the termination of the operation. — After Gensoul.
Note. — Figs. 4, 5, and 6 refer to operations considered in another connection.
(271)
CHAPTER XYIII.
THE TONSIL GLANDS.
The tonsil glands, situated on cither side of the fauces, between
the half arches, arc readily exposed by depressing the tongue through
the instrumentality of any convenient means. An instrument made
especially for the purpose, called a "depressor," will be found very
well adapted.
The tonsils, glandular organs, are made up of many lobules, with
intervening sulci lined by involutions of the common mucous mem-
brane. Inflammation, simple or acute, and chronic or morbid, is the
disease of these glands. With the first are associated the various
features of vascular change, passing from the most transient of con-
gestions to the most threatening of abscesses.
Fig. 58.— The Toxsil Glands.
Simple tonsillitis — angina tonsillaris — amygdalitis — is an inflam-
mation of the substance of the gland. Looking into the mouth, the
bodies, one or both, are discovered unduly colored and swollen ; if
the inflammation is of any severity in its grade, the patient experi-
ences pain and difficulty in swallowing, a sense of dryness, heat, and
fever in the fauces ; and these discomforts, influenced by the charac-
ter of the attack, may progress until it becomes impossible to swal-
low, and in many cases exceedingly difficult to breathe.
(272)
THE TONSIL GLANDS. 273
Glancing at the view, which exhibits the glands in a state of par-
tial enlargement, it is plainly enough seen that the isthmus would
be closed in proportion to such enlargement ; hence the difficulty ex-
perienced in deglutition and respiration. Tonsillitis ends either in
resolution or suppuration.
When the inflammation is met with in its incipiency, attempts are
at once to be made to resolve it by the use of antiphlogistic remedies,
— free scarification has occasionally been resorted to with the best re-
sults. Leeches externally, and blisters, will be found of the greatest
service, hot foot baths, etc. If the inflammation should have ad-
vanced to a point in which the system at large sympathizes, as
exhibited by the presence of fever, hope is still to be entertained
of recovery by resolution. In these cases I have found it good
practice to place the patient over a basin of steaming water, and
with the form enveloped up to the very mouth in blankets, secure
diaphoresis by a plentiful exhibition of the spiritus Mindereri — a
tablespoonful every 10 to 15 minutes until the result desired is pro-
duced. This, if the patient is robust, may be succeeded by a saline
cathartic. As a local treatment, it will be found very agreeable to
order a lemonade, made by crushing ice in a towel or napkin ; the
small particles of the ice thus acidulated may be taken little by
little into the mouth, and allowed gradually to dissolve. Another
application consists in a gargle of flaxseed tea, in which is dis-
solved the chlorate of potash. Tartar emetic, or the tinct. of digi-
talis, or of verat. viridum, are of much use in controlling the circu-
lation. A very useful combination, where the circulation runs high
and the system is irritable, is as follows :
R. — Liq. potass, citrat. ^iij ;
Spts. seth. nit. ^i ;
Tinct. verat. virid. gtt. xxv ;
Ant. et potass, tart. gr. i. M.
Sig. From 3i to Jss, according to circumstances.
In most cases of tonsillitis where the inflammation is extensive,
the uvula will be found to participate ; swelling, through serous effu-
sions occurring, not unfrequently to such an extent as to threaten a
very immediate suffocation. I know of nothing more satisfactory in
these cases than the draining of the cellular tissue in which the effu-
sion exists by snipping off with a pair of scissors the tip of the
organ. In the swelling of the glands themselves, where danger is
apprehended from the closure of the passage, or overpressure upon
18
274 ORAL DISEASES AND SURGERY.
the epiglottis, it is well to make free incisions, or these failing, to
amputate a part of one or both bodies. Indeed, circumstances may
arise where an opening into the larynx or trachea may aiford the
only chance to a patient for his life.
"Where, in defiance of all treatment, tonsillitis determines toward
suppuration, the best that can be done is to hasten the process as
rapidly as possible, providing, always, that the attendant swelling
is not formidably extensive. In these latter cases nothing better
can be done than to make premature incisions. Where the swelling
is not extensive or threatening, gargles of flaxseed tea will be found
both soothing and encouraging to the formation of pus, and may be
used with all freedom.
Hypertrophy, or chronic enlargement of the tonsils, is a condition
most common to scrofulous children, and pertains, consequently, to
early life, being, indeed, very rare after puberty, and never perhaps
seen in old age ; of the various patients upon whom I have operated
for the relief of this affection, I do not recall one over thirteen years
of age. An enlarged or hj^iertrophied tonsil differs very much in
its consistence and character, being in one patient indurated and
smooth, in another spongy and lobulated. In color an equal variety
is presented, varying in appearance from the scarlet of an arterial
injection to the dull blue of a passive venous stagnation. One of
the inconveniences associated with enlarged tonsils is the effort re-
quired in respiration, particularly during sleep, such effoi't in many
cases, being really painful to witness. Another, is the interference
with hearing, pressure upon the Eustachian tube frequently occlud-
ing this passage, particularly when the patient takes cold.
Fig. 59. — Hypertrophied Tonsil.
Tonsillar hypertrophy being a systemic expression rather than a
strictly local disease, very little true benefit has been derived from
the employment of the great variety of direct remedies which from
time to time have been recommended. A patient so afflicted is to
be treated from the constitutional stand-point, and to this end no-
THE TONSIL GLANDS. 275
thing in my experience has been more conducive to change than
cold salt-water bathing; indeed, I apprehend that, as a rule, more
attention will be found required to the direction of diet, clothing,
exercise, and general mode of life than to the administration of med-
icine. Where, however, medication seems demanded, it is to be di-
rected to the correction of any observable constitutional defect or
irregularity. Iodine and its preparations are not always, by any
means, indicated ; and not unfrequently, in their exhibition, by a fur-
ther debasement of the vital powers, much more harm than good has
resulted. It does not seem possible to lay down rules that shall or
can apply to the constitutional treatment of such cases, except so far
as to suggest attention to all the functions and the general tonic
medication always demanded.
Pressure by the finger, frequently repeated, punctures with the
point of a bistoury, the application of any of the scorbifacients, very
dilute gargles of the tincture of capsicum, — any or all these means
may have local trial; but it is to be regretted that the promise is
very little.
The local employment of the iodide of zinc has, in Europe, re-
ceived very warm commendations. It is used first as a strong solu-
tion, from ten to thirty grains to the ounce — afterward pure, or as it
deliquesces when exposed to the atmosphere.
An enlarged tonsil, truly hypertrophied, is best removed by
making a section of it. To this end the instrument known as the
tonsillotome is always to be recommended ; of such various instru-
ments, that known as Fahnstock's is perhaps the best. With this,
the section can be made in a single moment, and in hands at all
accustomed to operate, without the slightest risk.
In operations upon young children, with the tonsillotome, it will
be found best to employ ether, as otherwise the restlessness may
interfere with the proper introduction of the instrument. After ex-
cising one tonsil the child should have its head immediately thrown
forward, that the blood may not pass into the throat. As soon as
hemorrhage has stopped, the ether is to be readmlnistered, and the
section repeated upon the opposite side.
! To accomplish this operation with delicacy, it is only necessary
; to place one's self before the patient, whose head is suppoi-ted against
the breast of an assistant ; the tongue -holder may or may not be era-
I ployed, as seems most convenient. In cases where the gland may
[ be larger than permits the easy application of the instrument, it
j will be found very useful to use a hook, or the double hook forceps,
276 ORAL DISEASES AND SURGERY.
pulling the body into the fenestrum. This accomplished, it is only
necessary to slide the catch-pin. When the gland is thus fixed, the
blade is instantly made to incise it.
Many surgeons, immediately after this operation, and in many in-
stances before it, administer, in anticipation of inflammatory trouble,
a full dose of sulphate of magnesia. It is also thought well by many
to protect the incised parts against the irritating influence of atmos-
pheric changes by a confinement of several days in an even tempera-
ture. I think, however, that if the weather is moderately mild, it
may be found sufficient to keep the parts lubricated by a coating of
gum acacia, secured, by simply holding the pearls in the mouth
until they dissolve; at least, such practice has proven very satisfac-
tory in my hands.
Hemorrhage, of any marked character, after the operation, is not
common : instances occur, however, when the tonsillar artery must
be compressed, twisted, or tied ; but, as a rule, there is no trouble
from this source that a simple gargle of alum-water will not be
quite sufficient to overcome.
Ulceration. — Ulcers, both common and specific, are frequently
met with upon the tonsils. Nothing peculiar in their history asso-
ciates itself with the situation; they are to be treated in considera-
tion of their varying indications. (See Remarks on Ulcers.)
Gangrene. — This is an occasional, though very rare condition ;
when appearing independent of exanthematous relations, it is to be
looked on as indicative of great prostration in the life forces, and
must be expected to yield alone to vigorous constitutional treatment.
As local applications, Watson's chlorinated water, solutions of car-
bolic acid, or starch-water and creasote may be used.
Cystic Growths. — In Professor Gross's System of Surgery
reference is made to cystiform enlargements which have been ob-
.served in the tonsils ; with such conditions I have never happened
to meet. The treatment, however, would necessarily be simple, and
would be entirely analogous to that of ranula, which see.
Acute tonsillar enlargement sometimes compels the performance
of laryngotomy or tracheotom3\ A passing study of these opera-
tions would thus seem made a part of our subject.
When convinced that a patient may not otherwise be relieved, and
sufi'ocation is eminent, the surgeon may thrust a bistoury or scalpel
directly through the crico-thyroid membrane. This operation, if no
middle thyroid artery run over the membrane, is one of most simple
character ; and if the parts be then separated, and kept so, either by
THE TONSIL GLANDS.
277
the introduction of a tube, or by hooks of wire, which may pass
around the neck, the patient will experience the greatest relief
When the artery crosses the membrane, and has thus been cut, the
blood is to be prevented from entering the lungs by leaning the
person forward, the face downward; the vessel is then to be secured
in the most convenient manner, with ligature, if possible.
Fig, 60. — View of the Air-Tubes.
A. B.
A. Larj-nx, trachea, and bronchial tubes, viewed in front. 1, hyoid bone ; 2, thyro-hyoid
membrane ; 3, thyroid cartilage ; 4, crico-thyroid membrane ; 5, cricoid cartilage ; 6,
trachea; 7,8, two cartilaginous rings; 9, membrane which separates them; 10, right
bronchus and its divisions ; 11, left bronchus.
B. Larynx, trachea, and commencement of bronchial tubes, viewed from behind. 1,
upper opening of larynx; 2, 3, lateral grooves of larynx; 4, fibrous membrane of trachea.
Interspersed with small glands, beneath which are seen 5, muscular fibers ; beneath this
last are 6, 7, small fibrous bands ; 8, mucous membrane seen between them.
Tracheotomy is an operation which, while seemingly complex, is
yet most easy of accomplishment, at least I have found myself able
to perform it upon the living subject without assistance. Having
the patient upon his back, with the neck extended, an incision is
to be made directly in the middle line of the neck ; this incision,
278 ORAL DISEASES AND SURGERY.
under the circumstances we are considering, may be quite short,
and is to be commenced immediately below the cricoid cartilage.
Dividing skin, superficial fascia, and the delicate layer of the deep
fascia, we come upon the equilateral muscles running from the
sternum to the os hyoides and thyroid cartilage ; seeking the inter-
space separating these muscles, they are thrust to either side, — this
is easily done by using the handle of the knife, — the thyroid plexus
of veins is now brought into view, and is to be carried aside or
ligated, as seems most convenient; these manipulations bring into
view the trachea with its rings. Take now the tenaculum, and,
steadying the tube by pulling it upward, incise one, two, or three
rings.
The operation thus accomplished, keep the incision open by the
use of the wire, or, if preferred, introduce the canula and maintain
it in place by the strap, as seen in Subfig. 6, Plate VII.
In performing the operation, it is also necessary to bear in mind
that occasionally the inferior thyroid artery is found lying upon the
trachea, directly in its middle line. When this vessel is seen it be-
comes necessary to throw a ligature around it. My own observa-
tions in the dissecting-room would lead me to infer its presence in
this position in about one out of six cases.
(Edema of the glottis, a condition sometimes associated with
acute tonsillitis, is a very dangerous complication, being found
generally in the weak and anaemic. This complication, when really
threatening, may be aborted by blistering the neck with cantharidal
collodion, and afterward keeping up the watery discharge by paint-
ing the parts with glycerin. If, however, such a treatment is not
quickly responded to, the surgeon finds himself compelled to scarify
the parts. Subfig. 8 represents this swollen condition of the glottis.
To scarify these parts, seat the patient upon a chair, and, throwing
the head well backward, introduce the finger until it shall touch the
epiglottis; pressing now this organ toward the base of the tongue
so that the finger shall be back of it, carry a curved and wrapped
bistoury along the finger until it shall reach the swelling ; cuts are
now to be made from below forward. If the epiglottis is the part
aifected, and this is most commonly the case, the operation is ren-
dered much easier ; steadying the organ with the finger, it is to be
incised as in the first instance. Subfig. 7 represents oedema of the
epiglottis.
i
jiiC;
'y^
PLATE VII.
A VIEW OP THE OPERATIONS PERFORMED ON THE TRACHEA.
Tig. 1. — A front view of the Surgical Anatomy of the Trachea 1. Os hyoides.
2. Thyroid cartilage. 3. Thyro-hyoid muscles. 4. Crico-thyroid
muscles. 5. Thyroid gland and veins in front of crico-thyroid
ligament. 6. Kings of the trachea. 7. Common carotid artery.
8. Superior thyroid arteries. 9. Inferior thyroid artery. 10.
Carotid artery, as divided. 11. Outline of the top of the chest.
12. Innominata artery. 13. Inferior thyroid vein. 14. Trans-
verse vein. — After Bernard and Huette.
Fig. 2. — Kelative position of the Larynx, Trachea, and Blood-vessels. 1.
Os hyoides. 2. Thyro-hyoid ligament. 3. Thyroid cartilages.
4. Crico-thyroid ligament. 5. Cricoid cartilage. 6. Trachea. 7.
Internal jugular vein. 8. Transverse vein. 9. End of inferior
thyroid vein. 10. Veins. — After Bernard and Huette.
Fig. 3. — Kelative positions of the great vessels concerned in operations near
the top of the sternum. 1,1. Internal jugular vein. 2, 2. Sub-
clavian veins. 3. Subclavian artery. 4. Transverse vein. 5. In-
ferior thyroid vein. 6. External jugular vein. 7. Arch of the
aorta. 8, 8. Primitive carotids — After Bernard and Huette.
Fig. 4. — A view of the operation of Tracheotomy, as performed by Mr. Lis-
ten. 1. The tenaculum inserted into the trachea. 2. Position of
the bistoury in incising the rings. 3. Line and termination of the
external incision. — After Liston.
Fig. 5. — Extraction of a foreign body by Tracheotomy, the head being thrown
back and lowered, so as to facilitate the gravitation of the object.
1, 1. Blunt hooks holding open the wound. 2. Hand of the sur-
geon in the act of extracting the foreign body, by drawing it up-
ward from the bronchia. — After Boiirgery and Jacob.
Fig. 6. — A front view of the position and mode of retaining a canula in the
Trachea, as usually practiced. 1. The incision. 2, 2. A tape at-
tached to the wings of the canula and passing around the neck. —
After Bernard and Huette.
Fig. 7. — The appearance of the parts concerned in (Edema of the Glottis. 1.
The epiglottis cartilage, much swollen by serous infiltration of its
submucous cellular tissue. — After Gurdori Buck, Jr.
Fig. 8. — The operation of scarifying the Glottis for the relief of (Edema. 1.
The forefinger in its position as a director. 2. The knife in the
act of scarifying the part. — After Gurdon Buck, Jr.
(279)
CHAPTER XIX.
THE GUMS AND THEIR DISEASES.
The gums are simply a greater or lesser amount of fibro -carti-
laginous tissue (the fibrous far predominating) placed as protecting
cushions about the alveolar processes. The neck of each tooth is
closely enveloped by the dental pits of this cushion ; the mucous
membrane, which covers the common surface, being reflected around
the pits, and rendered continuous with the periosteum of the alveoli.
The gums, in a healthy state, are rather remarkable for their in-
sensibility, bearing, with very little or no response, the pressure and
irritation to which, in the process of mastication, they are so con-
tinuously subjected. The mucous membrane, of which this tissue
is really largely made up, is very heavy and thick compared with
its continuity in other parts of the alimentary canal, and is under-
laid by a network of vessels, which leads it to be esteemed of con-
siderable vascularity as reference is had to operations involving it.
Inflammation is the disease of the gums, but such perverted vas-
cular action, here, as everywhere else, has quite a variety of signifi-
cations. These significations are —
1st. Accumulations of tartar.
2d. Periodontitis.
3d. The mercurial impression.
4th. Scurvy.
5th. Syphilis.
6th. Dead or loose teeth.
7th. A crowded dental arch.
8th. Use of improper dentifrices and brushes.
9th. Improperly inserted artificial teeth.
10th. Malignant impressions.
11th. Anomalous conditions.
A comprehension of the diseases of the gums is found in the ap-
preciation of these various conditions or influences.
1st. Accumulations of Tartar.— SaMvavj calculus, a deposit from
(280)
THE GUMS AND THEIR DISEASES. 281
the saliva, combined with the various oral debris, when attached about
the necks of the teeth, necessarily becomes a source of offense, pro-
voking inflammatory action, the grade of which is marked by the
general condition of the individual. The most common type of in-
flammation thus induced is the chronic degenerative. The tartar,
pressing upon the gums and insinuating itself about and around the
necks of the teeth, soon interferes to such extent with the proper cir-
culation in the part as to yield the puffy, turgid condition, so familiar
in most of the cases. The mucous follicles lining the muco-dental
pits have, of course, their secretive ability soon destroyed, and thus
nothing prevents the insinuation of particles into these pits, and the
consequent increase in the power of the offense. This irritation, un-
combated, gradually progresses until the teeth become loosened and
fall out, when, carrying with them the tartar, the parts recover.
All deposits, however, existing under the common name of tartar
or salivary calculus, do not have such a destructive history. Thus,
it is very common to observe a greenish deposit, particularly upon
the teeth of the robust and uncleanly, which, so far as I have ob-
served, seldom results in any particular harm. Another kind, the
black, rarely exists but in very limited amount, and as rarely or never
does any greater ill than slightly irritating the festoon ; its situation
is most commonly the lingual face of the inferior teeth. It does hap-
pen, however, that this description of tartar, or something very anal-
ogous to it, is sometimes provoked, as it were, in depraved constitu-
tions, to extensive deposit ; it is a kind of mixture or agglutination
of tartar and sordes. The gums, from a constitutional influence, very
much depraved, are irritated not unfrequently by this jagged de-
posit into a state very little short of gangrene ; the breath is made
offensive, and the oral fluids, by the admixture, rendered entirely
unfit to be received by the stomach.
Yellow tartar, the deposit of the bilious and allied temperaments,
is the kind most generally met with, and, as a rule, is most destruc-
tive to the integrity of the teeth and gums. It is not at all uncom-
mon to find this deposit of such extent as to inclose in a common
mass half a dozen or more teeth, while its power of insinuation and
destruction is so great that, before attention may have been directed
to the process, the alveoli will be found destroyed and the teeth
ready to drop from the mouth. I have, in my own practice, fre-
quently been consulted in these cases, where nothing was of any
avail but the removal of the implicated teeth. This description of cal-
culus is evidently a direct deposit from the saliva, its situation cor-
282 ORAL DISEASES AND SURGERY.
responding with the location of the salivary orifices. I think it will
be found always associated with a sluggish condition of the secretive
action of the glands, as I am sure its most reliable prophylaxis is
found in their stimulation. This tartar has a rough, dry surface, and
is "-enerally most easy of removal, flaking away in masses at the
slightest touch of the instrument. The effect of its presence upon
the gum is to force it away from the teeth, or rather, it might be
more correct to say, to lift the teeth from the gums and their alveoli,
destroying entirely any relation of attachment between the parts.
The gums themselves, under its irritating influence, become puffy
and soft, and occasionally so tender as to render, in many cases, un-
bearable the ordinary pressure exerted in mastication, so that the
patient is compelled to subsist exclusively on soft food, or employ
other than the natural process of comminution. (See Chapter on
Salivary Calculus. )
2d. Periodontitis. — Ulitis from periodontitis is not at all difficult
to distinguish, and corresponds in character with the primary lesions
in being acute or chronic. If a tooth is acutely inflamed in its perio-
donteum, it is sore to the touch, and elongated. If it is chronically
inflamed, it is loose or discolored. Inflammation in the gum is
simply an inflammation of continuit}^. If the patient is in good
health, the action will be circumscribed ; if the reverse, it may of
course influence. To treat such an inflammation, the health of the
tooth or teeth is to be restored. An inflamed periodonteum is com-
monly associated with a dead pulp ; this is the first source of offense for
which we naturally look. If such a condition is found, and no cavity
of communication exists with the pulp canal, it will, in nine cases
out of ten, only be necessary to make such communication, and the
trouble quickly enough disappears. Tartar is the frequent source
of chronic periodontitis. Fish bones, or other foreign bodies, forced
into the membrane in mastication, excite inflammation.
Acute periodonto-ulitis uncontrolled ends in parulis, and from such
acute termination is very apt to pass to chronicity. Chronic ulitis
presents the condition of continued turgescence, soreness, loose teeth,
or fangs; suppuration frequently occurs at the seat of the original
abscess, and sometimes, from the affected alveolar pits, its cure, like
that of the acute condition, resides in a treatment directed to the
teeth. (See Periodontitis and Alveolar Abscess.)
3d Tlie Mercurial Imjyression. — Mercury first yields decided evi-
dence of its action by producing in the mouth a metallic taste, com-
plained of as coppery. A little time, and this taste is accompanied
THE GUMS AND THEIR DISEASES. 283
with some increase in the quantity of the saliva; still later the
festoons of the gums will be found congesting, commencing generally
about the necks of the lower central teeth. Succeeding this conges-
tion we have the dull whiteness, indicating the change in the epi-
thelial tissue (a form of aphthae). There now follows the elongation
of the teeth, increased salivary flow, stiffness of the gums, enlarge-
ment of the tongue, foul breath, etc.
The efi'ects which mercury shall produce on the mouth, or system
at large, depends on the quantity administered and the susceptibility
of the individual. I have myself exhibited the medicine in quantities
of from fifteen to twenty grains in the course of three days without
being able to perceive the local action; while, on the contrary, I have
known five grains to so swell the tongue that it required much effort
to prevent the patient being smothered. Children from five to ten
years of age have seemed to me markedly susceptible. I removed,
a short time back, the whole of the left half of the body of the lower
jaw, dead from but some three grains of calomel, as averred by the
practitioner who administered the medicine The patient was seven
years of age. Mercurial ulitis, when confined alone to these parts,
signifies but slight effect on the part of the action of the agent ; and
the immediate cessation in its employment will generally result in
the disappearance of these effects. If this should not, however, prove
the case, I think nothing better can be done than to scarify, and
paint the gums with tinct. of iodine, graduated to each particular
case, say, as a rule, half and half of the officinal tincture and water.
Chlorate of potash as a wash, and used internally, may also be em-
ployed. To an adult, ten grains of the salt, dissolved in a table-
spoonful of water, may be given four or five times in a day. As a
local application, one drachm to the ounce of water is a very good
strength. The bowels are to be kept in a lax condition by the ad-
ministration of Seidlitz powders or other saline cathartics. Where
mercurial ulitis passes to that stage which results in the breaking
down of the tissue, and this is sometimes the case where even ad-
jacent parts are not markedly affected, the treatment required is
much more imperative, and pertains, as a rule, quite as much to the
constitution at large as to the mouth itself. Locally, the fetor will
urgently demand attention, and one of the best means to correct
this will be found in the use of a solution of the permanganate of
potash, such solution varying in strength from two to ten grains to
the ounce of water. Constitutionally, vigorous tonic medicaments are
required, — not the least important of which are the iron and bark
284 ORAL DISEASES AND SURGERY. i
preparations. If hemorrhage intervenes, it may be necessary to era- j
ploy opium and lead internally ; or, as suggested in another part of j
this work, tinct. Erigeron Canadense, in doses of one or two drops,
repeated occasionally until such bleeding is controlled. Locally,
cobweb saturated in alum-water may be used. Laid carefully upon
the bleeding part, and retained in position, it will seldom be found
to fail. Monsel's solutions should not be used. The tendency in
extreme cases toward sloughing is a matter constantly to be borne
in mind. When the tumefaction is very great and indolent-looking,
the parts are still to be incised and the iodine applied ; but both
remedies are to be used with judgment and caution. I have known
gums in the condition alluded to, and which might perhaps have
been recovered, sloughed in mass by applications of strong tincture of
iodine. Always let the incisions at first be few, and the tincture at
least two-thirds diluted. The dilute aromatic sulphuric acid is also
a happy local remedy in these conditions. It may be mixed with
water until the acid taste is comfortably bearable — about 5i to 5viij
of water. A combination which I also occasionally use with much
benefit is composed as follows :
B. — Potassse chloras, §ss ;
Sodae boras,
Alumen pulv. aa Jij ;
Potass, permang. grs. xxv ;
Aqua cologn. ^ss ;
Tinct. cinchonas, ^ij ;
Tinct. myrrhae, §i;
Infus. quercus (fort.) ^iv. M.
Sig. Gargle the mouth pro re nata.
If, in defiance of all that is done, the parts should slough, one of
three things occur: the disease will seem to have exhausted itself,
and the parts, after a little rest, give evidence of recovery ; or the
bone follows the ulcerative action, and sloughs likewise ; or the
patient dies from irritation and exhaustion. (For treatment of Caries
and Necrosis, see other pages.)
4th. ScAirvy. — Scurvy proper, such as decimated the legions of
Louis the Ninth, and in even later days was so frequently the
scourge of protracted sea voyages, is a condition which modern
science and judgment have so combated that it may be trusted that
few of us will ever have occasion to meet with or treat it. Modified
forms of the disease are still, however, prevalent enough, and exist,
THE GUMS AND THEIR DISEASES. 285
with great variety of features, from simple indolent ulitis to general
I purpura.
j Puffiness of the gums, scorbutic in nature, is fairly judged, I
' think, from its dull, purple aspect, independent of its varying consti-
I tutioual conditions ; this venous congestion compares pathologically
i with the effusions of purpura proper. It would not, however, be at
: all truthful, or in accordance with the facts, to describe any particu-
lar train of constitutional conditions as constantly associated with
the scorbutic sore mouth, as met with in ordinary practice, and for the
reason that nothing else of the disease may appear but the local
manifestation. That it is a constitutional affection, however, and
not a local disease, is proven from the fact of absence of any source
of local irritation, and from the further fact of its constant presence
in the mouth, let the disease possess whatever other manifestations
it may.
" Scurvy," says Dr. Wood, "is generally very gradual in its ap-
proach, so that it is scarcely possible to say, in any particular case,
what was its precise time of attack. Attention is commonly first
attracted by an unhealthy paleness of complexion, a feeling, on the
part of the patient, of languor and despondency, with an indisposi-
tion to bodily action, and unusual fatigue after exercise ; a sensation
of weariness and aching in the limbs as from overexertion, though
the patient may have been at rest ; and some swelling, redness, and
tenderness of the gums, with a tendency to bleed from slight causes.
With the advance of the disease the face becomes paler, and assumes
a somewhat sallow or dusky hue, and often a degree of puffiness ;
the lips and tongue become pallid, and contrast strikingly with the
gums, which are purple or livid, especially at their edges, rise up
between and around the teeth, are soft and spongy, and bleed from
the slightest touch ; the breath is ofiensive ; purplish spots or
blotches appear upon various parts of the surface, beginning usually
upon the lower extremities and afterward extending to the trunk,
arms, and neck, though seldom affecting the face ; hemorrhage fre-
quently occurs, most commonly from the nose, gums, and mouth, but
sometimes also from the stomach, bowels, and urinary passages; the
feet become edematous, and the legs swollen and painful ; the gen-
eral debility increases ; and muscular exertion is apt to be attended
with palpitation of the heart, panting, vertigo, dizziness, and a feel-
ing of faintness. The petechial spots are obviously owing to the
extravasation of blood within the cutaneous tissue. Occasionally
portions of the surface look as if bruised without having suffered
286
ORAL DISEASES AND SURGERY.
anv violence; and blows, which, under ordinary circumstances
would produce no effect, now give rise to extensive ecchymosis.
Should the disease continue, all the symptoms become aggravated,
the complexion assumes often, with its paleness, a livid or leaden
hue • the gums swell greatly, and put forth a blackish fungous
gi-owth, so as sometimes to conceal the teeth, blood continually oozes
from them ; sloughing occasionally takes place, laying bare the necks
of the teeth, and extending, in very bad cases, even to the cheek.
The teeth become loose, and sometimes fall out; the patient is un-
able to chew solid food in consequence of the state of his gums.
The breath becomes intolerably offensive ; hard and painful tumefac-
tions occur in the calves of the leg, among the muscles of the thigh,
upon the tibiae and lower jaw, and in the hand, with stiffness and
contraction of the joints, especially the knee, and severe pain in the
extremities upon every attempt at movement; and the debility, be-
fore so prominent a feature in the case, now becomes excessive, so
that the least exertion is dangerous, and the patient sometimes dies
suddenly upon rising from bed, or upon being conveyed, without
great caution, from one place to another. Wounds, even slight
scratches, degenerate into unhealthy ulcers ; old cicatrices break out
afresh, and existing ulcers assume a new and much worse aspect.
The bones are said to be softened, united fractures are again opened,
and in the young, the epiphyses separate sometimes from the shaft.
" Throughout the complaint the tongue is usually clean and moist,
and the appetite and digestion remain unimpaired almost to the
last, unless the disease, as sometimes happens, should be complicated
with fever. Indeed, there is often a craving for food, especially for
fresh vegetables and fruits; occasionally, however, there is vomiting,
with epigastric distress and other evidences of stomachic disorder.
The bowels are mostly costive, and in some cases obstinately so,
but diarrhoea not unfrequently intervenes, with black or bloody and
offensive evacuations. The pulse is generally small, feeble, and
slow, but cases occur in which it becomes very frequent, and the
surface of the skin febrile, probably from the sympathy of the sys-
tem with various local irritative congestions. Great emaciation usu-
ally attends the disease when severe or lasting, but not invariably.
Little cerebral disturbance is ordinarily observable, and the patient
often retains full possession of his senses and intellect to the last,"
This description, condensed from Dr. Wood's valuable paper on
the subject, describes the disease in perhaps its severest forms;
I have never seen such cases of scurvy, although at different times
THE GUMS AND THEIR DISEASES. 28T
meeting considerable of it as manifested in the persons of sailors
and others brought to hospitals for treatment. Dr. Foltz, TJ. S. N.
in a report made by him on the scurvy which appeared in the
blockading fleet of the Gulf of Mexico, states that "lassitude and
indisposition to muscular energy were not among the symptoms
which ushered in the disease, and that there was great activity,
and not unfrequently cheerfulness, good appetite, and sound sleep
at night, after the teeth were loosened, the gums ulcerated, the
limbs edematous and discolored ; and when at last the patient gave
way, it was not an indisposition to corporal exertion, but an actual
disability."
Authors, however much they may disagree in their descriptions
of such various cases as have come under their observation, are
all agreed that scurvy results from the absence of fresh fruits and
vegetables, or their juices, necessary to furnish some principle re-
quired in the blood, and which is not, in such absence, otherwise
obtained. In the treatise published by Dr. Hamilton on Military
Surgery, the author says : In regard to the pathology of scurvy,
the belief prevails that it is due essentially to the absence of certain
staminal principles from the blood, and especially potash. It ap-
pears to be a pretty well ascertained fact that all, or nearly all, of
those remedies which have been employed successfully in the pre-
vention or cure of scurvy, contain potash. Potatoes, cabbage, cel-
ery, lettuce, lime, lemon, and orange juice contain it in large quan-
tity, unless their salts have been expressed by the application of heat,
as in boiling, or other modes of cooking. Lime, lemon, and orange
juice contains nearly one grain of potash to every ounce of the juice.
One ounce of potatoes yields one grain and a half, while one ounce
of rice yields only -005 of a grain. The substitution of rice in an
English workhouse for an equal amount by weight of potatoes was
followed in a short time by scurvy.
In the ordinary scurvy of the gums, which every practitioner is
aware presents itself more frequently in the very early spring, when
the old vegetables have been pretty well exhausted and the fresh
ones have not begun to grow, it is the common experience to dis-
cover that the patients have existed almost exclusively on salt meats ;
hence it is much the most frequently met with in the poorer class
of farm-laborers. The gums, in these cases, are of a purple color,
turgid, with the dental pits discharging pus, the teeth loosened, the
breath offensive, but the face not by any means pale, nor the habits
languid ; indeed there is little or nothing to signify that the local
288 ORAL DISEASES AND SURGERY.
manifestation is a systemic ofifspring. When the condition is ex-
treme, it is not uncommon to have fungoid growths (epulo-fungoid
tumors), alluded to by Dr. Wood, springing from the edges and
depths of the dental pits.
Treatment. It will be found good practice to treat these con-
ditions locally, as directed in mercurial ulitis. Constitutionally,
however, different indications are to be met ; a something pos-
sessed by a vegetable and acid diet is required by the blood ; with-
out stopping to discuss the question whether this may or may
not be potash, we act on the empirical conviction, and at once
direct such diet. Then the depressed or perverted life force is to
be elevated or relieved, and to this end nothing can equal the sheet-
bath, taken with water moderately warm and moderately salt: satu-
rating the sheet, it is quickly thrown around the body, and the
patient or an assistant rubs the sheet over the flesh until the whole
person is in a ruddy glow ; this is repeated each morning imme-
diately on rising.
As medicine, the vegetable acids may be freely used. Lemonade
is perhaps quite as good as anything that can be given. A combi-
nation which has some celebrity, is known as Turner's antidote ; it
consists of 3ij of potassse nitratis, mixed in §viij acidi acetici, ad-
ministered in tablespoonful doses ter die.
5th, Syphilis. — Syphilitic ulitis, I judge, from my own experi-
ence and observation, not to be an inflammation of the gum tissue
proper, but simply of its mucous envelope, or, on the other hand, it
is an inflammation commencing in the periosteum, and secondarily
affecting the gum tissue. I do not think I have ever seen a case of
pure uncomplicated syphilitic ulitis, while few conditions are more
common than mercurio-syphilitic ulitis and osteo-ulitis of syphi-
litic origin. The appreciations of such conditions are, of course,
not at all difficult ; the history of the case alone is sufficient to give
the diagnosis, while to the experienced eye a moment's glance is
enough to reveal such history. If the inflammation is confined to
the mucous membrane, the full extent of its surface will be more or
less affected, its color will be a dull red, it will be more or less
tender to the touch, and most likely ulcerated. If, on the contrary,
the bone or its periosteum is the primary seat of trouble, the gum
may simply be thrown up by the effusion beneath it ; or if it happens
that the gum itself has become inflamed, the action seems inclining
to localize itself as much as possible This, however, depends on the
state of the parts beneath, and the treatment that is being pursued.
THE GUMS AND THEIR DISEASES. 289
If the condition is one of pure uncomplicated venereal ostitis, the ex-
citement in the gum will be found localized to the immediately over-
lying parts ; but if a mercurial treatment has been pursued, we then
may have any extent of complication. The treatment to be pursued
in these cases is to be founded on existing conditions.
6th. Dead or Loose Teeth. — Dead teeth affect, secondarily, the
gum structure by continuity with the inflamed periodonteum. A
dead tooth, pcriosteally inflamed, is always sore to the touch, is more
or less elongated, and is discolored. An ulitis connected with such
diseased tooth or teeth is plainly discoverable by the absence of
other sources of irritation ; relief follows, of course, the cure of the
primary lesion.
7th. Overcroicded Condition of the Dental Arch. — (See Chapter
on Anomalie»of Dentition.)
8th. Use of Improper Dentifrices and Brushes. — Many gums are
subjected to continuous irritation and inflammation from the use of
agents in the way of dentifrices, brushes, or other dental applica-
tions, which, either chemically, vitally, or mechanically, predispose
and excite to deterioration. Perhaps in the whole range of practice
there is, in no single instance, less attention given to the require-
ments of the various cases than is manifested in the prescribing of
tooth-cleansing powders and washes. Charcoal, a favorite agent with
many, while most excellent in its place, is one of the most abused of
these remedies. How very common is it to find, after a few weeks
or months of the use of this material, the gums becoming pitted
with black spots about the necks of the teeth and loosening from
them. This is a result of the insolubility of the agent in the fluids
of the mouth ; gradually, but surely, it finds its way within the
mucous pits, and not being either washed out or dissolved by the
secretion, it quickly enough destroys the integrity of the relation ;
hence follows chronic periodontitis and the eventual loss of the
teeth, — the mass of gum tissue sympathizing during the whole
period, — producing chronic ulitis.
Pulverized coral and pumice are other agents mechanically de-
structive, although in their places very good, and, as will be re-
marked, recommended. Castile or other soaps, too freely used,
degenerate by the action of their alkalinity. Thus a constant use
of such agents is quite certain to be attended by puffiness and
chronic turgidity of the gums, by degenerated mucous discharges,
and by an offensive breath. Acids, on the other hand, employed of
too full a strength, inflame and irritate the gums, put the teeth on
19
290 ORAL DISEASES AND SURGERY.
edge, by dissolving their mucous envelopes and more or less of their
limo salts. An ulitis from the irritation of acid agents differs, hovr-
evor, from that produced by the alkaline, in being of a free, gener-
ous, acute, or, at worst, subacute nature, easy of control, and much
more injurious to the teeth than to the gums themselves. Irritation
of the gums commonly associates with injury done to the teeth.
We may refer to the following most interesting experiments per-
formed several years back by Dr. A. Westcott:
" 1st. Both vegetable and mineral acids act readily upon the bone
and enamel of the teeth.
" 2d. Alkalies do not act upon the enamel of the teeth ; the caustic
potash Avill readily destroy the bone by uniting with its animal
matter.
" 3d. Salts whose acids have a stronger affinity for the lime of
the teeth than for the basis with which they are combined are de-
composed, the acids acting upon the teeth.
" 4th. Vegetable substances have no effect on the teeth till after
fermentation takes place ; but all such as are capable of acetic fer-
mentation act readily after this acid is formed.
" 5th. Animal substances, even while in a state of confined putre-
faction, act very tardily, if at all, upon either the bone or enamel.
On examining the teeth subjected to such influences, the twentieth
day of the experiment, no visible phenomena were presented except
a slight deposit upon the surface of a greenish, slimy matter, some-
what resembling the green tartar often found upon teeth in the
mouth."
Dr. Westcott also adds the following experiments with agents in
very common use, some of which are very frequently most loosely
and injudiciously prescribed in tooth-washes and powders :
"Acetic and citric acids so corroded the enamel in forty-eight
hours that much of it was easily removed with the finger-nail,
"Acetic acid, or common vinegar, is not only in common use as a
condiment, but is formed in the mouth whenever substances liable
to fermentation are suffered to remain about the teeth after any con-
siderable length of time.
" Citric acid, or lemon juice, though less frequently brought in
contact with the teeth, acts upon them still more readily.
" Malic acid, or the acid of apples, in its concentrated state, acts
also promptly upon the teeth.
"Muriatic, sulphuric, and nitric acids, though largely diluted,
soon decompose the teeth. These are in common use as tonics.
THE GUMS AND THEIR DISEASES. 291
" Sulphuric and nitric ethers have a similar deleterious effect, as
also spirits of nitre. These are common diffusible stimulants in
sickness.
" Supertartrate of potash destroyed the enamel very readily. This
article is frequently used to form an acidulated beverage.
"Raisins so corroded the enamel in twenty-four hours that its
surface presented the appearance, and was of the consistency, of
chalk.
" Sugar had no effect till after acetous acid was formed, but then
the effect was the same as from this acid directly applied."
A very common cause of ulitis in persons with carious teeth re-
sults from the too free use of creasote. This agent, used pure, is a
powerful irritant, and has been the cause of some of the most severe
acute inflammations. Seen early, the cases exhibit the direct effect
of the agent in the escharotic result that has been produced on the
mucous membrane, — this being white, pasty, and sloughing. Out-
side of the immediate local use of oil or butter, if it is inferred that
free creasote remains about the mouth, such cases are to be treated
on common principles. A case occurred, some short time back, in
my own practice, where a girl, with an intent to commit suicide,
swallowed two drachms of the agent. Called immediately, I used
as an emetic the first thing at hand, namely, the soap on her wash-
stand, and followed the emetic with half a pound of common table-
butter. No particular bad results occurred ; the patient had a more
or less sore mouth, oesophagus, and stomach for three days, after
which she seemed about as usual.
Chloride of zinc, used in the mixing of the so-called bone plugs
now so freely employed in dental surgery, is another of the causes
of ulitis. Its action may be of a twofold character : either directly
upon the gum tissue, as by its careless use it is allowed to come in
contact with it, or through a periodontitis excited by the action of
the agent on the dental pulp. From this cause, cases occur in
which large portions of the gums are destroyed ; and not unfre-
quently the action extends to the alveolar process, necrosing the
sockets of the teeth.
A cause of chronic ulitis, which has been occasionally met with,
consists in a wedge of gold or other metal forced into the dental pit
by the dentist, while in the act of filling a tooth on its approximal
face. A matter of this kind is very apt to be overlooked by the
general practitioner, hence an unappreciated stubbornness in his case.
When ulitis is circumscribed, and the center of the trouble seems to
292 ORAL DISEASES AXD SURGERY.
be a tooth filled on an approxinial surface, attention may be first
directed to such condition. Let the practitioner take a strand of
common ligature silk, and, passing it between the teeth, feel if it
runs freely about the necks ; if it should catch, the probability is he
has discovered the trouble.
The too free use of arsenical paste in the destruction of the dental
pulp is a frequent source of utilis. I have seen two or three very
severe cases from such a cau.se. In the use of this remedy, it
is in every instance well to cover it in the cavity with a particle
of wax, or where this is not admissible (and there are certainly cases
enou"h where it is quite impossible), then a tuft of cotton, satu-
rated with gum sandarac, is placed over the application, and pro-
tected for a few moments until it hardens. In inflammation from this
cause the immediate local use of the sesquioxide of iron has been
recommended ; but, personally, I have seen no good results from
it, the harm being done before the patient applies. Syringing the
parts thoroughly, and a treatment directed on general principles, is
all that can be done.
Brushes used in cleansing the teeth, from their over-stififness, are
frequently a source of offense, really tearing the epithelium at each
cleansing, from the mucous membrane ; the patient complains of the
soreness and bleeding of the gums every time the teeth are brushed,
yet seems to fail in recognizing that he himself produces the trouble.
9th. Improperly inserted Artificial Teeth. — Ulitis, resulting in
fungoid degeneration, and in the most troublesome of chronic con-
ditions, is frequently witnessed as the result of ill-adapted den-
tures and of unsuitable material employed in their construction.
Teeth inserted on plates held in position by clasps or bands attached
to certain teeth, are a prolific source of offense. Where the bearings
of a plate are not accurate, the bands cut into the gum, fret and
irritate them, until, in the end, the teeth to which the clasps are at-
tached are loosened, the gum passes to a chronic degeneracy, puffs up,
losing much of its vitality ; otherwise a hypertrophied ring of the
tissue, hard and callosed, surrounds the diseased tooth, and serves
as a sort of protection to the adjoining parts. A case just now
comes to my mind in which a lady, wearing an upper set of teeth,
supported partially by atmospheric pressure and partly by a band
passing around the only natural tooth in her mouth, had provoked,
in this socket, an epulo-fungoid growth of such threatening character
that, failing to cure it by ordinary means, I felt compelled to ad-
vise an operation as the only hope of saving her life. Epithelioma
THE GUMS AND THEIR DISEASES. 293
I have also seen located by a similar cause ; having, in my own prac-
tice, the misfortune to lose one such case. In Mr. Heath's Jack-
sonian prize essay, drawings are given of certain papular hypertro-
phies (thought by the author to be quite rare specimens) on the
oral mucous membrane. These hypertrophies I have frequentlv
seen on the membrane beneath the cavities of suction plates ; thev
look like enlarged and indurated fungiform papillae. Another form
of such hypertrophy is induration of the membrane in full, lying be-
neath the cavity; the parts are raised by subeffusions, which organ-
ize and become as hard almost as cartilage. Still another form is
the rugose — several wheels running across the space ; these indura-
tions I have never known do any harm. In some instances they
remain permanent after the removal of the offense; but, as a rule,
they will be found to disappear in a few months after a plate is
taken away. Indeed, I met one lady having these hypertrophied
papillae, who told me she had had them for over a year, and had
never ceased to wear her plate.
Hypertrophy of the gum in mass occasionally results from the
mechanical irritation of dental plates. I am, at the time of writing
this, treating a lady suffering under such an enlargement ; the trou-
ble is in the upper gums, and they seem like thickened masses of
gristle, and, I am sorry to say, prove about as insensible to medici-
nal impressions.
Yulcanite, a material much employed in the construction of dental
plates, is, to many mouths, a source of unbearable offense. The
cases that have come under my own observation have been all alike,
— soft, flabby, relaxed, congested, and very sluggish in recuperation,
— the gum tissue seeming to be softened from surface to base. Acid
and astringent lotions are best adapted to the cure.
Silver is another material that it would, perhaps, be as well to dis-
pense with in the construction of dental appliances ; also gold too
much alloyed with copper, running down, as it is sometimes found,
to fourteen carats.
10th, 1 1th. In other parts of this work I take occasion to treat,
under what is deemed to be proper heads, various conditions, com-
monly associated under the common appellation of gum diseases, as,
for example, the epuHc growths considered in succeeding chapters.
Observation of Fig. 61 exhibits a congestion which has swollen
the gums and tissues of the hard palate to an extent which conceals
almost completely three posterior teeth which remain in the parts.
294 ORAL DISEASES AND SURGERY,
The patient, from whose mouth the drawing was made, had worn
a plate of vulcanite nine months ; the parts were a dusky red, — flabby,
relaxed, and exceedingly indolent. There was no particular complaint
of pain, simply a soreness, together with a tenderness on pressure,
Fio. Gl. View of Gums Inflamed by Vulcanite P;.ate.
which gradually had increased until the removal of the piece became
a necessity. The cause of irritation from these plates is variously
considered : the most likely, however, of which is the very complete
exclusion of atmospheric air, and the consequent heating which fol-
lows. To cure such cases it will be found, in most instances, a ne-
cessity to remove the denture, after which stimulating and astringent
gargles may be prescribed. A wash, used in the particular case
above described, which acted to entire satisfaction, was compounded
as follows :
B. — Aqua Cologn. ^i ;
Tinct. capsici comp. 5i ;
Sodae boras, 5y ;
Tinct. cinchonje, ^ij ;
Tinct. pyrethri, Ji ;
Aqua, ^iij. M.
Cases of hypertrophy from ill-fitting clasps or ill-fitting plates are
not unfrequently met with ; sometimes such an induration will be
found circumscribing a single tooth to an extent which half conceals
it, the band being accommodated in a space existing between the
gum and tooth. I have known such cases to give much concern by
the obstinacy of their persistence after the removal of the cause of
oflFense ; but such anxiety is seldom well founded, for even should
the induration remain it will exhibit no tendency to degenerate. In
the treatment it is only desirable to remove the offending band, and
leave the case to nature.
THE GUMS AND THEIR DISEASES. 295
As general hypertrophy of the gums is concerned, I might illus-
trate the condition by referring to a case at present under treatment.
The patient, a lady in fine health, middle aged, wears a plate of gold
containing seven scattered teeth. Wherever this plate bears, the
parts are enlarged, indurated, and scirrhus-like. If it were not for
the absence of the peculiar pain of carcinoma one might very readily
infer the presence of such disease. The only explanation of such
induration is to be found in the imperfect adaptation of the denture,
conjoined, perhaps, with a cachexia. The treatment has been the
very simple one of advising the patient not to wear the plate, nor
any other, until a cure is obtained. No medication has been deemed
necessary.
Still another class of cases exists in the hypertrophy of the mucous
membrane lying beneath the surface of suction cavities. Sometimes
this surface will be found simply thickened and hardened ; at other
times it will be seen broken into deep fissures; still again it is
observed studded with papillae, fungiform in character, and not un-
frequently possessed of a tendency to hemorrhage. I have met with
these various cases where quite serious results seemed threatened,
although but in a single one did ever any ill consequences ensue. In
this one case necrosis of the underlying bone exposed the nares.
Treatment. — This is generally to be tentative; the plate must
be removed, or at least the suction cavity must. If the parts do not
recover after such removal of the oifense, it may be found desirable
to touch with zinc, iodine, or capsicum. If caries or necrosis should
ensue, such conditions are to be treated as referred to in the chapter
on these diseases.
Fig. 62. — View of Case of Congenital Hypertrophy.
An interesting case exhibited in the cut, markedly illustrative of
the condition, is described in Professor Gross's System of Sur-
296 ORAL DISEASES AND SURGERY.
gcry: "The gum of the upper jaw formed a tumor of a' pale
color, inelastic, perfectly insensible, and of firm consistence, pre-
senting very much the appearance of the snout of a hog. It was
rouo-h on the surface, and was about an inch and a quarter in its
antero-posterior diameter, its width having been about one inch and
a half. At its free margin, which was quite irregular, was seen the
tip of the left central incisor. Extending back from this tumor, on
each side of the whole length of the jaw, was the enlarged gum,
forming a thick, broad ridge, completely imbedding the teeth. At
several points, particularly behind, the morbid growth was more
than nine lines in width ; in front, and at the middle, it was less.
It was of a more florid color than the main tumor, but of about the
same degree of consistence. Opposite the bicuspid teeth on each
side, it exhibited a remarkably granulated appearance, the excres-
cences having a pediculated form, and being folded upon each other.
Projecting toward the I'oof of the mouth, it greatly encroached upon
this cavity, lessening its capacity, and thus interfering with its func-
tion, as well with speech and respiration.
" The lower gum was in the same condition as the upper, being
equally hard and insensible, but less developed. It was of a bluish,
florid complexion, and larger in front and behind than at the inter-
mediate points ; its free surface was uneven, and so prominent as to
hide all the teeth, except the central incisors, the point of the right
cuspid, and the cusps of each deciduous and first permanent
molars."
The treatment in this case consisted of thorough removal by means
of scalpels and scaling instruments. A good deal of blood was lost,
and the operation, which had to be several times repeated, was
necessarily tedious. Professor Gross remarks that Dr. J. N. M.
Lynch, whose patient the boy was, informed him four years after
the operation, that the condition was returning, and that it was ac-
companied with marked disease of the heart, with considerable
enlargement of the tonsils, arches of the palate, and the papillae of
the tongue.
Fig. C3, a case of chronic ulitis, with recession, is a type of a most
common condition, and has a great variety of meanings. The prin-
cipal cause of such recession is found, however, according to my
own experience, in the accumulation of small quantities of tartar
just below the free edge of the gums. A second cause, and a very
prominent one, lies in a solidification of the tooth structure,— the
THE GUMS AND THEIR DISEASES.
297
equilibrium of circulation existing between the tooth pulp, perios-
teum, and gum being thus distui'bed. Causes strictly local, how-
ever, need only concern, as the appearance of the parts and the
health of the teeth are concerned ; they are susceptible of remedy,
needing only attention and the proper skill. It will be readily
inferred, from what has been said on previous pages, that local
lesions are not alone to blame for such conditions. " In forming
a judgment," says Mr. Bell, " upon eases of this description, and
even upon those in which the loss of substance is associated with
more or less of diseased action, it is necessary to recollect that the
Fig. 63. — View of Chronic Ulitis, with Eecession.
teeth in old age are removed by this identical process, namely, the
destruction of their support by the absorption of the gums and
alveolar processes ; and as this step toward general decay com-
mences at very different periods in different constitutions, it may,
doubtless, in many cases, even in persons not beyond the middle
period of life, be considered as an indication of a sort of premature
old age, or an anticipation at least, of senile decay, as far as regards
these parts of the body."
In depressed conditions of the life force, as witnessed in the
habitual drinker and debauchee, such recession is generally found
conjoined with suppuration, and affects all the parts alike; the gums
are turgid, sluggish-looking, and more or less purple ; the mucous
298 ORAL DISEASES AND SURGERY.
membrane lining the mouth and throat is a dirtj red ; the tremor
and prostration of the system at large show the constitutional
nature of the offense.
Another form of this recession is associated with the sickly and
weak; here, however, the part is even lighter than in health, is
shriveled and shrunken, clasping the neck of the tooth tightly and
closely, — seeming, indeed, shrinking within itself. These cases are
always anaemic, being found usually in the female sex, or in males in-
clining to phthisis. In short, as remarked by Dr. Harris, " every dis-
ease of the general system tending to increase the susceptibility of
the gums to the action of local irritants favor the production of the
condition." Everything that tends to induce such conditions may be
regarded as predisposing causes : such are bilious and inflammatory
fevers, the excessive use of mercurial medicines, the venereal virus,
any and everything tending to the deterioration of the fluids of the
body. Persons of cachectic habit are far more subject to it, and
generally in its worse forms, than those individuals in the enjoyment
of good health. Because of the truthfulness of such assumptions it
is seen that the condition is an occasion of warning. In my own
experience I have not unfrequently recognized that such a recession
of the guTus was a first indication of a finally destructive disease.
Treatment. — This is of course to be directed to the cause. Where
this shall be found to be of a strictly local nature, most excellent
effects are occasionally secured by scarifying the affected gums three
or four times a week, and touching them lightly with chloride of zinc,
a solution in strength of about grs. xx to water ^i. Sometimes, and
I have occasionally succeeded much to my satisfaction, the edges may
be pared and brought together with a single stitch ; this little opera-
tion, however, only applies where the tissues are reasonably loose
and fairly healthy, and the recession is Y-shaped. Compound
tincture of capsicum is an excellent provocative of granulations.
Iodine also acts happily, but it should not be allowed to touch the
teeth, — the parts are always to be scarified to allow such applications
to be of any service. The various washes recommended are, of
course, useful or not so, according as they may be adapted to the
peculiar indications ; of these, the stimulating and astringent will be
found most frequently demanded. Where the teeth are thus exposed
without apparent lesion, either of a local or general nature, the
trouble is to be esteemed as incurable.
Congenital Union of Gums.— Br. W. S Carter reports the follow-
ing anomalous case, which, with a few others, we present as in-
THE GUMS AND THEIR DISEASES. 299
I teresting studies in this direction of oral troubles : " Mrs. W. was
delivered, after an easy labor at full term, of a living male child.
The infant was perfectly quiet for a few moments after its birth, and
then spasmodic respiratory efforts were made. Thinking the throat
might be obstructed by mucus, I endeavored to introduce my finger
to remove it. The finger passed readily between the lips, but to my
astonishment I could get it no further than the gums, which both by
sight and touch I found firmly united.
" As it was necessary to act promptly, I immediately, with the
assistance of my partner, Dr. Tilford, divided the tissue uniting the
gums. This appeared to be about as thick as the gums, and was
cartilaginous, extending as far back on either side as the angle of the
jaw. Notwithstanding this free division, which enabled the child to
breathe with more facility, the jaws were immovable.
"After letting the patient rest a few hours. Dr. Sellers, of Browns-
burg, visited the patient with me ; and it was decided to use some
force to separate the jaws, and make a further careful exploration.
This exploration showed us a tough membrane, one-eighth of an
inch in thickness, passing from the palate bone above, and inserted
into the lower gum. Upon the division of this and the use of some
little force, the jaws were separated.
" In two weeks the gums had healed, the child took nourishment
readily, and was doing well.
" Other malformations also existed in this case, viz.: the fingers
and toes were webbed, and the ears were in rather a rudimentary
condition — the integument passing from the head over the anterior
surface of the upper third of each of these.
" When the mother was about three months pregnant, her son,
about six years of age, had a severe convulsion, the jaws being spas-
modically closed. She was alone at the time, and her terror was
excessive; and, indeed, since then, during all the remaining months
of her pregnancy, she states the frightful scene has scarcely ever
been absent from her mind."
"We have delayed," remarks the editor in whose journal this in-
teresting communication appears, "for some weeks the publication of
Dr. Carter's extraordinary case, in order that we might, if possible,
find recorded some similar cases or case ; but after a diligent search
we have been utterly disappointed. Even Saint-Hilaire, to whose
study of the various anomalies of organization science is so greatly
indebted, fails us in presenting any analogous instance.
"While almost any one of the external openings of the body may
300 ORAL DISEASES AND SURGERY.
be imperforate, yet this condition much oftener affects the inferior
than the superior orifices of the trunk — e.g. closure of the anus as
a cono-enital condition is more frequently met with than closure
of the eyelids, closure of the vagina than of the external auditory
meatus.
" In rc'-'ard to congenital adhesions of the mouth hitherto de-
scribed, they have been from adherence, sometimes complete, in
other instances partial, of the lips. Even this malformation the
illu-strious Boyer spoke of as a possibility, never having seen it; but
Yelpeau discovered that Haller had pointed out its occurrence in the
human species and also in the inferior animals, that Schenkius had
met with cases upon which he had to operate, and that Desgenettes
had seen a seven months' foetus with imperforate mouth.
"In Saint-Hilaire's work, chapter iii., Bes Anomalies 2^o,r con-
tinuite des parties ordinairement disjointes, section i., Des Anoma-
lies par Imperforation, will be found the following, which may be
of some interest in connection with Dr. Carter's report : The imper-
foration of the nares is much less frequent than that of the eyelids ;
nevertheless, Littre and Jean Bianchi have seen it in subjects in
whom other irregularities also were found, and Oberteuffer has also
several times observed the same condition.
" In the case mentioned by Littre, the closure of the nares was
complicated with closure of the mouth, the skin passing over both
apertures, an anomaly of still less frequent occurrence. The closure
of the mouth has also been seen where the nares were unobstructed,
but these cases presented various other deviations also.
" As to the possible influence of the sudden and severe terror to
which the mother was subjected, which Dr. Carter mentions, in caus-
ing the malformation, it probably is better neither to affirm nor, still
less, to deny. Certain it is that the tendency of the observant and
thoughtful in our profession is, not to reject as ' old wives' fables'
all that is told us of the very strong influence of maternal impres-
sions upon the foetus, fables which have so long found such general
credence with mothers and with the public. Those who are inter-
ested in the study of this question will find an admirable and philo-
sophic discussion of it, by Dr. Alfred Meadows, in the seventh volume
of the London Obstetrical Society^s Transactions. It occurs in con-
nection with the report of a case of Monstrosity, given by Dr. M.,
the mother attributing the deformities of her offspring to the fact
that during the earlier weeks of her pregnancy she was greatly hor-
rified by being shown some of Aristotle's plates, in which were ex-
THE GUMS AND THEIR DISEASES. 301
hibited some deformities resembling this, and specimens of other
monstrosities." — (Western Journ. of Medicine.)
" Stomatilis and Pharyngitis Leucaemica. — In Virchowh Ar-
chives, Dr. F. Hosier relates the case of a male 40 years old, and
previously of sound health, in whom, in the course of some fifteen
months, there took place gradually a swelling of the glands on both
sides of the throat, attended with inflammation of the mucous mem-
brane of the mouth and pharynx, with flaccidity of and hemorrhage
from the gums, followed by swelling of the axillary and inguinal
glands, and finally of the liver and spleen. There was now an evi-
dent increase in the white particles of the blood. In the case de-
scribed, the only etiological agent to which the morbid phenomena
it presented could be referred was inordinate exertion of mind and
body. The condition of the throat was of especial interest. Its
mucous membrane was red and swollen, and over its surface there
were spread numerous medullary elevations having a smooth shining
appearance. Both tonsils were enlarged, and their surfaces pre-
sented the appearance of a congeries of large, dense, medullary
knots. The secretions of the surface of the mouth and larynx and
of the salivary glands were greatly increased by talking. After a
thorough rinsing of the mouth, its secretions gave an acid reaction.
The patient had not suffered previously from any disease of the
mouth or throat. The patient was attacked with this only after the
lymphatic glands of the neck had become enlarged, and at first, with
their increase or diminution the throat affection became worse or bet-
ter. Finally, under the use of quinia and iron, remedies which exerted
a beneficial influence on the entire morbid phenomena, the patient got
well. Dr. M. believes that the form of stomatitis and pharyngitis
here described is a specific disease resulting from a leucsemic dys-
crasy. The inflammation of the mouth, which in its symptoms had
a close resemblance to scorbutic stomatitis, was probably caused by
au irritation due to some morbid chemical product in the blood and
the secretions of the lymphatic glands, by which, also, according to
Dr. M., is to be explained the affection of the mouth met with in
cases of diabetes, the nature of which is still, however, unknown."
"Blue Line in Saturnine Affections, and its Pathognomonic
Value. (Archives de Medecine Navale, and Gazette Hebdoma-
daire.) — Dr. Falot refutes the authors who believe that the blue line
along the gums is formed by an accidental deposit on the buccal
mucous membrane of lead furnished by dust contained in the air or
food, or still more in fluids that have been adulterated or accident-
302 ORAL DISEASES AND SURGERY.
ally charged. According to M. Grisolle, among others, the blue line
is the livery of the lead-worker, not a symptom of poisoning, but a
simple deposit, and a sign of the worker's occupation. M. Falot
quotes the observations of Beau, Barlow, Gregory Smith, and Le-
coq, all of whom observed the blue line in patients undergoing an
internal treatment with pills of subcarbonate or acetate of lead ; and
he gives, in addition, the reports of some cases of his own, which
were gathered in an epidemic of colic in a ship's crew at the Ga-
boon, the cause of which was lead-poisoning. Finally, after having
established by experiment the impossibility of reproducing the blue
line artificially by touching the gums corresponding to the incisor
and canine teeth of the lower jaw with a brush dipped in acetate of
lead, and after having proved that oxygenated water, and water
sharpened by sulphuric acid, the ordinary reagents of lead, had no
influence upon the blue line when it is plainly established. Dr.
Falot proves that the line is the result of an elimination of the lead,
and indicates by its manifestation that the lead, carried along by the
circulation, comes to be deposited in the tissue of the gums, where
it forms a combination which reveals its presence by a more or less
intense blue coloration. M. Falot finishes his contribution by rep-
resenting the blue line as a sign of the penetration of lead into the
economy, and he derives the important conclusion for forensic medi-
cine, that its presence may denote lead-poisoning, although an analy-
sis of the viscera may not have revealed the smallest trace of the
metal."
CHAPTER XX.
CARIES OF THE MAXILLA.
Caries of bone is a disease most analogous to ulceration in the
soft parts. As the jaws are concerned, it is confined almost ex-
clusively to the superior bones. The causes inducing this condition
are of course various ; yet dead teeth and roots of teeth will be
found far to preponderate.
Caries of the jaw present all the external features which char-
acterize the ordinary alveolar abscess, whether in its acute or chronic
forms. This, however, would be inferred, such lesion being so
commonly its origin. When the attack is acute in its nature, ulitis
or periostitis will always be found associated with it. If the disease
originates as a pure ostitis, then the gum in turn quickly sympa-
thizes ; if, on the contrary, the inflammation arises from a tooth,
periodontitis will distinguish the offending agent. In all inflamma-
tions about these parts, whatever their character and cause, the
abortive treatment cannot too quickly be attempted. From failure
to attack with sufiScient vigor such inflammations, I have not un-
frequently known the whole bone to be destroyed.
Caries once established, a diagnosis is made easy through the in-
strumentality of the sense of touch. One or more fistulous openings
will be found to exist in the gum, or it may be in some neighboring
part ; through these sinuses it is only necessary to carry a probe,
when the bone is found riddled, honeycomb-like, and easy to break
down. In such examinations it always will be found advantageous
to replace the ordinary probe with the common dental excavator, as
otherwise, from the less accurate touch attained through the first
instrument, it may be possible to mistake the denuded bone of ordi-
nary alveolar abscess for the more formidable and extensive dis-
ease. In carrying the instrument through the opening of an alveolar
abscess, it is remarked that the bone is denuded ; but the touch dif-
fers from that present in caries, in the fact of this denuded bone
being hard and resisting. Not always, however, for it has been just
remarked that periodontitis and alveolar abscess are the most com-
(303)
304 ORAL DISEASES AND SURGERY.
mon cause of ostitis and caries, reference being alone had to the i
pure, unconiplicatod cases of alveolar abscess. As a rule, when a ,
sharp instrument introduced can be made readily to pass into the '
substance of the bone, and to break it down, caries is present. If, '
on the contrary, the bone is solid and resisting, even although found
denuded, caries does not exist.
An ostitis, however provoked, does not by any means necessarily
run into osseous ulceration, no more than is ulceration necessarily a
result of an inflammation in the soft parts. There are, however,
certain individuals, or perhaps it is better to say conditions, which
markedly predispose to such ulcerations ; of these the strumous is
without doubt the most marked. The bones of scrofulous subjects
break down easily, also persons who have received the mercm'ial
impression. Cancerous caries of the upper jaw is frequently to be
met with ; while, aside from such conditions, it has seemed to my
experience as true, that in persons of the most robust and vigorous
health a slight cause has been suflBcient to develop the disease. A
case this moment recalled (a very marked one) will serve to illus-
trate the probability.
In the autumn of 1867 a gentleman from a distant State visited
Philadelphia for the purpose of having an opinion concerning a
flstule that existed over the apex of the right upper lateral incisor
tooth which had long resisted the ordinary applications and injec-
tions used by his professional adviser at home. This fistule had
originated from the lateral tooth, which was a dead one, and was con-
sidered simply an alveolar abscess ; the only question thought to
be involved being the loss of the tooth, which the patient was most
desirous to save. The gentleman coming first under the care of a
personal friend, I had an opportunity to see him in consultation,
when a thorough examination revealed a softened, honeycomb-like
character, not only of the right, but also partially of the left jaw,
necessitating an operation of very extensive character, so far as the
removal of softened bone was concerned.
In this case I failed to recognize anything wrong with the gen-
eral health of the patient, in Avhich opinion I was joined by his
professional adviser; the person being young, and of more than
commonly vigorous habits. The primary lesion was, without doubt,
the dead lateral incisor. Why it should have provoked such exten-
sive disease one is at a loss to say.
In this, as in many cases, the disease was developed, and ad-
vanced without any very marked acute manifestations, a not un-
CARIES OF THE MAXILLM. 305
common feature in caries, and one which is of much importance to
be borne in mind. A whole jaw may be softened and destroyed,
while the patient rests under the false impression that he has no
trouble that is beyond cure through the loss of a tooth. I have
occasionally met with cases of this kind, where even the physician
has been alike deceived.
The slowness or the rapidity with which caries progresses is in-
fluenced by individual conditions. Thus, in the periods of dentition,
it will commonly be found to have rapid progress, unless, indeed,
the vital forces are very resisting ; while in the mercurially weakened
bone caries seems sometimes analogous to a simple mechanical dis-
integration, as if, indeed, the particles of bone had lost the power
of cohesion.
The peculiar affinity existing between this disease and the cellular
tissue of the bones leads to the inference that it is more common to
persons whose skeletons are loose and spongy in character than to
the reverse class, — and this is markedly true ; hence strumous
children are very subject to caries, as is so often witnessed in their
articular complaints.
In many subjects the condition seems to be that of a semi-
fatty degeneration, the animal portion of the bone becoming quite
soft and greasy ; indeed, even the osseous particles thrown oif
present the same aspect. The relationship of the disease with
tubercular deposits is so fully established in the minds of many
that they incline to the conviction that such tubercle is present at
any and all points of the manifestation of caries. That this, how-
ever, is not fully true, is affirmed by examples such as have been
alluded to. That constitutional causes have, however, much more
to do with the development of caries than local injuries, is suffi-
ciently evident in the immunity of the numberless persons who
have been brought, without ill result, under the influences of similar
local sources of irritation.
It has been suggested that caries may exhibit itself in various
ways. Yet, however and whatever the manifestation, an ostitis
must precede the ulcei'ation. About the jaws the great majority of
cases have, in their incipiency, nothing to distinguish them from
ordinary periodontitis; and it is by far most frequently the case that
the acute attack has been long past before this peculiar ulceration is
developed, it seeming to be that the resistive power of the bone is
gradually worn out by the presence of chronicity ; the inflamed
tooth has died, and its devitalization is the source of ofiense. Nearly
20
306 ORAL DISEASES AND SURGERY.
every case of caries of the jaws that I have seen could have been
aborted by the timely removal of a certain tooth or teeth — not of
course all but that great majority which have had the exciting
cause of dental irritation.
A carious bone presents peculiarities according to the duration
of the disease and the several phases of causes inducing it. If
seen early, there is to be observed simply the increased vascularity
and cono-ostion of the inflammation. A little later, and a caco-
plastic exudate occupies the cells, which, in their turn, have become
enlarged, and their walls softened ; these, still later, commence grad-
ually to break down, together with the semi-organized lymph ex-
uded into them ; in proportion as such exudation has been, and is,
extensive, and the breaking down is rapid, so the caries may be
said to be dry or moist ; such exudation and degeneration are
markedly exhibited in many cases of hip disease, or white swelling
of the knee-joint, where the discharge may amount to quite as much
as a pint a day. In now looking at the bone, we find it riddled with
irregular cavities, many, or all, of which are lined by a sort of im-
perfect secretory membrane, or perhaps it would be more correct to
say, a glazing of organized exudate corpuscles. If the disease is to
involve the whole bone, such will be its general condition. If, how-
ever, there reside in the part the vital force capable of resisting the
disease, then from the center outAvard will be observed a change in
the character of the lymph exuded. The farther we get from the
center the more bland and healthy is the exudate ; while the com-
plete filling up of the cells exhibits the wall of protection present
in circumscril)ed healthy inflammation of the soft parts. It is to be
observed, however, that this protecting wall is most apt to give
way before the advance of the disease, — seeming to retard, but not
to check it. In other words, nature seems seldom able to complete
a line of demarkation, as witnessed in necrosis.
Treatment. — To do all that can be done in these cases is not
at all difficult. If inflammation of the bone exists in an acute stage
it is to be treated on general principles : cathartics, diaphoretics,
counter-irritants, hot pediluvia, leeches, the general abstraction of
blood, any or all these means being bi'ought into requisition, the
practitioner being influenced alone by the resistance of his case.
If a periosteally inflamed tooth be the cause of the inflammation,
as is most frequently the case, such tooth is to be removed or treated;
generally, however, I think it will be found sufficient to scarify the
gums, give a hot foot-bath, apply a blister to the back of the neck,
C ABIES OF THE MAXILLA. 307
and administer a saline cathartic. If such a course should not
abort, or conquer the trouble, then thi-ee or four Swedish leeches
may be applied directly to the Inflamed part, this being easily ac-
complished by introducing a napkin back of the middle of the roof
of the mouth. If even this should not succeed, and the patient is
plethoric, blood may be taken from the arm. It is, however, fre-
quently the case that even what may be viewed as the acute stage
will be found of an asthenic type. In these cases, conjoined with
the local depletion, tonics will be demanded : iron, quinia, beef
essence, cod-liver oil being indicated. If, when a case is first seen,
the caries may have become established, as recognized by the ex-
istence of fistulse, the honeycomb bone, etc., vigorous tonic medica-
tion, conjoined with stimulating injections, may be tried. Of such
injections, the tinct. of iodine, carbolic acid, tinct. capsicum comp.,
and chloride of zinc, will be found as promising as any. Of the
tonics, I presume a common experience will give to the chalybeates
the preference. It is not, however, from the medication alone that
a cure is commonly to be expected. In caries nature seems unable
to throw off the incubus of the disease ; and the cases are rare in-
deed where a relief, by operative means, will not be found impera-
tively demanded.
To operate for caries of the jaws one seldom requires more than
two or three curved chisels, a scalpel, syringe, and alum-water.
Taking the fistulae for the guide, the bone is exposed by a simple
incision. Next, with a chisel, suitable in size, the softened bone is,
little by little, cut away.
The extent to which caries will occasionally be found to have
progressed will be a matter of surprise. One can do no better, how-
ever, than follow the softened bone, wherever it may lead. I have
very frequently, in this way, been led from an apparent simple be-
ginning, to remove nearly or quite all of the upper jaw. Danger
from hemorrhage has not been, in my experience, any special occasion
of anxiety; indeed, I fail to recall a case in which the injection of the
alum-water has not been all-sufficient for its control. When healthy
bone is reached in an operation, it is distinguished from the carious
both by the touch and sight. Under the chisel the first is hard and
springy, the latter soft and brittle ; passing, with the chisel, from
the diseased to healthy tissue, one could not fail to remark a
difi"erence. To the sight, healthy bone is white and vascular; carious
bone is dark and non-vascular, or it is a deadish white, or oleagi-
nous. A very observable difference between caries and necrosis
308 ORAL DISEASES AND SURGERY.
consists in the absence, in the former, of the odor associated with
the latter, caries running its whole course without necessarily giving
the slightest annoyance from this cause; at least, where proper
cleanliness has been observed.
The use of the syringe, after an operation for caries, is of the
greatest moment ; the capacity should not be of less than one gill,
and every particle of debris is to be carefully washed away. In the
after-treatment, this instrument will also be found to perform good
service — repeated washings being very conducive to the cure.
CHAPTER XXI.
NECROSIS.
Necrosis, while common to both superior and inferior maxillae,
exhibits the most decided preference for the latter, attacking it per-
haps in twenty cases to five of the former. The disease may com-
mence as an ostitis overwhelming the bone in mass, and destroying
it. Or, as commonly witnessed, it is produced by a periosteal in-
flammation, this membrane being separated from the bone by a de-
generating plastic exudate. In such inflammations and separations, it
would be inferred the layer of bone immediately adjacent to the mem-
brane would be the first to be affected; this is so truly the case
that timely incisions and timely combating of the inflammation are
most influential in the limitation of the disease. The superior jaw,
however, is much more liable to take on a general inflammation than
the inferior ; but this higher vascularity and susceptibility enables it
to resist the destructive action and limit the part overwhelmed.
Inflammation of the jaws, whether osteal or periosteal, are prima-
rily to be treated on general principles. If acute in character we may
first try the effect of the hot pediluvia and saline cathartics. These
failing, the parts may be well scarified, or leeches may be applied ;
or blood taken from the arm. Diaphoresis may be employed. In
short, antiphlogistics of any and every nature, promising control
of the excitement, may be pressed into service. If all, however,
should fail, and pus be formed, it cannot too soon have vent given it.
When, on the contrary, the inflammation is chronic and asthenic
in character, with the necessity for free scarification will exist a
demand for local stimulating douches and the administration of
tonics. Of the supporting medicines applicable to these cases, the
very best I think will be found in the union of sulphate of quinia
with the muriated tincture of iron. A combination very frequently
employed is as follows :
R. — Tinct. ferri chl. ^i ;
Quinia sulph. 5'- M.
Sig. 15 drops in water four times a day for adult.
(309)
310 ORAL DISEASES AND SURGERY.
The most intractable cases of ostitis occur in the periods connected
with dontition, whether first or second, the irritability being in-
creased aad kept up by the excitability associated with this process.
Hence the great amount of care necessary to guard against any in-
crease in the natural vascularity of such age. The trouble aroused,
nothing can be done, however, beyond such treatment as applies to
ordinary cases; except, indeed, it will be found that there exist a
greater necessity for the use of sedative medicaments. Ostitis, or
periostitis, of a maxillary bone, like as occurring in other bones, can
mostly be traced to an influencing cause ; whatever may be this
cause, local or constitutional, the primary indication is its removal
where possible.
Dental Necrosis. — Dental necrosis, death of the teeth, or death
of the neighboring bone from causes associated with the teeth, may
claim attention as being the most common of all the troubles of the
ossa corpore.
A tooth has a twofold source of vitality — an internal or tubular
circulation, secured from its pulp, and an external or periosteal.
The destruction of this internal circulation, through the killing of
the nerve and filling the root-canal by the dentist, is so common an
occurrence as to be familiar to almost every one.
By the majority of teeth, if properly treated, this destruction
seems to be sustained without much apparent inconvenience. Such
treatment consists in extracting from the cavity every particle of
the dead pulp, and so filling it with gold or other material as to
prevent the introduction of more irritating matter. When teeth,
however, are not properly treated, or when there is great suscepti-
bility in the system to inflammatory action, the destruction of the
pulp results in an extension of the destructive action to the peri-
dental membrane, yielding the trouble known as periodontitis ; this,
if not aborted or resolved, ends in the death of the tooth.
A dead tooth is not, however, fortunately, treated in all cases by
the system, or even in the majority of cases, in so summary a man-
ner as a piece of dead bone. As a rule, there exists a wonderful
forbearance on the part of nature to its presence, and the organ may
be retained in its cavity and made to serve a useful purpose for a
long time. True, it is discolored, and, providing there is no decom-
posing pulp in the canal, in proportion to this discoloration may the
degree of death— if I may so speak— be judged. A tooth lowers in
the scale of vitality in various degrees. It may be deteriorated as
the death of part of its pulp is concerned, or as the death of all of it
NECROSIS. 311
is implied — as regards the whole or any part of its periosteum.
When both pulp and periosteum are dead, the tooth, of necessity,
must be dead with them, and in proportion to their destruction, so
is its destruction.
Some systems are so irritable that all the skill in the world could
not make the mouths retain a tooth in which alone the pulp is dead.
Others, on the contrary, are so unimpressible that half the teeth in
the mouth might be utterly dead, and yet no complaint be made. I
once, as an experiment, replaced in the mouth a central incisor tooth,
which had been extracted twelve hours before, and although it had
been carried in the pocket, enveloped in the usual collection of dust,
tobacco, keys, knife, etc. the whole intervening time, I kept it in its
socket until the parts became reconciled. Many years have since
passed, and it seemed to me, when last I saw it, about as useful as
in its palmiest days.
The irritation, inflammation, and death of a tooth are generally the
result of caries exposing its pulp. The first stage in the destruc-
tive process is the death of this part* — here it may end, the pulp
sloughing off" at the foramen, and the periosteum assuming the full
duties of nutrition. If this is not the case, the periosteum becomes
involved ; if it too should die, the root is left as if scraped ; the tooth
is then dead. A dead or partly dead tooth is recognized by its loss
of translucency, opacity varying from the slightest discoloration to
complete blackness.
A dead tooth is not, however, necessarily associated with caries.
Inflammation resulting in its destruction, may be induced by at-
mospheric changes, blows, etc. This should be recognized, so
that by reason of the absence of caries a diagnosis may not be
obscured.
A dead tooth, when exfoliated, is thrown oif in two ways: either
by chronic or acute action. When by acute means, violent inflam-
mation is set up in all the surrounding parts, the tooth is elongated
and loosened, much pus is discharged, and eventually the tooth
drops from its socket ; this accomplished, the trouble subsides. In
chronic exfoliation, the parts indurate, one or more sinuses form as
in abscess, all the parts about the tooth are thickened and rough, as
if some ugly disease was in process of development, the tooth gen-
erally grows dark, perhaps black. It does not get loose, but frightens
* The pnlp of a tooth is composed of most delicate connective tissue, in
which ramify the vessels and nerve.
312 ORAL DISEASES AND SURGERY.
into its removal. If such extraction be not resorted to, the disease
involves the bone, and tooth and alveolus become eventually cast
ofiF as a common sequestrum. Another, and more common chronic
form, consists in the gradual absorption from about the roots of the
dead tooth of its alveolar process. This is most common to old
persons, although not by any means so confined. This form of ex-
foliation is usually very slow in its progress, extending over a period
sometimes of several years. Cases, however, frequently present —
confined to young persons — where several teeth are cast off in this
manner within eight or nine months.
Teeth sometimes die from the filling up of their tubules by
secondary dentine, the organic function residing in the tubes being
thus destroyed. This never occurs but in what are commonly re-
cognized as very dense teeth, and is seldom found associated with
caries. Such teeth loosen day by day, and finally drop from their
cavities. To arrest this trouble seems impossible. I know of no
treatment that has ever seemed to have the least effect.
Alveolar Necrosis. — The periosteum enveloping the root of a
tooth is reflected to its alveolus, hence it is commonly termed the
" alveolo-dental periosteum." As the result of such relationship of
structure, an inflammation originating in a tooth extends itself to
the surrounding bone, and according to its severity, affects the parts
involved ; hence portions of alveolus, overwhelmed, as it were, by
the force of the attack, sometimes die and sequester. This form of
necrosis, however, is not very common, and would perhaps with
proper treatment seldom occur.
The dentist, for the purpose of destroying the pulps of teeth,
applies a mixture of arsenic, morphia, and creasote. This is placed
in the cavity of decay and covered with cotton or wax; it hap-
pens, however, occasionally, that from its improper application, or
some difficulty of retaining it in place, this paste oozes down around
the neck of the tooth, and thus acts upon parts not intended in its
application, inflaming them ; in this way alveolar necrosis is some-
times induced : the portion destroyed is seldom, however, very con-
siderable, and generally exfoliates in from two to four weeks. The
local application of the sesquioxide of iron has been thought by
some to exert a happy effect, applied immediately on the discovery
of the accident. Repeated syringings are not to be neglected.
Alveolar necrosis is sometimes induced by the application of
chloride of zinc, used by the dentist as an obtunder of dentinal sen-
sibility, and also for the purpose of controlling the slight hemorrhages
NECROSIS. 313
caused by the slipping of instruments in the operation of filling ; the
first effect is of course upon the gum, inflaming and engorging it,
the effect upon the bone being secondary. Nothing better than the
ordinary antiphlogistic applications can be employed. The action
here is much more tardy than in the destruction induced by arsenic,
the sequestrum is never very considerable, the alveolus perhaps of a
single tooth. The action of nature, in the separation, should always
be awaited. Cases of what, for want of a better name, might be
termed anomalous, sometimes occur. An instance will illustrate.
I. B., an Irish laborer, consulted for pain in the two inferior in-
cisor teeth, — no caries, no periosteal inflammation, nothing indicating
disease, was observable ; the pain increased day by day, until at the
end of the second week the two teeth and their alveoli were found
detached, and were dissected from the gum. This case is one of a
very few of the kind that I have seen. The nerves are not
found dead if examined at such time, as under ordinary circum-
stances one would so expect to find them ; there is no soreness of
the teeth on pressure, and, strangest of all, there ai-e none of
the common phenomena of inflammation. The practitioner in these
cases must be guided by such indications as he may be able to seize
upon.
Necrosis from Want of Room for Eruption of Wisdom Tooth. —
This most commonly is found associated with the lower jaw. The
close relationship of the second molar with the ramus, makes the
egress of the advancing wisdom tooth an impossibility; hence an
irritation resulting in inflammation. The serious extension of the
trouble to the bone is always, however, preceded by more or less
trismus and difficulty in deglutition ; thus every chance is given for
surgical relief. This form of necrosis is to be looked for between
the seventeenth and twenty-fifth years. The extraction of the second
molar allows the wisdom tooth to fall forward ; thus the irritation
is removed and a cure effected. These cases are, if rightly treated,
as simple and harmless, as they are severe and prostrating if left
to chance or improperly managed. Extract the second molar tooth,
and do not attempt the removal of the offending one — that is, if such
extraction will be found difficult.
Exfoliations of laminae of bone are very common after the opera-
tion of extraction.
Such scales vary in size from that of the finger-nail to a pin's head ;
they seldom require any particular attention.
Phosphor-Necrosis. — Outside of the association of a patient with
314 ORAL DISEASES AND SURGERY.
phosphorus, there is nothing which, to an ordinary observer, would
distinguish the incipient condition of this loathsome disease from a
case of commonly severe periodontitis.
The first sign of a commencing phosphor-necrosis is found in one
or more teeth becoming sore to the touch, feeling, on occlusion, as if
raised in their sockets; a short time, and the surrounding gum
begins to swell : in the character of this swelling is the first dis-
tinctive sign. It is not the acute, firm, inflammatory swelling of
periodontitis, or ordinary necrosis, but from the beginning has a
puffy, debased, and degenerating look. You feel as if you might
hesitate in adopting any very decided antiphlogistic treatment, or,
indeed, in employing any other than an expectant one.
Phosphorus acts both on the upper and lower jaw-bones, but,
according to my observation, seems to have a much more decided
predilection for the lower ; as nine to twelve, perhaps.
The history of a case of phosphor-necrosis might be epitomized
as follows : either from a local or constitutional influence, the latter,
most likely, a degenerative inflammation commences in the alveolo-
dental periosteum, or in the substance of the bone ; I incline most
strongly to the belief of its commencement in the latter. The de-
generation of this bone progresses until its enveloping periosteum —
which remains unaffected, as its vitality is concerned — separates
from it. The bones die in bulk or in part. In the lower jaw,
the body alone commonly dies, the rami remaining unaffected.
In the upper, one cannot well infer where the demarkatiou will
occur. During this process of death, the periosteum, particularly in
the lower jaw, is most active in the reproduction of new bone, this
new bone enveloping the dead, not, according to my observation,
completely, but below and on the sides, making a gutter, as it were,
holding the dead bone. The separation of the dead from the living
bone, when the dead part is at all extensive, occupies a period of
from seven to nine months, and is attended with the formation of
many sinuses, both in the mouth and about the neck, being very
exhaustive to the patient, both on account of the great suppurative
drain and the nauseating character of the discharge. The whole of
the soft parts associated with the affected jaw, the periosteum per-
haps excepted, sympathize warmly during the process of the dying
and separation, looking, indeed, as if very badly affected with scurvy.
At the period above alluded to, the separation being completed,
the surgeon may remove, with little effort, the sequestrum; the
sinuses then heal, and the parts recover with as little deformity as
NECROSIS. 315
attends the extraction of the teeth and the ordinary absorption of
the alveolar process.
This, I think, will be found the common history of the disease.
I have seen and treated many cases, and it is thus that it has pre-
sented itself to my observation. I might perhaps add, that the
teeth, influenced by the advancing disease, loosen one by one, so as
to make necessary their removal long before the bone is ready to
come away.
The treatment pursued in phosphor-necrosis consists in the em-
ployment of means which shall circumscribe as much as possible the
disease, which shall hasten the process of limited death and the ac-
cruing separation, and which shall support the patient under the
drain to which he is necessarily subjected.
Acting on the impression that there may exist, either in a systemic
or local relation, phosphorus, whose force may be susceptible of neu-
tralization, we direct both locally and internally the mineral antacids,
— the ordinary magnes. carb. is perhaps as good as any other; a tea-
spoonful twice each day in a goblet of water. In the mouth, as
much as may be laid on a three-cent piece may be used three or
four times a day; this local and systemic medication is, by the way,
a very admirable prophylactic to unaffected workmen.
When a case presents in its very incipiency, that is, simulating a
developing periodontitis, we commence the local treatment just as we
would that of the periodontitis. If the inflammation has about it
anything of a healthy acuteness, we limit as much as possible all ex-
ternal irritation, by softening in the gas flame or by the stove a piece
of gutta-percha, and moulding it over some opposite tooth, or tooth
farthest removed from the seat of trouble ; a mouthful of cold water
hardens this cap, and thus occlusion against the sore tooth or teeth
is prevented. A dose of Epsom salts or other saline cathartic is
ordered, and a mustard poultice is applied to the- side of the face or
back of the neck. A hot pediluvium is found sometimes to act very
happily as a derivative ; or a diaphoretic, such as the spirits of Min-
dererus, may serve a very good end.
If we first see the case — and this is most apt to occur — when a
discharge has made passage for itself by opening through the gum
at the neck of a certain tooth or teeth, we immediately make a free
incision through the soft parts down upon the bone, and syringe the
parts thoroughly with some medicated water, stimulating or antisep-
tic, or both, as indicated. Having the parts well cleansed, we stuff
the wound which has been made with cotton or sponge. This is
316 ORAL DISEASES AND SURGERY.
repeated the next day and the next, until, particularly as the syring-
inff is concerned, it maybe absolutely necessary to repeat it a dozen
or twenty times per diem, the progress of the disease being so
marked by discharge and offcnsiveness. As day by day the cotton
or sponge stuffing is renewed, it is insinuated gently between the
separating periosteum and bone. This manipulation will be found
to hasten the separation wonderfully, and expedite the cure of the
case.
It might here be asked, perhaps, by some one, " Is not this pro-
cess of working off the periosteum an unsurgical proceeding, com-
pelling an extension of the disease beyond that which would have
been the result if left to itself?" I can only answer from my own
experience in different modes of treatment, and say that I am per-
fectly satisfied that this is not the case, and that the result is for the
good of the patient in every way : the portion of bone destined to
die has its death markedly hastened ; the sooner the death the
sooner the separation ; the sooner the separation and exfoliation of
the sequestrum, the less exhaustive to the system.
The compound tincture of capsicum, with an excess of myrrh and
an addition of the permanganate of potash, is an excellent wash for
the mouth in these cases. Cold water, with a little common salt
dissolved in it, can be used ad libitum.
The sinuses which are so apt to form upon the neck, in defiance of
all treatment, and which greatly annoy by their discharge, are most
comfortably treated with dressings of patent lint. Once formed, it
is a waste of time to attempt the healing of them ; they will only
get well when the source of offense in the dead bone is removed.
I never have been able to heal one before.
It has been remarked that the death is limited in the lower jaw
to the body of the bone, the horizontal portion, the demarkation
occurring at the angle. This, in the majority of instances, will be
the case, particularly if the treatment has been properly directed.
Seven months will be found the minimum required for the course
of the disease ; nine months the more common time ; and fifteen
the maximum. The drain during most of this time is immense, the
patient requiring the most generous tonics and substantial fare.
Attention to the repair of this wear and tear is, perhaps, of greater
consequence than any local treatment ; certainly, if I could not
have both, I would think my chances best with the former. To
commence, however, with the ordinary medicinal tonics, is ill ad-
vised. One cannot keep on forever with them, and by an em-
NECROSIS. 317
ployment of them in the beginning of the disease, we lose their pow-
erful assistance at a time when every help is found weak enough at
the best. Good underdone roast beef is quite enough for the first two
or three months, then an addition may be made of generous malt
liquors, together with the salt-bath. The latter portion of the time
will demand iron, quinine, brandy. The hemorrhages, sometimes so
profuse, are held very well in check by the exhibition, once or twice
weekly, of tinct. Erigeron Canadeuse.
The period at which a sequestrum is ready to be taken away can
only be known by repeated examination, the proper treatment be-
ing to wait always until the separation is complete, be such
time longer or shorter. Nothing, I am satisfied, is gained by ex-
pediting the removal through operative proceedings, as by break-
ing away the bone, using the chain-saw, etc., while the risk to
life is very considerable. To wait patiently, keeping the system ca-
pable to the demand on it, is the surgeon's highest duty ; to do more
is to do harm.
The removal of the bone is always to be effected from the inside.
I do not think an outside incision will ever be found necessary. If
the opening along the gum, obtained in the treatment, is not great
enough, it is easily enlarged to an extent desired.
A step preliminary to the removal of the body of the lower jaw,
is its division at the symphysis. This is most easily accomplished
by means of the straight-cutting forceps. It is better to cut little
by little, from above downward, than to crush through the bone
with a single cut ; it does not hurt or shock nearly so much. The
operation is not a severe one, seldom demanding the patient to be
etherized, yet it is generally enough to be borne at one sitting.
To take away the bone, I have never found anything better than
the ordinary tooth forceps, such as is in common use for the extrac-
tion of the inferior incisors and bicuspids. With such forceps,
perfect control of the part is secured, and the removal, as a general
rule, easily effected.
A trouble frequently encountered, and one which, undistinguished,
would prove confusing and deceptive, consists in a grasping of the
sequestrum, when extensive, by the lateral overlying tissues — not
the new bone, but the indurated soft parts. I recall just now a case
which I once had under treatment, where the dead bone being thus
held, the physician had been waiting for the separation a period of
over two years, being deceived entirely as to the condition of the
part. To satisfy one's self as to the state of parts, pass a small hook
318 ORAL DISEASES AND SURGERY.
under the bone, and lift : if the bone yields springy, it is only thus
held, and may with safety be pulled through; if, on the contrary,
it is firm and unyielding, it is to be left alone, separation has not
yet taken place.
In the reproduction of the new bone, which, at the period for the
removal of the old, will be found to have obtained such character as
to keep up perfectly the shape of the parts, the observer will be
struck with the excess deposited along the middle line of the mouth ;
it seems as if the floor was a mass of bone, and which, indeed, it
really is. Nothing, however, will be found necessary to be done
with this excess, nature taking all proper care of it.
Phosphor-necrosis attacking the upper jaw is not, I think, so
much to be dreaded as that associated with the lower. It is seldom
so formidable in its nature or so destructive in its progress. I have
seen the disease in these parts run its whole course with an entire
absence of acute action. A portion of bone dies, and the surrounding
soft parts seem utterly indifferent. One would scarcely know any-
thing abnormal was going on were it not for the indication given
in the loosening of the teeth; these drop out somewhat as they
would out of the dried skull. This, however, is, of course, not the
common history. The inflammatory action is of the same type as
that associated with the disease in the lower jaw, but more limited
in extent and consequence, and much more susceptible to remedial
measures. A bad feature consists in a marked tendency to recur-
rence of the trouble, but I believe this will mostly be found to be
within the control of the surgeon. I think I am justified in saying
I have commonly found it so. The removal of a sequestrum here
is a trifling matter, comparatively little dissection letting the piece
pass.
At the Medical Congress in Zurich, Switzerland, Professor Bill-
roth, in citing his experience with phosphor-necrosis, remarked that
in attacking the upper jaw it seemed to act with greater and more
destructive force, and was more unmanageable.
I do not know how to reconcile these differences in clinical ob-
servation, unless an explanation maybe found in the implied greater
tendency to return which exists on the part of the disease, when
situated in the upper jaw. In the lower jaw the full part that is to
die seems impressed from the beginning, — that is to say, a certain
portion seems predestined to die, and it dies in defiance of all you
may do. Not that the evidence of the disease is general over all
the involved part from the beginning ; on the contrary, the incipient
NECROSIS. 319
stage is markedly localized ; but then, day by day, and week by
week, the trouble extends over the apparently predetermined, or pre-
impressed, part. When the death occurs, it is a single death, and
when the piece is cast off, there is not apt to be any renewal of the
trouble. The sequestrum of the upper jaw, on the contrary, is
generally small, some portion, most likely, of the alveolar process,
but unless the treatment is of the most supporting and specific kind,
it is apt to repeat itself, again and again ; but your treatment will
be responded to here, and thus, with care and attention, you have
the amount of destruction comparatively under control. If it is
found more unmanageable in Zurich, then the means would not
seem to be so well adapted to the end as those here employed, or
otherwise the circumstances must be different.
Again, at the same Congress frequent resections are commended.
To be so commended, they must, of course, have been found to
answer a good purpose. The patients Avho have their jaws resected
for phosphor-necrosis disease in this country generally die, or if
happily they escape death, they do not find their disease cured
without an inflammatory sequestrum at last.
Fig. 64. — Appearance of Patient with Phosphor-Necrosis.
This case, taken from life, represents a patient as he appeared
with the disease five months in progress. At the end of eight
months I removed the jaw at the articulation, — the loss was very
fully repaired at the date of operation — the parts having excellent
motion.
An important objection to the operation of resection, even were
320 ORAL DISEASES AND SURGERY.
the question of life not involved, is the great resulting deformity.
Let nature take her course, and of this there is little or none. My
very last patient was a gentleman for whom I removed — or rather
waited on nature's removal — the whole body of the inferior maxilla,
and I will guarantee that no one could tell whether it had been a
case of necrosis or of simple extraction of all the inferior teeth, with
the consequent alveolar absorption, so perfect has been the repair in
accordance with the destruction. The objection that this new bone
keeps up the trouble by becoming involved in the diseased action,
is not according to my experience. If it becomes involved, 1 think
it has not been properly cared for. Careful and properly repeated
syringings with water medicated with iodine and creasote will pro-
tect it.
Syphilitic Xecrosis. — The hard palate seems particularly liable
to suffer from attacks of specific diseases, the venereal ulcer of the
overlying soft parts, and that of the soft palate being observed as
among the most common of the constitutional affections. That
these ulcers are, however, strictly venereal, I am oftentimes led to
doubt; certain I am that they appear and exist, with greatest viru-
lence, where mercury has been used with unnecessary freedom.
Venereal ulcers of the mouth are of two kinds : the superficial and
the ordinary ulcer of necrosis ; either of them being represented in
general appearance by the non-indurated chancre. The superficial
ulcer may be found both upon the hard and soft palates, but is much
more common to the latter. These ulcers — as the chancres — vary in
size and character : being sometimes very amenable to treatment ; at
others, resisting and phagedenic, even to the destruction of the parts.
Their treatment is to be conducted on general principles. I know of
few surgical conditions requiring nicer general judgment or more
attentive care ; it is, really, to blow hot to-day and cold to-morrow,
and vice versa. As a rule, such ulcers are oblong in form, from an
eighth to an inch or more in length ; more or less excavated, the
cavity being filled with a dirty-white semi-solid paste. The truest
comprehension of these cases is found, as my experience leads me to
infer, in looking at them as one looks at scorbutus.
Touching locally with the acid nitrate of mercury, or with a mix-
ture of equal parts of iodine and creasote, not unfrequently causes
them speedily to assume healthy action. I have never seen a case
in which the internal exhibition of the mineral acids did not seem to
be in some degree useful; and particularly have I found this to be
the case where a phagedemic tendency existed. Whatever remedies,
NECROSIS. 321
however, be employed, the venereal basis of the trouble is always to
be kept in mind. Syrup of the pyrophosphate of iron, conjoined with
minute doses of corrosive sublimate and iodide of potassium, will,
under certain conditions, compel such ulcers to disappear as if by
magic. A combination which may be employed is as follows :
B. — Hydrarg. bichl. gr. ij ;
Potass, iod. 5ij 5
Syr. ferri pyrophos. ^iij;
Syr. sarsaparilla, §v. M.
Sig. Tablespoonful ter die.
The ulcer of necrosis, looking like the preceding, diflTers from it
in having a sinus leading from the pasty mass, which constitutes
the apparent bottom to dead or dying bone beneath. The ulcer in
this case is not the trouble to be cured, — indeed, could not be cured
while the underlying disease existed. Ulcers of this class being
an attendant condition, are always situated over bones, generally
about the suture of the maxillary and palate bones. They are
always preceded by an engorged and tumid state of the parts in
which they are situated, indicative of the osseous trouble beneath.
The character of this tumidity is always a matter of much concern,
as in proportion to its solidity will generally be found the extent of
destruction in the soft parts ; the variability of this destruction is
seldom, however, in proportion to the disease below. I have seen
the whole palatine process die while the indicative ulcer has not
been larger than the eighth of an inch in circumference ; I have, on
the contrary, witnessed the smallest sequestrum attended with the
largest ulceration.
Incisions into and through this tumid engorgement will always
be found satisfactory practice. The cuts, however, are to be made,
not carelessly, but with judgment ; always taking into consideration
the vitality of the part. These incisions, if made through the peri-
osteum, will frequently be found to exercise quite a controlling influ-
ence on the ostitis, just as in cases of ordinary necrosis, while the
effect upon the soft parts is always for good. The treatment which
should succeed the incisions is only to be determined by the cir-
cumstances of each particular case ; not unfrequently it will be found
amply sufficient to keep the parts well cleansed, and await the com-
ing away of the sequestrum ; never, however, forgetting to meet the
constitutional indication. In other cases, as when, for example, the
phagedenic type is assumed, the most vigorous and well-directed
21
322 ORAL DISEASES AND SURGERY.
local treatment is necessitated ; when cases are first seen in the open
ulcerated condition, semi-indolent, as is frequently the case, I know-
no treatment equal to packing the ulcer with cotton saturated with
creasote and iodine. I have had cases come to me for treatment
where the bone would be found exposed to the size of a silver three-
cent piece, and where all the consequences of a large opening into
the nares were to be apprehended, yet, by such an application re-
peated every other day, allowing the cotton to remain in the ulcer
the intervening time, in the course of two weeks the denuded bone
has entirely granulated over, and the parts have remained perma-
nently cured.
Breaks occurring in the hard palate, associating the oral cavity with
the nares, are easily remedied by a covering of gold or silver plate.
An impression of the full roof of the mouth is taken in wax; into
this plaster in a cream form is poured ; to the cast thus procured is
fitted the plate of metal, supported by the teeth, or by atmospheric
pressure, precisely as in the case of a plate for the attachment of
teeth. Any reasonably ingenious mechanical dentist can meet the
indications.
In breaks of the soft palate a simple wad of cotton may be tem-
porarily used with a considerable degree of satisfaction. Astonishing
results in the way of diminishing or closing these breaks, both in the
hard and soft palates, may not unfrequently be secured by freshening
the edges and touching every second or third day with iodine, zinc,
acid nitrate of mercury, or the compound tincture of capsicum.
Great care is, however, to be exercised in this practice not to over-
stimulate the parts, very ugly degenerating inflammations being
sometimes the result of an overexcitement.
An ugly feature in the syphilitic ulcer is its tendency to recur :
a palate, looking healthy to-day, will assume to-morrow an indo-
lent relaxed type, becoming semi-yellowish ; some point or other
will take on a fatty look, and in a few hours break down into an
ulcer. This may recur a dozen times; the explanation is to be looked
for in the systemic condition. Such recurrence of the ulceration may
extend over a period of six or eight months, in defiance of the most
careful attention. I have certainly found it so in my own practice,
and imagine it to be a common experience. The salt-bath will be found
in these cases invaluable, affording, as it does, an increased vitality.
ExANTHEMATOus Xecrosis. — Necrosis occurring as a sequel to
the exanthematous fevers, belongs, so far as I know, exclusively to
the dentitional period. Two cases in my own practice occurred
NECROSIS. 323
about the sixth year of age, and were both attendant on attacks of
measles. The accompanying view is from a photograph of pieces
constituting the full half of the lower jaw, which I removed, some
two years back, from the mouth of a little German boy.
Fig. 65. — Sequestrum after Measles.
A clinical report of this case, made and published at that time by
Dr. H. L. Gilmore, may have, to the student, some instruction in
it, as it describes the practice pursued.
" Our first case this afternoon is the little German boy seen by
you at a previous clinic. When last exhibited, I told you that we
could scarcely hope to save his life, so depressed was his general
health ; since then, however, a great change is remarked. He has
been using salt-baths daily, living on the best and most nourishing
food, drinking lager beer, and taking iron and quinine. The parts
have been almost hourly syringed, and the ofiFen.sive and semi-putrid
discharge, instead of passing into his stomach, has been kept washed
away.
" In the treatment of cases of extensive necrosis like this before us,
there are three marked indications. The first is to keep up the life-
force of the patient. The second is to insure against deformity, by
securing new bone, to replace the dying. The thi7-d, to get away
the dead bone as soon as nature permits.
" The first and second indications are met on a common principle,
namely — constitutional and local tonic, and stimulating treatment.
As soon as we see that the death of the circumference of the bone is
not to be avoided by that preliminary treatment, which applies to
the demands of the inflammation in its acute stage, we at once apply
ourselves to saving the periosteum by a process of enucleation. We
introduce, as rapidly as we can, tents of cotton and sponge between the
bones and periosteum, which, by their expansion, effect the end de-
sired, hasten necessarily the death of the denuded bone, and pre-
serve for the repair the osteo-genic power. Here will be found
exhibited the necessity for great cleanliness, and not unlikely for
local stimulation. Permanganate of potash, from 3 to 5 grs. to the
324 ORAL DISEASES AND SURGERY.
ounce of water, will be found an admirable disinfectant. Tincture
of iodine, or the tinct. with a small addition of creasote, is the best
stimulant I am acquainted with ; I think the latter will provoke the
periosteum to effort when nothing else will, — at least this seems to
be my personal experience.
"As a rule, I think new bone can be made to envelop the old; but
there are cases where such a result cannot be secured. Such a case
is the one before us. I have done everything possible for this boy,
but there is no attempt at repair. An explanation is to be found, of
course, in his general condition ; he is a very scrofulous subject.
His necrosis is the result of an attack of measles. The removal of
the dead jaw must, of course, to some extent deform him, — that is, if
we are not mechanics enough to invent some antagonizing piece of
apparatus, to be worn until a cure is effected. If the boy was able
to bear a longer drain upon his system, I would leave the dead bone,
and continue to try to get the envelope of new bone ; but this would
not do, the drain must either cease, or the lad must die. The effort
to secure new bone could only be continuous of what I have been
doing, and it really would seem as if it were useless to do in this
way more than has already been done.
" I cannot learn, with any positive certainty, exactly how long this
disease has been going on; the parents say several months. If you
get such a patient cured within a year you will have managed your
case very well, — the rule always being to wait for the reparation of
the bone, hastening and advancing the exfoliation by any non-
operative means in reason, but never anticipating the natural cure
by section with saw, knife, or chisel.
" Having then done for this boy all in our power, and having, as
the result, a dead half-jaw, which, from the irritation kept up by
its presence, is day by day injuring him, there is nothing left to be
done but its removal, and this I will now proceed to effect in your
presence.
"When I touch the bone with a probe I recognize it as dead bone.
Dead bone has a peculiar feel when struck : it emits a dull leaden
sound, has a rough surface, and can be recognized as being more or
less necrosed. When, however, the lower jaw-bone is dead, and is
not enveloped by a gutter of new bone, it is found held very firmly
in its place by the surrounding indurated soft parts. This is often-
times a source of great deception, leading to the injurious inference
that the bone is not exfoliated, and as a consequence, permitting its
undue retention. This is the condition in the present case. To
NECROSIS. 325
satisfy myself, I introduce this delicate hook beneath the bone. In
lifting with it I find the bone yields with a kind of spring, as if I
were pulling against cartilage. This satisfies me that the bone is
loose, and needs only to be freed from this indurated ring to be capable
of a comparatively easy removal. We will now etherize the boy,
and lay this ring open as far as the coronoid process. Not forgetting,
however, in the incision, the relation of the internal carotid artery
to this process
" The bone extracted included both the coronoid and condyloid
processes, and the body as far forward as the incisor tooth.*
"After the operation, there was directed one-eighth of a grain of
acetate of morphia. Lead-water and laudanum to the face, and fre-
quent syringings with medicated water."
Other Exanthems. — Necrosis from other of the exanthems I
have not personally happened to meet with, although from scarlet
fever it is much the most frequent; while, as well, a reasonable
number of cases are reported from smallpox. From measles I have
had three cases.
Mercurial Necrosis. — Ostitis, and exfoliation from the undue
use of the mercurials, are so common as to have been observed by
every practitioner. The history of each case is that of a progressive
pytalism : first, the coppery taste, enlargement of the tongue, saliva-
tion; second, soreness of the teeth, recession and loosening of the
gums, discharge of offensive pus, exfoliation. Many interesting
cases of this condition have come under my own notice, some of
which are alluded to in other parts of this volume. Generally, the
cases will be found associated with children, induced by the great
vascularity and susceptibility of the bones at the dentitional period.
I judge, from my own observations, that a practitioner in the use of
this medicine must look, for a rule of practice, in every individual
child he may have occasion so to treat.
In the treatment of mercurial ulitis, I have called attention to
a .practice by free scarification and the local use of iodine. Many
cases of threatened necrosis have been by these means aborted, but
very great care is to be exercised that the low vital force be not
still further depressed. (See Chapter on Ulitis.)
The treatment of ulitis is the treatment of ostitis.
In the special treatment of a sequestrum, it is to be looked
* Two years later I saw this patient — the deformity was very trifling, and
he certainly seemed to use his jaw without inconvenience.
326 ORAL DISEASES AND SURGERY.
upon as a matter of much importance that the dead piece be de-
tached by nature alone, assisted by the surgeon only as in other
paragraphs described. Particularly does this seem important in
the young jaw, as thus it may happen that we shall not disturb,
unnecessarily, the germs of developing teeth.
Much stress has been laid by some practitioners on the preserva-
tion of such teeth as are associated with the sequestrum, and advice
given that incisions be made through the soft parts that shall allow
the bone to be drawn away from the loosened teeth. Such treat-
ment can certainly only apply to very few and peculiar cases. As
a rule of practice, I am confident it must be found of little significa-
tion.
CHAPTER XXII.
THE TUMORS OF THE MOUTH.
In entering on a consideration of the tumors of the mouth and
jaws, we are to recognize and appreciate certain general governing,
or underlying principles.
1st. Tumors of this location, alike with those situated in other
parts, are analogous and heterologous, or benign and malignant.
2d. The maxillary bones, because of their great vascularity and
exposure to sources of irritation, are, perhaps, more disposed to enter
on pathological conditions than any other of the ossa corporse.
3d. The principal source of irritation to the maxillary bones is to
be found in diseased teeth.
4th. Malignant tumors of these bones are perhaps to be esteemed
only as local exhibitions of an existing cachexia. The character of
the diseased action, the result of local injury, will be determined by
the diathesis.
5th. Tumors of the maxillary bones which may, with most assur-
ance, be looked on as benign, are the encysted, the common inflam-
matory, and the exostoses.
6th. Those, the character of which may be esteemed doubtful,
and malignant, are the sarcomatous — fibro-plastic — and the carcino-
matous.
7th. There is not, unfrequently, such a running together, so to
speak, of the appearances presented by benign and malignant
growths as to render distinctive diagnostic signs only appreciable,
if indeed, at all so, to the very experienced. Certain general features,
however, associate commonly with the two lesions, which are to be
studied with the greatest advantage.
1. Benign tumors, it will be found, are mostly to be referred to
some cause, and are apt to be in proportion to this cause. They are
found circumscribed by healthy structures, lymph in a greater or
lesser state of organization surrounding and marking their line of
extent.
2. They do not seem to have other than the most innocent rela-
(327)
328 ORAL DISEASES AND SURGERY.
tion with adjoining organs, any disturbance of function from their
presence being referable to mechanical rather than to pathological
causes.
3. In structure they are found homologous ; they represent more
or less truly the parts to which they are allied, and possess scarcely
any other than a single formative capacity. They do not defy con-
stitutional treatment, but are more or less influenced by it. If
removed by the knife, they do not return.
1. Malignant tumors are, on the contrary, not at all in proportion
to a cause which may seem to be the provocative. They are not
healthily circumscribed, but their elementary particles are most apt
to be found infiltrated, inserted, or diffused in the interspaces and
cavities of the tissues in which they lie. They are associated with
a cachexia which is not unfrequently more marked than the local
disorder. Thus the vis vitse is not unfrequently so prostrated that
the patient is found dying with systemic depression. (The common
idea that the cancer patient has the color of a cold buckwheat cake
is not entirely without truth ; it is not always seen, but, I believe,
exists in a proportion of cases.)
2. A marked diagnostic sign (perhaps the most marked) of a can-
cerous tumor, is the effect of its presence on surrounding glandular
structures ; these becoming enlarged and indurated, and remaining so.
3. The removal of any supposed cause, or the removal of a cancer-
ous tumor itself, will not effect a cure.
4. True cancer seems not amenable to any constitutional treat-
ment. There are, I think, the best of reasons for inferring that all
reports of cases cured have originated in mistaken diagnosis.
5. Malignant tumors have, through the cachexia, a varying form-
ative capacity: they multiply, and, as it were, propagate themselves;
if one is removed, a second comes to take its place, either appearing
in the site of removal or in some other locality.
In the study of these marked and distinctive features, the practi-
tioner will find himself led to perceive the first and most important
of the differences in maxillary tumors; he will be led also to ap-
preciate the fact of a relationship which is to compel him to look on
certain of the homologous growths as not being entirely devoid of
danger; he will also find data for judgment which will serve him in
every individual case.
Benign Tumors. — For convenience of study, we will class under
this head the cystic growths, the common inflammatory, and the
TUMORS OF THE MOUTH. 329
exostoses, premising that, as the first class is concerned, we shall
have occasion further on to recognize exceptions.
Cystic Tumors. — The cystic tumors of the mouth are of two
kinds : simple and compound. The simple cysts seem to be mere
expansions of the outer plate of the bones — wind-bags, as the older
writers called them ; a fair expression to convey the idea of their
character, yet requiring considerable qualification. The second class,
the compound, are cysts containing peculiar contents, which con-
tents have induced the cyst and constitute the lesion to be studied;
of the latter class, the odontocele is by far the most common, and
such tumors vary from the simple encystment of a perfected tooth
to some perverted development which requires the nicest discern-
ment of the microscope to investigate. Under the head of cystic
tumors might also, with propriety, be noticed those occasional ex-
pansions of the walls of the maxillary sinus dependent on engorge-
ments.
The Simple Cyst. — All writers on surgery have remarked the
existence, in the mouth, of this form of tumor. A simple expansion
of the bone with varying fluid or gaseous contents ; different authors
differently describe and name them. The term spina ventosa is,
perhaps, about the most unmeaning that has been applied. As
I know them, their history may be written as follows: there is
first remarked on the side of the jaw, either superior or inferior (no
preference seems to exist), a slight flattened enlargement ; this in-
creases slowly, until the swelling reaches the size of half a hickory
nut; they are seldom seen larger. No pain attends the growth,
and outside of the mental disquietude necessarily induced, no
functional or other constitutional disturbance attends. The slow-
ness of growth is such that it requires from one to three years to
reach the size alluded to. This tardiness, absence of pain, and
constitutional disturbance constitute marked diagnostic signs. An-
other sign, and one on which every writer with whom I am ac-
quainted lays particular stress, is the giving forth, on pressure,
of a parchment-like crackling; with this last I seem, however,
to have had a peculiar experience, for while I have treated quite my
share of such cases, it has not been my fortune to find such crackling
sound in any single one of them, and while of course it would ill be-
come any individual to assert that such a crackling never can be
heard, yet I would impress that such a sign is not by any means
an ever-present indication, consequently is not to be given the
heed demanded for it. In most of these tumors on which I have
330 ORAL DISEASES AND SURGERY.
operated, septi, more or less ia number, have been found supporting
the vault ; with the existence of such pillars it is plainly enough
seen that yielding would be out of the question, so that the practi-
tioner is not to be deceived by the firm character of the tumor. The
gum covering such cystic tumors is always perfectly normal, — no
congestion, nor anything indicating its implication ; a matter im-
portant to observe, as, should the diagnosis be in anywise obscured,
the practitioner would have, at least, the satisfaction of feeling a
tolerable assurance as to the benign character of the gi'owth as well
as to its non-acute character.
Of the number of cysts of this class that I have seen, every one
have been situated in the outer or vestibular walls of the bones.
Why they should be so, or indeed whether it is always the case, I
do not know. I only offer my own experience.
A diagnosis made out, the cure is very simple. A common
treatment, and one generally practiced, because of its little trouble,
is to make a crucial incision through the body of the tumor, and,
breaking up such septi as may exist, stuff the cavity with lint
saturated with the tincture of iodine ; this, if there is no foreign
body in the cavity, as, for instance, the root of a dead tooth, will
invariably cause the base to throw out granulations, and thus
obliterate the cyst.
Another mode not unfrequently resorted to, is to dissect from the
tumor, in flap-form, the overlying gum, and with a chisel cut away
the vault of the cyst ; the parts are then carefully syringed and the
flap laid back. This latter operation requires much more time,
much more skill, and gives much more pain. The first is not nearly
so objectionable to the patient, and is equally as effectual.
Concerning hemorrhage, little anxiety need be felt. I never found
it give any trouble ; it may be necessary to syringe the cavity with
a little alum-water, or some other astringent, but even this is not
commonly needed.
Caf^e — . Mrs. C , aged about twenty-one, applied to me, some
two years back, for treatment of a tumor occupying the canine fossa
of the left superior maxillary bone. The growth had been eighteen
months in progress ; was about the size of half a walnut, perfectly
solid to the touch, painless, and entirely healthy-looking ; the great-
est disquietude of the patient being mental, her mother having died
from scirrhous cancer.
Diagnosis — Simple cyst.
Treatmept. — Crucial incisions were made ; several delicate septi
TUMORS OF THE MOUTH. 33I
of bone, which the cuts discovered, were broken up ; the cyst was
injected for the first three days with weak stimulating liquors. No
inflammation developing, tufts of cotton were saturated with tinct.
of iodine, and the cyst stuffed. In one week the site of the cavity
was occupied by healthy granulations ; in three weeks the patient
was entirely cured, and left the city for her home in an adjoining
State.
Case — . About nine months back, a German woman applied with
a cystic tumor, similar to the above ; it was certainly as unyielding
as solid bone. This tumor was treated by making a crucial incision
through the soft parts alone, the flaps were dissected off, and the
cyst being exposed, was cut away with a chisel-shaped instrument.
The flaps fell naturally into the cavity, and were left, even without
a stitch, to take care of themselves. The cure was complete in about
a week.
There is a tumor of the soft parts of the jaw — cystic, but not
osseous — which is not to be confounded with the class just de-
scribed. Both look, occasionally, precisely aUke, but the latter
yields under pressure, as any tumor of a semi-soft part would
yield. Mr. Paget alludes to such a disease in his lectures on Surgi-
cal Pathology, pages 342-3. "A woman," he says, "thirty-eight
years old, was under my care in 1849, in whom, at first sight, I
could not but suppose something was distending the antrum, so
closely was deformity of the face due to such disease imitated. But
the swelling was soft and elastic, and projected the thin mucous mem-
brane of the gum of the upper jaw, like a half-empty sac. I cut
into this sac, and let out nearly an ounce of turbid, brownish liquid,
sparkling with crystals of cholesterine. The posterior wall of the
cyst rested in a deep excavation on the surface of the alveolar border
of the upper jaw ; an adaptation of shape attained, I suppose, as
the result of the long-continued pressure of the cyst, which had ex-
isted six years."
Mr. Paget also makes mention of a young man under his care with
a similar tumor, which, he says, was the result of an injury to the
gum or alveolar border six months previously. In neither of these
cases, says he, could I find any disease of the maxillary bone.*
Their origin, so far as my experience goes, is in a diseased tooth-fang.
* These cysts I have several times met with. They are what may be
termed cold, or non-acute alveolar abscesses.
332 ORAL DISEASES AND SURGERY.
I do not know what so close an observer as Mr. Paget means when
he says he could find no disease of the bone. There ought to be at
best one little shotlike hole somewhere about the surrounding osse-
ous wall ; at any rate, such is the history as I have met with them.
A succeeding case, which Mr. Paget mentions, seems to prove the
tumors are the same as I refer to. "A lady," he says, " had a small
cvst of this kind, which had existed twenty-seven years, filling and
discharging almost daily. It had its origin in a blow, by which the
two median incisors were loosened."*
A few winters back a physician from Kentucky applied to me for
treatment of a tumor of the lower jaw, which had existed for over
two years ; it had the feel of a fibroid body. This gentleman, with
the imaginative qualities common to the practitioner, when he him-
self becomes the patient, had succeeded in satisfying himself of the
cancerous character of his trouble. An incision through the growth
demonstrated it to be a cold alveolar abscess. In a single week he
was cured ; the treatment required was, simply keeping patulous the
incision, and using a few stimulating injections.
In the Western Medical Journal, vol. x. pages 185 to 228, is a
learned article from the pen of Prof Gross, on " Excision of the
Maxillary Bone." In the course of this paper, he makes the following
allusion to the osteoid cysts :
" The sero-cystic tumor of the upper jaw is uncommon, and, for-
tunately, devoid of malignancy. Its usual site is the alveolar pro-
cess, where it has been known to attain the volume of a hen's egg,
and even of a large orange. It is composed of a thin, semi-trans-
parent, or slightly opaque bag, occupied by a colorless or sanguineous
fluid, or by a glazy, mucilaginous substance. Sometimes, though
rarely, there are two such cysts, either closely connected together or
separated by a kind of osseous septum. The bone around the tu-
mor is expanded into a thin, elastic, crackling, parchment-like shell,
and is easily penetrated by a sharp instrument, the puncture giving
vent to the characteristic contents of the cyst." This, Prof. G.
thinks, is the best diagnostic sign of the morbid growth. " The gen-
eral health," he remarks, "remains unaflFected in the disease, which
is always tardy in its progress, and m anifests no disposition to ex-
tend among the adjacent structures." Where any doubt exists as to
the real nature of the case, he advises a resort to the exploring
needle, which he says will usually at once dispel it.
* This history is that of chronic alveolar abscess in every particular.
TUMORS OF THE MOUTH. 333
Prof. G. thinks it is not often this tumor calls for removal of the
affected bone ; he gives it as his experience that, in general, it will
suffice to puncture it occasionally with a small trocar, to evacuate
' its contents, the escape of which, he says, he has found to be often
followed by the rapid contraction and final obliteration of the sac.
Where there is a strong tendency to reaccumulation, he recommends
that a large opening should be made, and tincture of iodine thrown
in, to promote the object in view.
The cystic tumor of Paget is, I presume, the same disease of the
jaw to which the name spina ventosa was originally applied — spina
to express pain resembling the pricking of thorns, and ventosa to
indicate that the tumor was filled with wind. The term is not yet
obsolete, but, like epulis, is employed so freely that no one now
knows what it means.
Recapitulatory. — The cystic tumor is an osseous cyst of the jaw,
which forms just beneath the outer plate of the alveolar process,
and has its cyst as a result of the expansion and attenuation of
the external lamina.
It is seen as a bulb on the alveolar face, is commonly met with
about the size of half a hickory nut, the gum which covers it is
perfectly natural in appearance. It may yield to the touch, or it
may not.
The most satisfactory, and, withal, perfectly safe means of diag-
nosis, is to pass a keen scalpel or lancet into the growth ; if it is the
tumor we describe, the knife will give to the touch the sense of
having passed through a bony wall into a cyst.
The septi, alluded to as existing in the simple cysts, are occa-
sionally replaced by what is known as a multilocular cyst, — that is
to say, a common tumor is made up of many cysts. As these
cysts increase in number, so the complexity of the tumor increases ;
and it may be that we will feel ourselves compelled to decide that a
cure is best promised by the complete extirpation of all the portion
of bone implicated.
Examination will reveal that these cysts vary much in charac-
ter ; sometimes they will be discovered unlined and empty, some-
times a kind of serum will be found to fill them. Again, as in a
case operated on by myself, they will be found filled by a pulpy,
liver-colored, turgid, lining membrane. This is the class that afBli-
ates with what is to be described as cysto-sarcoma ; as these tu-
mors pass from simplicity in their expression, we come to class
them with the latter disease, and to esteem them as belonging to
334
ORAL DISEASES AND SURGERY.
doubtful growths. It has been my experience that as such tumors
increase hi complexity they discolor the overlying mucous mem-
brane, so that as this membrane is changed, we judge the growths
allied to cysto-sarcoma.
The Compound Cyst.— In this class of the cystic growths we
have the running together of the benign and malignant conditions
which make so necessary to their proper appreciation that general
comprehension of the subject alluded to on a former page. Without
doubt the dentigerous cyst is by far the most common type of the
compound oral cystic growths; but in the malignant cysts teeth
are sometimes found, or some dental association is seen to exist ;
Fig. 66. — Odontocele.
hence, not to confuse the subject in the outstart, we are to under-
stand here that in the use of the term compound cyst, we mean
benign cysts which contain irregularly-developed teeth or dental
tissue.
A common odontocele is the simplest form of an osteo-dental
tumor ; it may present itself in any part of the maxillary structure,
and what is of much consequence to remember, may have, as the
primary lesion, a supernumerary tooth.
Illustrations. — A young lady, aged sixteen, presented herself,
having a tumor, intramaxillary, evidently, occupying the anterior
left side of the hard palate. Her exact condition is as follows : she
TUMORS OF THE MOUTH. 335
has never had a single tooth of the permanent set extracted. Yet
she lacks, to make up the complement common to her age, the canine
of the affected side. The tumor is, of course, an odontocele, or at
least so great is the probability of such being its character, con-
sidering the absence from the dental arch of the tooth, that any sur-
geon would feel justified in founding a proposed operation on such
conviction.
In 1861 the following very interesting case o'f odontocele came
under my observation. The patient, desiring a set of artificial teeth,
had, about a year previous, had extracted all the teeth of the upper
jaw, and, as is customary, had been dismissed for a period of some
four months, not desiring to wear a temporary denture. At the end
of this time the impression of his mouth had been taken, the parts
being in a good healthy condition. The teeth were made, placed in
position, and worn with entire comfort for a period of several
months.
About eight weeks before presenting himself to my notice, these
artificial teeth were found to be getting loose, as if from some pro-
jection at the right border of the myrtiform fossa. Applying to his
dentist, surprise was expressed at the occurrence, and advice given
that the further progress of the case should be awaited. At this
period the gums were more or less congested, and were putting on
quite an angry appearance ; a few days later a fistule formed. His
dentist, confident that no portion of the roots of any of the teeth
had been left in the alveolus, now dismissed the case, advising him
to seek surgical assistance. In this condition he came under my
observation.
The case presented the following features : much engorgement of
all that portion of the gum and lip covering the incisive and ca-
nine fossas, and which extended in a triangular direction to the inner
canthus of the right eye, much soreness on pressure over all the
affected parts, the fistule discharging thin, and occasionally bloody
pus.
Examination with the probe gave the impression that it struck
against the root of a tooth, and which would certainly have influ-
enced the making up of the diagnosis if experience had not assured
me that no tooth could, under ordinary circumstances, have had a
fang extending such a length.
Deducing from the conditions present the imperative necessity for
an operation, and the patient willingly acceding to the conclusion,
the followimg course was pursued. The patient was etherized ; an
336 ORAL DISEASES AXD SURGERY.
assistant, having sponge and water at his side, took charge of the
lower jaw and lip. A second assistant steadied the head and held
the superior lip well out of the way of the knife.
The parts being thus very fairly exposed, a pointed and somewhat
delicate-bladcd bistoury was passed through the superior fleshy
boundary of the canine fossa to the inner canthus. To my surprise,
it passed not only through the soft parts, but in the return cut sunk
readily into the bone. A first flap was now dissected posteriorly
from the dead mass : a second was bounded mesially by the nasal
bone, ala, and left prominence of the myrtiform fossa. The blood
being sponged away, I discovered, lying in the very center of the
carious bone, a cuspid tooth of ordinary size and development, the
apex being in immediate relation with the floor of the orbit.
That this tumor had existed for a long time is not of course
to be doubted, but it excited the attention of the patient only on the
setting up of acute inflammatory action. This inflammation soon
destroyed the integrity of the vault of the cyst; hence the softened
carious state in which I found it. The interest associated with the
case lies in the absence of all the teeth, and the consequent loss of
data for the diagnosis.
Osteo-dental tumors dependent on the development of supernu-
merary teeth are quite common ; they are generally easily recognized
from their position and size, being never larger than an ordinary pea,
and mostly situated in some part of the palatine processes of the
superior maxillae. Any obscurity, however, in these tumors is read-
ily dispersed by thrusting a bistoury or exploring needle into them.
The dental surgeon particularly would remark from the sense of
touch whether or not the contents is tooth substance.
Osteo-dental tumors not unfrequently have as their contents un-
developed teeth. Only a few days back I saw a couple of bicuspid
crowns, evidently long dead, which had been removed from one of
these oral compound cysts.
Such osteo-dental tumors, then, as just illustrated, may be viewed
as the most simple of these compound cysts. Another class, the
complex osteo-dental cyst, may now claim attention. No better
illustration of this class of tumor can be found on record, perhaps,
than in the memoir of the Guadeloupe banker's son, by M. Forget,
presented to the French Academy, and so ably and happily repub-
lished in English some years back by the publishers of the Dental
Cosmos. As the illustrations and text are still in possession of the
TUMORS OF THE MOUTH. 337
journal, the reader interested in the subject cannot do better than
give them most attentive consideration, Avhile certainly I cannot do
better than by using them. We preface by remarking, that by a
complex osteo-dental tumor we mean a cyst containing some com-
plex mass, which common observation, or the microscope, reveals
as being made up of irregular developments of dental tissues.
Observation. — 1. Osteo-Dental Tumor, size of a large Egg, en-
cysted in the thick j^fift of the Inferior Maxillary — Ulcerous In-
flammation of the Parietes of the Cyst — Numerous Ossifluent
Fistulse — Resection of the left half of the Body of the Jaxo and a
portion of its Branch — Cured.
Early in May a banker, of Guadeloupe, introduced to M. Forget
his son, whom he had brought to Paris with the intention of sub-
jecting him to the necessary surgical operation for the remedy of a
disease of the inferior maxilla, which had made its first appearance
when the patient was five years old.
History of the Disease. — At that period (five years), young L.
suffered from pains in his left jaw ; they were for some time inter-
mittent, then continuous and acute. When the patient was seven
years of age, two small healthy molars were extracted, under the
impression that they were preventing the evolution of the second
teeth. The operation gave great relief, and the pain ceased; but
shortly afterward a small, round, hard tumor appeared on the ex-
ternal face of the jaw, near the alveoli of the teeth that had been
removed. The tumor caused no suffering to the patient, and made
no sensible progress for a period of eight years. The whole of the
left side of the jaw then became tumefied, and the bone, in the lan-
guage of the patient, broadened and rounded. He also observed, at
this time, that the large molars, which were regularly developed on
the right side, were wanting in the diseased part.
This morbid enlargement was accompanied by frequent fluxions of
the gums, cheek, and whole left side of the face. The recurrence of
this fluxion was attended with great pain, and caused an increased
tumefaction in the soft parts to such an extent that the difference
between the sides of the face became absolute deformity.
In November, 1854, a violent inflammation occurred in the base
of the jaw and the cervico-maxillary region. Antiphlogistic treat-
ment was employed, two applications of leeches were made, and the
inflammatory symptoms decreased, and, fifteen days afterward,
purulent matter formed in the thick part of the cheek, which opened
spontaneously, allowing the issue of a large quantity of fetid pus.
22
338 ORAL DISEASES AND SURGERY.
The opening of the abscess became fistulous, the surrounding tissue
then detached, and, under them, the bone was naked for a very con-
siderable extent.
Present Condition. — Young L., aged twenty, strong, well de-
veloped, with an excellent constitution, and health perfect in all
respects, excepting the local affection.
The disease appears externally in a considerable tumefaction of
the left cheek, which is more than three times its natural size, and
the tumor has caused a very marked eccentric development to the
corresponding maxillary bone.
When the patient opens his mouth, which he does without effort,
the whole left side of the bone was seen to resemble a large turkey-
egg — the base of the jaw being confounded, without appreciable line
of deniarkation, with the internal and external faces, which describe
a very considerable curve.
The tumor is uniform, without depressions or any irregular swell-
ings upon the surface. It does not yield to pressure, and no part
of it gives that sound of crepitation which is characteristic of at-
tenuation of the osseous tissues. The external swelling hides the
superior and lateral part of the neck ; the enlargement of the bone
has forced the tongue from its true direction, and the floor of the
mouth has been driven from the left to the right.
The alveolar ridge, singularly enlarged, contains none of the grind-
ing teeth, except the first bicuspid, which stands regularly in its
socket. The tissue of the gums is dark-red, and unusually thick
and hard. In a circumscribed spot, about the size of a twenty-
centime piece, the tissue is broken, and exhibits an unequal, wrinkled,
grayish surface, which gives a dry sound when struck with a metal,
as if the crown of a tooth were hidden in the cavity.
In order to complete the symptomatic description, it is added that
there are many ossifluent fistulous openings at the base of the tumor,
and much hypertrophy and hardening of the submaxillary lymphatic
ganglion.
The functional disorders arising from the pathological condition,
at first very slight, are noticed at this stage as increasing every day:
embarrassment of vocal utterance, mastication painful and incom-
plete, deglutition effected with difficulty, and respiration very diffi-
cult every time inflammation is renewed in the tumor ; lastly, the
patient suffering from two serious inconveniences — one, the very
marked deformity of the face ; the other, the incessant flow of fetid
pus, proceeding from the complicated fistulae of the osteo-dental caries.
TUMORS OF THE MOUTH.
339
M. Forget here describes the operation, the usual resection. One
incident, however, should be remarked : in making his anterior cut
with the chain saw, he alludes to coming in contact with a tooth
placed horizontally in the thick part of the bone, precisely under the
alveolus through which he was cutting.
Fig. 67.
Anatomical Examination op Tumor. — With the surrounding
soft parts, it is described as being an exact ovoid. The soft parts,
adhering to its external face, were found marked with many fistular
passages, ending at inflamed and ulcerous points of osseous tissue.
This tissue was thin, soft, and depressibJe, and perforated by two
orifices leading into the interior of the cyst, from which exuded a
purulent, viscid, reddish liquid. A stylet introduced into one of
these passages was stopped by a hard body, which, under percus-
sion, sounded like a compact tissue deprived of its periosteum. This
object was reached by dissecting off the gums, which, condensed
into a thick bed, formed a sort of operculum for the upper part, com-
pleting the cyst in which the morbid product was situated. The dis-
340
ORAL DISEASES AND SURGERY.
section exhibited that the jaw from the ramus to the premolar had
been changed into a cavity containing a compact, saxaform, ovoid
mass, the size of a large eg^, grayish, unequal surface, studded with
small tubercles, surrounded by a bed of enamel, and completely
buried in the thick part of the bone. (See Fig. 67.)
Next, the tumor was divided along its axis into two unequal parts,
each confined to the corresponding half of the osseous cyst that was
comprised in the division. This revealed the composition of the
tumor : it was formed of a smooth, glossy, compact, homogeneous,
ivory-like tissue, of a whitish-brown color. In the center of it a
kind of regular disposition of its elements is described as existing,
discernible by the naked eye. (See Figs. 68 and 69.)
Fig. 68.
Between the tumor and the wall of the cyst was a thick, fibro-
cellular tissue, free on the side of the former, where it covered the
whole intramaxillary portion, and was joined to the latter by fila-
mental prolongations of a cellulo-vascular appearance — these being
attached to the numerous openings that covered the face of the cyst.
The external surface of this membrane was bathed with a muco-
purulent liquid, smelling like dental caries.
At the base and anterior extremity of the tumor, an indentation
is described fitting the crown of a large molar that stood between it
and the maxillary bone. (See Fig. 69, h.) A portion of the same
tooth caused a slight elevation on the external face of the jaw. (Fig.
68, c.) M. Forget also describes the tooth encountered in the oper-
TUMORS OF THE MOUTH.
841
ation. (Fig. 68, d.) Its location, as will be seen, is directly beneath
the alveolus of the first molar, which is standing in its true position.
(Fig. 68, e.)
Fig. 69.
All the teeth, with the exception of the last two molars, it will
thus be seen, were found, and the space appropriated for them was
filled by the tumor. What, then, queried M. Forget, could have be-
come of these two great molars ? It could not be, he argued, that
the bulbs, compressed from their very origin, had disappeared with-
out leaving a single vestige of their existence. The numerous in-
stances, he held, that had occurred of the simultaneous development
of teeth and anomalous productions in the very center of the maxil-
lary would not allow him to think of accepting such an explanation.
In all the analogous cases that had fallen under his observation, the
teeth were of the ordinary dimensions, and complete in number, al-
though removed from their normal position, and sometimes buried
even in the morbid substance itself.
Let us now, that we may fully comprehend .such a class of cases,
pursue the study of this particular one.
Fig. 61 represents the left half of the body of the inferior maxil-
lary bone, hollowed into a large cavity, containing an ivory-like,
bony tumor.
d. Side view of the alveolar edge.
a. Orifice of the dental canal upon the surface of the resection of
the bone in the continuity of the ramus.
342
ORAL DISEASES AND SURGERY.
b. Plane of the cut iu front, showing the second small molar which
was found in it.
e. Crown of the first molar, in regular position.
Tig. 70.
Figs. 68 and 69. The two halves of the anatomic section, divided
according to its axis (osseous cyst, and included tumor).
Fig. 68. — c. Crown of great molar, seen through a notch in the
outer wall of the cyst.
d. Second small molar.
e. First small molar.
a and b. Points of the same wall, perforated by the prolongation
of the tumor.
/. Summit of the most elevated of these.
Fig. 69. — a. Interior aspect of the tumor.
b. Great molar inverted.
c and d. Cellulo-fibrous membrane, interposed between the osseous
cyst and tumor.
TUMORS OF THE MOUTH. 343
Fig. 70. Microscopical examination.
M. Forget, in presenting this case to the French Academy, re-
marked that it was a duality of anatomical and pathological lesion,
so rare, that after the strictest research, he was led to believe it un-
exampled in the human species. Thus, then, we have here, side by
side, each extreme, and understanding each, there is not likely to
come anything between that we may not be able readily to explain.
A dental germ assuming, or compelled to an abnormal position,
may have various sequelae. It may make a maleruption ; it may re-
main encysted ; it may die after partial development, or it may hetero-
geneously develop.
We have then but to consider heterogeneous development, and we
have mastered the pathology of the lesion, and all its various phases.
First, let us dissect a tooth — for the parts of a tooth are the parts
of such tumors. A tooth is made up of enamel, dentine, cementum,
pulp substance, and peridonteum.
Enamel of the Teeth. — Cortex strata, adamantina dentium;
crusta dentium adamantina ; substantia vitrea.
The enamel of a tooth is that portion which caps the crown. In
structure it is fibrous ; its fibers radiating from the center to the
surface.
In microscopic structures, the enamel (Owen) consists of long
and slender, solid, prismatic, for the most part hexagonal, fibers of
phosphate, carbonate, and fluate of lime ; which are essentially the
contents of extremely delicate membranous tubes.
Dentine. — Os dentis, substantia ossea ebur dentis. This is the
portion of the tooth between the cementum and enamel and between
the pulp and the enamel. It makes up the great body of the organ.
Dentine is composed of numberless tubules, these being not larger
than the one ten-thousandth of an inch in diameter ; their course is
waving, each tubule having several curves resembling, according to
Retzius, the Greek letter '?. " Professor Retzius confirms the observa-
tion of Miiller, that the tubes contain an organic earthy matter in
granular masses, which disappear under the action of dilute muriatic
acid. The cells, and the small tubes which radiate from them, also
contain earthy matter, as in bone. They are naturally white and
opaque ; but, after maceration in dilute muriatic acid, become color-
less and transparent."
Chemically, dentine differs from enamel principally in the absence
of the fluate of lime.
Cementum — Crusta Petrosa. — The cementum of a tooth is that
344 ORAL DISEASES AND SURGERY.
portion which invests the fangs. In character, it corresponds quite
closely to the osseous structures. The microscope demonstrates
clearly the existence of Haversian canals, and the so-called corpuscle
of Purkinje, or, as Robin prefers to term them, osteoplasts.
" In growing teeth, with fangs not fully formed, the cement is so
thin that the Purkinjean cells are not visible ; it looks like a fine
membrane, and has been described as the periosteum of the fangs,
but it increases in thickness with the age of the tooth, and is the
seat and origin of what are called exostoses of the fangs, which are
wholly composed of it." " It is the presence of this osseous sub-
stance," says Professor Owen, " which renders possible many well-
known experiments of which the human teeth have been the subject;
such as their transplantation, and adhesion into the combs of cocks,
and the establishment of a vascular connection between the tooth and
the comb," etc. Under every modification, the cement is the most
highly organized, and most vascular of the dental tissues, and its
chief use is to form the band of vital union between the denser con-
stituents of the tooth, and the bone in which the tooth is implanted.
Dental Pulp. — The pulp is that vascular, reddish-gray, highly-
sensitive substance, occupying the cavity of the tooth. It is made
up of delicate connective tissue, in which ramify the dental nerve,
artery, and vein.
" When," says Mr. Nasmyth, "the internal structures of a dental
pulp are examined, the number of minute cells which present them-
selves in a vascular form is remarkable ; they seem, indeed, to con-
stitute the principal portion of its bulk." Mr. N. describes them as
" varying in sizi?, from the smallest microscopic appearance to one-
eighth of an inch in diameter ; and as being disposed in different
layers throughout the body of the pulp." This tissue is highly en-
dowed, and, perhaps, more liable than any portion of the body to
take on morbid action ; fungoid degeneration is, perhaps, its second
most common disease.
Periodontal Membrane. — This is the periosteum of the tooth.
Anatomically and physiologically it differs little from this general
class of membranes. Pathologically, I think it may be remarked as
being more susceptible to disease, and more disposed to assume
quickly the acute conditions. For example, inflammation of the
periodontal membrane is easily provoked, and, once inflamed, it is
ever after surprisingly prone to reassume morbid action. Again,
we need only call to mind its epulic outgrowths ; the frequency and
varied character of these growths.
TUMORS OF THE MOUTH. 345
Familiar with tooth structure, we turn to Fig. 70, as referred to,
and trace a perversion of development in all these structures ; see
them forming a tumor, strictly dental, yet to the last degree anoma-
lous and abnormal.
We return now to the microscopic examination of tumor, made by
Professor Ch. Robin. Fig. 70 (400 diameters). This figure repre-
sents a portion of a slight cut made into the tumor represented
(Fig. 69, a).
The preparation is taken from near the free edge, or the irregu-
larly mammillated surface of the tumor. The latter is formed
principally of the ivory or dentine, easily recognized upon the thin
section by its very fine tubes, disposed in parallels, or nearly so,
through part of their extent (Fig. 70, e).
These tubes, radiating more or less regularly from the little de-
pressions or cavities observable in the mass of the tumor (Fig.
69, a), very near to each other through part of their extent, these
tiibes of ivory become more rare, fine, and ramified as they approach
the surfaces of the dental tumor (Fig. 70, d,f), and end in a very
sharp point toward the lines of junction between the ivory and the
enamel (a, b, c), and the cement (/, g, h). The presence of the ivory,
which forms the greater part of the tumor, demonstrates its dental
nature very clearly.
Enamel. — Another important particular is the presence of the
enamel on the surface of the tumor, where it, in some measure,
covers the irregularities with a varnish which moulds itself upon
them in order to penetrate more or less deeply into the fissures or
depressions that divide the tumor superficially into lobes.
This bed of enamel varies in thickness from microscopic dimen-
sions to a millimeter (-03937 inch), or near it, and is as irregular in
places on the lower or adhering face as it is on the free surface,
which the microscope alone allows to be seen. The portion of the
section of the tumor that is here delineated (Fig. 70) is taken at the
level of one of the points where the enamel (a, b) in a manner pene-
trates (c) into the body of the ivory mass of which the tumor is
principally formed.
The enamel is easily recognized by its narrow prisms, from six to
eight-thousandth of a millimeter in width, which are in immediate
juxtaposition (Fig. 70, a, b). The figure shows them inclined, as by
the accidents of the cuts in making the section. When the cut is
perpendicular, or nearly so, to their greatest axis, their prismatic
form, with five or six faces, is easily seen ; this is shown in the
neighborhood of 6, Fig. 70.
346 ORAL DISEASES AND SURGERY.
Cement. In the depth of the fissures, and here and there in the
mass of the tumor, near its surface, and especially that part of the
surface hidden in the adventitious cavity of the maxillary bone, the
microscope discovers some trails or beds of variable thinness, formed
entirely of the substance of the cement (Fig. 70, g).
The cement is inclosed between masses of ivory, and is consoli-
dated by the immediate contact (Fig. 70) with the masses between
which it lies. It extends itself in places with the surface of the
tumor to the neighborhood, and even to contact with the enamel.
The section represented in the plate is taken at a point that shows
this arrangement (Fig. TO,/, g, h). There are, besides, thin pieces
of cement extending far forward into the body of the tumor.
The cement is known to be no other than the osseous substance.
The figure before us exhibits the characteristic elements belonging
to it. These are the microscopic cavities, called osteoplasts, or, in-
correctly, osseous corpuscles, for they are excavations. The air
that fills the dry bone makes these cavities appear black under the
microscope (Fig. 70, g)\ but, in the fresh state, they are full of
liquid, and are pale and more difficult to observe than in the dry
pieces.
These cavities, which are, in breadth and length, from one to
three-hundredths of a millimeter, are always of very irregular shape,
on account of the presence of the fine tubes that start from all their
peripheries, and traverse even the substance interposed between the
osteoplasts.
The best joined pieces show that these little canals are subdivided
two or three times, and are then inosculated with those of neighbor-
ing osteoplasts. The portion of cement, shown in the plate, does
not exhibit this arrangement, which was visible, nevertheless, in the
parts close to it.
The cuts in the tumor exhibit, moreover, little openings, that are
either full or empty, of a grayish or brown pus. These small orifices
are from two to six-tenths millimeter and upwards in width, and
from about one to two millimeters apart. The microscope shows
that these orifices accompany the narrow, irregular cavities, some-
times in the form of elongated conduits, hollowed out of the ivory
which they pass through. The instrument also shows that the
tubes of the latter start from these cavities to radiate toward the
surface of the tumor, in the same manner as the tubes of the ivory
in the normal tooth start from the natural cavity of the dental pulp.
These narrow, irregular cavities, more or less elongated, traverse the
TUMORS OF THE MOUTH. 347
mass of the tumor, and some of them even reach within a few milli-
meters of the surface.
These cavities are, in reality, nothing more than the pulp cavities
of this morbid product, either rugous from desiccation or still con-
taining some remnant of the dried pulp in the form of a brownish or
grayish powder.
Recapitulation. — The result of all these observations of the case
is thus epitomized by M. Forget.
1st. An original union of the follicles of the last two molars fol-
lowed by an intimate union of them, caused by phlegmasial or other
actions.
2d. Under the same morbid influence, the excess of vitality in the
organic elements of the follicles has produced hypersecretion of an
ivory-like osseous substance.
3d. That the irregular aggregatism and diffusion of these consti-
tutes the pathological growth.
4th and lastly. Its growth has formed in the cyst, and it has main-
tained therein a permanent inflammation which has disorganized the
osseous tissue and altered the structure of the adjacent soft parts to
such an extent that a radical operation was necessary.
Thus we have studied the extremes: a simple cyst, with a tooth
in it, and a tumor so complex in character and structure that no one
but the microscopist might hope to be able to recognize it. Yet
these tumors, differing so widely in their features, are alike in the
most important one of being benign. Their prophylaxis is the same,
and for a good distance their surgery runs side by side.
Dental tumors, intermediate to these two classes, are of various
features. But, with an ability to recognize the dental elements —
with an understanding of the minute histology of enamel, dentine,
cementum, and pulp substance — what difference can it make, having
eyes and a microscope, how these elements aggregate ?
I once saw a tumor taken from the maxilla, which looked like a
mass of ivory ; it was quite as large as two of the molar teeth put
together. I need scarcely say that it was two of the molars ; their
germs had in some way affiliated, and, remaining encysted, had pro-
duced this abortion. The microscope revealed very distinctly the
tubulated character of the mass; this pronounced it dental quite as
satisfactorily as though the shapeless lump had been moulded to the
tooth-form.
I have had shown me, as great curiosities, teeth with ivory masses
348 ORAL DISEASES AND SURGERY.
projecting at right angles from their crowns. I never, however,
have seen this anomaly where it was not plainly evident that the
projection was a twin tooth— the result of germ union ; — there
would be a tooth missing in the arch.
Manv curious illustrative instances could be mentioned of anoma-
lous incongruities in dental evolution ; but, as we are prepared to
understand, we would find them in character the same — enamel,
dentine, ccmentum, and pulp structure. The arrangement only
would be found to differ; with our eyes, or assisted by the micro-
scope, we could or should be able to say of any of them. This, and
this, and this is dental.
The ability, then, to distinguish a dental from a malignant osteoid
tumor, must certainly prove a source of much satisfaction; for, as M.
Forget curtly remarks, if intervention cannot be too radical in an
instance of cancer, it is certain, on the contrary, that more caution
and moderation are necessary when it is a question of a lesion,
which is essentially local and of a benignant nature, and allows the
surgical operation to be restricted to the precise limits of the lesion,
without its being necessary to provide against an improbable repe-
tition by encroaching upon the osseous tissues that border on it, and
thus su1)jecting the patient to a mutilation which could not be justified.
Data. — 1. There are twenty teeth in the deciduous denture,
which twenty are to be replaced by thirty-two, each of which is to
be at least twice the size of its predecessor.
2. A contracted maxilla, having no accommodation for certain
teeth, the germs of which are in the jaw, gives us, among other
lesions, irregularity in dental evolution.
3. Irregularity in evolution yields morbid conditions, as described,
and which conditions are influenced, not unlikely, by peculiarities of
the general organization and manner of interference with develop-
ment.
4. An overcrowded arch will surely yield periodontal and other
minor troubles, and may produce lesions of grave character. The
extraction of certain of the bicuspidate teeth of the permanent set
should, therefore, be practiced, whenever time shall make evident
the existence of contraction on the part of the arch.
5. Dental tumors vary from simple cystic growth to such perverse
and anomalous evolutions, that the microscope only is capable of
explaining them.
fi. A dental tumor is an abnormal growth, having its point of de-
parture and development in irregularity of dental evolution.
TUMORS OF THE MOUTH. 349
7. Dental tumors are benign; operations for their cure promise all
success, and may be practiced in exclusive consideration of the dis-
ease as it locally exists.
8. The existence of a dental tumor is to be inferred, caeteris pari-
bus, when there is deficiency and derangement in the dental arch.
CYSTIFORM ANTRA.
Fig. 71 represents a cystic tumor, or, rather, expansion of the
walls of the antrum, as occasionally met with. The cyst repre-
sented in the view occurred in the person of a young gentleman
some twenty years of age, from whose jaw I removed it two years
Fig. 71. — Antral Cyst.
back. This cyst, the size of an ordinary orange, was successfully
treated without external incision, the soft parts being dissected
off by pulling outward and upward the angle of the mouth ; the
wall of the cyst, about the thickness of ordinary parchment, was cut
away with a chisel. This particular cyst was without contents of
any kind. After the removal of the vault the soft parts were per-
mitted to fall into the cavity of the sinus; no deformity at all re-
sulted, and no trouble has since been experienced.
An interesting feature in this character of cases is found in the
tenacity on the part of the antrum, after operation, to maintain its
cavity. I have tried my best to obliterate this sinus by compel-
ling granular activity in its mucous membrane, but so long as I have
been enabled to watch my cases, and in one that I recall, seven months
elapsed before the overlying tissues so covered in the part as to con-
ceal it from observation ; in none of them have I been able to satisfy
350 ORAL DISEASES AND SURGERY.
myself as to what was the subsequent condition of the sinus ; my
impression is, however, that the mucous membrane maintains itself,
and that a species of cavity continues to exist.
Hydrops antri is another form of cystiform enlargement of this
cavity. The dilatation in these cases is gradual and painless, and
when the bone becomes expanded to any considerable extent, fluctu-
ation is commonly apparent, the vault of the cyst yielding readily
enough to pressure. If any obscurity exists, it may be removed by
the use of the exploring needle. It sometimes happens, in these
cases, that the floor of the orbit becomes the yielding point, or it
may be the canine fossa, the tuberosity, or the hard palate ; the lat-
ter boundary, however, according to my observation, is the most fre-
quent seat of the enlargement forming the tumor within the mouth.
Hydrops antri depends, in many cases, on the formation of a
cyst within the cavity. In others it may be viewed as a simple
mucous engorgement, the natural outlet into the meatus being,
from some cause or other, obliterated. A very expressive illustra-
tion of the first of these conditions was exhibited in a specimen
taken by myself some three years back from the antrum of a
young man. In this case the cyst seemed to spring from the
root of the second molar tooth, or its immediate neighborhood ; the
mucous membrane had been dissected up, and covered the cyst as a
reflex tunic. Although this particular tumor was not large enough
to exhibit external evidence of its existence, yet there are no reasons
for inferring that such tumefaction would not eventually have re-
sulted. A case of interest, in this direction, is recorded in the prac-
tice of Dr. Chase, of Iowa City, who reports it in the Dental Cosmos,
accompanied with diagram.
Description of Case. — "An Irishwoman, aged forty years, came
to have the right first upper molar extracted. I found her teeth in
a bad condition generally : they were decayed and loose, and the
gums congested. This particular tooth was decayed and very loose.
On pressing it, the alveolus seemed to move with the tooth. Ad-
joining it in front, was the root of the second bicuspid — the crown
gone.
" As she was of that class who make no attempt to preserve their
teeth, I extracted the molar without hesitation. She had told me
that her 'jaw' had ached for three or four months previous to this
time. On applying the forceps, the beaks readily passed under the
gums without lancing, and the tooth, much to my surprise, came
away with a very slight application of force. But this surprise was
TUMORS OF THE MOUTH. 351
not equal to my astonishment, when I saw what I had brought
away with the tooth, namely, a large quantity of alveolar substance,
Fig. 72. — Secondary Cyst of the Antrum.
6
1, root of second bicuspid attached to alveolus ; 2, neck of tooth and border of alveolus ;
3, walls of antrum, palatal side ; 4, center of crown of tooth ; 5, tumor ; 6, tartar, cover-
ing the cavity of decay. The buccal aspect of the tooth was similar in appearance to the
palatal surface which is seen in the engraving.
the bicuspid root, and a fibrous connective tissue tumor, nearly an
inch in diameter, attached to the tooth, and inclosing two of the
roots, namely, the posterior buccal, and the palatine roots.
"After being in alcohol three days,* the tumor was nearly white,
and had shrunken to one-third its original size. On cutting it open,
it was found filled with a solid structure. The consistence was that
of tubercle, or pressed cheese-curd ; the color, light yellow, tinged in
most parts with red.
" The roots within the tumor were nearly free, and covered with
their periosteum, which had thickened into a loose, spongy mass,
extending even to the base of the body of the tooth. The appear-
ance was like that of roots involved in alveolar abscess. The walls
of the tumor were not composed of detached dental periosteum.
There were apparently two coats, the outer, fibrous, like periosteum ;
the inner, a mucous one, like the lining of the nasal cavity."
The pathology of the case, as inferred by Dr. Chase, is, that the
tooth decayed to the pulp cavity, that the pulp, after repeated in-
flammatory attacks, died. Putrefaction of that organ occurred, pro-
voking periodontitis ; after awhile suppuration occurred, and the
disease became chronic. The periodonteum became thickened and
spongy, continued irritation caused a proliferation of connective
* It is to be regretted that an examination had not been made at once.
352 ORAL DISEASES AND SURGERY.
tissue corpuscles, thus eventuating, finally, in the formation of the
cyst.
This inference is, I think, the true explanation of the cyst ; the
trouble, however, was seated primarily on the bicuspid and not the
molar roots — involving the latter secondarily. This tumor, although
it possessed not the contents of the one operated on by myself, yet
has a similar pathological signification : it constitutes a most in-
structive study.
In cases of this kind it will be seen at a glance that, however
patulous the natural outlet might be, the contents of the tumor could
not by such means find egress. In the second character of cases,
the contents are just within the cavity, but the engorgement of the
tissue bounding the outlet has closed the foramen. A case described
in the chapter on Diseases of the Antrum exhibits the dangerous and
destructive efifects of such accumulations when unappreciated and
untreated.
CHAPTER XXIII.
EXOSTOSIS AND SUBACUTE INFLAMMATORY TUMORS.
The term exostosis, as the reader will recall, is derived from the
expressive roots ef , out of, and (xrrsov, a bone ; an osseous tumor
which forms at the surface of bones, or in their cavities ; the first is
called exostosis, the latter enostosis.
The following varieties have been named: "ivory exostosis, that
which is ivory-like ;" lamina exostosis, that which is made up of dis-
tinct fibers or layers ; spongy exostosis, that which is like the spongy
tissue of bone.
Hyperostosis is precisely the same thing as exostosis, both being
inflammatory hypertrophies. Inflammatory osseous tumors are
hyperostoses.
Because, however, there are great differences in the expression of
these conditions, I shall write of them under special heads.
Exostosis, as commonly met with in the mouth, is strictly benign.
It is generally recognizable by its extreme slowness of growth, the
entire absence of pain, — except when it meets with some peculiar ob-
struction, — and its freedom from surrounding disease. It does not
tend markedly to ulceration, and does not, except mechanically,
affect the parts even most directly associated with it.
True exostosis has its origin in local irritations, perhaps always.
It is true that reference is made by authors to an ossific diathesis,
but, as truly remarked by Miller, "A skeleton so susceptible is prone
rather to the more common inflammatory products of caries, ab-
scesses, ulcers, and necrosis."
That local irritation is the chief cause of exostosis is satisfac-
torily proven, I think, by reference to parts most subject to this
interference. The teeth, for example, are found exostosed in a thou-
sand instances to one of any other bone, and certainly no bones are
so constantly found in irritative conditions. I use the term "bone,"
reminding the reader that the portion of the tooth which takes on
this morbid action is almost, in every proper sense, true bone.
Non-specific exostosis, occurring on any portion of the maxillary
23 ( 353 )
354 OEAL DISEASES AND SURGERY.
bones removed from the alveolar borders, is an exceedingly infre-
quent affection. With every opportunity for observation, I am sur-
prised at the fewness of the cases I recall ever to have seen ; and
most of these have been small, and of little consequence.
Around the base of the alveolar processes, however, and particu-
larly on the lingual aspect of the lower jaw, this affection, in a minor
form, is exceedingly common ; certainly I have seen hundreds of
examples, the enlargements varying from the size of a small shot to
that of a rifle-ball ! As pathological relations are concerned, how-
ever, they seem of little consequence ; I never knew one to result in
any harm ; the treatment I have adopted in such cases has been the
very simple one of letting them alone.
It is not improbable though that cases may present when opera-
tions seem demanded. I have felt called to operate upon some two or
three of such as I have met with. The mode of procedure is simply
to lay off from the tumor the soft parts, and, with a chisel, cut away
the mass ; there is no hemorrhage or other trouble attendant on the
operation. (See nyperoHtosia.)
Exostosis of the fangs of the teeth — exostosis dentium — the usual
seat of the disease in the maxillary regions, finds location both in
the cemental and dentinal structures of these organs ; for while I
have seen two or three cases where the crowns of the teeth were
enlarged, as if from a species of exostosis or hypertrophy, yet these
were so anomalous that I may describe the growth as being associ-
ated exclusively with the fangs ; and even here, I think, it will be
found in the majority of instances confined mostly to the apex,
growing, bulblike, as it were, about the end of the root.
The diagnosis of exostosis in these situations is not by any means
easy. The most frequent pathognomonic feature, however, is a
sense of continued uneasiness about the parts, not generally amount
ing to pain, but serving as a constant reminder of the presence of
the tooth. The tooth itself may or may not be carious. Pressure,
or the stroke of an instrument, does not, in ordinary cases, either in-
crease or diminish the soreness ; the sense of fullness about the
parts is particularly observed where the absorption of the alveolus is
not proportionably active with the exostosis. In these latter cases,
the extremest symptoms of neuralgia are not unfrequently produced,
and which, not comprehended, are of course treated without avail.
One of the most remarkable cases of dental exostosis on record is
related by Mr. Fox. The subject was a young lady, who, at the
time she sought the professional aid and advice of Mr. Fox, had suf-
EXOSTOSIS, ETC. 355
fered so severely and so long that the palpebrse of one eye had been
closed for nearly two months, and the secretion of saliva had for
some time been so copious that it flowed from her mouth whenever
it was opened. She had tried every remedy which had been recom-
mended by the ablest professional advisers, without realizing any
permanent benefit, and was only relieved by the extraction of every
one of her teeth.
The practitioner may infer from the mention of this case that he
is likely to meet with many gradations of the trouble. The cure
will consist in the removal of the affected member : this, after the
diagnosis, is always easily accomplished with the aid of a pair of
cutting-forceps.
In the venereal, scorbutic, and tubercular hypertrophy or exosto-
ses of the maxillary bones, the features of the common disease be-
come quickly evident in the local trouble, so remarkably so, in-
deed, that no one would be at all likely to misunderstand things,
presupposing the general disease be understood. The growths are
rapid, painful, and always more or less amenable to constitutional
treatment.
Scrofulous and scorbutic tumors differ from the venereal in being
more loose and spongy in structure, and, in consequence, more apt
to run into abscess, being possessed, as it were, of elements for their
own destruction.
In these forms of maxillary disease, the lesion is commonly
heralded by deep-seated, dull pains, which precede by some time
the visible enlargement of the pai't. After the tumefactive process
once sets in, it goes on, if uncombated, until the parietes of the bone
are completely disparted. Associated with this enlargement is an
unhealthy condition of the soft parts.
As the disease advances, the center of the tumor softens, while
the character of the pain changes, becoming sharp and throbbing ;
as pus forms, sinuses are created, and thus ulcerations occur on the
face of the tumor.
The treatment of inflammatory tumors of these and similar types
is to be conducted in consideration of their twofold requirements.
The systemic influences are to be corrected, while locally, I think I
am justified in asserting that, as a rule, they will succumb to the
treatment commonly directed against similar abscesses of the soft
parts. I have great confidence in the use of tents and stimulating
injections.
There is a simple inflammatory tumefaction of the maxilla some-
356 ORAL DISEASES AND SURGERY.
times met with, which might be mistaken for specific exostosis.
It is to be distinguished, however, by the greater rapidity of the
swelling and by the greater soreness attendant on it; it comes,
as a cold in the head, or on the chest, — comes without, in the ma-
jority of cases, the patient being able to assign any cause, and it is
found soon to give way to the same class of antiphlogistics. This
tumefaction is extra rather than intramaxillary ; it is, more than
likely, a periosteal exudate ; it has, of course, no constitutional asso-
ciative lesion.
In this connection, attention may be directed to a form of tumor
frequently found in the mouth, and which, I think, is pathologically
classible with the exostoses. I allude to an apparent expansion
of bone frequently found in association with a strumous diathesis,
and so invariably in connection with periosteally diseased teeth or
roots of teeth ; not always, however, are these expansions or growths
in association with the strumous condition, as I have often enough
treated them in individuals whose constitutional conditions seemed
perfect.
These tumors have a common history. The nerve of a tooth dies
and the periosteum takes on a chronic irritative condition, or per-
haps a tooth has been fractured in attempts at extraction, and the
root, or some portion, has been left in the socket. After a time,
sooner or later, a slight swelling, apparently of the gum, is ob-
served. This may readily enough be taken for a chronic alveolar
abscess; there is no pain, however, associated with the enlarge-
ment, which is soon seen to differ from the abscess in the slow-
ness of its evolution; it is also hard, and perfectly unyielding under
pressure. As we watch the case month after month we find it
gradually enlarging, giving to the observer the impression of an ex-
pansion of the bone under the gums, although, as we understand,
there are no special or marked signs of such cystiform condition. If
we pass an exploring needle into the tumor, it feels as if cutting its
way through spongy bone; and so indeed it does, as dissection
will reveal to us that the cancellated structure has taken on hyper-
trophic action, and it is such spongy enlargement that bulges out
the overlying parts and makes the tumor. 1 have treated a great
number of these growths, and invariably in connection with the in-
ferior jaw. I do not think they would often be found in the superior,
such chronic conditions being here more apt to induce caries, which
disease we know to be as uncommon to the lower as it is common
to the upper jaw. These tumors, so far as I have seen, have no
EXOSTOSIS, ETC. 357
tendency to take on malignant action ; they either remain fixed in
character, after growing to the size of a half walnut, or, in very bad
subjects, they degenerate into abscess, and, discharging the offending
body, cure themselves. Such spontaneous cure is, however, very
rare.
The surgical treatment of these tumors is both simple and
effectual. It is enough, not unfrequently, to remove the tooth or
root, particularly if, in connection with such removal, we keep the
socket open for a few weeks with a tent of cotton or sponge. A very
certain method, and one which I am in the habit of employing in my
own practice, consists in cutting away, with a delicate gouge, the
enlarged mass : this is easily enough accomplished by using the
opening made in the extraction of the tooth as a means of ingress to
the mass ; it can in this way be cut out, piece by piece, without any
external incision, and with a wound not larger than that made by
the preliminary extraction. After such operation the parts are to
be well syringed and a tent kept in the tooth-socket to insure granu-
lations from the circumference of the wound. In two or three weeks
the cure will commonly be found complete.
In this connection I may call attention to an obscurity which
sometimes seems to exist in the diagnostic relationship of diseased
teeth, — that is, no teeth or roots of teeth may seem to be present.
A sufficiently close observation, however, will always detect in the
neighborhood a fistulous opening; it may be very minute, but it is
seldom, if ever, absent. If a probe be passed into this orifice it will
lead to the offending agent.
HYPEKOSTOSIS.
In connection with the simple tumors, reference may now be
made to general facial hyperostosis sometimes existing. In a work
lately published by Mr. Heath, being the Jacksonian prize essay for
1867 of the Royal College of Surgeons, England, the following
illustrative diagram and description of case are given :
The patient, when about forty-five years age, and apparently in
perfect health, was exposed to a cold wind ; immediately after which
he perceived an itching and heat in his eyes, and swelling of the
face rapidly supervened. A small tumor formed just below the
inner angle of each eye, which burst, and after twelve weeks he was
able to resume his employment. He suffered from inflammatory
attacks in the tumors, with much pain in the head on more than one
occasion, and consulted many medical men ; but no treatment re-
358
ORAL DISEASES AND SURGERY.
lieved the disease or retarded the growth of the tumors, which in-
creased slowly, and were of stony hardness. The eyes were pro-
jected from the orbits l)y the tumors, and the right eye inflamed and
burst, while the left was accidentally ruptured by a blow. The patient
Fig. 73. — Hyperostosis.
lived to over sixty years of age, and died of apoplexy, having been
occasionally maniacal during the last two years of life. The por-
trait is taken from the work of Mr. Howship (Practical Observations
on Surgery). The skull of the patient is preserved in the College
of Surgeons, and shows, as might be anticipated from the portrait,
two large masses of almost exactly symmetrical form and arrange-
ment, which have partially coalesced in the median line. The
growths are as hard as ivory, and consist of very close, cane llous
structure. They project more than three inches from the face and
an inch beyond the malar bones on each side. The man attributed
the growths to repeated blows received on the face in fighting.
The skull of a Peruvian (3093 College of Surgeons) is also
alluded to by Mr. Heath. In this case the disease is of a more
diffused character, all the bones of the face, as well as the frontal
and the adjacent parts of the sphenoid and parietal, being enlarged
and thickened in a remarkable manner. The nasal fossae and orbits
are nearly closed, the superior maxillary bones having grown into
great knobbed and tubercular masses, in which their original form
can hardly be discovered. The hard palate is similarly diseased.
The lower jaw is enormously enlarged at its right angle, and in the
greater part of its right half it measures upwards of five inches in
circumference, and all but three of its alveoli are closed up. A
EXOSTOSIS, ETC. 359
section of the lower jaw shows that its interior is composed of an
almost uniformly hard and compact, but finely porous, bone. There
is no history attached to the specimen.
Hyperostosis is simply exostosis or enostosis. It is analogous to
hypertrophy of the soft parts, and must have a similar history.
As can be very well understood, varieties in form and character
present themselves. These growths are sometimes associated ex-
clusively with the face of a bone, as in the ordinary exostosis. In
these cases the periosteum may separate the two bodies. In other
cases there is hypertrophy of the bone proper. The condition is one
of disease only as there is a lack of correspondence in other parts.
Any section, as in a specimen in Dr. Gross's collection, exhibits the
peculiar features of bone substance ; it may be that the cancellous
substance is compressed into solidity, but there is the deraarkation
between it and the cortical boundary, and the analysis remains the
same, — that is, as the constituent parts are concerned. When these
hypertrophies associate exclusively with the endosteum, as in the
long bones, they obliterate or diminish the medullary canal, and, if
of sufficient size, expand into a tumor, greater or less in size, the
external parts.
The history of any form of hyperostosis is the history of certain
of the phenomena of inflammation ; there is, from some cause or
other, irritation attended with vascular changes, the effusion of plas-
tic matter succeeded by the osseous. What this source of irritation
is, and how to control it, are matters, unfortunately, too often beyond
our conceptions.
Reference has been made on a preceding page to the hypertro-
phies of the specific conditions ; such enlargements are easy enough
to understand, even if not so easy to remove ; but the hyperostoses
here considered are not of such character, but seem to be of an en-
tirely local signification ; hence a local source of offense may not be
sought for in vain, as, for example, in Mr. Howship's case, where the
ostitis might very plausibly be attributed to the blows received.
The inflammatory thickening of bone, alluded to a few pages back in
connection with diseased teeth roots, is but another exhibition of the
results of local irritation.
That the hyperostoses are to be viewed, and in every way
treated, as simple overgrowths, is certainly well exhibited by Mr.
Quekett, who, submitting to microscopic examination portions of all
the osseous tumors in the Royal College of Surgeons, confirms the
position in all particulars. The rates of the growths of such tumors
360 ORAL DISEASES AND SURGERY.
are I presume, influenced by individual susceptibilities or peculiari-
ties • there is certainly in this respect the greatest possible differ-
ence. In the Osteographia of Mr. Cheselden is the engraving of
an osseous tumor surrounding the head of a tibia, which measures
exactly one yard in circumference. An imposing case is also figured
in Mr. Pagct's Surgical Pathology.
In this growth, as Prof. Clark describes it, the hardest parts have
neither Haversian canals nor lacunae. In the less hard parts the canals
are very large, and the lacunae are not arranged in circles around
them, and everywhere the lacunas are of irregular or distorted form.
Fig. 74. — Osseous Tumor.
The above remarkable specimen of an osseous tumor of the left
upper maxilla, from the Traite de Pathologie Externe, found in the
Musee Dupuytren, is described in Mr. Heath's essay as being lim-
ited behind by the pterygoid process, internally by the intermaxil-
lary suture, above and externally by the malar bone. The tumor
encroaches considerably upon the cavity of the mouth, and reaches
back as far as the front of the spine. Its form is bilobed, and in
the deep sulcus between the lobes can be seen a molar tooth. All
the other teeth of the jaw have disappeared, and there is no trace of
their alveoli. The left orbit and nasal fossa are not sensibly dimin-
ished in size, but the cavity of the mouth is almost entirely occupied
by the posterior lobe of the tumor. The lower jaw has, in this
case, undergone several remarkable alterations. It must at first have
pressed upon the growth, and produced the deep sulcus between the
lobes; but in its turn the tumor has reacted upon the lower jaw with
the following effect: it has caused a double luxation of the jaw, the
left condyle resting against the root of the zygoma, and the glenoid
cavity being filled with soft material. The teeth of the left side of
EXOSTOSIS, ETC. 3gl
the lower jaw have disappeared, and absorption of part of the coro-
noid process and the whole of the alveolus has taken place, so that
only the base of this part of the bone is left. The outer surface of
the tumor is smooth, and presents numerous vascular grooves of
good size ; at many points it is perforated with holes. The vascu-
larity of the other bones of the face does not appear to be aug-
mented.
In Guy's Hospital Reports, Mr. Hilton describes a case in which
a tumor similar in signification to the one just described sponta-
neously separated from the face. The patient was a man aged
thirty-six, who, twenty-three years before Mr. Hilton saw him,
noticed a pimple below the left eye, close to the nose, which he irri-
tated, and from that spot the tumor appears to have originated.
The tumor, in its growth, displaced the eyeball, giving rise to ex-
cruciating pain, which subsided on the bursting of the ball. It
began to loosen by a process of ulceration around its margin six
years before it fell out, which event was unattended by bleeding or
pain. The tumor weighed 14| ounces. It was tuberculated exter-
nally, and an irregular cavity existed at the posterior part. A sec-
tion presented a very hard, polished sui'face, resembling ivory, and
exhibited lines in concentric curves, enlarging as they were traced
from the posterior part. The huge cavity left by the tumor was
bounded below by the floor of the nose and antrum, above by the
rontal and ethmoid bones, internally by the septum nasi, and exter-
nally by the orbit, which had been considerably encroached upon by
the tumor. — Heath'' s Essay.
THE TUMEFACTION OF CARIES.
Still another form of the inflammatory tumor is that frequently
associated with caries. These enlargements are the result of un-
derlying pus and debris, which, instead of forcing a vent, lift
off the tissue from the bone. It might be thought that such tume-
factions would not be at all dilficult to diagnose, but this would be
found an error, as the thickening of the walls of the tumor is not
unfrequently so great as to give the feel of a solid body; then,
again, ragged-looking fistulaeoccasionally exist, which, when probed,
do not lead with any directness to the diseased bone ; while still
again it happens that there is no carious bone to lead to, as the dis-
ease has ended in necrosis, and some perhaps insignificant sequestrum
has concealed itself by an encystment in the walls of the tumor.
CHAPTER XXI Y.
THE EPULIDE8.
Epulis. — The derivation of this word is from the Greek em ooXov,
signifying " upon the gum."
It is applied by common consent, or rather, I should say, is meant
to be applied to a class of tumors having origin from the alveolo-
dental periosteum.
In the study of these tumors, every one, I presume, has felt him-
self more or less confused and confounded. It would, indeed, be
surprising if such should not be the case, considering the diversi-
ties in description by various writers. And yet these discrepancies,
numerous as they are, may be, I think, easily explained away.
First. I will take it on myself to say that the term epulis, when
used pathologically, is entirely without meaning or expression, and,
as a noun-substantive, should at once be discarded from surgical
nomenclature. There is no special disease which can be called
epulis, and called so with a distinctive meaning. Let me illustrate:
salivary calculi rest upon the gum (e-t ouXov). Is not therefore a
calculus an epulis ?
The term is inadequate in expression, used as a noun, and must
ever remain so, because from the alveoli of the teeth grow tumors
of various signification. Thus, we have fibroid, the fibro-rccurring,
the myeloid, the polypoid, the encephaloid or carcinomatous, the
simple pulp fungoid, etc. Hence the confusion which marks the
writings of nearly all authors on the subject — each, without prefa-
tory explanation, describing the various growths under one common
head. Take even Mr. Fergusson, so eminent as an oral surgeon, for
example: "Epulis," he tells us, "is a disease which begins as a
small spot on either the outer or inner surface of the gums." Again,
he says: "Epulis consists of a swelling of solid bone, the hard
parts of the bone being primarily affected." Again : " Epulis is an
osseous cyst, containing a glairy or a serous fluid." He also in-
stances a polypus, and calls it, too, an epulis.
Mr. Paget, on the contrary, seems to ignore the existence of epulis.
(362)
THE EPULIDES. 363
Let the student turn to his history of the myeloid diseases, and see
how he treats our £tti oulov.
I have studied this subject closely ; I think I may lay claim to
being familiar with most authors who have written in the direction,
and I have satisfied myself that the various discrepancies are only
seeming; that all differences are to be reconciled simply by the abne-
gation of the word epulis, as a noun-substantive, using it only as
an adjectival-noun. Let me illustrate : suppose the spot upon the
gum to which Mr. Fergusson alludes should be of the charac-
ter of epithelioma — then, pathologically speaking, it might be
cancer ; but, being situated upon the gum, ettj ouXov, it would also
be epulis. Take the bony tumors (evidently osteo-sarcomatous,
as in our classification w^e are hereafter to study them), wait until
their growth shall extend so as to emerge from the gums, they
will still remain sarcomatous, but they will also have become
epulic.
So also the myeloid tumors instanced by Mr. Paget as being mis-
taken for the epulides ; being upon the gums must necessarily have
been true epulides, and those who disagreed with Mr. Paget, call-
ing them by such names were right — right in a sense. Yet also was
Mr. Paget right.
The one class called them epulic, because they were situated
upon the gums, and it was their creed so to call all tumors so
situated. The other designated the growths pathologically ; the
tumors were marrow-like, the situation of them was of no conse-
quence. Now, let us see how easy it would seem to be to recon-
cile these different descriptions of one and the same disease. Sup-
pose we drop the word epulis, as a noun-substantive, as a term
having pathological meaning, and apply it in accordance with its
anatomical derivation. The tumors were myeloid, they were situ-
ated upon the gums — we will call them " epulo-myeloid ;" is not
the difference here reconciled, and is not the compound solidly ex-
pressive ? An epulo-myeloid growth is a tumor situated upon the
gums, marrow-like in pathological character. Here is expressed at
once, and happily, as it seems to me, location and character.
If the reader is prepared, from the argument, to accept of the
change proposed, all confusion will be found to have disappeared.
We have no longer any tumor of the mouth which we know as an
"epulis;" but we have epulo-myeloid, epulo-fibroid, epulo-fibro-
recurring, epulo-carcinoma, or whatever other class of tumor patho-
logically may present itself to us situated upon the gums. By such
364 ORAL DISEASES AND SURGERY.
change in nomenclature, we make this pons asinorum an easily-
crossed one ; we create a term as patent to the scholar, and as
expressive, as the compound expression gastr-algia, cephal-algia,
gastr-itis, cerebr-itis, etc.
History of a few Cases Illustrative of Practice in this Direction.
Case I. — Some four years back, Mrs. T., the sister of a medical
friend, was l)rought by the brother to my office for consultation on a
tumor (about the size of an ordinary pea) growing from the alveolus
of an upper molar tooth. I thought this tumor belonged to the class
pulp-fungoid. There was the broken palatine fang in the jaw, but
so deep as to be only fairly discernible to the probe ; I could not
see the origin of the growth, but inferred its character ; by separating
carefully the alveolus from the fang, I was enabled, after some little
trouble, to get the root from its bed. The little tumor proved to
be an outgrowth of the periodontal membrane, and not an excres-
cence from the pulp ; in character it was distinctly and decidedly
fibrous — it was, then, an epulo-fibroid tumor. It did not look like a
growth from the periosteum, but rather as if its origin was in the
crusta petrosa, and it had carried the periosteum before it somewhat
like the infundibuliform fascia is made a tunic to the descending in-
FiG. 75. — Small EpuLO-riBRoiD Tumor — from Life.
testine in an oblique inguinal hernia. The removal of the fang
brought the growth cleanly way ; of course, no scraping or cutting
of the parts was at all necessary; the growth was evidently an
emanation of the dental aspect of the periosteum, and had in no way
involved its alveolar reflection. Xo treatment of any kind outside
of the removal of the tooth was employed ; the patient remains per-
fectly cured.
THE EPULIDES. 365
Case II. — Mrs. J. presented herself some time in 1862, with a
livid, threatening-looking tumor, the size of a hickory-nut, occupying
the left alveolar face of the upper jaw, extending from the lateral inci-
sor back near to the tuberosity. This tumor diminished in size during
sleep, and increased during the time of any excitement which tended
to accelerate the circulation, sometimes seeming like a solid body, at
others, like a spongy mass ; it evidently was erectile in its nature,
analogous to the ordinary naevi. It was an epulo-erectile tumor.
Fig. 76. — Eptjlo-Erectile Tumor.
Separating the growth from the gum, its association with the
periosteum was plainly evident ; while the probe revealed extensive
caries of the neighboring bone. An operation, which resulted in
complete cure, was performed as follows : the lip being held well
out of the way by an assistant, an incision was made, extending
from the central incisor tooth of the affected side back to the tuber-
osity, a similar cut being carried back on the palatine face of the
tumor to the place of beginning: these cuts were made freely through
the soft parts down to the bone, and completely circumscribed the
tumor, with a reasonable margin to spare. The central incisor was
next extracted, and, with the ordinary cutting-forceps, a cut was
made through its alveolus, extending almost to the labio-nasal angle.
A second pair of cutting-forceps was now taken up, and by two cuts
the width of its blades, the involved bone was removed ; the section
extending, as is evident, from the situation of the left central incisor
to the tuberosity. Considerable hemorrhage attended the operation,
although the section was well outside of the vessels involved, three
ligatures being required.
After- Treatment.— l^hQ lady being of very full habit and of
markedly sanguine temperament, magnesia sulph. gss was ordered
the evening of the operation. As an opiate, morph. sulph. gr. ss.
366 ORAL DISEASES AND SURGERY.
Day after Operation. — Marked inflammatory action, attended with
considerable swelling of the tissues of the face.
B. — Plumbi acet. 5ij ;
Tinct. opii, ^ij ;
Aqua, ^xvi.
Ordered a cloth wet with the preparation to be kept continuously
upon the face.
Third day. Inflammation increasing ; eyes completely closed from
the great oedema of the lids ; mag. sulph. reordered, with hot pedi-
luvia ; eyelids heavily painted with tinct. iodine.
Fourth day. Erysipelas set in ; the face looking like a glistening
red ball ; patient restless, nervous, and frightened ; painted the
whole face with tinct. iodine, oflScinal strength ; the lead-water and
laudanum continued ; iron and quinine internally.
B. — Tinct. ferri chl. Jiij ;
Quinia sulph. grs. xxv.
Sig. Fifteen drops in water every three hours.
Also a diaphoretic.
B. — Liq. ammoniae acetatis, gij.
Sig. Tablespoonful every ten minutes until profuse perspiration is
induced.
Sirth day. Erysipelas evidently yielding ; iron and quinine ; paint-
ing with iodine, lead-water, and laudanum, continued.
Seventh day. Much improved; the erysipelatous redness gone;
skin wrinkling ; patient can see a little from one eye ; continued the
painting with the iodine, and the application of the lead-water lotion.
Ninth day. Inflammation all gone ; patient quite comfortable ; the
exposed bone covered with a thin layer of healthy granulations ;
case progressing well.
Twelfth day. Patient attending to household duties ; mouth of
course very tender, but advancing toward a cure rapidly.
Twenty-fifth day. Patient may be called well ; needs no further
attention.
To complete the case, artificial teeth have been inserted, the plate
being made to fill up the place of the lost bone. No one would
ever suppose, in looking at the lady, she had lost such a portion of
the jaw.
Case ITT._Mrs. S., of Camden, N. J. Epulo-fibroid tumor of left
superior maxilla. This tumor was the size of a large walnut, the
THE EPULIDES. 367
bulging of the clieek from its presence quite deforming the patient;
growing very rapidly ; painless. Patient had been confined with her
fourth child five weeks before presenting herself
Operation. — This was performed three weeks later, the infant
being eight weeks old. The tumor, or all that portion of it which
was free of the bone, was cleanly removed with the scalpel, together
with a margin of surrounding healthy tissue. This step exposed
the bone, which was found carious. This was to be removed, and
which was easily and happily effected through the use of the gouge,
little by little being cut away until healthy structure was exposed.
The surgeon recognizes such healthy structure both by its feel under
the instrument, and its appearance ; healthy living bone being white,
studded with minute bleeding points. Hemorrhage during the oper-
ation was considerable, but was controlled, without ligature, simply
by throwing alum-water into the wound from an ordinary syringe.
After- Treatment. — Very little required ; a wash of the perman-
ganate of potash, five grains to the ounce of water, was given as a
disinfectant, there being for a few days a somewhat disagreeable
odor from a decomposing blood clot. No antiphlogistics, or systemic
treatment of any kind was required, not a bad symptom having ap-
peared, the patient being entirely well in three w'eeks from the day
of operation. In this case the floor of the antrum was removed and
the cavity wholly exposed. At the completion of the cure, it was,
however, closed up.
Case IV. — Mrs. T., West Chestnut Street. Tumor of four years'
growth ; loosely fibrous in structure, occupying one-half of the roof
of the mouth, giving a most disgusting and threatening appearance.
The growth had first appeared between the bicuspid and first molar
teeth, and at the time of my first seeing it, had entirely destroyed
the inner alveolar plate of all the portion of the jaw with which it
was associated. In raising the tumor from its bed, all the under-
lying palatine process, as far as could be seen, was found to be
diseased.
Operation. — This consisted in cutting away as much of the growth
with the scalpel as possible, and completing the operation on the
bone with the gouge ; the hemorrhage very profuse, the use of a com-
press being necessary for its arrestation ; and this only effected after
several hours.*
* Hemorrhage sometimes attends these operations where the ligature cannot
be applied, and wliere it is not expedient to employ measures which are apt
368
ORAL DISEASES AND SURGERY,
After- Treatment. — Very little required; some overinflammatory
action, but which quickly and readily yielded to low diet for a few
days, and a single dose of sulphate of magnesia. In three weeks
the case was in condition to be dismissed.
Case T. Mrs. C, colored. Epulo-fibro-recurring tumor of upper
jaw ; had been twice imperfectly removed by her physicians ; the
osseous structure in neither instance being included in the opera-
tion. Tumor the size of a small orange, and involving the whole
antrum of the affected side. Proposed the removal of the whole
maxilla, the only operation which I conceived promised permanent
relief The operation was objected to by the patient.
History of Case. — Day by day the tumor increased in volume ;
soon the floor of the orbit was thrown up and the eye protruded
upon the cheek ; a short time longer and the growth passed into the
cranial cavity, destroying the patient.
Case YI. — Recurring epulo-fibrous tumor. These two views, from
life, represent the case of a young lady as an epulic tumor appeared
Figs. 77 and 78. — Epulic Tumors.
when first operated on, and as it reappeared and was reoperated on
some four months after the first.
I subjoin the history, because it exhibits what experience will
designate as a proper mode of practice in such cases.
The patient, a young lady of much more than ordinary personal
attraction, applied for treatment of the tumor as represented in the
first view. The necessity for an operation being explained to patient
and parents, I made the following suggestions : First, that a section
to be attended with secondary bleedings, as, for example, the acutal cautery.
In this case the compress was made of a tuft of cotton, saturated with alum-
water.
THE EPULIDES. 369
be made which should simply remove the tumor and alveolar pro-
cess connected with it. If this should succeed, there would be
no deformity. Second, if the growth should reappear, then a second
operation to be performed, which should remove the bone proper,
except a simple rim of continuity. Third, if this, too, should fail,
then the complete section of the bone to be made ; this of course
would be deforming, but it would be the only resource.
In December, 1866, the first of the operations was performed; the
bone outside the section looked perfectly healthy, and gave every
promise of a satisfactory result. In two weeks healthy granulations
had covered the bone, and in one month the patient was dismissed
cured. The following March, however, a small tubercle ^appeared
in the very center of the site of the original tumor, and in the course
of three weeks half a dozen new tumors or lobules had sprung up.
The second operation, as proposed, was now performed, the conti-
nuity and natural arch of the bone being preserved unbroken. This
was successful. The patient now (1869) remains perfectly well.
The site of the removed bone being occupied by artificial teeth, — not
the slightest deformity is to be observed.
Fig. 79. — Skction ov Eone as first and afterward made.
This is a type of many similar ones that have occurred in my
experience. It might be thought the better practice to make the
deep section first. It may be that this is so, but the first operation
is so very simple compared with the second, is so quickly done, and
with so little shock or risk, and is, withal, so frequently successful,
that the mean of my cases indorses the practice suggested.
The history of the epulides is progressiveness. The case repre-
sented exhibits the disease in what might be termed its incipiency.
When the bone in its whole thickness has become involved in the
morbid condition, there is but the single operation that promises any
hope of cure, and that is — complete and full section.
Fig. 80 represents the celebrated case of Mary Griffiths, operated
on by Mr. Liston in 1836. The following summary of it is given
by Mr. Liston in a paper on Tumors of the Jaw:
The patient had labored under the disease for eight years, and
24
370 ORAL DISEASES AND SURGERY.
had been sulycct to a partial removal of the growth when of incon-
siderable size. The tumor was of fibrous nature as regards its dis-
position, form, and intimate structure. It differed somewhat, how-
ever, in outward appearance, in consequence of its exposed situation.
Fig. 80. — Fibrous Epulis of Upper Jaw.
The growth sprang originally from the gums and sockets of the in-
cisors and canine teeth of the left side ; at an early period it pro-
truded from the mouth, unconfined and uninfluenced by the pressure
of the lips or cheek. It had assumed a most formidable size and
appearance, concealed the palate and pharynx, and gave rise to great
inconvenience and suffering. The surface had been broken by ul-
ceration, but upon close inspection of the projecting part, and of
that covered by the cheek, it was found to possess a firm consistence,
and to present a peculiar botryoidal arrangement of its parts.
An operation proved perfectly successful.
CHAPTER XXV.
OSTEO-SARCOMA.
However much — and it may be justlj — the term osteo-sarcoma
is abused, it still manages to hold its place in surgical nomenclature.
Employed indiscriminately, as it long has been, it must certainly be
perplexing enough to that class of professional men who study
names and shadows rather than the substance of things ; for, like
the word epulis, osteo-sarcoma has been made to represent the most
unlike pathological conditions, and the greatest diversity of features.
The term, as is seen, is a compound one, and is derived from the
Greek dariuv, signifying bone, and adp^, meaning flesh ; and by those
who created the term, could only have been intended to stand as the
representative of a class of tumors which were fleshlike in appear-
ance, either fleshy tumors in or upon bony structures, or a transform-
ation of bone into fleshy substance.
I cannot say that, to me, the term seems such an ill one ; it is cer-
tainly expressive; it is no fault of the word that men will misuse it.
Be it as it may, however, there are so great a number of oral tumors
which are made to come within its classification, that no direction of
our study demands from us a closer understanding ; and such under-
standing implies that we should look at the subject from every stand-
point.
Osteo-sarcoma cannot, from its origin, apply to a strictly special
disease ; it is a noun of multitude, just as is epulis when it is used
as a noun. We speak of the human face when we would direct at-
tention to the countenance ; so, also, we speak of the face of a land-
scape, the face of the moon, or the face of things generally. Now,
the word face is, without doubt, a very admirable word, but still it
tells nothing of the many different kinds of faces. To be special, it
must have some adjectival prefix. With such prefix we get every
proper shading of the expression, and can employ it freely to our own
satisfaction, and to the making of ourselves perfectly understood by
others. Thus, we say of one man that he has a bright face, of an-
other that he has a dull face, etc. Osteo-sarcoma requires equal
(371)
372 ORAL DISEASES AND SURGERY.
latitude. Tims we have a fleshy-looking tumor which is benign;
and we have another which is malignant. Both of them are sarco-
matous, inasmuch as they are fleshlike ; yet they are very different
kinds of tumors, so far as a prognosis would be concerned.
By the term "fleshlike," I do not, however, understand that mus-
cle-like structure is specially implied ; as all descriptions, however
far back I have been able to go, seem to refer rather to an imperfect
sort of fibrous or fil)ro-plastic tissue.
Prof. Gross, speaking of the diseases of the maxillary bones
which seem to require the operation of excision, says they — the
diseases are generally described under the vague and unmeaning
name of ostco-sarcoma, and constitute a group of affections defying
every attempt at correct classification. That this declaration, he
says, is not a mere assumption unsupported by facts, the writings of
pathologists and surgeons al)undantly testify.
Prof. Henry H. Smith, in his Surgery, page 483, thus writes on
osteo-sarcoma : the bony and fleshy tumor, or osteo-sarcoma, is an-
other ancient name, sometimes indiscriminately applied to a tumor
analogous to spina ventosa. Both these tumors are malignant in
their character, and would be better designated as enchondromata,
or as cancer of bone, the growth being generally due to a deposit of
carcinomatous matter in the bone, causing an expansion both of its
compact and cancellated tissue. In spina ventosa, he says, the
greatest development is of the cancellated structure ; while in osteo-
sarcoma it is rather the compact layer and the external pei'iosteum
that are involved, the cancellated tissue being filled with a fleshy
carcinomatous structure ; while the enlarged cells are sometimes
also filled with limited effusions of blood, or a lardaceous, soft,
pulpy deposit.
Mr. Fergusson says the non-malignant or benign tumors are rep-
resented by what Mr. Abernethy calls simple sarcoma. These are
tumors of a solid fleshy character throughout ; or they may consist
of a bag or cyst, which contains fluid, or of a combination of these
two, for there may be one cyst or more in a tumor whose general
character is sarcomatous ; and in another case a cyst may ultimately
assume the appearance of a more solid growth.
Prof. Gross, in his work, " Gross on the Bones," defines osteo-
sarcoma as an alteration of the osseous tissue, in which the sub-
stance of the bone is converted into a mass more or less analogous
to cancer of the soft parts. The origin, he says, is, in most cases,
referable to an hereditary disposition or to external violence ; it gen-
OSTEOSARCOMA. 373
erally comes on with deep-seated, lancinating pains, which continue
a considerable time before there is any evident enlargement or
swelling. The form of the tumor he describes as either smooth
and circumscribed, or unequal, and, as it were, tuberculated, etc.
For continuation of this paper, see his book, page 181.
Eustachius speaks of certain calcareous concretions deposited
about the necks of the teeth (tartar or salivary calculi evidently),
and Mauget classes such concretions with the sarcomatous growths.
Prof. Dunglison, in his dictionary, defines osteo-sarcoma as a dis-
ease of the bony system, which consists in softening of its laminae,
and their transformation into a fleshy substance analogous to that of
cancer, accompanied with general symptoms of cancerous affection.
Mr. Paget says the name of cartilaginous tumor may be given to
those which Miller, in one of the most elaborate portions of his
work on cancer, has named enchondroma. In a foot-note, Mr. Paget
says another name employed for these tumors is benign osteo-sar-
coma. In a second foot-note he says, under the vague name osteo-
sarcoma many include together and seem to identify all growths in
which bone is mingled with softer tissue.
Miller, in his " Principles of Surgery," says by the term osteo-
sarcoma is understood a tumor composed partly of bone and partly
of fleshy suljstance, as the name ini})lies : the latter constituent of a
simple, non-malignant character. The formation is usually attribu-
table to external injury, perhaps slight, and originates in the cancel-
lous texture of the bone. The osseous part is analogous to the
fibrous interlacement in tumors of the soft parts. It is, as it were,
the stroma, in which the other constituent is deposited, dense and
solid, centrally radiating in spiculse outward, w^hich always diverge
and interlace, leaving interstices more or less wide, in which the
fleshy substance is deposited, etc. See page 442 for differences, as
given by this author, between osteo-sarcoma and enchondroma and
osteo-cephaloma, etc.
Lebert places the whole class among the cancroid growths, and
denies that tendency to return furnishes any sufficient evidence of a
cancerous origin.
Miller, in another part of his " Principles of Surgery," says he
desires candidly to admit that the class is "not certainly a well-
defined one." It has been doubted, he says, whether some variety
of these fibro-plastic growths would not be more properly classed
among the malignant tumors, as they have been found prone to re-
turn, after excision, with singular obstinacy.
374 ORAL DISEASES AND SURGERY.
Spina ventosa, as remarked by Prof. Smith, is freely enough con-
founded with the osteo-sarcomatous growths. Now, the first is a
term meant to imply an empty cyst, such as on a previous page I
described as simple cysts : ventosa, a word from the Arabic, signify-
ino- windy; while the latter implies a solid, or comparatively solid,
tumor. This definition difi"ers, I am aware, from that given by Prof
Smith; but I employ the term, and recognize it only in accordance
with its literal meaning. If, then, spina ventosa means a sharply-
defined empty cyst, or, to give another definition to the prefix spina,
"a cystic tumor accompanied with pricking pains," then it cannot
simulate so as not to be recognized.
And so I might go on through all the authors upon my shelves —
each one describes the disease, but classifies it differently. A review
which I made of many authors reminded me graphically of Brum-
macher's impressive anecdote of the bringing of the priests from
the Babylonian war by Alexander: "Bild und Zeichen ist nicht das
Wesen." But I have quoted enough — and have chosen authors
presumed to be familiar to my readers — to exhibit the confusion
which exists in the nomenclature of this direction of the maxillary
tumors, and to excuse me, I trust, from any appearance of egotism
in choosing my own terms and my own way to describe these dis-
eases. I do not know that I shall succeed better than many others
in making myself understood, but I shall, at least, adhere strictly
to the text, and map out the tumors as I have met with them in
practice.
I choose, then, the compound osteo-sarcoma, and I mean the term
to apply to a class, and not a species. I mean it to stand as the repre-
sentative of any tumor in or upon bone, which is osseo-fibro-plastic.
Let that tumor be benign or malignant — this proposition is to be
distinctly borne in mind.
Osteo-sarcomatous, or osteo-fibro-plastic (synonymous) tumors are
to be esteemed doubtful growths. Thus I have seen two or more
alike, to the unassisted eye ; yet one has succumbed readily to treats
ment, while the others have bid defiance to every operative pro-
ceeding, and have gone on to the destruction of the patients. In
minute structure (pathological character) such tumors must have,
of course, varied greatly.
The fibrous tumors of the jaws described by Mr. Paget — see his
Lectures on Surgical Pathology — I would class with the osteo-
sarcomatous ; so also the growth which he describes as myeloid.
(See same Lectures.) Of the first, he says, as to situation and con-
OSTEOSARCOMA. 375
venience, the fibrous tumors of the jaws may be found isolated and
circumscribed, growing within the jaw, divorcing and expanding its
walls, and capable of enucleation ; but in a large number of these
tumors, the periosteum, with or without the bone itself, is involved,
or included in the outgrowing mass. In the case of the upper jaw,
either the periosteum or the fibro-mucous membrane of the antrum,
or nasal walls, or both these, may be included in such a tumor. In
all these cases the tumor lies close upon the bone, and cannot be
cleanly, or without damage to it, separated, except on the outer sur-
face ; commonly, indeed, bony growths extend from the involved bone
into the tumor ; and sometimes the greater part of the bone is as if
broken up in the substance of the tumor.
The character of these growths, Mr. Paget remarks, is easily re-
cognized in the fibrous tumors of the gums and alveoli.
In the chapter on the Epulides, I referred to a tumor which is a
fibrous outgrowth from the alveolo-dental periosteum. This same
class of growths spring from the lining membrane of the sinus max-
illare, and, enlarging, dispart the bones, bulging out as a tumor upon
the face : they are osteo-sarcomatous tumors, or, it would be more
correct to say, sarcomatous tumors, purely fibro-plastic in struc-
ture, and perhaps exclusively benign. Such growths, if early and
properly removed, are not apt to return. I have met with these
tumors over and again ; they always seemed to me to have asso-
ciation with the bone only, when such association was forced, as it
were, on them. Such tumors are exclusively periosteal in their im-
mediate relationship. I have examined them with the microscope,
but have found them made up almost exclusively of simple fibrous
tissues. If these tumors have not advanced too far, you will see
them, on taking away the outer wall of the antrum, as some foreign
body which has been impacted closely within the part ; they have
not the slightest pathological association with the bones, if we ex-
cept their periosteal pedicel or base. Indeed, such seems the tend-
ency to exclusiveness, on the part of these growths, that I have
seen them when they were as large as a fcetal head, the integument
of the cheek alone covering them, the bone which must have orig-
inally formed their external envelope having completely disappeared
through absorption.*
The myeloid tumors of Mr. Paget seem to me justly classible with
the sarcomatous, inasmuch as they so closely resemble fibro-plastic
* These tumors are not the polypi of the antrum.
376 ORAL DISEASES AND SURGERY.
structures as to lead to the inference that such portions as seem
marrow-like are rather the result of retrograde metamorphosis— a
metamorphosis into the medullary type of carcinoma—than of
original pathological development. It was on account of their
being made up of the fiber cell that M. Lebert gave such growths
the name " fibro-plastic."
I do not, however, presume to dispute pathology with Mr. Paget:
so far as the purpose of our present classification is concerned, I
have only to do with the fleshy appearance of these tumors. Mi-
nutely they may have been made up of marrow-like substances, but
if in general appearance they are fibro-plastic or fleshlike, then they
belong to the class sarcomatous, or, when found associated with bony
tissue, osteo-sarcomatous.
A myeloid, says Mr. Paget, like a fibrous tumor, may be either
inclosed in a bone whose walls are expanded round it, or, more
rarely, it is closely set on the surface of a bone, confused with its
periosteum. The sketches of fibrous tumors pictured in his Sur-
gical Pathology, page 406, might, he says, be repeated for myeloid
tumors.
Mr. Paget sets down these two kinds of tumors as being equally
common to the jaws, both the superior and inferior.
AVhcn, he says, the myeloid is inclosed in bone, the tumors
usually tend to the ovoid or spherical shape, and are well defined,
if not invested with distinct thin capsules ; seated on bone, they are
(as exemplified by the epulic structures) much less defined, less
regular in shape, and often deeply lobed. They feel like uniformly
compact masses, but are in different instances variously consistent.
The most characteristic examples are firm, and (if by the name we
may imply such a character as that of the muscular substance of a
mammalian heart) they may be called fleshy. Others, he says, are
softer, in several gradations, to the softness of size gelatin, or to
that of a section of granulations. Even the firmer are brittle, easily
crushed or broken, they are not tough, nor very elastic, like the
fibro-cellular or fibrous tumors, neither are they grumous or pulpy,
neither do they show a fibrous or granular structure on their cut or
broken surfaces.
Mr. Paget describes sections of these tumors as appearing smooth,
uniform, compact, shining, succulent, with a yellowish, not a creamy
fluid. A peculiar appearance, he says, is given commonly to them,
by the cut surface presenting blotches of dark or livid crimson, or of
a brownish or a brighter blood color, or of a pale pink, or of all these
OSTEOSARCOMA. 377
tints mingled on the grayish-white or greenish basis color. (In a
foot-note, Mr. Paget quotes from Lebert, who says the greenish-
yellow color that may show depends on a peculiar fat, xanthose.)
The tumors, he says again, may all be pale, or have only few
points of ruddy blotching, or the cut surface may be nearly all suf-
fused, or even the whole substance may have a dull modena or crim-
son tinge, like the ruddy color of a heart, or that of the parenchyma
of a spleen. Mr. Paget believes that many of what have been
named spleenlike tumors of the jaws have been of this kind. The
color they present, he says, is not due merely to blood in them ;
some of it is appropriate to their texture, as is that of the spleen or
that of granulations, and it may be quickly and completely bleached
with alcohol.
The following are the microscopic appearances which Mr. Paget
says are peculiar to the myeloid growth, being imitated in no other
morbid structure.
1. Cells of oval, lanceolate or angular shape, or elongated and
attenuated like fiber cells, or caudate cells, having dimly dotted con-
tents, with single nuclei and nucleoli.
2. Free nuclei, such as may have escaped from the cells, and
among these, some that appear enlarged and elliptical, or variously
angular, or are elongated toward the same shapes as the lanceolate
and caudate cells, and seem as if they were assuming the character
of cells.
3. The most peculiar form ; large, round, oval, or flask-shaped, or
irregular cells or cell-like masses, or thin disks of clear or dimly
granular substance, measuring from one three-hundredths to one-
thousandth of an inch in diameter, and containing two to ten or
more oval, clear, and nucleolated nuclei.*
Corpuscles, such as these, in*egularly and in diverse proportions,
imbedded in a dimly granular substance, make up the mass of a
myeloid tumor. They may be mingled with molecular matter, or
the mass they compose may be traversed with filaments or with
bundles of fibro-cellular tissue and blood-vessels, but their essential
features (and especially those of the many-nucleated corpuscles) are
rarely observed.
Many varieties of aspect (as remarked by Mr. Paget) may thus
be observed in myeloid tumors, and beyond these they may even be
* These microscopic elements, as referred to in the chapter on Epulis, are
presented on page 449 of " The Surgical Pathology."
378 ORAL DISEASES AND SURGERY.
so changed that the microscope may be esseutial to their diagnosis.
After they partially ossify, well-formed cancellous bone being devel-
oped in them, cysts, also filled with bloody or serous fluids, may be
formed in them, occupying much of their volume, or even almost
excluding the solid texture.
Mr. Paget says he lately amputated the leg of a woman, twenty-
four years old, for what was supposed to be a cancerous tumor
growing within the head of the tibia. She had pain in the part for
eighteen months, and increasing swelling for ten months, and it
was plain that the bone was expanded and wasted around some soft
growth within.
On section, after removal, the head of the tibia, including its ar-
ticular face, appeared expanded into a rounded cyst or sac, about
three and a half inches in diameter, the walls of which were formed
by this flexible bone and periosteum, and by the articular cartilages
above ; within there was little more than a few bauds or columns of
bone, among a disorderly collection of cysts filled with blood, or
blood-colored serous fluids. The walls of most of the cysts were
thin and pellucid; those of others were thicker, soft, and brownish
yellow, like the substance of some medullary cancers, a likeness to
which was yet more marked in a small solid portion of tumor,
which, though very firm, and looking fibrous, was pure white and
brainlike.
iS^one, Mr. Paget says, who examined this disease with the naked
eye alone, felt any doubt that it was an example of medullary cancer,
with cysts abundantly formed in it. But on minute investigation,
none but the elements of the myeloid tumors could be found in it ;
these, copiously imbedded in a dimly granular substance, appeared
to form the substance of the cyst walls, and of whatever solid mate-
rial existed between them. The white brainlike mass was appa-
rently composed of similar elements in a state of advanced fatty
degeneration, but neither in it nor in any other part could be found
a semblance of cancer cell.
Mr. Paget fails to inform us as to a return of the disease ; it does
seem to me that in the present state of our knowledge of cancer
growths, it would have been a very difficult matter to have classed
such a tumor with the non-malignant. It certainly was very hetero-
clitic in character, and whatever we individually may feel disposed
to think of such a structure, it serves to exhibit the merging of the
benign into the malignant, and their relationship. A consideration
of such cases as this should serve to keep the practitioner on his
OSTEOSARCOMA. 379
guard, preventing his being too confident in any prognosis he may-
give to a patient.
An epitome of the myeloid may thus be presented:
They are a class of fleshy tumors called by M. Lebert fibro-plastic,
because, he says, they are made up of fiber cells. They are called
myeloid by Mr. Paget, because he thinks they much more resemble
marrow than fibrous tissue.*
In character, according even to Mr. Paget, they vary from simple
semi-fibrous, semi-marrow-like structures to those so heteroclitic
that they seem to merge into the medullary.
Their favorite seat seems to be about the bones, either intra or
extra, being, perhaps, more common to the maxilla than in the other
osseous structures.
They are growths which usually occur singly, they are more fre-
quent in youth, and very rare after middle age ; they generally grow
slowly and without pain, and usually commence without any known
cause, such as injury or hereditary disposition.
According to Mr. Paget, they rarely, except in portions, become
osseous ; they have no proneness to ulcerate or protrude ; they seem
to bear even considerable injury without becoming exuberant ; they
may shrink or cease to grow ; they are not apt to recur after com-
plete removal, nor have they in general any features of malignant
disease.
Since writing the above I have accidentally fallen upon a classifi-
cation of the tumors of the upper jaw, made by Mr. Hancock. After
alluding to various classes, he says : " In addition to these, Mr.
Paget adds what he terms myeloid tumors of the part ; but while the
examples he quotes resemble on the one hand so much the fibrous,
on the other the medullary tumors, their true character, whether in-
nocent or malignant, is so very doubtful that I should hesitate in
admitting them as a distinct class."
I am pleased to quote this from Mr. Hancock. There are already
quite enough subdivisions without counting in such as can be done
very well without. Indeed, it is because I so prefer a general, tangi-
ble, rather than a hair-splitting classification, that I am disposed to
stick to the embracing term of sarcoma. I understand pretty well
what one means when he tells me of an osteo-sarcomatous form
of growth ; he has only further to tell me whether it was benign,
* Mr. Paget does not call all fibro-plastic tumors myeloid ; be only says a
myeloid is ditferent from tbe ordinary fibro-plastic of Lebert.
380 ORAL DISEASES AND SURGERY.
disposed to malignancy, or already malignant, and I understand
exactly what he means.
Fibrous tumors proper, and the fibro-plastic, have general features
in common, that is, they belong to the class of sarcomatous growth ;
but then, in a pathological sense, they have such differences that an
epitome, at least, of their history should be reviewed by us.
In some instances, fibrous tumors are seen under the microscope
to have a concentric development; this species is slowest of growth,
is most benign, and never attains any great size.
In another species the fibers interlace in a most complicated and
irretj-ular manner. This kind attains the largest size, and seems
striding toward the heteroclitic.
A third class consists of an aggregate of nodules, and is compared
by Dr. Humphrey to a conglomerate gland ; the tumor being made
up of small masses closely compressed together, having an uneven,
knotty outline.
Fibrous tumors affecting the bones (Braithwaite) are usually
found upon those of a spongy nature, upon the ends of the long
bones, the phalanges, pelvis, and lo\ver jaw. (I will take the liberty
here to correct the author. I have described these tumors as as-
sociated with the alveoli, with the external periosteum, and with
the antrum of Highmore, and I know that they do thus affect both
jaws, as I have met with them often enough practically, and so has
every one who has had any extent of experience.) So far, says this
author, as I have met with them, they are confined to the exterior
of the lower jaw, growing from the periosteum and creeping along
the surface of the bone in such a manner as to prove almost to a
certainty that they originate in some morbid condition of the peri-
osteal fibers. The bone underneath these tumors may suffer absorp-
tion in consequence of the pressure produced, but does not seem to be
affected in any other way. They appear upon the maxillary bone
more frequently than upon any other part of the skeleton. On the
lower jaw they spread along the ramus, encircling it beneath and on
the sides, so that the bone is almost concealed by the tumor. In some
instances they form within the substance of the jaw, probably from
the alveolo-dental membrane, and as they increase, the walls of the
bone become spread out over them. They grow up around the teeth,
and when they project into the mouth may be soft and fungous.*
* Presenting tliis phase the tumor may be classed with the epulic, but it is
seen that on this account, tiiere need be no confusion. Many epulic tumors
are osteo-sarcomatt>us.
OSTEOSARCOMA. 381
In some instances the fibrous tumors of the jaws exhibit a semi-
cartilaginous structure, and now and then fibers or plates of bone
are formed in various parts of them. The progress of the disease
is well illustrated by a series of tumors of the jaws in the College
of Surgeons, London, from the museum of the late Mr. Liston.
These preparations serve to show how necessary it is to bear in
mind the mode of growth of these periosteal fibrous tumors of the
jaws, because from their disposition to creep along the surface of
the bone, whether it be an endosteum or periosteum, they are liable
to return after removal, unless the immediately adjacent as well as
affected parts be excised. The histories attached to the specimens
teach that very large fibrous tumors, both of the upper and lower
jaws, together with the bones on which, or in which, they grow, may
be successfully removed.
Now, as to the degeneration of sarcomatous tumors, it is, I think,
a question be3^ond doubt that a tendency, greater or less, to retro-
grade metamorphose belongs to this class. I need only instance
the m3'eloid growths of Mr. Paget, just considered. Certainly
nothing could more closely resemble medullary cancer, in, we may
say, its incipient stage. And what are we to understand of the re-
curring fibrous tumors, if there is no carcinomatous association ?
Concerning the diagnosis of the sarcomatous tumors, and the
ability to follow them through their gradations, it seems most im-
portant that we should not be ignorant of the distinguishing signs
that exist.
I remarked that osteo-sarcoma was not uufrequently confounded
with spina ventosa. Now the point at which these two different
conditions most nearly approach each other is in the hydatid and
other cysto-sarcomatous growths.
Cysto-sarcoma, as implied by the prefix, is a tumor of only semi-
solidity, its interior, or stroma, being made up of cysts and fleshy
substance. These cysts are original formations, and not of second-
ary character, — that is, they are not the result of molecular disin-
tegration. They are lined sacs, having a distinct secretory mem-
brane. Miller describes the contents of these cysts as widely
differing, and which every one must have observed : " They are
more or less fluid, sometimes a clear gluey liquid, sometimes a
gelatinous, pale mass of semi-solid consistence, elastic, and project-
ing beyond the level of the cut cyst on a section being made ; some-
times a solid, consisting of a fibrous deposit, organized very imper-
ectly, if at all ; sometimes of an exanthematous or poppy consistence,
382 ORAL DISEASES AND SURGERY.
as in many encysted tumors ; sometimes, but more rarely, a dark fluid,
like printer's ink, is contained ; sometimes blood is mingled with the
contents, either in the solid or in the coagulated form."
The very nearest approach, however, made by cysto-sarcoma to
spina ventosa, is in that class, very well named by some one, as I
remember to have seen, the " cysto-succulent." These are sarco-
matous tumors, the stroma of which is made up of very loose fibro-
cellular tissue. They might well, in their contents, be likened to
that of a water-melon, solid enough on section, but compressible to
a few shreds. The fibrous contents of the stroma are, however,
always a distinguishing sign. These tumors are very rare, and par-
ticularly so about the bony structures.
Miillcr has described a variety of these cysts of sarcomatous
growth, which he calls cysto-sarcoma phyllodes. " The tumor," he
says, " forms a large firm mass, with a more or less uneven surface.
The fibrous substance, which constitutes a greater part of it, is of a
grayish-white color, extremely bard, and as firm as fibro-cartilage.
Large portions of the tumor are made up entirely of this mass, but
in some parts are cavities or clefts, not lined with a distinct mem-
brane (an exception to the rule in cystic tumors). These cavities
contain but little fluid, for either their parietes, which are hard, like
fibro-cartilage, and finely polished, lie in close apposition with each
other, or a number of firm, irregular laminae sprout from the mass
and from the walls of the fissures, or excrescences of foliated or wart-
like form sprout from the bottom of the cavities and fill up the in-
terior. These excrescences are perfectly smooth on their surfaces,
and never contain cysts or cells. The laminae lie very irregularly
and project into the cavities and fissures like the folds of the psal-
terium in the interior of the third stomach of ruminant animals.
Sometimes the laminae are but small, and the warty excrescences
from the cysts are very large, while, in other instances, both are
greatly developed."
Cartilaginous, or the enchondromatous tumors of Miiller, might,
perhaps, for all practical purposes, be classified with the sarcoma-
tous, for while it might demand some little stretch of the imagina-
tion to convert a cartilage into looking like a fleshy mass, yet surgi-
cally the species are very much alike, — that is, both are reasonably
benign, both are little amenable to the action of the sorbefacients,
and both are better treated by the knife than in any other way.
As we understand the osteo-sarcomatous tumors proper to be out-
growths associated commonly with periosteal membranes, so we are
OSTEOSARCOMA. 383
led naturally to ask ourselves as to the cause of their formation.
This I conceive to be twofold : first, as the result of local irritation ;
I second, as the result of constitutional conditions ; and, still again,
: we may combine these two, laying the predisposing cause on the
I one and the exciting on the other.
'■ My attention was once directed by William Gibson, late Professor
' of Surgery in the University of Pennsylvania, to a case markedly
' illustrative of this latter condition. An old gentleman, Mr. F.,
seventy years of age, was struck on the cheek by a stone. He
soon had growing from the site of the injury a tumor, diagnosed
by Professor G. as osteo-sarcomatous. The growth of the body was
so rapid and so formidable as to incline to the view of its intimate
relationship with malignancy. No one would, I think, doubt the
twofold relation of such a tumor.
When osteo-sarcoma takes on this rapid growth, its innocency
may always be doubted ; when the development is slow and TCgular,
and particularly if the origin can be traced to some local irritant,
extirpation may be expected to result in a complete cure.
When these tumors are fairly and openly benign, we find no con-
stitutional disturbance associated with them, at least none that are
outside of strictly mechanical influences.
Osteo, or simple sarcomatous tumors of the sinus maxillare, should
not be mistaken, as has too often been the case, for polypi of the
nares. It sometimes happens that these tumors, particularly the
softer kinds, find their way through the outlet of the sinus into the
nostril, and there simulate very closely a common fibrous polypus ;
such tumors have been often highly aggravated by operations founded
on such mistaken diagnosis. Again, polypi of the nostrils may find
their way through the same passage into the sinus, and, enlarging,
represent very fairly the ordinary sarcomatous tumor of that cavity.
Now, pathologically speaking, being about one and the same thing,
it would be little difference where or how the growth should develop,
but as operative proceedings are concerned, a mistake of the kind
becomes quite an awkward matter.
As regards changes common to the sarcomatous tumors, they may
be considered under the heads of softening, suppuration, and ma-
lignant degeneration.
Softening, says Dr. Humphrey, appears to take place in two
ways:
First, as a chronic process, affecting some circumscribed portion
of the tumor, which is usually at or near the center. The change is
384 ORAL DISEASES AND SURG ERF.
observed to commence with a slight discoloration, a yellowish or dark
tinge, which is followed by a loosening or incipient disintegration of
the structure ; at the same time a line of demarkation is formed
around the altered portion, which becomes separated, like a seques-
trum, from the surrounding mass. Both the detached portion and
the cavity are at first rough and thready on their opposed surface ;
the former undergoes still further disintegration and solution, be-
coming broken up into a number of smaller fragments, which float
about in a dark, dirty, turbid fluid, and which may ultimately dis-
appear.
The process of destruction may go on in the adjacent portion of
the tumor, enlarging the central cavity till the whole is reduced to
a fluid or a semi-fluid mass, walled in by the capsule of the tumor,
which now stands in the relation of a cyst wall to the disorganized
contents.
In some cases the softening process is completed without extend-
ing the circumference ; the ragged processes hanging into the in-
terior of the cavity are removed. The latter acquire a smooth lining,
and look like a simple cyst lying in the cavity of the tumor.
A second mode in which softening takes place is more rapid and
diff"used, the whole or the greater portion of the tumor being affected
at once. The change commences with the infiltration into the mass
of a serous fluid whereby its texture is loosened and its components
separated, at the same time the tissue of the tumor is softened, and
interstitial absorption is set up in it.
As the result of these processes combined, the tumor is soon
broken up into detached fragments, and reduced to a diffluent pulp,
or it may be completely liquefied. These changes. Dr. Humphrey
suggests, "are occasioned by some altered nutrition analogous to in-
flammation; they may be induced by some accidental cause, as an
injury ; nevertheless they are not necessarily attended with any con-
stitutional disturbance at all corresponding with the extensive
destruction which is in progress."
Sujypuration. — This is very rare; it may commence internally, or
progress from without inward.
Cancerous Degeneration. — The general conditions and features
of such degenerations have been considered in the body of the chap-
ter. It remains, however, to point out a second cancerous relation,
namely, the existence of compound tumors. Dr. Lewis relates a
case where melanotic cancer was deposited in the stroma of a fibrous
tumor, and Dr. Humphrey exhibited a large fibrous tumor completely
OSTEOSARCOMA.
385
enveloped in cancer. In such cases we can only infer the fibrous
tumor to have existed through a provocative local irritation, while
the cancer conjoined with it is a separate and distinct disease, the
result of cachexia.
Fig. 81. — Osteo-Sarcomatous Tumor.
This specimen, from the person of an old woman, commenced
within the antrum, and progressed four years before causing death.
In character it was fibro-plastic, with here and there osseous masses.
Fig. 82. — Cysto-Sarcoma.
This specimen represents a case just operated on by myself. The
reader will, from the text, understand it without any special descrip-
tion. The patient was a young man aged about thirty.
25
CHAPTER XXVI.
OSTEO-CARCINOMA.
In the previous chapter various tumors were referred to, differing,
as species are concerned, agreeing as to a general classification;
these various species being grouped under the common class term
sarcoma.
The class we are now to consider — the heteroclitic — is one which
has been equally divided and subdivided, specified and synonymed
with the preceding, — so much so, indeed, as to elicit from most
authors a confession as to the confusion which seems to render any
simple and exact description almost impossible.
Much experience has suggested to my mind that there is but a
single cancerous affection of the jaws, or perhaps I will be better
able to make myself understood if I say two ; all peculiarities,
modifications, and associations are but pathological features de-
veloped by age or circumstances in the one or the other of these
general classes. If this tenure is right, when I describe one, or
at best two conditions, with their associations, 1 shall, for all
practical purposes, have told all that need necessarily be known
for the general guidance of the surgeon. I think so, at least.
Carcinoma is a word gotten from the Greek xapy.ivoq, signifying a
crab. According to the classification of Fische, which it suits our
purpose to adopt, it applies to a family of diseases which embraces
the different forms of cancer.
Osteo-carcinoma is a term, then, which I will adopt to apply to
any truly cancerous tumor of the maxillary bones ; it embraces the
two species which I have said are the only malignant growths found
associated with these bones. These species are the types medullaris
and scirrhus.
Scirrhus of the maxillae is an infrequent condition — a quite rare
disease. Medullary matter is the pathological feature which charac-
terizes the mass of the carcinomatous tumors of these parts; so
constant, indeed, is its presence, that it would scarcely be amiss to
say that medullary disease is the only cancer of the jaws.
(386)
OSTEO-CARCINOMA. 387
I suppose I have, in the course of my observations, met with two
decided cases of scirrhus of the maxillary bones, both being associated
with the superior jaw ;* certainly I have not seen more than these
two cases. It appears first as a hard mass, a little lump, perhaps,
associated seemingly with the overlying soft tissues, movable for
a time, but soon becoming fixed, and implicating all the immediately
surrounding parts, "casting out its claws," as the people have it.
If, after amputation, a scirrhous mass is bisected, it is found to
resemble in its stroma the substance of a turnip.
The hardness of scirrhus, says Mr. Paget, when compared with
that of most other tumors, is extreme ; it is about equal to that of
fibro-cartilage, and is associated with a corresponding rigidity,
weight, and inelasticity. A characteristic appearance is a slight
concavity assumed by these tumors on section, which belong to no
other tumors. It differs again on section from the sarcomatous
tumors in having no distinct grain or fibrous plan of arrangement.
In microscopic structure it varies still more markedly, its cells
being not constant but heteroclitic. Scirrhus, like medullary cancer,
tends, but much more slowly, from the occult to the open stage.
With these few remarks on scirrhus, which will serve at least to
exhibit that I am not unaware that such form of cancer does occa-
sionally exist in the jaws, w^e will pass to the medullary form, and
which I will now assume is the carcinoma proper and peculiar of
the parts.
Miller has, however, several sections on malignant scirrhus of the
maxillary bones, which he considers under the heads osteo-cepha-
loma, osteo-carcinoma, osteo-melanosis, and osteo-cancer. Against
these subdivisions I shall not take the liberty to object, leaving it
for the reader to judge whether they are not but one and the same
disease with modifications.
Our subject can, I think, be divested of much obscurity, if at this
point we stop for a single moment to consider the meaning of certain
terms which long usage has so associated with cancerous condi-
tions that they must, I am sure, long years ago, have gotten far be-
yond the meaning originally intended for them. Take for example
the term fungus hsematodes. It is a term used freely and loosely
by surgical writers, and is frequently accepted to mean most malig-
nant cancer. Let us analyze this term : Ave find it made out of the
* Since writing the above I have met with scirrhus proper of the lower
jaw.
388 ORAL DISEASES AND SURGERY.
Greek altm, siffnifying blood, and eiSoq, meaning appearance — of
bloody appearance. Any and all granulations being of bloody ap-
pearance, are therefore fungi haematodes. If, however, it was meant
to be applied strictly to pathological features, we might employ
it learnedly to express the common proud-flesh of any adynamic
ulcer.
Writers use the term as a synonym of medullary cancer, but when
they describe fungus haematodes, they get a condition and not a prin-
ciple. They might, with the same propriety, use the word suppura-
tion as a synonym of inflammation. Fungus haematodes is a phe-
nomenon, as suppuration is a phenomenon, as pain is a phenomenon
attending a cause. Such looseness in describing disease cannot but
confuse the student and render our nomenclature unreliable as a
source for finding expressive terms; terms that shall be patent every-
where, and under all circumstances. Thus Mr. Hey, who was the
originator and maker of the term fungus haematodes, employed it
as the representative of the open state of medullary cancer ; it cer-
tainly Avell expresses the phenomenon, but has no more special
meaning.
Alibert calls all the haematocies by this same name, and as they
are all of bloody appearance, certainly he is justified in so expressing
himself.
Dupuytrcn employs the term in describing the erectile tumors,
while Graefe presses it into service in describing the " Telangiecta-
siae." Thus, as a first example, we see that there is no peculiar dis-
ease of the jaw which can be called fungus haematodes. We do not,
however, eschew the term ; we cannot do without it, as it represents
a feature.
Let us take a second. I instanced Miller's fourth classification of
cancer of the maxillary bones, the osteo-melanosis. Now the term
melanosis refers to a pigment, and signifies simply black or colored
structure. I will not myself say that Miller errs in this classifica-
tion, but will simply note down what Mr. Paget says concerning
the colored cancers.
" The melanotic or melanoid cancers are," says Mr. Paget,
"according to my experience, with very rare exceptions, medullary
cancers modified by the formation of black pigment in their ele-
mental structures. On this long disputed point there can, I think,
be no reasonable doubt. I have," he says, " referred to a case of
melanotic epithelioma [see his Lectures, page 582], but with this ex-
ception, I have not seen or read of any example of melanosis or
OSTEO-CARCINOMA. 389
melanotic tumor in the human being which might not be regarded
as medullary cancer with deposit of black pigment."
These remarks and experiences of Mr. Paget exhibit quite satis-
factorily, I think, the fact that this classification is an unneces-
sary, not to say an unscientifiic one. The deposit of pigment is
not the disease, but merely an accidental feature appearing in its
course.
May I not, then, be permitted to suggest that the term, in the
special sense in which it is employed by Mr. Miller, may be dropped
without detriment to nomenclature ?
The osteo-cephaloma of Miller is medullary cancer.
Osteo-carcinoma ; I have given the derivation of this term, and
exhibited its character as a noun of multitude.
Miller, in his classification, thus writes : " Osteo-carcinoma is com-
paratively rare ; when it does occur it is usually as a secondary
symptom of malignant cachexia, the primary indication of which
has been the formation of carcinoma in the soft parts."
If, in this classification. Miller is compared with other authors, his
meaning will be difficult to make out. If he had not so specially
classified the disease, I would suppose he meant the same as Fische ;
but osteo-carcinoma, as Fische emplo3'S the term, and as we here fol-
low him, is not a very rare condition ; on the contrary, it is unfor-
tunately a quite common disease. I would ask, then, considering
the character of the term carcinoma as a noun of multitude, if this
classification of Miller might not also be dispensed with ?
Osteo-Gancer. — This is another classification ; it is used as a sign
of the malignant ulceration of bone. The only objection to be
urged against the term is, that it makes another unnecessary class.
We would scarcely suppose that an ulceration could occur as the
primary lesion. If, then, it is a secondary condition, it is only an
attendant phenomenon, and can have no claim to the distinction of
special classification — the disease, or rather the condition, would be
carcinoma in a state of ulceration, and it seems to me, if we should
describe it as ulcerating osteo-carcinoma, we would give it all proper
signification, while, at the same time, we should make still one less
of these special confusions.
Synonyms. — To these, when learnedly made, no objections can
perhaps, be urged. So many names for one thing is, without doubt,
confusing enough to the student ; but then, this is a matter which
time and study make familiar to him, and more than this, reason-
able and proper.
390 ORAL DISEASES AND SURGERY.
I would have my reader, then, infer that if, in the study of the
malignant disease of the jaws, he will agree to throw entirely aside
the unjust nomenclature which so surrounds the subject, and ap-
l)roach the study on general principles alone, he may, from a single
stand-point, at a single glance, take in the whole of the subject.
And first, to return to what has been alluded to as the persistent
tvpe medullary matter. This form of carcinoma is named from its
resemblance to brain substance. Its synonyms are many, generally
good, but a little confusing when associated with degenerating sar-
coma; but on this point I hope the student is sufficiently fortified.
I have remarked that one classification made by Miller, of the
cancerous tumors of the jaws, is osteo-cephaloma : this is a syno-
nym of medullary; the only form of cancer of the maxillary bones,
with the exception mentioned. Now in Mr. Miller's book is a com-
parison which he has drawn between osteo-sarcoma and osteo-
cephaloma; the comparison embraces ten conditions. If the reader
will closely study them he will truly have his subject in a nutshell.
1. Says Mr. Miller: Osteo-sarcoma is seldom found prior to adult
age; osteo-cephaloma may occur at any period, and is as frequent in
the adolescent as in the adult.
2. Osteo-sarcoma is usually attributable in its origin to external
injury. Osteo-cephaloma is most frequently of spontaneous origin.
3. Osteo-sarcoma is slow and gradual, and more or less uniform
in its growth. Osteo-cephaloma is much more rapid, and tends to
enlarge unequally, growing chiefly at those points where there is
least mechanical resistance.
4. Osteo-sarcoma is usually almost, and sometimes altogether,
painless, unless when some nervous trunk or plexus is compressed.
Osteo-cephaloma, from the first, is attended with severe lancinating
pains.
5. Osteo-sarcoma is firm, and yields but little to touch, even undue
pressure is scarcely painful ; and obscure crepitus is often felt.
Osteo-cephaloma is soft and elastic from an early period; the shell
of bone and all other original texture soon becoming merged in the
medullary formation. It is elastic, and affords no crepitus when an
original tumor, and pain is aggravated by compression.
6. Osteo-sarcoma entails but little disorder of the general health.
Osteo-cephaloma is attended by marked cachexia, even from the be-
ginning.
7. A casual abrasion of the skin, or mucous membrane investing
an osteo-sarcoma, shows a simple character, and may be brought to
OSTEO-CARCINOMA. 391
heal under ortHnary treatment. A similar breach in the surface of
an osteo-cephaloma does not heal, but widens more and more and
becomes the site of fungous protrusions.
8. Osteo-sarcoma does not invade the neighboring tissues, but
pushes them aside by its expansion, and abides within the bone in
which it was developed. In the upper jaw, for example, it remains
limited to the expanded confines of the antrum, and at those points
where the bony and even membranous parietes are deficient, there
is no ulceration followed by fungous protrusions, but only a mode-
rate increase of growth in a lobulated form, with or without a raw-
ness of the surface. Osteo-cephaloma, on the other hand, pushes
no texture much aside, but early involves all; the antrum is soon
passed beyond, and the base of the cranium is affected even before
much show has been made externally. Whenever deficiency of the
investing texture occiu"s, ulceration and fungous growths are sure to
follow.
9. Osteo-sarcoma long continues in the occult condition. Breach
of the surface, when it does occur, does not extend rapidly, and
evinces no tendency to malignity of character. The discharge is
purulent or puriform, not profuse. There is no tendency to hemor-
rhage unless by accidental injury, and then it is slight, and easily
controlled by pressure. Osteo-cephaloma soon passes from the oc-
cult to the open stage. The ulcer spreads, and is obviously the
seat of malignancy. Discharge is profuse, fetid, and bloody. Hem-
orrhage is not unlikely, of spontaneous origin, and little amenable
to control.
10. Osteo-sarcoma does not spread, either by contiguity in the
tissue, or remotely by the lymphatics. Osteo-cephaloma does both;
at an early period the lymphatics are manifestly and hopelessly in-
volved.
These comparisons by Mr. Miller are very happy. The reader
must not forget, however, the tendency of sarcoma to pass into car-
cinoma, and that there is, very frequently, a period in the history of
the former in which it is almost impossible to say whether the simple
or malignant structure predominates. The comparisons refer to
marked conditions in the two diseases, — that is, true and unmixed
osteo-sarcoma and decided osteo-carcinoma or cephaloma.
Practically, says Mr. Miller, it is of the utmost importance that
we should be able to distinguish between the two diseases: each is
of not unfrequent occurrence, and each requires distinct rules of
treatment.
392 ORAL DISEASES AND SURGERY.
Osteo-sarcoma admits of operation to a late period ; its extirpation
may be fearlessly attempted with a good hope of success even after
the tumor has an enormous bulk, and experience has shown that the
operation, though it may be bloody and severe, yet seldom termin-
ates but in a fortunate issue.
Osteo-carcinomatous tumors are, on the contrary, — I would speak
my own experience if I were to say, — not at all amenable to treat-
ment of any kind. Miller thought they might be operated on at an
early period successfully, but I must say (and clinically I have seen
a great deal of this disease) I never saw one cured. This assertion
implies, however, that the diagnosis has been correct; there are
so-called medullary cancers cured every day. Cancerous deposits
seem so evidently the work of systemic conditions that when you
remove a part containing the localized disease, you seem but to have
exposed the conduits which are engaged in bringing to the bulk
fresh material : you cannot get beyond the disease with your knife ;
all adjoining parts are more or less infiltrated with the materise
raorbis.
"I entirely differ," says Mr. Hancock, "from Mr. Stanly and Mr.
Liston, that medullary carcinoma commences in the antrum of High-
more and extends backward to the pterygoid process ; but, on the
contrary, from what I have observed, I firmly believe that the dis-
ease commences in the cancellated structure of the body of the
sphenoid bone and bones at the base of the cranium, and that, how-
ever early we may perform the operation, we never succeed in eradi-
cating the mischief, which is sure to return at a longer or shorter
period, according to circumstances."
It strikes me that if Mr. Hancock had only for one moment con-
sidered the constitutional relations of cancer, he need not have found
himself in dispute with his illustrious peers. For my own part, I
know that medullary disease does begin in the maxillary sinus, for
I have over and again seen such cases, and so also may it begin, as
location is concerned, almost anywhere else about the body; the
tumor is not the disease, but only the local expression of it.
But however this may be, I quoted Mr. Hancock's expression only
as it is indicative of a general experience of the difficulty of getting
away by operation even all of what is apparently the local disease;
and how could it be otherwise, seeing the tumor is not encysted,
being rather an infiltration, as it were ?
What then is to be done in this condition ? I can only answer,
let every man use his best judgment. We know the history of the
OSTEO-CARCINOMA. 393
disease : that it tends to fungoid conditions, that it becomes so offen-
sive as to make the patient not only disagreeable to his friends but
also to himself, that it is associated with most unbearable pain,
etc. We may feel ourselves justified in operating for a twofold
reason: first, that we may give to the patient temporary relief;
second, with the hope that the reappearance may be in some in-
ternal situation, rather than the site of removal ; thus at least put-
ting out of sight a disgusting mass which it can be of little use to
have under manipulative control.
There are, however, the following general indications which
should always be taken into consideration, and which, being met,
may possibly result in good to the patient :
1st. As the disease is due to or accompanied by perverted nutri-
tion, every effort should be made to remove any derangement in the
nutritive organs, while the general health should be cared for thi'ough
the generous use of rich diet, tonics, and alteratives.
2d. To remove or check local irritation.
3d. To continue the constitutional treatment through all stages
of the disease, not neglecting the quieting assistance of the opiates.
4th. To operate early, if at all, provided the disease presents such
conditions as to warrant interference.
5th. To select such means for its removal as will be likely to pro-
duce the least irritation.
Professor Smith thinks the greatest amount of good is to be got-
ten from the chalybeates. He recommend's Vallet's mass in do.ses
of from five to ten grains three times a day. In one case, he says,
in which he was consulted with a view to operating, and declined
on account of the rapid progress of the disease, he suggested the
use of Vallet's mass conjoined with the application of the powdered
carbonate to the sore, and the patient lived for eight years without
the disease having made any very great progress. Justamond, of
London, says Dr. Smith, gave from sixty to one hundred and twenty
grains of the ammonio-chloride per diem ; while Carmichael, of Dub-
lin, expresses himself as having derived much benefit from washing
ulcerated scirrhus with a solution of sulphate of iron.
Chloride of zinc and solutions of the salt are favorite preparations.
I believe, from what I have seen, that if it were possible to cure a
cancer by local means, chloride of zinc would prove the most for-
midable antagonist we could bring to bear against it. Its power
to arrest phagedenic action is wonderful. The medicine has more
than a cauterant property: it is peculiarly alterative. Judiciously
394 ORAL DISEASES AXD SURGERY.
applied to any indolent, irritable, or bad ulcer, it will be found to
tend markedly to a change for the better.
Concerning the use of this agent in cancer, vre have many com-
mendations, particularly from European surgeons; but, as can be
very readily apprehended, nowhere in the range of its application
is more judgment required for its proper employment than here, for
it is a cauterant, a stimulant, an antiseptic, and alterative. Dr.
Zuerine, of Vienna, relates a case of cancerous ulceration of the
septum nasi which threatened to destroy the whole nose ; one grain
and a half of the chloride of zinc, he says, were dissolved in one
ounce of distilled water, and the scabs being removed, the sore was
penciled over several times a day with the solution ; at the end of a
fortnight a healthy granulating surface was found underneath the
thick crust which covered the sore, and this being occasionally re-
moved, and the solution reapplied, it cicatrized in five weeks.
Mr. Tuson has published some cases to show the value of cer-
tain preparations of chlorine in cancerous affections. In one which
he publishes there was an extensive cancerous aflTection of the right
breast and neck, which was treated unsuccessfully for a long time,
till a paste was applied, made of one part of chloride of zinc to three
of flour ; this was well mixed, and moistened with water, and then
applied over the ulcerated parts. The zinc was also given internally ;
half a grain was ordered in a wineglassful of caraway-water every
morning. The chloride of zinc paste was applied again, and when
the slough separated, the ulcerated surface healed kindly. The can-
cerous deposition continued for some time, and the dose of the metal
was increased to three-quarters of a grain and continued for three
months. The improvement, although very striking, was not per-
manent, as the patient suffered a relapse which ended fatally. The
case, however, was sufficient to show that the treatment had made
considerable impression on the disease, and especially in healing
the open cancer, which Mr. Tuson had found to be the result in
several other cases.
The great suffering associated with carcinoma makes necessary
the free use of opiates, both locally and internally. Stramonium,
belladonna, aconite, opium and its preparations, hamamelis, are
highly recommended. As much as twenty grains of sulphate of
morphia have been administered during the course of a single
twenty-four hours. Injections by the subcutaneous method, where
morphia is to be long continued, are now generally resorted to. Bat-
ley's solution answers best for this manner of use.
CHAPTER XXVII.
EPITHELIOMA.
In connection with the carcinomatous tumors of the mouth, it
may not be out of place to refer to the affection, not uncommon in
the oral cavity, known as epithelioma. This is a disease commenc-
ing frequently as a superficial ulceration either upon the gums or
mucous membrane of the cheek, and implicating by extension the
underlying osseous structure. When first observed, the ulcer may
not be larger than two or three lines, yet even so small, may be dis-
tinguished by the sore being ragged and irregular. If seated upon
the gum, examination with a delicate and pointed probe will reveal
caries of the bone already in progress. When a diagnosis is doubt-
ful, a few days of ordinary treatment will discover, by its uselessness,
the intractable nature of the trouble, and set at rest any doubts.
Epithelioma as situated upon the lower lip is familiar to every
one; here seems to be its favorite seat. Commencing as a slight
fissure, it runs on to the speedy destruction of the patient, involving
in a very short time the whole lip and surrounding parts, or, as in
less malignant cases, circumscribes itself in the form of an indurated
mass, remaining for a long time, gathering force, as it were, for a final
onslaught.
Epithelioma is cancer, but it differs from medullary, as fatality is
concerned, in seeming to have primarily but a local signification —
at least so it seems to me : left to itself, it will certainly destroy the
life of one affected with it ; taken in time, I am confident it may be
cured. Let me qualify, however: safety through early operation
may exist only in the less marked form of the disease. That I have
cured epithelioma by operations, I have surviving patients to show.
That they have died after operations quite as carefully and judi-
ciously performed, the grave, I am sorry to say, holds examples
from me.
When commencing in the skin, epithelioma is apt to present itself
in the warty or indurated form ; on clean mucous membrane, as an
ulcer. Situated upon the lip or anus, having thereby associations
(395)
396 ORAL DISEASES AND SURGERY.
with both skin and mucous membrane, it may present itself in either
form, or even pedunculated. When indurated, the virus of the dis-
ease seems circumscribed ; when ulcerated, it appears to be more or
less infiltrated through the adjoining tissues. This relationship of
the virus in the two conditions would seem to be proven by the rela-
tive success of operations performed upon them ; the indurated, par-
ticularlv the warty, being always the most amenable to treatment.
It is generally understood that the edge.^ of an epithelial ulcer are
hard and indurated, but this is not always the case, as my own expe-
rience has exhibited to me. Indeed, such ulcers are very much like
chancres, hard and soft, and would be exactly like them were it not
for the dilference in the bottoms of the sore, the one being pasty,
the other fungous.
The relative frequency of epithelioma situated inside the vestibule
compared with that upon the lip, its favorite seat, is about as three
to twelve. The relative danger of positions may be reversed. Situ-
ated within the mouth, operative interference cannot be practiced
at too early a period ; in other situations, circumstances may ex-
cuse delays. Operations, to promise any hopes of success, must be
thorough ; it is not enough to remove the apparent disease, the
more of neighboring parts embraced in the incisions the better.
Complete excision, when it can safely be practiced, is always the
preferable treatment.
Two cases, directly opposite in character and result, will serve as
instructive illustrations.
Mr. N., carpenter by occupation, was sent to me laboring under an
indurated tumefaction involving a full half of the inferior lip : the
tumor was semi-bluish, slightly lobulated and painful, had existed
for over a year, was gradually enlarging and softening. The diag-
nosis of epithelioma but verified the opinion of several other practi-
tioners who from time to time had examined it. Recommended the re-
moval of the whole lip, which was concurred in by the patient. The
gap, which was made in the ordinary V shape, great as it was,
being carried from either angle of the mouth to the symphysis
menti, was filled up without any considerable effort by forcing the
cheeks toward the mesial line, retaining them in position by an
extemporized Dewar's compressor, and approximating the edges of
the wound with the hare-lip pin and suture. The wound united
happily by first intention throughout, and although at first the
stretched tissues bound the lower jaw so closely as almost to pre-
vent the patient opening the mouth, yet at this date, and indeed
EPITHELIOMA.
397
in three months after the operation, so completely had the parts
accommodated themselves to the new condition of things that one
would almost fail to detect that the natural parts had ever been
interfered with. The success of the treatment has been all that
could be desired ; nearly three years have passed, and there is not
the slightest evidence of a return of the trouble.
Tig. 83.— View of Cask.
Case II. — EpitheJioma of Gum. — M. G., aged about twenty-one,
farmer by occupation, was sent to me about two years back by Dr.
Edward Townsend, whose dental patient he was. Dr. T., while
treating a bicuspid tooth, remarked at the neck a slight ulceration,
but which appearing of little consequence, scarcely at the time com-
manded more than a passing thought. Attempting, however, at a
later period its cure, its obstinacy in yielding excited his suspicions,
and being unwilling to assume the trouble of the case, he directed
the patient to my care. Examination made on first meeting the
patient revealed a small ulcer on the left superior gum between the
bicuspid teeth, in size about half as large as the silver three-cent
piece, jagged, covered with a whitish gummy secretion, and ap-
parently superficial. The passage of a sharp probe through the
center of the ulcer revealed the characteristic carious, softened, and
periosteally denuded bone. Satisfied in my own mind of the char-
acter of the ulceration, yet unwilling while there might be an unre-
futed doubt, however slight, to depress the patient by informing
him of the nature of his disease, I placed him under ordinary treat-
ment for a period of two weeks, at the end of which time, finding
my experience agree with Dr. Townsend, I laid before him his con-
dition, advising an immediate resection of the affected and adjoining
parts. Unwilling to submit, the patient desired consultation, and in
turn the advice of every prominent surgeon in the city was obtained.
Opinions differing, he, by my advice, submitted himself to various
proposed remedies, being treated two weeks by one gentleman, eight
398 ORAL DISEASES A\W SURGERY.
weeks by a second, and nine by a third, the disease progressing, but
slowly, all these weeks. At the end of this time I again proposed
and insisted upon an operation, informing the patient of the neces-
sarily increased magnitude of the portion of bone and soft parts to
be removed • still refusing, I declined to take further responsibility
in the case. The patient making me a visit at a later period, I found
the ulceration involving the Stenonian duct, and extending from the
symphyses to the tuberosity of the bone. At this visit I informed
him of the utter hopelessness of any operation for his relief, the dis-
ease being too extensive From this time to that of his death, which
happened in a few months, he was in the hands of different adver-
tising impostors, and of the treatment pursued I know, and desire to
know, nothing. Whether or not an early operation would have saved
this patient from his early death I may not of a certainty say, but
from a rea»sonable experience in the direction I may assert that with-
out the performance of such proposed operation he had no possible
chance.
Fig. 84. — View of Case as first seek.
Case III. — Col. W., merchant. Epithelioma involving, when first
seen by me, lip, tongue, and cheeks — case hopeless. The disease in
this patient began as a minute tubercle just over the genial bodies
of the inferior maxilla ; thought little about it, only received atten-
tion when found ulcerating, such attention, from misappreciation of
its character, consisting in the too common application of caustics.
Aggravated by such treatment, the ulceration commenced rapidly to
spread, defying, when too late understood, every means employed
for its arrest. Shortly after coming under my care, the lip fell off in
mass, the root of the tongue indurated to such an extent as to inter-
fere with both respiration and deglutition, and the patient, a fine
robust man, died from prostration.
EPITHELIOMA.
399
It must be clearly seen that whatever chance existed for this
patient, it lay not in exciting and aggravating by caustics, but in
the complete removal of the primary tubercle with all the immedi-
FiG. 85. — View of Case.
ately adjacent tissues. That error, if error there be, shall be on the
safe side, I make it a rule always to cut away, with a large margin,
such tubercles : if they are benign, little harm has been done ; if
they are malignant, the free removal has perhaps saved a life.
Epithelioma when involving only a part of the tongue, and when
markedly circumscribed, may be operated on with a warrantable de-
gree of success ; it is better in these cases, particularly if the indura-
tion is at all extensive, to amputate all that portion of the organ in
mass associated with the disease ; for this purpose no better instru-
ment can be employed than the ecraseur of Chassaignac ; no hemor-
rhage attends the operation, and if the system has been properly
prepared, the subsequent inflammation is not of any considerable
importance. When, however, not only the tongue but neighboi'ing
parts are involved, any operation promises very little, — one ulcer or
tumor may be managed, two seldom or never. (See Diseases of
Tongue.)
The term epithelioma is not, however, to be received as neces-
sarily equivalent to a dangerous disease. In the work of Professor
Henry H. Smith, on Surgery, occur the following passages on this
subject, which can only be read by the student to his profound ad-
vantage :
" When from any cause irritation is developed in the skin, its ap-
pendages, or in the mucous membranes, the normal action that daily
400 ORAL DISEASES AND SURGERY.
casts off dead epithelial cells is increased, and may be followed by
hypertrophy, or by such thickening, degeneration, and ulcerative
action as will materially modify the normal condition. Tumors thus
formed on the skin and mucous membrane by the accumulation of a
largely increased number of epidermic and epithelial cells, united
together by filaments of fibrous tissue, and furnished with blood-
vessels, as the result of the organization of the fibrinous deposit,
have been called, by Hannover, Epithelioma.
" Epithelioma vary considerably in appearance. If the result of
the irritation caused by pressure on the skin, they constitute Corns
of common language, and are a true hypertrophy of the epidermis.
When the epidermic cells are closely packed together by pressure,
they create Hard corns ; when the cells are more distinct and dis-
posed to a papillary arrangement, owing to the presence of a greater
amount of moisture, they form Soft corns.
"When the epidermic cells accumulate upon a surface in conse-
quence of the increased action that follows a local congestion or
simple redness, they form the varieties of skin disease known as the
Squamae or Scaly Class, as Psoriasis. Condylomata and Venereal
warts are analogous tumors, usually found on the points where the
skin and mucous membranes blend, as the corona glandis of the
penis, the vulva, and anus, or about the lips and nostril. Both
venereal warts and condylomata are developed apparently in some
instances in consequence of a peculiar contamination, as has been
described under the head of secondary syphilis. When closely ex-
amined, condylomata are found to be formed of a congeries of papillae,
sometimes flattened on the top, while others have fissures that lead
down to a common stalk. When small, condylomata are mostly
composed of epithelial scales, but in the larger growths there is
more or less areolar tissue supplied with small blood-vessels. A
vertical section exhibits a vascular loop surrounded by a basement
membrane, external to which are layers of epithelial cells that vary
in thickness.* Common skin Warts, as often seen on the hands,
belong strictly to the class of epithelioma, being formed of epithelial
cells not compressed, and of a papillary form. These are mainly
the result of some local irritant that increases, on a circumscribed
spot, the epidermic cell action. All these tumors, when inflamed,
may undergo fatty degeneration, softening, and ulceration, creating
ichorous and irritating discharges, and sympathetic irritation of ad-
* Bennett's Lectures.
EPITHELIOMA. 401
jacent lymphatic glands, those of the groin occasionally enlarging
from irritated corns on the toes, and those of the axilla from inflamed
warts on the fingers.
" The greater vascularity of mucous membranes modifies the forma-
tion of epithelioma in this tissue, the induration or small scaly wart
degenerating and ulcerating, and creating, through inflammatory
action, more or less induration of the parts immediately adjacent.
" When any irritation develops this action on a mucous membrane
or where raucous tissue and skin blend, it is apt to create an ulcer-
ated epithelioma that is difficult to heal. This variety is found on
the margin of the lip, in the aire of the nostril, in the inner canthus
of the eye, after fissure of the nipple, on the tip and margin of the
tongue, on the os uteri, as well as on the vulva, prepuce, and anus.
The rodent skin ulcer of the scrotum, and lupus are also assigned to
this same class of growths. When in these localities epithelioma
is developed, it commences as a flattened induration or scale, which
is followed by a slight crack or fissure, and an ichorous watery ex-
udation that is irritating. Hence increased action, then ulceration,
with induration of the margin, so as to give an apparent depth to
the ulcer, which is, in reality, quite superficial. The pus from this
ulcer being small in quantity, soon dries and forms a scab or scale,
which, being accidentally removed, is followed by slight bleeding and
another crust, the reproduction being in this manner continued for
months. When these ulcers are examined microscopically they
present on the surface masses of epithelial cells in all stages of de-
velopment. The lymphatic glands near these ulcers often enlarge,
and are secondarily affected, in consequence of which many writers
regard this variety of epithelioma as analogous to cancer. That
epithelioma may assume the cancerous peculiarities under some cir-
cumstances, is beyond question ; but it is equally certain that it is
erroneous to regard all epithelioma as cancerous, some of the cases
being only evidence of disordered epidermic and epithelial cell ac-
tion, and capable of perfect cure.
" The opinions of pathologists, on the identity of epithelioma and
cancer, are, however, yet much divided, Paget, Yelpeau, and Schuh
regarding it as cancer, and calling it epithelial cancer, while Lebert,
Hannover, Bennett, and Lawrence deny its cancerous nature.*
Lawrence thus arranges the arguments :
* Lawrence on Cancer, 1858.
26
402 ORAL DISEASES AND SURGERY.
I. For Epithelioma being Cancer.
" 1. Its infiltrating character.
" 2. Its tendency to infect the lymphatic glands.
" 3. Its tendency to recur after removal.
" 4. Its fatality.
II. — Epithdioma is not Cancer.
" 1. From the excessively rare occurrence of consecutive deposits.
" 2. Its anatomical structure.
" 3. The absence of primary cachexia.
" 4. Its frequently local origin.
" A careful study of the question, seconded by some experience,
induces me to regard the question as thus correctly stated :
" 1st. Epithelioma exists as a distinct growth, characterized by
epithelial cells, as in corns, thickened skin, horns, warts, etc.
" 2d. These may become the seat of cancerous action, and run the
course of cancer to degeneration, though in the least marked form,
being then well designated as ' cancroid.'
" 3d. There is a cancer of the skin and mucous membranes, origin-
ating in the follicles, that presents the usual elements of cancerous
action elsewhere, which yet presents epithelial cells, and the other
normal elements of the tissue invaded.
" 4th. Simple epithelioma is to be regarded as really a hyper-
trophy which, when inflamed or irritated, ulcerates and undergoes
the usual changes of healthy inflammation.
" When, as is sometimes seen, a sebaceous follicle participates in
the increased epidermic cell action of epithelioma, it results in a
thickened growth that is so indurated as to be called a Horn. Some
of the instances of this development, and especially one well known
to visitors in Paris, on the forehead of a woman, have attained
several inches in length.
"Anatomy of Epithelioma. — The cut surface of an epithelioma
is generally grayish white in color, and the texture is solid or semi-
solid, quite friable, and does not generally yield anything resembling
the ' cancer juice.' Microscopic examination shows infiltrated among
the textures of the part affected, great numbers of cells of irregular
shape, ^-^g to -j-^^-^ of an inch in their long diameter, which more or
less closely resemble normal epithelial scales ; whence the name of
the disease. Besides these free nuclei, the peculiar bodies, the
EPITHELIOMA.
403
'globes epidermiques ' of Lebert, and the 'laminated capsules' of
Paget, can be observed, as well as spindle-shaped cells, which are
often found in considerable number, according to Wedl, who asserts
that the idea that epithelioma exhibits no forms which cannot be re-
ferred to the epithelial type, is based on the most imperfect research.
" Diagnosis. — A clinical diagnosis can generally be made before
the removal of the tumor, if the age of the patient and the papillary
character of the growth, as well as its locality, be regarded. Occa-
sionally ulcerated scirrhus of the skin and mucous membranes, and
perhaps lupus, may be confounded with epithelioma. Both these
errors will, however, at once be rectified after the removal of the
growth and a study of its minute anatomy, with the assistance of
the microscope.
" Treatment. — Epithelioma demands varied plans of treatment,
in accordance with the nature and locality of the growth. Hard
corns and the scaly varieties are often cured readily by protecting
the part from pressure, or by softening ointments and plasters.
Condylomata and venereal warts may be destroyed by chromic or
nitric acid or powerful astringents. The same treatment is applicable
to warts on the hands or generative organs, not the result of syphilis,
being in the latter case consequent on inattention to cleanliness or
the presence of acrid discharges. The ulcerated variety will gen-
erally require such treatment as is applicable to cancer of the skin,
under which head it will be stated. Epithelioma of the canthus of
the eye, alse of nose, and the superficial variety seen on the lip, os
uteri, etc., is best treated by the repeated application of the dry,
powdered sulphate of zinc, as proposed by Simpson, of Edinburgh,
the application being repeated until a healthy surface is produced,
and then dressed as a healthy ulcer. In the simpler forms seen in
the OS uteri I have obtained much success from this treatment. The
addition of powdered gum arable will dilute the application when
desired, and also favor its adhesion to the surface."
PLATE VIII.
APPEARANCE AND POSITION OP SOME OF THE TUMORS SEEN ABOUT
THE NECK.
Fig. 1. — A large Cystoma of the right parotid region, caused hy the devel-
opment of a sebaceous follicle in consequence of a blow upon the
part. Commencing as a lump the size of a nut, this tumor gradu-
ally increased to nearly the size of the head; gave exit at one
time to sebaceous matter ; had a broad base ; was nearly immov-
able ; had the veins enlarged upon its surface, and showed a small
ulceration in front, from which fetid, acrid, and bloody sanies had
escaped. As the tumor enlarged the jaw became closed ; sensation
of the face diminished, and there were all the other symptoms due
to pressure on the vessels and nerves of the part. The tumor dif-
fers in appearance from scirrhus of the parotid gland in its size
and period of development. It was readily removed, and is rep-
resented as an example of one of the class of tumors of the parotid
region not involving the parotid gland. — After Auvert.
FiQ. 2. — Large Adenoid Tumor of the Neck dependent on degeneration of
the lymphatic glands of the neck. Arising as a small swelling
caused by an enlarged gland below the angle of the jaw, it gradu-
ally increased until it occupied the entire side of the neck, involv-
ing many glands, and reaching from above and behind the ear to
below the clavicle, so as to turn the head to the opposite side. Its
appearance was that of an irregularly lobulated mass : it was un-
accompanied by pain, was perfectly firm and hard, and gave no
sense of fluctuation at any point. Under the use of chloroform it
was successfully removed by Mott. — After Mott.
FiQ. 3. — Appearance of an immense Adipose or Lipomatous Tumor of the
Neck. This tumor was not painful ; had no pulsation ; was formed
of numerous large lobes, with the superficial veins distended over
them, and was attached to the neck by a large pedicle which ex-
tended from the angle of the lower jaw on the right side down to
the sterno-clavicular articulation, its weight being so great that
the patient could hardly retain the erect position. The tumor was
found to be covered by a strong capsule formed of the surrounding
cellular tissue', and to have originated in a hypertrophy of the sur-
rounding adipose tissue. — After Auvert.
Pig. 4. — A large Cystoma of the left Parotid and Submaxillary Kegions,
which was to the touch semi-elastic, unequally lobulated, and due
to a chronic irritation of one of the sebaceous follicles, the duct
of which had become closed, and thus caused a retention and de-
generation of its secretion. — After Auvert.
(404)
CHAPTER XXYIII.
TUMORS OF PARTS ASSOCIATED WITH THE MOUTH.
The sebaceous, the cystic, the fatty, and the glandular tumors are
those most frequently found in association with the integuments.
The first, the sebaceous, are perhaps the most common, and are
as simple in nature as they are easy of cure. As the result of a
blow or other cause, the orifice of one or more of the duets of the
sebaceous glands becomes obstructed ; the secretion continuing and
having no outlet becomes necessarily accumulated; hence the
gradual expansion of the duct and formation of a tumor. As this
tumor continues to enlarge it becomes more and more solid, the
result of the absorption, or, if not this, at any rate the disappear-
ance of its more liquid contents, until finally, to the touch, it be-
comes springy and elastic. A section of such a tumor exhibits a
delicate cyst wall or envelope, and cheesy or semi-fatty contents ; it
is seen to lie in the integument as distinctly as a walnut lies within
its hull.
Sebaceous tumors are found of every size, varying, indeed, from
a hazel-nut to a foetal head ; they are generally spheroidal in shape,
but frequently, because of influences exerted by neighboring parts,
become changed, even to a lobulated character.
The diagnosis of a sebaceous tumor is generally not at all difficult
— it rolls under the touch, can be circumscribed by the grasp, has a
detached feel, as if confined to its place alone by the skin; the tis-
sues enveloping it are perfectly healthy, while, however large it may
be, no evidences are given of constitutional association. Exceptions,
however, exist to this simplicity in some special cases, as, for ex-
ample, where the presence of the tumor has excited inflammation in
the surrounding parts, thickening the cyst and forming attachments,
or where the attenuated skin has ulcerated, or where the contents of
the cyst has degenerated.
Sebaceous growths are only to be gotten clear of by operation. In
many cases it is only necessary to make a sufficient incision in the
skin, and the tumor can be enucleated, just as the crystalline lens is
(405)
406
ORAL DISEASES AND SURGERY
removed in the operation for hard cataract. In other cases it is
necessary to incise the tumor through its center down to the base ;
this exposes the cyst or sac, which is to be dissected away. In in-
stances of moderate or large growths it is the practice to commence
with an elliptical incision, making the skin removed correspond
with the requirements of the parts after the tumor shall have been
taken away. In doing this it will be found much better to have too
much than too little integument — even very large flaps will be found
soon to accommodate themselves to the parts beneath.
Fio. 86. — Small Sebaceous Tumor, showing its sacculated condition.
The contents of sebaceous tumors, while really of a common
character, yet vary very much not only in appearance, but in con-
sistence. Yet, whatever this consistence, the springy, elastic char-
acter, as the touch is concerned, is preserved. Prof. Gross, in his
" System of Surgery," describes such tumors as of soft and doughy
consistence, giving this as one of the diagnostic features. The ob-
servation certainly differs from my own, and I am at a loss to ex-
plain such difference. These tumors, while very fi'equently multi-
form when appearing upon the scalp, where they are known as the
common wen, yet seldom appear but as single upon the face.
Sebaceous tumors have little vascularity, the supply of vessels
being confined to the sac, which, as will be inferred, is the attenuated
duct and glandular substance ; hence the growth is of very slow
character. Little or no pain attends the development, and they are
entirely devoid of danger, as any tendency to malignant degeneration
is concerned. The sac, because of attachments which it has formed
outside, is generally, on such aspect, rough and cellular-looking; on
the inner face, on the contrary, it is smooth and glistening.
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 407
Cystic Tumors. — Cystic tumors, or, more justly spcakiug, cellu-
lose tumors, are of not unfrequent appearence in the cheeks. They
might be described as an hypertrophy of the subcutaneous cellular
tissue, and would be very well represented by esteeming them as
made up of a number of air or serum injected cells, grouped to-
gether, and limited by the adjacent fascias. The skin above such
tumors is always attenuated and generally discolored, even to an ap-
proach to purple, looking, indeed, as if just ready to slough awav,
and yet being tenacious of its vitality to an extent quite wonderful.
Similar tumors are occasionally found in the substance of the lips,
but are much more apt, in this situation, to be made up of a single
cell rather than many. In origin they may be said to be idiopathic,
coming, as it were, of themselves, and occasionally disappearing as
spontaneously, having, in the interim, failed to respond in the
slightest degree to treatment.
These tumors, unless in situations which permit of the use of
the knife, which is their effectual cure, are found very difficult to
manage ; the only thing that ever seemed to me of the slightest
service was the daily smearing of the surface with creasote ointment,
and this practice will be found unsatisfactory enough. In their
treatment I have broken up the cells, have laid the tumor open in
bulk, and stuffed the cavity, have used every conceivable kind of an
injection, and then, completely discouraged and baffled, have left the
case to nature, which, after six months, or it might be a year or
more, would finally effect a cure.
The most common seat of such tumors is over the line of the
Stenonian duct ; and, if I had not succeeded in satisfying myself
thoroughly to the contrary, I would have to believe that some con-
nection existed. Whether cured by nature, with or without assist-
ance, they are peculiarly liable to recur. I have known them appear
and disappear as many as half a dozen times. They seldom rise
much above the level of the cheek, are oblong in shape, and, indeed,
now that the idea just strikes me, look more like a varicose vein
with hypertrophied valves than anything else to which perhaps one
might compare them.
Another kind of cystic tumor, appearing in the integuments of the
face, occasionally met with, may be compared to a cyst of cartilage.
Such cysts seem to prefer as a locality the side of the nose, and when
in this situation are connected with the lateral cartilages. If opened
from beneath, they will discharge, on compression, a puslike fluid, but,
in a very few minutes after such pressure is removed, will refill, or
408
ORAL DISEASES AND SURGERY.
will, at least, reassume their original form, recovering, perhaps, by
the elasticity which resides in them
Another, and the only other situation in which I have met with
such tumors, is in the substance of the lip ; but here they more re-
semble fibro-cartilago than when upon the side of the nose. Extir-
pation by the knife is the proper treatment, although it not unfre-
quently happens that a cure may be effected by cutting into the cyst,
scarifying its walls, and stuffing with medicated lint; the tinct. of
iodine being used first, and alum-water and capsicum after.
Fig. 87. — Cartilaginous Cyst.
Fatty Tumors. — The fatty tumors are much more common to
the posterior and lateral aspect of the neck than to the face. Where-
ever appearing, however, they are recognized by their extreme slow-
ness of growth, by the tissues overlying them being unaffected, by
the absence of pain, and of constitutional association. To the touch
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 409
they are not so diagnostic, being at one time springy and elastic, at
another dull and doughy. Being an hypertrophy of the common fatty
tissue, they are not distinct and circumscribed as the sebaceous, con-
sequently are of broader and more diifused base ; such tumors may or
may not be sacculated, such sacculation, however, referring to a very
imperfect cyst even when any signs of one may be present. Fatty
tumors seldom manifest any tendency to degeneration, troubling
more from a constantly increasing bulk, and the annoyance of their
presence, than from any real harm inflicted. Fig. 3 in the plate rep-
resents a most unusual form of the lipomatous tumor, a case such as
is seldom met with. In this instance the growth, from its very
weight, has become pedunculated, the vascular enlargement being a
natural and simple result of mechanical interference with the circu-
lation. Fatty tumors are only to be treated by the knife ; it is simply
a waste of time to try other means.
Fig. 88. — Lobulated Lipomatous Tumor — after Miller.
Glandular or Adenoid Tumors. — Glandular tumors, represented
in the plate. Fig. 2, belong markedly, although not exclusively, to
the scrofulous condition, being found, most generally, upon persons
so affected. These tumors are generally situated upon the side of
the neck, involving one or more of the superficial ganglionic chain.
In undecided cases I have known them of such torpidity that two or
three years would scarcely suffice to develop them to the size of a
walnut, while, in other cases, the enlargement will be so rapid that
a very few months may be sufficient to obtain the prominence marked
in the plate. Unlike the previous classes of growths, the adenoid
are very susceptible to constitutional and local treatment, being, in
410
ORAL DISEASES AND SURGERY.
such manner, quite as frequently caused to disappear as by the use
of the knife.
Fig. 90. — Yiew of Fatty Tumok
PiQ, 89. Microscopic Structure removed from ukder the Tongue
OF AN Adipose Tumor (Bennet). (Liston).
When appearing upon the face, such tumors imply the enlarge-
ment of the buccal glands ; in these instances they are not so apt to
have the scrofulous association as when found upon the neck. In
considering such growths, we are primarily to investigate the cause
or causes exciting to their development. Scrofula, the common
cause, has been, to some extent, considered in another part of this
work ; its general recognition as a dyscrasiac disease suggests the
necessity of such a course of medication as shall tend to restore the
lost tone, and build up the system at large ; hence the use of tonics
so freely prescribed in such connection. Regarding the local reme-
dies to be employed, a common preference seems to be given to the
iodine in tincture. Overstimulation, however, it is not to be forgot-
ten, is quite as bad, or even worse, than no stimulation at all, and,
by a too free use of this agent, even more harm than good can be
done. Harmony in the system at large being secured, it will be
found to need very little local stimulation to provoke absorption
in the tumor ; hence a philosophical treatment of such cases con-
siders not only medicaments proper, but the bath, dress, food, exer-
cise, etc.
A local treatment to be used in very indolent growths, consists of
equal parts of the belladonna and mercurial ointments. Such an
ointment, in my experience, causes these tumors to absorb very
rapidly, or otherwise to degenerate into pus. I have used this
combination in many cases with the most satisfactory results.
Another mode of treatment is by the blister. For this purpose
the cantharidal collodion will be found admirably adapted. Blisters
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 411
should be in proportion to the size of the tumor, never covering
more than an eighth or quarter of its free surface.
In cases where it may be thought preferable to use the knife,
should the tumor be upon the face, the incisions are to be made in
the line of the underlying muscles, thus insuring as little deformity
as possible from the scar.
Adenitis from a syphilitic association may yield tumors of the
cervical and buccal glands. A diagnosis in these cases is secured
from the history of the case, or, if this is not to be procured, an en-
largement will always be found to be associated in the posterior
cervical chain. This is a most diagnostic sign, and will seldom
mislead.
ACCIDENTAL TUMORS.
Tumors of the parts we are considering, which might be termed
accidental, are the erectile, the lepidoid, the verrucous, the keloid,
and the horny.
Angionoma, Yascular, or Erectile Tumors. — Under this desig-
nation are included naevi materni, or mother marks, and the venous,
arterial, and capillary growths.
Naevi, as suggested by Professor Smith, cannot always come
justly under the designation of tumors, from the fact that they fre-
quently exist without apparent elevation ; situated in the skin, yet
producing no visible thickening of it. These marks are of very
various size, form, and color, being sometimes found several inches
in length, and again as mere spots. In form they may represent
certain familiar objects, as fruits, animals, etc. The color of them,
generally, some shade of red, varies from the arterial scarlet to the
dull purple of a venous congestion. Nsevi, even although to the eye
they may not in many instances appear vascular, yet certainly differ
only in degree from the telangiectasis, being commonly capillary
hypertrophies, as is sufficiently witnessed when wounds occur in
them. That such vascularity does not, however, shade off into the
adjoining tissue is sufficiently well recognized ; indeed, just the con-
trary, the connection being indeed very limited. Such tumors are
supplied by two or three large vessels, the hypertrophy of whose
radicles may, for practical purposes, be esteemed as constituting the
tumor; hence, in operating on such growths, if the incisions are
made wide of the tumor, there is found no more perhaps than ordi-
nary hemorrhage — one or two vessels alone demanding the ligature.
Arterial Tumor. — This is a form of the erectile growths which
412 ORAL DISEASES AND SURGERY.
has an individuality, inasmuch as it consists fairly of a congeries of
vascular twigs, held together by the more or less imperfect remains
of the associated skin and cellular tissue. It is not, as has been sug-
gested, an aneurism, but is rather a simple enlargement of terminal
vessels, proven from the fact that such enlargement accompanies the
vessels of supply for a greater or lesser distance ; that it differs,
however, from the naevi, just described, few are prepared to admit.
It is, perhaps, a formidable nsevus, but nothing more, both being, in
varying degrees, erectile tumors.
The origin of these growths, while in many instances referable
to local injuries, yet in most cases are fairly to be presumed of con-
genital character. It is very true that they may appear even later
in life, yet the impress existed, although it might have been but a
little red spot not larger than the head of a pin, and may have en-
tirely escaped attention.
The growth of such tumors is markedly variable. I have met
with them where twenty years seemed scarcely to have changed
their character, while in other instances a single week has exhibited
alarming progress. In some cases the attenuation of the coats of
the vessels is so great that one might well imagine he can see the
flow of the blood, while in other instances, a hypertrophy of the
associate tissues is so marked as to comparatively solidify the part.
In color the arterial tumor will also be found to vary, the shading
being influenced by the conducting facility of the veins which are
to pass off the circulation. Pulsation exists in many of the cases,
and is synchronous with the ventricular systole. To the touch, the
tumors are soft and doughy, being made to almost disappear under
pressure, yet filling up the moment such pressure is removed; they
have no definite form, the outline being modified by circumstances,
of which we know nothing. One marked diagnostic sign of such
tumors is the effect produced on the size by the condition of the
circulation; verat. viride, or digitalis, by lowering the action of
the heart, will almost cause those of moderate size to disappear.
Even the quietude of sleep and recumbency markedly affect them.
Passion, on the other hand, excitement, or any mental emotion dis-
turbing the pulse, will cause them to enlarge, even in some instances
to bursting, such enlargement being most marked in cases where a
state of atrophy characterizes the connective tissue. The common
danger from these tumors is ulceration, which, in many instances,
resulting in severe hemorrhage, has gradually, if not suddenly,
exhausted the patient.
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 413
The Venous Tumor. — This is still another form of the erectile
growths, differing, however, from the one just described, in the fact
that the venous, rather than the arterial, twigs, are in a state of en-
largement. A description of the one is a description of the other,
saving in the matters of color and pulsation, the latter being gen-
erally dark, almost to a dull purple or grayish-black, and of course
deficient in pulsation. Like the arterial, the venous tumors are
sometimes slow of growth, at other times rapid; they appear without
assignable cause, other than the congenital impress.
Fig. 91. — Venous Tumor.
Treatvient. — Nsevi are treated on a common principle ; by ampu-
tation with the knife, by strangulation, by compression, by injection,
and by the application of caustic remedies.
Excision is chiefly confined to small tumors, before, as remarked
by Prof Gross, they have acquired much functional activity, or
given rise to any marked enlargement of the neighboring arteries.
In these cases excision is the easiest and most rapid way of getting
clear of them. The general experience to cut as wide of the growth
as convenient is the principal rule ; as the vessels of supply are cut,
an assistant compresses them with thumb or finger ; and while such
vessels are frequently very formidable looking, yet it may happen
that when the tumor is entirely away, not a single ligature shall be
required. Should the hemorrhage not, however, cease, it will be
found the easiest matter to catch them with the forceps or tenaculum,
and throw a ligature around them.
A removal effected, and the bleeding controlled, nothing remains
but to close the wound with a few stitches of the interrupted suture,
and to support it with adhesive strips.
414 ORAL DISEASES AND SURGERY.
Strangulation, the most common mode of operation, is effected by
transfixing the tumor with one or more ligatures, and thus sloughing
it away. As a general rule, it will be found necessary to transfix
skin as well as tumor ; but should cases present where the overlying
parts arc healthy, then a crucial incision may be made, and the flaps
laid off before such transfixion ; the tumor removed, the flaps are
laid back in place, and dressed secundum artem.
Compression applies to pressure however made. Take a piece of
ivory, metal, or other convenient material, adapt it to the part, and
confine by means of bandage or adhesive strips. This mode of cure
is rarely applicable, being used only over bony surfaces, and where
the tumor is quite small. A practice, which in one instance, where"
the tumor was situated upon the finger, answered a satisfactory pur-
pose, consisted in the daily application of tinct. iodine four times the
officinal strength, together with the use of an india-rubber ring.
Collodion, daily applied, has been recommended
Injections have many advocates : of agents thus used, the princi-
pal are iodine, Monsel's solution, nitric acid, and creasote. Such
mode of treatment is always, however, more or less risky, and is not
to be commended. The practitioner disposed to try it has only to
use the ordinary subcutaneous syringe, break up, with its point, the
structure of the tumor, or some portion of it, and follow with the in-
jection. Several cases of death are on record from such injections.
Caustic remedies, used to destroy such tumors, are of various
kinds, — the Vienna paste being mostly preferred ; this is the potassa
cum calce of the pharmacopoeia: it is used by making an applica-
tion of from ten to twenty minutes, succeeding it with an emollient
poultice.
Another method is to paint the part with the blistering collodion,
and, after the cuticle is raised, apply crystals of the chloride of zinc.
Landolfi's caustic is thus composed :
B. — Bromin. chlorid. 3 parts;
Zinci, 2 parts ;
Antimon. 1 part ;
Pulv. rad. glycyrrh. 1 part. M.
Still another is called Fell's. It is composed as follows :
R. — Pulv. rad. sanguinar. Canaden. ^i ;
Zinci chl. Jij ;
Aqua, f5ij.
This is paixed, forming a thick paste.
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 415
The application of Dr. Mackey, of Edinburgh, is as follows :
R. — Hydrarg. bichlor. 4 parts ;
Collodion, 30 parts. M.
Paint the part thoroughly ; four hours afterward apply a warm-
water dressing ; the eschar will slough out in from three to six
days.
In the application of any caustic, trouble, more or less severe,
from a resulting inflammation, is always to be anticipated ; this
every patient, or the friends, should understand, as it is impossible
to know just how a case shall come out. After the use of a caustic,
and the slough of the part, the resulting wound is to be esteemed
and treated as a simple ulcer.
Starvation is still another method of treating the erectile growths.
This consists simply in finding the vessel or vessels of supply, and
cutting off the circulation by ligation ; this mode has many advo-
cates, and is certainly well where the vessels are in a position to be
conveniently operated on.
The seton is still another mode. This is introduced by threading
the needle with tape or other material, and passing it beneath the
growth. The seton, whatever the material, should be as large, if
not larger, than the needle which carries it ; thus, by the pressure
secured, guarding against hemorrhage.
In considering the treatment of nsevi, it is not to be forgotten that
there are cases which, if left to themselves long enough, might
effect self-cure. Young children, afflicted with nsevus, are hurried
to the surgeon, under the impression that it must necessarily spread,
and that therefore the sooner the disease is removed the better.
Such haste will not always be found necessary, or even prudent.
For a short time after birth a nsevus may continue to grow — for
several weeks, perhaps, then it may cease to enlarge. If it is of a
simple cutaneous variety, it may become the seat of ulceration;
this may spread, but it will destroy the naevus. In other instances,
a naevus, after growing to a considerable size, will become the seat
of atrophy, will dwindle, shrink, and degenerate, until little or
nothing of it is left.
Lepidoid Growths. — The lepidoid growths are generally mul-
tiple, inferred, primarily at least, to be strictly epithelial in char-
acter, and exhibit themselves as elevated patches of varying size,
scattered irregularly over the parts affected, the common localities
being the cheeks, nose, and forehead.
416 ORAL DISEASES AND SURGERY.
The orio"in of the term, from Aejrt?, a scale, and devdpov, a tree,
affords the idea of the condition the part presents, simply a number
of scattered barklikc scales separated by healthy skin. The dis-
ease without any doubt, is most common to persons of sandy and
florid complexion, having light or reddish hair, with marked cuta-
neous circulation.
Appearing first as scales not larger than a pin's head, the disease
may year by year progress, until finally the scales which, like all
epithelial tissues, have been falling off and renewing themselves,
cease to develop, leaving ulcers. The dermis beneath exhibits a
granular, glossy surface, looking like limited fungi glazed with
lymph; the intermediate skin soon becomes dense and fibro-cartila-
ginous, and if not cured, cancerous degeneration succeeds.
In the treatment of this condition, the paint, composed of tinct.
of iron and quiuia, will be found most reliable. If, however, it
should not effect an immediate good, it is better to at once dispense
with its use, and depend strictly upon constitutional influences. As
a common wash or simple source of protection, bran-water will be
found very soothing. A local application as follows has also been
highly recommended :
B. — Hydrarg. bichl. gr. i ;
Glycerin,
Eau de Cologn. aa ^ss. M.
Verrttcous Growths — Warts. — Warts upon the alse of the nose
are familiar objects to every one. They consist of an hypertrophy
of the papillary structure, and are frequently covered with a sort of
secondary growth, as in what are known as the seed-warts; the
structure is essentially cellulo-fibrous.
Warts are not only objectionable from the stand-point of a de-
formity they produce, but when situated upon the face seem pecu-
liarly inclined to degenerate, assuming a vascularity which always
impresses as threatening. In treating a wart, the practitioner may,
if he choose, first apply dilute chromic acid ; this, in many instances,
will blacken and kill the growth, the tumor sloughing away in the
course of five or six days, leaving the resulting ulcer a perfectly
simple one. But chromic acid is not to be applied to the vascular
wart; on the contrary, if irritable, as generally first seen by the
practitioner, they are to be soothed by the most gentle of applica-
tions, after which they are be thoroughly removed with the knife —
a rule always good in this direction is "Do not irritate." I have
TUMORS OF PARTS ASSOCIATED WITH MOUTH. 417
seen many a vascular wart provoked into the most alarming of as-
pects. A wart, situated upon the face, unless like the simple, hard,
insensible excrescence as met with upon the hands, cannot be too
carefully or judiciously treated.
Keloid Tumors. — Keloide, the French term, signifying a disease
resembling scirrhus, is the name given to one of the most peculiar
and inexplainable of the skin affections. This condition, first de-
scribed by Alibert, is characterized by nodules, or more generally
wheals, scattered irregularly about the body — most commonly, how-
ever, confined to the breast, arms, neck, and face. It occurs in both
sexes, may appear at any time of life, and is thought to be more
common to the black than to the white
Keloid is a disease of the skin and subcutaneous cellular tissue.
That it is an atonic condition is inferred in my own mind from the
fact that in every individual case in which I have seen it there
seemed to be a scrofulous association. This, however, may have
been accidental, as I do not find it referred to by others.
Of the exciting causes of keloid, dermatologists express no opinion :
it is traumatic, and it is idiopathic; it appears upon a skin which
before has seemed entirely healthy, and it springs up in the cicatricial
tissue of a wound. The cicatrices of bad burns from dry heat very
frequently so represent this disease that one might be readily mis-
taken for the other. Keloid certainly constitutes a diathesis ; I
have seen it develop after a simple puncture which opened a boil,
while the observations of others have remarked it appearing in the
cicatrices of smallpox, after scarification in cupping, after vaccina-
tion, blistering, etc. Processes or roots pass into neighboring
parts, thus extending the disease; the excrescences, to the touch
are hard, semi-elastic, and rough; the color differs from the sur-
rounding parts — varying as do the cicatrices of burns. According
to the observations of Professor Gross the parts itch and are more
or less uncomfortable. Any peculiar sensation I have myself,
however, never heard complained of, except, indeed, as the loca-
tion of some wheal would interfere by its stiffness with free motion
in a part.
A keloid tumor seems to be an imperfect fibrous development, a
species of sarcoma — although it certainly differs from the latter con-
dition in never, as far as I know, tending to degenerate.
Treatment. — This has, in every instance, proved so unsatisfac-
tory, that surgeons are agreed in the practice of letting them alone ;
27
418 ORAL DISEASES AND SURGERY.
even the knife is useless, or worse than useless ; if a nodule or
wheal be removed, one or perhaps half a dozen will certainly spring
up in its place. Where the tumors interfere much with motion, they
may be lubricated with glycerin or oil, but otherwise nothing can
be effected by treatment — the only satisfaction to be derived by the
patient resides in the consciousness that keloid never degenerates
into cancer.
CHAPTER XXIX.
THE ANTRUM OP HIGHMORE, AND ITS DISEASES.
Eighteen years spent in a direction of practice which should
have afforded every opportunity for observation, and as well a
scope of view, which necessarily offers to one who is not an un-
frequent visitor at hospitals and clinics — combine to impress me
with the truthfulness and propriety of the conclusion, that the dis-
eases of the antrum, outside of such tumors as have been described, are,
for the most part, simple in character, easy of diagnosis, and not, as
a rule, at all difficult of treatment. Indeed, I have not unfrequently
thought that, for the purpose of general study, one would not be
entirely without justification in asserting that there were but two
sources of trouble to be found in this cavity ; the first, and prom-
inent, being lesions secondary to the diseases of the teeth. The
second, the troubles common to mucous membranes, wherever
situated.
Certain I am, at any rate, that, without fear of successful contra-
diction, I may assert that the great majority emanate from the first
of these directions ; while the atonic conditions, represented by the
dropsies, the puruloid secretions, the mucous engorgements, and the
ulcerations, are nothing different from the ordinary mucoid affections,
except as modifications may be made by situation, the last being con-
clusively proven, I think, by the fact that what is the cure of the
one is the cure of the other.
While thus asserting, however, that in these two directions lie
the chief sources of trouble, I would not by any means be understood
as implying that the subject is unworthy investigation outside of
such considerations ; on the contrary, I am bound to confess that I
find recorded more than one description of diseases of the cavity,
which to me, at least, are as anomalous on principle as they are in
description, and which I can only explain on the ungenerous sup-
position that the authors must have drawn somewhat on their de-
scriptive powers, or otherwise that the antrum has some of the
strangest anomalies.
(419)
420 ORAL DISEASES AND SURGERY.
Again, as a class coming between these uncommon and the common
affections, wo have it, not at all indirectly, that there exists sequela
of certain of the exanthemata which have a special and peculiar
affinity for this cavity; while, in sj-jihilis, I have myself seen the
very first event in the secondary train exhibiting itself in a dis-
turbance of this sinus. That this latter, however, is rare, I well
know from observation extending over thousands of cases in hos-
pital ; indeed, syphilitic troubles of the antrum are so infrequent
even in the tertiary stage of that affection, that my observations
would lead to the inference that the cavity never takes on the disease
unless when, from continuity of structure, it absolutely has forced
upon it, as it were, the trouble, either from its relationship with the
hard palate in the oral direction, or with the turbinated bones in the
nasal ; for, while the practitioner will surely hear complaints, yet, if
he investigates the cause of trouble, he will find, as I so often have,
that mercurial inflammation of periodontal membranes is the source
of offense, rather than the specific condition. Clumsily performed
surgical operations are also the occasional causes of morbid conditions
being set up in the cavity, and which, when existing, would of course
be so evident as to force the consideration of them upon the atten-
tion — the most common of these being the breaking of the fangs of
teeth in attempts to extract these organs.
With these preliminary remarks, we pass, then, at once to a con-
sideration of the premised principal cause of antral trouble — diseased
teeth.
In the chapter treating on "Anomalies of Dentition," attention
was directed to the close relationship of the fangs of several of the
teeth with the floor of the antrum, and to the fact that it was not
unfrequent to find these fangs — particularly the palatine of the
second molar — penetrating the sinus, thus associating their peri-
osteums, and furnishing a continuity of structure.
In the same chapter attention was also called to such diseases
and conditions of the alveolar border as were apt secondarily to
affect the antrum ; means of diagnosis and treatment being sug-
gested. The reader who may feel sufficient interest in the subject
might find it not amiss to review the chapter alluded to, before pro-
ceeding to the consideration of the clinical cases presented, and
which, I think, will sufficiently illustrate this department of diseases
of the antrum.
Case I. — Indolent Tumor on the Right Cheek. — A woman had
ANTRUM OF HIGHMORE AXD ITS DISEASES. 421
an indolent tumor on the right cheek about the size of a pigeon's
egg, occasioning much disfigurement, but altering the color of the
skin very slightly. The patient had often suffered violent toothache
on this side, and, though young, had few teeth now remaining, and
these all carious; otherwise she was in very good health. The
tumor was prominent toward the cheek, palate, and nostril, yielded
on pressure, and gave a slight noise as it returned to its position.
These symptoms caused the practitioner to suspect the existence
of some fluid, which it was necessary to evacuate and follow with
suitable injections. For this purpose, the cheek was drawn aside,
and an incision made into the bone above the gum, with a bistoury,
enlarging it before and backward, till a sufficient opening was ob-
tained, from which escaped an inodorous mucous fluid. The bone
was at no point denuded of its periosteum, the wound was dressed
with a pledget of lint saturated with spirits of wine, and the next
day the patient was better. On the third day she was feverish, the
sinus was swollen and painful, and the discharge acrid and fetid.
These symptoms were controlled by proper remedies, and, after
twenty-four days, the walls of the sinus were nearly restored to
their normal condition.
The canine tooth of this side being very obliquely situated, it was
thought proper to extract it, and thereupon followed an escape,
through its socket, of fluid contained in the sinus, though the tooth
itself seemed perfectly sound. Through this orifice injections were
made. The opening made in the external wall healed promptly,
without any exfoliation ; in six months the tumor entirely disap-
peared, and the patient was cured. (From Baron Haller's Collection
of Medico-Chirurgical Theses.)
The translator of the above case, in commenting upon the treat-
ment, pointedly remarks: "One cannot fail to see the uncertainty,
not to say obscurity, of the treatment here adopted. Though all
the teeth were carious, and their extraction was plainly indicated,
an incision in the external wall of the antrum, or, more correctly, its
destruction, was determined upon. The result we see in the symp-
toms which supervened on the third day, which were, perhaps,
hastened by the spirits of wine. We have here a canine tooth quite
displaced and involved in the tumor ; yet it was long before the idea
of its extraction occurred, though the subsequent discharge, through
its socket, proved how advisable it would have been at the com-
mencement of the treatment. In this way the time of cure might
have been shortened by half."
422 ORAL DISEASES AND SURGERY.
Case 11.— Distention with Softening of the External Walls of
the Sinus. In , says this same surgeon, I was consulted in the
case of a large tumor of the right cheek. The external wall was
much distended and softened, and yielded to pressure, upon the re-
moval of which it gave a sound resembling the crushing of an egg-
shell. The nose was turned to one side — the nostril was ob-
structed — yet the patient suffered no pain, and the skin, though
distended, preserved its natural color. On examination of the
mouth, I found that the crowns of the bicuspidati and molars were
destroyed by caries, which induced me to advise the extraction of
their persistent fangs ; the patient consenting, this was immedi-
ately done. The shock occasioned by the extraction of each of the
fangs, caused a portion of fluid to escape from the sinus through the
natural opening ; it was thin, reddish, saline, and inodorous, and,
in all, about three spoonfuls. The tumor could now be made to dis-
appear by pressure, but would again return to its full size. Pressure
caused no escape of fluid through the nasal, and but slight through
the alveolar opening, which was at the bottom of the first molar
socket, and large enough to admit the finger.
The internal membrane of the sinus was entire, except at the
alveolar opening; through this I made injections of warm water,
strengthened with a little alcoholic vulnerary fluid. The next day
I injected the sinus repeatedly with a decoction of agrimony* and
honey of roses, meanwhile not neglecting external compression. In
fifteen days the parts returned to their natural condition, all crepitar
tion of the bone ceased, and the discharge was very slight. I now
had recourse to stimulating solutions. On the second day the dis-
charge had ceased, and the alveolar opening was reduced to a mere
fissure, and in a month from the extraction of the teeth the patient
was fully restored.
Case III. — Periodontal Abscess affecting the Antrum. — A patient
was brought to me who, for more than three months, had sufi"ered
with a tumor like the above, on the right side. The maxillary
cavity was distended to a level with the orbital margin ; the nose
was turned to one side, and the vault of the palate was remarkably
prominent. I removed the fangs of the first two molars, the crowns
* A mild tonic and astringent. An injection of more character would be
as follows :
R.— Glycerin, ^i;
Tinct. opii camph. ^ij ;
Aqua Cologn. 5iv. M.
ANTRUM OF HIGHMORE AND ITS DISEASES. 423
of which had been destroyed by caries, and which I believed to be
the immediate cause of the disease. I then enlarged the opening at
the bottom of one of the sockets, through which escaped a large
quantity of a serous inodorous fluid. Pressure upon the palate and
external wall caused its escape through both the alveolar and nasal
opening; this compression, together with suitable injections, soon
terminated the disease.
The teeth on the left side being in a similar condition, their re-
moval was urged ; but to this the patient would not consent. In
three months she came to me with a precisely similar swelling of
this side, which, having the same cause, I cured in the same
manner.
Case IY. — Abscess of the Antrum caused by a Tooth. — The fol-
lowing very interesting and instructive case is from the practice of
Dr. J. D. White, and was reported for the Dental Cosmos by his
son, Horace Meredith White, M.D.:
"Mr. S., aged twenty years, light complexion, peculiar whiteness
of the skin, a characteristic of the family, had been complaining for
some time of a fetid discharge from the right nostril ; of heat, and a
sense of tension in the right superior maxilla.
" He applied to his physician, who gave him a wash, with the
belief that the parts would speedily return to their normal condition,
he supposing the affection to be merely an increased discharge de-
pending on a slight local hyperaemia, the result, perhaps, of the bad
state of the weather at the time. The parts, however, did not re-
cover, the discharge became much more fetid, and evidently was
principally composed of unhealthy pus, though it was not as copious
as it had been previously ; the pain was not severe, but the heat of
the parts more elevated, and the sense of tension increased. The
patient was irritable and pale ; the heat of the body was rather
above the average temperature. This was the condition of the patient
when he came under the care of Dr. W.
" Upon examining the anterior nares nothing could be discovered
to account for the discharge ; the mucous membrane being a little
inflamed, but not sufficient to occasion it. A diseased state of the
antrum was suspected, and the mouth was examined to ascertain if
a diseased tooth could be the cause. The second molar, upper jaw,
right side, w^as unsound. Part of the crown w^as decayed away ; the
bulbous portion of the nerve, and the filaments of the buccal roots,
were dead, but that part in the palatine root was living, and occa-
sioned the patient pain. A little arsenical paste was applied to de-
424 ORAL DISEASES AND SURGERY.
II
8troy it. No sign of alveolar abscess was present in it or any other |
tooth. The next day the nerve in the palatine fang was removed
without trouble ; a careful iuispection was now made, and important
information was received. Upon examining the right nostril with j
a speculum, a little pus was seen in the middle meatus. The patient I
was requested to incline the head toward the left side ; he did so, !
and upon looking at the parts again, a large amount of pus was
found. This, together with the facts stated already in this paper,
and that there was no other assignable cause of the discharge, were
deemed sufficient to establish the diagnosis — abscess of the antrum,
caused probably by the unsound second molar tooth.
" Extraction was advised and submitted to. Upon the removal
of the tooth no pus escaped. A probe was introduced into the alve-
olus previously occupied by one of the buccal roots, and readily
passed on into the antrum ; pus now followed the withdrawal of the
instrument.
" The cure was completed on general principles."
Dr. White concludes the description of his case by remarking a
coincidence which it will not be at all amiss to repeat here — a coin-
cidence which could only have been alarming enough to the patient.
The gentleman had repeatedly visited a horse belonging to his father,
which had a profuse discharge from the nose, and which was thought
to be glanders. The horse's malady was prior to that of the pa-
tient, and, of course, could only have caused him to fear that he
had contracted the disease from it.
Dropsy of the Antrum. — This, which is only another name for
mucous engorgement, is not unfrequently, as I have had occasion to
observe, the result of a reflected chronic periodontal inflammation.
In such cases, we have the analogue of similar inflammation in the
cavity of the mouth ; the membrane becomes puffy and thickened,
the mucous secretions become inspissated, the natural opening of
the sinus (simply through this thickening of the mucous membranes,
the folds of which are the natural outlet of the cavity) become ob-
literated. All egress being closed, the result is not difficult to sur-
mise : if there should not occur atresia of the occluding membranes,
and no correct surgical assistance is afforded, there must, of course,
result either the gradual attenuation of the weakest portion of the
parietes of the cavity, or the setting up of active and severe inflam-
mation. If, on the contrary, the natural outlet has a partial restora-
tion, it is not at all unlikely that a troublesome — and, if misunder-
stood — a tedious and unmanageable puruloid discharge will ensue :
ANTRUM OF HIGHMORE AND ITS DISEASES. 425
this being the result of a continuance of the cause of trouble. Re-
calling illustrative examples from my own practice, I remember par-
! ticularly the case of a child who, previously to coming under my
care, had been treated nearly two years for the occasional discharge
of muco-purulent matter from the left nostril ; the child was of bad
temperament, being a cross of the bilio-lymphatic. This patient I
j had the satisfaction of relieving in a single week, the treatment being
I wholly directed to the dental arch, if I may except a course of salt
sheet-baths — continued long after the local cure, and which had been
i directed in consideration of the relaxed condition of her general
I system.
i The relation of temperament and conditions are to be closely con-
sidered in connection with these diseases of the antrum ; it is, of
course, far from being every one who is troubled with a bad tooth,
the fangs of which penetrate the cavity, that has secondary disease
as the result. I have just now under treatment a patient suffering
j from necrosis of the whole roof of the mouth, the result of a syphi-
litic cachexia, the exciting cause of the local trouble being an inci-
sor tooth anomalously developed. This tooth, the extreme point of
which presented just back of the incisive foramen, had been mistaken
by a practitioner for the point of a sequestrum, and being worked
and cut at, periostitis had developed ; and when the dead bone, which
is the result, is ready to come away, I am sure I shall find both antra
exposed.*
Without such predisposing cause, it is evident that this extensive
disease would never have been excited. It is the same, as in every
direction of surgical practice — one man receives a wound, a cut per-
haps on the face, and it troubles him so little that he scarcely stops
for a moment his work to examine the injury ; another receives pre-
cisely the same kind of a wound, and in a week he is dead from ery-
sipelas.
A purulent condition of the secretions of the antrum may be
viewed as one would view a gonorrhoea ; indeed, Mr. Bell, the
English author, describes the conditions as being similar. "Both
diseases," he says, " consisting equally of an altered secretion ; in
the one, of the pituitary membrane, and in the other of the muscular
lining of the urethra, which, in neither instance, possesses any of
* This proved to be the case ; the lost process being now replaced by an ob-
turator. For the making of such an instrument, see '^Palatine Defects."
426 ORAL DISEASES AND SURGERY.
the characteristics of abscess, though the matter in both is puru-
lent."
Certainly, if we allow for some differences, as influenced by cause
and location, the description of the one would very well answer as
the description of the other. In both we have the same perverted
secretion, the same molecular change, the same sthenic and asthenic
modifications.
As a gonorrhceal discharge is always preceded by certain inflam-
matory conditions, and as, after the subsidence of the acute attack,
the discharge may long continue profuse, or, on the contrary, may
decline to a scarcely perceptible minimum ; so, in antral puruleney,
must we have the associated inflammation, and may have the pro-
fuse or limited secretion.
In antral diseases, however, as may be readily inferred, very
much depends on the nature and associations of the secretion. A
profuse discharge, with closure of the orifice of the cavity, must
necessarily entail the most untoward consequences ; the walls of
the cavity will attenuate until (unless surgically relieved) the weak-
est point will give way, the rupture being most apt to occur, either
within the orbit, or the mouth. Not unfrequently, however, this
weakest portion seems to be the canine fossa, and the opening has
occurred at the tuberosity. My own experience would lead to the
inference that the hard palate is, by far, the most common point
at which the matter seeks egress. You will see a tumor bulging
out from one side of the mesial line, and which advances more
or less rapidly, until fluctuation becomes very distinct. A sign
diagnostic of this class of tumors is, that its internal boundary is
apt to be quite abrupt, and does not pass the line midway to the
mesial division. The establishment of a fistule relieves it at once
of the sense of distention, and if it has formed in a convenient
place, as within the mouth, the patient may feel disposed to con-
gratulate himself on having come to a sufficient cure. Unfortu-
nately, however, in the majority of cases, this satisfaction is of
short continuance ; for, independent of the fact that the disease at
once takes on the chronic form, making the sufferer an object of
disgust to those with whom he is brought into immediate contact
— the fetor of the discharge, under some circumstances, being really
unbearable ; yet, also, is the undue retention of the secretion within
the cavity such a source of irritation to the parts that, not unfre-
quently, the most serious lesions result. In some instances, the
whole of the bones of the face are destroyed.
ANTRUM OF HIGHMORE AND ITS DISEASES. 427
The causes influencing retention of these secretions are twofold :
First, the external wound is apt to heal, and to continue impervious
until an increase of the secretion induces sufficient pressure to cause
its absorption, as in any case of abscess. In the second place, the
passage is blocked up by flocculi within the cavity.
Puruloid secretion in the antrum may, from the onset, be of so
I limited a character that — like secretions in certain of the ovarian
cysts — years may pass before marked inconvenience results. I am
acquainted with a case, that of Mr. C , late an eminent mer-
chant of this city, in whom, after five years of great mental and
physical suffering, a disease of the antrum, supposed to be malig-
nant, was found to be nothing but simple muco-puruloid engorge-
ment depending upon a dead tooth. In this case the trouble had
commenced with a feeling of heaviness and oppression in the body
of the jaw; the parts had gradually enlarged until finally there
was distention of the cheek to the size of a large fist, the eye
being thrown entirely out of position from the rising of the roof of
the antrum. Much treatment had been given the case without the
slightest accruing benefit. No attention, however, had been directed
to the dental arch — the teeth, although the patient was sixty years
of age, being apparently in the most perfect condition.
The result of this case was the diagnosis, on the part of a surgeon
to whom he finally applied, of a dead nerve in one of the bicuspid
teeth ; the organ, although as healthy-looking as any of its fellows,
responded to the stroke of an instrument in the manner as described
in the chapter on Alveolar Abscess ; this tooth was extracted, and in
six months the health of the patient was perfectly restored.
A circumstance connected with the extraction of the tooth in this
case offers an example of practice of which it is well not to lose
sight. The practitioner who related to me the circumstances of the
case informed me that he expected to find associated with the tooth
fang a pyogenic membrane, and to have the extraction followed by
a gush of pus, in both of which, however, he was disappointed.
The fang was clean, and the blood which followed the operation
had nothing peculiar about it. Not to be thus balked, he passed a
probe up the alveolus of the extracted tooth, which, meeting a resist-
ing yet yielding body, he punctured in the direction of the antrum ;
the withdrawal was followed by a profuse purulent discharge. This
resisting body may be simply flocculi, as alluded to, or it may be
the mucous membrane proper to the parts — most likely it Avould be
found the latter, for we are to remember that it is not alveolar or
428 ORAL DISEASES AXD SURGERY.
antral abscess with which, in these cases, we are dealing, but simply
what might be termed a mucitis, and, of course, a break in the con-
tinuity of the membrane is not necessarily, to be looked for. The
practitioner, in this case, only approximated to the exact condition ;
he thought, evidently, that the trouble was tooth abscess discharg-
ing itself into the sinus, whereas (while the treatment was perfectly
adapted to the requirements) the case was one of simple mucous or
muco-puruloid engorgement, the result of reflected irritation.
The diagnosis of mucoid and puruloid engorgement of the antrum
is, as a rule, not difficult to make out. At first there is inflammation,
and this, as suggested, is found most likely to have origin about the
teeth. As the trouble advances, the patient begins to complain of a
sense of heaviness about the body of the cheek. If the secretion
is active, there will be much pain, sometimes sharp in character, but
more frequently heavy and unbearably dull. In all chronic perio-
dontal inflammation, we have this same dull pain, but then it differs
from the pain of engorgement in being confined to the alveolar arch;
in this latter trouble the greatest pain is found, I think, associated
with the floor of the orbit, which, as will be remembered, makes the
roof of the antrum. At length, as the secretions accumulate, the
parietes of the cavity begin to attenuate and expand. The tumor
now forming may be distinguished from others — first, by the his-
tory of the case ; second, by dryness of the nares of the affected
side, the result of the closure of the orifice of the antrum ; third,
by the gradual and regular enlargement ; fourth, by the non-asso-
ciation of the integuments of the cheek ; and, fifth, by the fluctua-
tion which it will finally yield.
To treat successfully such a trouble, we have only to search out
the source of offense, and, where it is possible, remove it. If this
should prove to be a tooth, we may, if necessary, secondarily treat
the antrum through the alveolus. Where the trouble is thus of
strictly local origin, we shall find that we need to do very little
more than employ daily some stimulating injection: diluted tinc-
ture of iodine is a favorite M'ith me. Where the acrid character
of the retained secretion has provoked degenerating ulcers, I have
obtained the very happiest eflects from weak injections of chloride
of zinc.
If, on the contrary, such bad conditions of the antrum be associ-
ated with constitutional causes, I need not suggest that such causes
must have our attention. In these latter cases, however, where the
cure promises to be tardy, we may give to a patient complete relief,
ANTRUM OF HIGHMORE AND ITS DISEASES. 429
locally, by making an opening into the antrum, and keeping it patu-
lous by means of a cotton tent; this, combined with the daily em-
ployment of such injections as may seem indicated, will be found to
yield most decided benefit.
Concerning abscess proper of the antrum, I think it may be set
down as the rarest of rare diseases. Bell and Bordenhave each
mentions a case. Abscesses, described so frequently as occurring in
this cavity, will, I think, commonly be found to have their origin in
the alveolar border, and if treated as any ordinary case of alveolar
abscess, will generally at once succumb. (See chapters on Alveolar
Abscess, and Anomalies of Dentition.)
" While," says Dr. Richardson, " we cannot trace out the nature
of that condition of the blood which gives rise to purulent forma-
tions, we are informed by observation of the external conditions
which foster it. We learn that the pus-producing disposition is an
indication of deterioration of blood. We see that when the system
is enfeebled, whether by diathesis hereditarily supplied, as by the
strumous diathesis — whether by epidemic influences, or whether by
deprivation of nitrogenous food, or the inhalation of bad air — that
under these circumstances the tendency to purulent formations in
local structures is marked, and that, in extreme instances of the kind
named, the act of suppuration may take its absolute origin from
blood thus depressed.
" Hence we have reduced almost to a principle in medicine, the
saying, that suppurative tendency is a sign of an impaired or viti-
ated nutrition. Hence, also, we reason in speculative argument,
that pus is blood transformed into a lower form of organization, and
we adduce, in evidence of this view, that the purulent fluid is in-
capable of organic construction, and that animals in which the respi-
ration, the circulation, and the animal temperature are more than
ordinarily active, the formation of pus, even in an open wound, is
an occurrence almost unknown."
These remarks, from the lectures of Dr. Richardson, cannot fail
in being suggestive; they have indeed much meaning; but I must
be permitted to suggest, to the student reader, at least, that their
signification is limited. Puruloid conditions are, without doubt,
and as the rule, perhaps, indications of asthenia ; but it would be
very Avrong indeed to jump from such data to the conclusion that
every puruloid disease requires treatment from the constitutional
stand-point, and particularly will this hold good as the diseases of
the antrum are concerned.
430 ORAL DISEASES AND SURGERY.
All diseases should be treated on princiijle ; M. Ricord, as will be
recalk'd by many of my readers, has a favorite prescription for gou-
orrhceal purulency, which runs as follows :
B. — Pulv. cubebae, ^vi.
Ferri carb. ^iij. M.
Now, anybody can understand that such a combination would
most naturally act well on a debilitated system ; and I should sup-
pose it would be a most happy prescription for half the roues of
Paris. Where applicable, it would answer as well for the puruloid
antrum. I remember, during the past summer, treating a gentleman
for a gonorrhceal difficulty, which he had contracted almost immedi-
ately after my getting him over an attack of syphilis. I treated this
patient locally over six weeks, the discharge constantly increasing
in quantity. At the expiration of this period I put him upon co-
paiba, tinct. of iron and quinia, and sent him to the seaside for a few
weeks. The discharge at once began to diminish, and after the
eighth day disappeared entirely. A success of this kind would not,
however, lead to the inference that every man afflicted with a puru-
lent discharge should be treated with tonic stimulants. On the
contrary, I have had the opportunity of prescribing very frequently
for this condition — gonorrhoea. Yet it is seldom that indications
have seemed to me to call for anything more than a strictly local
treatment; at any rate, I have generally succeeded, happily and
quickly, in getting the patients over their trouble.
On a previous page it was suggested that puruloid conditions of the
antrum had origin chiefly from two directions : first, from diseased
teeth ; second, from constitutional disturbance, manifesting itself in
the mucous tissue. It was also desired to convey the inference that
where the fault was markedly in the first of these directions, the
practitioner would err on the right side, if, in his first consideration
of the case, he should incline to look upon the tooth only in the
light of an exciting cause, searching farther for what might be the
predisposing condition. It is, however, to be inferred that lesions
of the cavity may exist, and yet constitutional conditions have
really nothing to do with them, and in the treatment need not at
all to be taken into the account.
As a line in practice, however, running between these two con-
ditions, I may allude to the fact of having met cases where inference
of constitutional association seemed most marked, yet, without a
resort to other than local treatment, I have soon cured my patient.
ANTRUM OF HIGHMORE AND ITS DISEASES. 431
These are the kind of cases in which the medical man must feel his
way ; if he be an observer, it is not likely that more than a week
will pass without yielding him just conclusions.
Coming now to the investigation of cases where the cause is
to be found alone in some cachexia, we have only to refer back
to the general features of disease as manifested on mucous mem-
branes.
The most common, and indeed not very unfrequent cause of en-
gorgement of the antrum — particularly mucous engorgement — is
simple catarrh of the Schneiderian membranes. The patient takes
a cold, the excitement expends itself about the nares ; by simple
continuity of structure the lining membrane of the sinus becomes
vascularly excited ; perhaps the duplication at the orifice, because
of greater nearness to the central ring of inflammation, becomes con-
gested to such extent as to close the opening ; thus we have the
elements for engorgement, and the mucus thus confined will, if not
vented, sooner or later act as such a source of irritation that it will
become to the membrane of the cavity almost precisely what the
virus of gonorrhoea becomes to the same character of membrane
lining the urethra. Trouble from this cause is, however, generally
so slight and so quickly over that it is seldom prominently marked,
either to patient or practitioner.
The symptoms designating this condition are, first, simple vascu-
lar excitement of the membrane lining the nares, accompanied with
increase of mucus.
As the grade of inflammatory action advances to complete con-
gestion, the excess of mucus associated with the immediately pre-
ceding stage is succeeded by a most uncomfortable deficiency in the
secretion.
This dryness is associated with all nasal inflammations of ad-
vanced grade, but when the trouble is to implicate the antrum, it is
even specially marked. A single moment's consideration of the
parts makes this very plain : the nares are the natural outlets for
the antral secretions; in ordinary Schneiderian catarrh the exten-
sive secretory surfaces of the antra are comparatively unaSected : of
course they serve to lubricate, to a greater or less extent, the pas-
sages. When, however, the grade of inflammation is of suflicient
extent to congest the duplicatures of membrane which form the nasal
outlets, then, because of the retention of the mucus, the extreme
dryness is induced. This excessive dryness may be said, therefore,
to offer the first diagnostic sign of antral engorgement from simple
432 ORAL DISEASES AND SURGERY.
catarrh From this point the disease advances or declines. If it
declines, the trouble may have proved of such trifling inconvenience
as scarcely to have attracted the attention of practitioner or patient.
If on the contrary, it advances, the patient will soon be made con-
scious of the advancing engorgement by a sense of growing heavi-
ness in the cheek, attended by pain of a dull, sluggish character.
The progress of the disease from this condition is precisely the same
as that described as accruing from dental troubles.
Treatment. — This is to be conducted on general principles.
Where the disease is seen in its incipient stage, it will, perhaps, be
found unnecessary to do more than administer a saline cathartic; or,
what I have found a most satisfactory treatment, is to administer to
the patient at bedtime one-sixth or one-quarter of a grain of sulphate
of morphia dissolved in an ounce of the liq. ammonite acetatis. This
latter treatment will seldom be found to fail in breaking up these
limited congestions.
Where, however, the disease has advanced to engorgement, and
the antrum is found to be enlarging, it may be necessary, in order
to insure against even more serious lesions, that treatment shall be
directed immediately to the cavity. To accomplish this, extract the
second molar tooth, and penetrate the cavity through the alveolus of
the palatine fang ; in this way such medication as may seem indi-
cated may be readily employed ; indeed, for a cure it may be only
necessary to keep patulous the wound, leaving the rest to nature, or,
if there should seem a lack of vital force, I do not think a much hap-
pier stimulant can be employed than the tinct. of iodine.
Furuncular Epidemics. — It will be found, I think, the conclusion
of every one who has observed in the direction, that during the ex-
istence of furuncular epidemics, mucous and purulent engorgements
of the antrum are most common. This is not strange, if we con-
sider the epidemic condition in the light of an exciting cause alone,
for in no single instance where my attention has been called in such
direction, have I been unable to discover a predisposing cause in a
dead or diseased tooth. The same condition of things exists in re-
gions where the intermittents are endemic. All the odontalgias and
cephalalgias of such a country are apt to be quotidian, tertian, or
quartan. Furuncle is a condition associated, it would seem, with
some derangement of the digestive or cutaneous functions. When
epidemic, it would be in proof that a condition existed adverse to
the performance of certain physiological functions. With the exist-
ence of a predisposing cause of disease about the antrum, it is not
j ANTRUM OF HIGHMORE AND ITS DISEASES. 433
j at all strange that the addition thereto of an exciting cause should
at once increase the effect of the irritant even to the production of
active disease, — and such, in truth, is the case : the patient escapes
the purulency of boils, but he has purulency of the antrum.
Treatment. — This I need scarcely refer to: it consists, imprimis,
in removing the source of local irritation ; secondly, in correcting
the constitutional disturbances.
Scorbutus. — This diathesis, as may be inferred, predisposes to an-
tral purulency and ulceration. To understand the local condition
thus induced, it would be only necessary to examine the gums in an
individual so afflicted ; the condition of the antrum is akin to the
condition of the mouth. The treatment, to be successful, must be
from the constitutional stand-point. If injection of the cavity seems
indicated, it must be gotten at as before directed, or a canula can be
passed into it through the natural opening in the middle meatus ; the
latter is, however, diflBcult, and therefore liable to objection.
TJie Exanthemata are said to associate, not unfrcquently, their
sequelas with this cavity. Treatment thus demanded could need no
special consideration, — it would be a treatment founded on general
principles.
The ATercurial Diathesis. — I have before referred to the troubles
of the cavity thus provoked. Mercuiy holds a double pathological
relation to the antrum ; it predisposes from its constitutional rela-
tions, and actively and locally excites, through the periosteal inflam-
mation it excites in the alveoli of the teeth. (The same I should
also have remarked of scurvy.)
Treatment. — The indications here are twofold. Resolve, if pos-
sible, the inflammation about the teeth (see chapter on Alveolar
Abscess), and eliminate the mercury from the system. The chlorate
of potash and the common muriate of soda are valuable medicines in
this direction ; the latter I frequently employ, and with marked
success.
Syphilis. — This is a disease which it might be inferred would, of
course, have an afiinity for such mucus-lined surfaces as the antrum.
Now mine may be a singular experience, but in contradiction of
many authors who have written on the subject, I must say that, with
the wide scope afforded by such a hospital as Blockley (where, for
over a year, I gave the study of the venereal disease the closest at-
tention), I was unable to find a single case of diseased antra which
could with justice be attributed to the cachexia. As I remarked on
28
434 ORAL DISEASES AND SURGERY.
a previous page, I have met cases where the origin has been traced
for me in such a direction ; and I will not deny that, in some cases,
this origin may be justly so traced ; but, in every case that I have
seen, the mercury administered for the cure of the syphilis has
seemed to me as having much more to do with the condition than
any dyscrasis induced by the virus. (See this subject continued in
chapters on Ozsena and Tumors.)
CHAPTER XXX.
NEURALGIA.
i
I The terra neuralgia is from the Greek roots veupov, a "nerve,"
and (ilyoq, "pain." It signifies a condition, or an effect, and not a
jcause; or if this definition is not absolutely a correct one, the ex-
Iceptions to the rule it would form are, I am convinced, exceedingly
jrare. For such reasons it is, as commonly employed, a very ill
and deceptive term, expressing a condition, about as the term sup-
puration would convey a definite idea of the phenomena of inflam-
mation.
Neuralgia, as the word has been made to have definite applica-
tion, refers to paroxysmal pains, localized or metastatic, presenting
no manifestation of any lesion at the seat of pain outside of the single
phenomenon.
The pains of neuralgia are mostly, although not exclusively, acute
in character, are confined to the tract, or to the periphery of a cer-
tain nerve, remit, or more commonly fully intermit, are alone ac-
companied with tenderness of the part involved when an accidental
associate lesion may exist, or when an irritation is so severe, or has
been so long continued, as to have reacted on the neighboring vas-
cular system.
When, then, a practitioner has his attention directed to a seat of
pain without apparent lesion, the matter of first importance is an
appreciation of its cause. To say that such a one has neuralgia,
and to treat him with nervines, is to say just nothing, and to do
nothing, except indeed by accident. A first duty is to search for a
cause, and if discoverable, remove it, if that be possible. Now these
causes of neuralgia are, as I shall further on show, sometimes very
evident, and very easy of removal ; and it will be seen by the illus-
trations I shall offer, that one, from lack of observation, utterly fails
in giving a relief very easily, and naturally, afforded by another.
Rheumatism and neuralgia are frequently confounded ; but bow
do the conditions disagree ? Rheumatism is always accompanied
(435)
436 ORAL DISEASES AND SURGERY.
with va?;iMiIar perversion, the pain is not distinctly localized, but is
diffuscul over apart involved; it is a soreness, as a general thing,
rather than a sharp, acute, concentrated pain. Movement aggra-
vates this soreness, changes in temperature aifect it ; it is not parox-
ysmal, although it may be, and generally is, remitting; in short, it
has a history, and this history is not difficult to read.
Gout is another constitutional condition occasionally mistaken
fur neuralgia; but such a mistake should not occur, for here, too, is
a history. Gout occurs in the high, indolent liver; it is decidedly
inflammatory in its local manifestations. It attacks in preference
the small joints; it is accompanied by oedema, by congestion, and
by enlargement of the veins ; if it is metastatic, the seat of transfer
presents like vascular phenomena with the original inflammation.
But is there not a condition, a disease, which is, or might be,
termed neuralgia ; as, for example, gout is a disease with an indi-
viduality, or rheumatism is a disease. If, without being influenced
by other than my own observations, I were to answer this question,
I should incline to say there is not; and my reasons for the denial
would lie in the fact that I have in one way or another become
conversant with so many cases which have stubbornly resisted a
long course of treatment founded on an abstract neuralgic theory,
but which have rapidly and readily yielded on the discovery and
removal of some true lesion of which the pain was simply a sympa-
thetic connection, — as, for instance, otalgia, hemicrania, or even
sciatica, from an exposed tooth pulp, from a splinter of foreign sul)-
stance, or from the pressure of an exostosis. It is certainly true
that there is a class of persons which might be termed neuralgic ;
these do not belong strictly to what is called the nervous tempera-
ment, but are the anaemic and prostrated. A plethoric temperament
disposes to inflammation, but plethora is not inflammation, it is only
a predisposition ; the nervous temperament is only a pi*edisposition.
One could not deny that cases, called neuralgia, and treated with-
out ideas of a definite lesion, do very frequently get well ; but has
not the indication been accidentally met, just as with the Dewee's
carminative we treat the restless child and cure it without definite
idea of the ailment, having in a single medicine the requirement
of various conditions ? I think this is so.
If neuralgia, then, is simply a phenomenon, simply the expression
of an immediate or distant lesion, the preliminary treatment lies in a
search after a cause. But is this cause always evident ? It truly is
not, at least to our present acquirements ; but still it exists, and
NEURALGIA. 437
failing to discover it, we are compelled to desert principles and ex-
perimentally treat with the hope of an accidental success.
Are there predisposing causes of pain radiation? Undoubtedly
there are, and these may, and always should, receive a proper de-
gree of attention, as, in guarding against them, it might be that the
proper lesion would not, in itself, be sufficient to inaugurate or main-
tain the neuralgia. Thus, of the exciting causes, a damp, cold at-
mosphere is probably one of the most potent. Fatigue, overexcite-
ment, excess in drinking, poor diet, the too free use of coffee or tea,
loss of sleep, costiveness, diarrhoea, — in short, any and everythino-
which interferes with the easy and proper performance of functional
life.
In miasmatic neighborhoods, neuralgia frequently assumes the
periodic type, evidently influenced by the malaria. And it is with-
out doubt true, that the exhibition of quinine will and does, not uu-
frequently, cure such cases; whether this is because the medicine
controls the full and complete cause of the trouble, or only removes
an exciting cause, which, in its absence, gives to nature the mastery,
I scarcely know, it being, without doubt, certain that it is not by
any means always the case, that in the destruction of the periodicity
the pain is removed.
Syphilis is another of the exciting causes of neuralgia. I hav^e
known a patient have great pain from diseased teeth, which could
be held completely under control, although not cured, by iodide of
potassium, — proved to be from the teeth, as with the subsequent
removal of these organs the trouble disappeared.
To epitomize the subject, we might say that in a state of health
the nervous system represents the poised balance : it is neither ex-
cited nor depressed ; it works in entire harmony with its require-
ments. Apply now a source of irritation, and this harmony, or
balance, is destroyed. According as the amount and extent of irri-
tation, so is the amount and extent of derangement. Life, says
Bichat, rests upon the tripod of innervation, respiration, circula-
tion. Whatever affects one of these legs affects the whole body.
To appreciate the phenomena of neuralgia is, then, to appreciate the
phenomena of irritation ; is to search over the economy until what-
ever lesion exists is exposed and comprehended.
If a first view is directed to the nervous system itself, we look for
a lesion in the part which, by the expression of pain, seems most
markedly implicated. The most decided cases of neuralgia are, with-
out doubt, odontalgic, — a tooth decays until the cavity containing the
438 ORAL DISEASES AND SURGERY.
delicate nerve is exposed ; the neuralgia has the simple, single
si"-nification of a direct irritation ; exostosis of a tooth root presses
on nerves ramifying in the alveolo-dental periosteum : the significa-
tion is a similar one.
Let us refer to a neuralgia occurring in the stump of amputation.
Is the cause not most frequently found in the squeezing and pinch-
in"- of a nerve caught in the cicatrix? Is it not the same history
where tumors grow about and press upon some nerve periphery?
But I had meant rather just here to call attention to derangement
in nerve substance itself, without associated or influencing lesion,
if we might be able to find such derangements. Might I instance
neuromatous expansion as found in stumps — and which are, evidently
enough, sources of pain? Are there idiopathic inflammations of
nerve substance ? or do nerves in themselves degenerate and ulcer-
ate ? We may look at the subject from a still wider stand-point.
There is no earthly doubt that a pure nervous irritation of the sys-
tem at large may exist. There is certainly an individuality exist-
ing in this system. It has a mode of action of its own, and this
action, as remarked by Dr. Wood, is susceptible of exaltation, de-
pression, or deprivation in itself, and from the influences of its own
peculiar agents. But can or do these vicissitudes express themselves
ever, or even occasionally, in sharp neuralgic pains ? Connected
with the digestive function we have often nausea and vomiting;
with the secretory, disorder of the liver and kidneys; with the respi-
ratory, hurried and otherwise irregular breathing ; w^ith the circu-
latory, a frequent and agitated, though seldom full or energetic, pulse.
"As the offices of the brain," says Wood, "are various, so also must
be the signs of its excessive excitation. Irritation in the brain obeys
the general laws of that morbid affection. If moderate, it exalts the
healthy functions without otherwise altering them ; if stronger, it
more or less degenerates the functions ; in great excess, it entirely
changes or abolishes them. Thus, sensation and perception may
be rendered simply more acute ; or may be deranged, producing
vertigo, pain, and every variety of disorder, in vision, hearing,
touch, etc., from buzzing in the ears, unnatural coloring of objects,
a sense of tingling, formication, etc., to complete hallucination. The
intellectual faculties and the emotions may be excited into inci'eased
vigor, or may be completely perverted, as in delirium and insanity.
The general overseeing faculty of the brain may be simply stimu-
lated to increased vigilance, to a more ready and rapid response to
all the intimations of its dependent functions ; or it may be thrown
j NEURALGIA. 439
tinto excessive disorder, evinced by restlessness, jactitation, obstinate
"sleeplessness, etc. The motor faculty may merely impart increased
activity and energy to the muscles under the influence of the will ;
or it may throw off more or less completely subordination to that
principle, and give rise to every variety of spasm and convulsion.
Finally, all the functions above referred to may be overwhelmed by
an excess of irritation, and more or less completely lost in stupor
I and coma. This is nerve irritation, from causes or influences which
preside in, or in association with the system, and to be considered
•alone in connection with the sy.stem."
Reactions of vascular perversion on the nervous system are to
I be considered. Coup de soleil and apoplexy may be esteemed the
I opposite conditions in such reactions How frequently have all the
phenomena of partial compi'ession — headache, giddiness, buzzing in
the ears, disordered vision, tingling, formication, numbness, drowsi-
ness, mental confusion, spasms, convulsions, etc. — been quickly re-
solved and removed by the accidental rupture of a nasal vein having
communication with a meningeal sinus ! And how happily, when
similar conditions hav^e come on from long-continued chlorosis, has a
course of iron relieved them ! Every portion of the encephalic mass,
every portion of its continuation in the spinal canal, every nerve
periphery, requires a certain amount of, and a certain character of,
blood, to keep it in proper poise and nutrition. Too much blood, and
too nutritious, and we have derangement from overstimulation ;
too little, and too poor, we have it from lack of pressure, lack of
nutrition, and from, in many cases, effusions.
Derangements in respiration act as predisposing causes to neu-
ralgia. A patient who labors under an inability to aerate his blood,
whatever may be the cause, fails to relieve that fluid of certain
poisonous qualities, which, of a necessity, sooner or later must dis-
turb the nervous economy.
Anything and everything, in short, it may be said, which acts as
a depressant in the vital economy, whether by overstimulation or
by under-nutrition, is to be thought of, and considered, in neural
derangements ; overstudy, sensual excess, indigestion, hepatic and
nephritic diseases, repression of the cutaneous circulation, the de-
pressing passions, as fear, grief, melancholy ; the employment of
sedative poisons, as opium, tobacco, chloroform ; living in an atmos-
phere impregnated with irrespirable gases, — any and all of these
may assist some otherwise incapable lesion in determining an attack
of neuralsria.
440 ORAL DISEASES ASD SURGERY.
The most extreme case of nervous mania that has ever come under
mv own observation, accompanied with general hyperaesthesia and
local neuralo-ia, was in the person of a carter, addicted to habitual
smokin"-. For three days this man was uncontrollable by any but
physical restraint ; at the end of which period, having secured a
short interval of sleep and quiet, I placed between his lips a pipe of
the strongest tobacco. I finally cured the patient, making the sec-
tion of a nerve, and treating him with tobacco and sedatives, just as
one treats delirium tremens with whisky and sedatives. In this case
I am entirely satisfied that the local neuralgia was goaded to its
intensit}' by the perverted condition of the general nervous system.
Several cases of similar import I can recall, associated with the
improper use of opium, and with the abuse of the sexual instincts.
In a letter to the London Times, republished in the Medical
Times mid Gazelle, Sir Benj. Brodie expresses his general disap-
probation of the habitual use of tobacco, and makes the following
observations on its deleterious effects:
" The effects of this habit are indeed various, the difference de-
pending on difference of constitution and difference in the mode of
life otherwise. But, from the best observations which I have been
able to make on the subject, I am led to believe that there are very
few who do not suffer harm from it, to a greater or less extent. The
earliest symptoms are manifested in the derangement of the nervous
system. A large proportion of habitual smokers are rendered lazy
and listless, indisposed to bodily, and incapable of much mental, ex-
ertion. Others suffer from depression of the spirits, amounting to
hypochondriasis, which smoking relieves for a time, though it ag-
gravates the evil afterward. Occasionally there is a general nervous
excitability, which, though very much less in degree, partakes of the
nature of the delirium tremens of drunkards. I have known many in-
dividuals to suffer from severe nervous pains, sometimes in one, some-
times in another part of the body. Almost the worst case of neuralgia
that ever came under my observation, was that of a gentleman who
consulted the late Dr. Bright and myself The pains were universal,
and never absent; but during the night they were especially intense,
so as almost wholly to prevent sleep. Neither the patient himself
nor his medical attendant had any doubts that the disease was to be
attributed to his former habit of smoking, on the discontinuance of
which he slowly and gradually recovered. An eminent surgeon,
who has a great experience in ophthalmic diseases, believes that, in
some instances, he has been able to trace blindness from amaurosis
NEURALGIA. 44I
to excess in tobacco smoking ; the connection of the two beino-
pretty well established in one case by the fact that, on the practice
being left off, the sight of the patient was gradually restored. It
would be easy for me to refer to other symptoms indicating deficient
power of the nervous system to which smokers are liable ; Ijut it is
unnecessary for me to do so ; and, indeed, there are some which I
would rather leave them to imagine for themselves than undertake
the description of them myself in writing.
" But the ill effects of tobacco are not confined to the nervous
system. In many instances there is a loss of the healthy appetite
for food, the imperfect state of the digestion being soon rendered
manifest by the loss of flesh and the sallow countenance. It is dif-
ficult to say what other diseases may not follow the imperfect as-
similation of food continued during a long period of time. So many
causes are in operation in the human body which may tend in a
greater or less degree to the production of organic changes in it, that
it is only in some instances we can venture to pronounce as to the
precise manner in which a disease that proves mortal has origin-
ated. From cases, however, which have fallen under my own ob-
servation, and from a consideration of all the circumstances, I cannot
entertain a doubt that, if we could obtain accurate statistics on the
subject, we should find that the value of life in inveterate smokers is
considerably below the average. Nor is this opinion in any degree
contradicted by the fact that there are individuals who in spite of
the inhalation of tobacco smoke live to be old, and without any ma-
terial derangement of the health ; analogous exceptions to the gen-
eral rule being met with in the case of those who have indulged too
freely in the use of spirituous and fermented liquors."
With such general considerations of the matter, I may pass to
illustrations in the recital of individual cases. By the study of
these cases the student will, I trust, secure proper ideas of practice.
Case I. — Mrs. B., the wife of an undertaker, suffered for a long
period from periodic attacks of pain about the face and head. This
person, exceedingly quiet and retiring, spent most of her life in
sunless rooms, surrounded by the melancholy paraphernalia pertain-
ing to the business of her husband. She w^as anaemic, and of poor
general health and spirits. Although this patient had certain bad
teeth, yet the pain had never seemed associated with them ; indeed,
so insensible were these organs to ordinary agents of irritation, that
a diagnosis was founded alone on her general condition and sur-
roundings, and remedies applied entirely in such direction. Tonics
442 ORAL DISEASES AND SURGERY.
were administered, window-shutters were unbowed, exercise and
amusement, conjoined with generous living, were advised; even
with this entire change the patient failed to improve, but, on the
contrary, grew worse. The diagnosis thus discovered to be at fault,
the teeth were extracted; still the condition persisted, and the pain
increased. She was now treated for over a year, the pharmacopoeia
bein"- exhausted in her case. Called in consultation, I determined
to make a most careful exploration of her whole system. At this
period the pain had assumed and continued the impression of an
iron clamp over the head, terminating beneath, and which clamp
seemed daily contracting itself The terror and pain of this im-
pression had become so great as to convert the patient almost into a
lunatic. I found, by inquiry, that her internal organs had been
most carefully examined, and inferred not to be in fault. My own
investigations, therefore, were commenced externally. First, was
there any remaining tooth or teeth implicated? I examined for
caries, for pulpitis, for nodules, for necrosis, for supernumerary teeth,
for exposed cementum ; but fully assured myself these organs were
in no wise involved. I examined the spinal cord, and through its
expressions, the encephalic mass ; organically, the trouble was not
reflex from these points. I examined every articulation, the line
of every artery, vein, and nerve, so far as I might follow them. I
passed in review every observation and fact which might enlighten
me, but without success, so far as any discovery of an exciting cause
was concerned. Finally, I retui'ned to the oral cavity. The teeth
which had been extracted the year before were the molars and pre-
molars of the left superior jaw. Might there not possibly have been
just the smallest particle of one of these teeth left in its socket ? I
was making pressure in the canine fossa, when the patient made
slight complaint ; it was the only point which yielded difference in
sensation. Now, what was this sensation, and what did it mean?
It was not pain of which the patient complained, not discomfort ; it
was simply difference of sensation. But it w^as an only point which
bad yielded expression ; it was therefore differentially just to infer
that here existed something, — the lesion, perhaps, of which we were
in search. Acting on this only hint, I obtained the consent of the phy-
sicians in attendance to make an exploratory trephine of the antrum,
and, on performing the operation, discovered lying within the cavity
that branches of the intraorbital nerve running across it had enlarged
to the size of ordinary knitting-needles. These enlarged nerves, of
which there were two, I cut away. The patient was immediately
NEURALGIA. 443
relieved, and, although a year has passed, she has had no recurrence
of her neuralgia.
Case II. — This day, October 16, 1868, have treated and dismissed
a patient, a young lady, who shortened a summer and fall campaign
to come to Philadelphia for advice concerning neuralgia faciei, and
of the ear and scalp. She describes her agony as being sometimes
so great that only from chloroform could she get even a temporary
relief; has been taking tonics and opiates throughout the summer ;
has had no pain in any of her teeth, although on the upper jaw is a
pulpless molar. Examining her mouth, my attention was attracted
to a peculiar overriding of the second bicuspid tooth of the lower
jaw by the first molar ; the employment of a delicate curved probe
revealed caries of the first of these teeth, exposing the pulp ; the
tooth was extracted, the distant and apparently dissociated neu-
ralgia instantly disappeared.
A tendency to nervous irritability which exists in this patient may
very well be rearoused by the presence of the upper dead molar; if
this should prove the case, she is advised to have it extracted.
Case III. — Neuralgia of Neck and Arm from Carious Molar. —
Dr. Hyde Salter, well known in connection with clinical practice, had
sufi'ered much from attacks of inflammation in the left lower anterior
molar, which was extensively excavated by caries. At the age of
seventeen these acute symptoms had ceased for two or three years,
leaving nothing but a grumbling uneasiness in it. At this time
neuralgic pains began to extend from the tooth down into the neck
and left side, and thence over the collar-bone down the left arm —
these pains enduring several days and then remitting. There was
no actual pain in the tooth itself, nor any tenderness in it, nor in the
adjacent gum, nor any appearance of inflammation. The situation
of the pain in the neck and clavicular and supramaxillary regions
was exactly that of the descending cutaneous branches of the cervi-
cal plexus, and the part of the arm where the aching was the most
intense and intolerable was at the insertion of the deltoid. These
symptoms disappeared with the extraction of the offending tooth,
and have never since returned.
Case IV. — Intense Neuralgia of the Eyeball and Face; Altera-
tion of the Color of the Iris ; Carious Teeth— Mrs. C, aged thirty,
had suffered for ten years from severe neuralgia, affecting the left
eyeball and left side of the head and face, the iris of the affected eye
having changed from a deep and bright hazel to a dull gray. The left
lower dens sapientiifi and the first upper bicuspid being found badly
444 ORAL DISEASES AND SURGERY.
carious, these were extracted, and the operation was attended by a
terrible paroxysm of neuralgia; but after this had subsided the
patient experienced relief for about three months, when, the old
pain returning, the second upper bicuspid was found to be carious
and intensely tender, and upon its removal a considerable exostosis
was found on the root. The pain vanished with the tooth. {Guyh
Hosjnfal Reports.)
Case Y. — Neuralgia of Loicer Jaio ; Necrosis. — M. C, a laborer,
applied for treatment, complaining of unbearable pain situated about
the roots of the inferior central incisor teeth. The most careful ex-
amination revealed no explanation, and the patient was dismissed
for the day with an opiate prescription. A second, and many suc-
ceeding examinations, failed to yield a diagnosis, opiates being con-
tinued during the period. At the end of some three weeks an in-
flammation supervened, resisted all treatment, and finally terminated
in a necrosis, which cast off the two teeth with their alveoli ; the
exfoliation completed, the neuralgia disappeared.
Case VI. — Dr. Benjamin Rush relates a case of neuralgia in the
nates, which, resisting other means of treatment, finally yielded to
the extraction of a tooth.
Case YII. — 3Iegrim. — A protege of the Princess of Conde was
bled in the arm and foot twenty times for megrim of five years' stand-
ing. It at last being thought advisable to open the jugular vein, the
princess applied to M. Petot to perform the operation. But this
surgeon, not seeing the necessity for so frequent depletion, begged
to examine the mouth, and found in the lower jaw, in which the
patient had for a long time pain and numbness, eighteen, instead of
sixteen, teeth, resulting in a very crowded denture. By extracting
the second molar on either side he gave complete and permanent
relief in twenty-four hours.
Case Till. — Neuralgia Faciei and Odontalgia from Menstrual
Irregidarities. — A lady of rank (Rayer), long suffering from amen-
orrhoea, was subject to frequent epistaxis, pain in the side, and swell-
ing of the abdomen and feet. These symptoms were overcome, and
for a year she enjoyed good health ; but last summer, in consequence
of mental distress, a severe neuralgia came on, which was cured for
a time, but soon returned with the following curious symptoms:
every evening the pains recurred, preceded by the discharge from
between the upper canine and bicuspids of the left side of a matter
which was at first thick, viscid, and bloody, but afterward clear,
and so profuse as to fill a small vessel. The pains continued the
NEURALGIA. 445
whole night. No remedies gave any relief but opiates, which sup-
pressed both the pain and discharge and gave sleep.
Case IX. — A nun (Wepser), aged forty, was seized, at one of her
menstrual periods, with pain in the head, eyes, and teeth. A tooth
on the left side was extracted, but without relief; the pain passed to
the right side, and for five weeks, with occasional intervals of from
half a day to two days, caused much suffering, first on one side of
the head, then on the other, the principal seat of the pain being a
space two or three fingers broad on the side of the head. When the
attacks were violent they were preceded by a strongly-marked chill,
the throbbing of the temporal artery was very perceptible, the eye
injected, and when the paroxysms were at their height flushings
were experienced. In the treatment of this case, as the teeth were
discovered to be not at all in fault, the surgeon opened an issue in
each arm and a third on the neck, all three of Avhich were made to
discharge freely. Attention was also paid to the nervous system,
with a view to give it tone and strength. Not much regard was
paid to the amenorrhoea, because at such age the menses are usually
very scant.
In both the above cases the practitioners failed of a successful
treatment, and evidently for the reason that, in both cases, treat-
ment was misdirected. A reflected or radiated irritability of the
uterus was without doubt the lesion — an ulcer or other local lesion
being the offense.
Affections of the NervouH System dependent on Diseases of the
Permanent Teeth. — Mr. Salter contributes to Guy''s Hospital Re-
po7^ts a most interesting paper under the foregoing title, which con-
tains much information of direct and practical value, and with
which illustration, and some suggestive features in treatment, the
chapter may be concluded. " Disorders of this kind," says Mr.
Salter, " are divided into those which are reflex, secondary, and re-
mote ; and those which are direct, immediate, and from contiguity.
In the former category would rank epilepsy, neuralgia, paralysis ; in
the latter local pain, facial palsy, some forms of amaurosis, etc. In
other instances, such as those in which exalted sensibility of the
tegumentary nerves of the face, or erratic pains through the maxil-
lary nerves are associated with toothache, it might be difficult to say
whether the phenomena are mostly reflex or direct ; they probably
comprise both conditions. . . The posterior lower molars are
but little removed from the tonsils and Eustachian tube, from the
parotid region, and from the external auditory passage. The fangs
446 ORAL DISEASES AND SUEGERF.
of the upper back teeth are close to the orbit and its all-important
contents ; and more posteriorly they approach the spheno-maxillary
fossa and fissure. Thus it is easy to account for the nervous com-
plications which are directly entailed by the spread of inflammation
from the periosteum of diseased teeth.
" By far the commonest reflex nervous disturbances to which den-
tal irritation gives rise are neuralgic pains of the head ; and this is
especially the case where the upper teeth are implicated. In the
supra and infraorbital nerves, the globe of the eye, the temples, and
particularly a spot near the vertex, a little on one side (the side of
the affected tooth), in all these regions ' dental neuralgia' is really
very common ; and I have observed, not unfrequently, that, where
the pain has continued long, the integument has become hot, and
tender, and red. . . .
" The several branches of the trigeminus appear to be the most
susceptible of reflex affection, caused by the dental irritation of one
of them ; but next to the different elements of the fifth nerve, the
branches of the cervical and brachial plexuses are most commonly
involved. Thus pains in the neck, shoulder, acromion process, in-
sertion of the deltoid, or bend of the elbow, are by no means uncom-
mon, and with them occasionally a loss of motor power, a weary
sense of fatigue in the flexor muscles, and an inability to grasp
firmly with the hand. It would really seem that there is occasion-
ally, and in some individuals, a special and exceptional communica-
tion between the fifth nerve and those of the arm. Dr. Anstie has
seen two instances in which wounds of branches of the ulnar nerve
have caused reflex neuralgia of the fifth nerve. And he remarks
upon this circumstance : ' That the mental perception of the patient
should, in each of these cases, refer the pain, not to any point in
the course of the injured nerve, but to the branches of the trigeminal,
affords, in my opinion, a strong suggestion that that portion of the
central nervous system with which the trigeminus is directly con-
nected, presents some congenital or acquired peculiarity of organi-
zation.' This idea is fully borne out by what one occasionallj^, but
only occasionally and exceptionally, sees in the occurrence of bra-
chial neuralgia and paralysis caused by dental irritation of the
branches of the fifth nerve.
" Reflex nervous irritation, dependent upon dental disease, is
most uncertain and capricious in its manifestations. One person
will suffer much from a comparatively slight cause, while in others
the same condition more severely developed will produce no such
NEURALGIA.
447
result. There is, unquestionably, in some persons a neuralgic diath-
esis ; and it is not improbable also that, in some individuals, there
may be a congenital or induced peculiarity in the centric, or, perhaps,
collateral relations of certain nerves, by which the exalted polarity
of one may be passed on, and so reflected upon another with ab-
normal facility. In persons obnoxious to these forms of neuralgia
from dental irritation, nothing is so liable to produce an attack as
exhaustion or depressed nutrition ; and patients will often tell you
that the attacks only come on when they are very tired, or have
gone long without food.
"Pain is only one of the phenomena of reflex dental nerve irritar
tion. It may induce muscular sjmsm, muscular paralysis, paral-
ysis of some of the nerves of special sense, perverted nutrition.
"As regards the teeth themselves which excite this exalted nerv-
ous irritability, nearly all their diseases appear capable of causing
this condition. Thus :
" Caries, with or without exposure of the pulp ; exostosis ; hy-
pertrophy of the crusta petrosa ; nodular developments of dentine in
the pulp cavity ; periostitis, plastic or suppurative ; impaction of
permanent teeth in the maxillary bones ; crowding of teeth from in-
sufficient room.
" Each and all of the above-enumerated abnormities of teeth have
caused manifestations of reflex nervous irritation, though, as I have
remarked, they may exist in the severest forms without producing
any such result.
"Mr. Salter then records a series of cases illustrative of the vari-
ous pathological conditions referred to, of which we are forced to
give the following brief abstract :
KEFLEX AFFECTIONS.
''Facial Neuralgia from Dentine Excrescence in Pulp Cavity. —
A woman complained of severe neuralgic pains obviously connected
with an upper central incisor. The pain was of a gnawing character,
abiding, but not constantly severe ; frequently merely a conscious-
ness of the presence of the tooth, but at other times sharp and dart-
ing, flashing up the side of the face, etc., through all the branches
of the superior maxillary division of the fifth nerve of that side, and
considerably augmented by sudden pressure, a tap upon the tooth,
or marked change of temperature. The tooth was apparently sound,
though somewhat elongated and slightly loose. No exostosis was
448 ORAL DISEASES AND SURGERY.
found on the root after extraction, but, on making a section of it
(vertical, from side to side), an excrescence of dentine was dis-
covered growing from the side of the pulp cavity and occupying, for
a short space, more than half its diameter. The removal of the
tooth, though accompanied with a violent paroxysm of neuralgic
agony, was followed by a total cessation of the pain, which never
recurred.
"Cranial Nexiralgia from an Impacted Canine Tooth. — Miss
B had ' cut ' all the permanent teeth in due course and position,
except the left upper canine, the proper space for which was oblit-
erated by the contact of the lateral incisor and first bicuspid. At
the time when the right upper canine appeared, a hard swelling was
noticed in the palate, on the left side, and toward the front of the
mouth, and this slowly developed into a prominent rounded ridge,
extending obliquely behind the left incisors, and left first bicuspid.
No inconvenience was felt up to the age of eighteen, when severe
headache, confined to a spot on the vertex toward the left side, at-
tended by local heat, etc., temporarily relieved by pressure, made
its appearance. This headache, which was recurrent in its nature,
lasted until the patient was twenty-six, no actual pain being felt in
the impacted tooth, although the region about it became hot and
tender upon the supervention of the headache. The removal of the
tooth by Mr. Cartwright — an operation involving much chipping
away of the bony cavity in which it was imbedded — was followed
by immediate and permanent relief, thirty years having elapsed
with no return of the symptoms.
"Intense and General Neuralgia from Exostosis on Fangs of
Teeth. — Miss B. P had gone through her first dentition with-
out trouble, but on account of some crowding on the advent of the
permanent teeth, an upper and lower bicuspid on either side were
extracted to make room. During adolescence she was attacked by
neuralgic pains, at first confined to branches of the trigeminus, but
afterward extending to the arms, legs, etc., indeed, nearly the whole
body. The teeth, though apparently sound, had a tendency to
elongate and spread, especially the upper incisors, with which the
pain was at first chiefly associated. The offending teeth always
gave pain on being slightly struck. Mr. Bell removed, from time
to time, the teeth most obviously connected with the neuralgia, in
each instance with temporary relief of the suffering, and in every
case the fangs of the extracted teeth were found incrusted with
nodular exostosis, though the teeth themselves were free from caries.
NEURALGIA. 449
When Mr. Salter saw Miss P. (in 1851) only the two lower left
bicuspids remained, and these were causing a continuance of the
neuralgia, which ceased after their removal. On the fangs of both
these teeth were the expected nodules of exostosis. This patient is
stated to have been remarkably anaemic, the gums being ' like wax
stained of the palest pink,' and the alveoli remaining white and
bloodless for some seconds after extraction before blood enough
oozed from the broken vessels to partially fill the hollow sockets.
'' Neuralgia of the Arm from Carious Teeth and from undue
Pressure of Artificial Teeth. — In the case of Mrs. E , caries of
any of the lower teeth on the left side has been immediately followed
by severe neuralgic pain at a spot, small and circumscribed, on the
front of the left forearm, about two inches below the line of flexion.
Having now lost all her teeth, and wearing a complete artificial set,
whenever the lower denture hurts the jaw on that side, the same
symptom is manifested. The right side has never been similarly
affected.
"Chronic Trismus from Impaction of Lower Dens Sapientise. —
In a man aged twenty-three, with large teeth and comparatively
small maxillary bones, the lower wisdom teeth were imbedded, and
unable, from want of room, to come into place. The result was re-
current pain and swelling within the mouth, followed by a sudden
attack of 'lock-jaw,' apparently caused by contraction of the left
masseter muscle, which, after four months' duration, was cured by
extraction of the left second molar, the wisdom tooth being out of
reach. The posterior fang of the extracted tooth was much eroded
by absorption.
" Wry-neck from Carious Teeth of Lower Jaw. — A young woman
whose head had, for more than six months, been drawn down nearly
to the left shoulder, with considerable pain, was relieved in a few
days by the removal of a stump and a partially decayed tooth from
the left side of the lower jaw.
" Epilepsy from Carious Tooth. — A boy, aged thirteen, under the
care of Dr. Ramskill, had frequent attacks of epilepsy, occurring
about seven or eight o'clock in the evening. Examination detected
' a molar tooth considerably decayed, with a swollen gum around
it, and partly growing over into the cavity.' It was not very tender
to the touch, nor did the examination give rise to toothache. The
extraction of this tooth was followed by cessation of the fits.
" Tetanus from 3Iechanical Irritation of the Pulp. — The case of
a gentleman (quoted from Tomes''s Dental Surgery), who, having
29
450 ORAL DISEASES AND SURGERY.
broken off a front tooth, went immediately to a prominent dentist in
Paris and had an artificial crown pivoted with a gold peg upon the
fan". After severe pain for four or five days, trismus set in and was
soon followed by tetanus and death.
'' Neuralgia of Face, Neck, and Arm, with Partial Paralysis of
the latter, from Carious Wisdom Tooth. — Miss W , ' was suf-
fering from constant aching pain in the left side of the face and neck,
and in the left arm. The pain sometimes became intensely severe.
The arm had lost nearly all muscular power.' These symptoms,
after resisting all medical treatment for two years, disappeared in a
few hours after the removal of the tooth.
"Amaurosis causedhy Crowding of Teeth. — In this case (reported
by Mr. Hancock in the Lancet of 1859, p. 80), a boy, aged eleven,
whose sight had been previously unimpaired, found upon waking
one morning that he was entirely blind. About a month afterward
he was admitted to Charing Cross Hospital, where it was discov-
ered that his teeth were 'much crowded and wedged together; the
jaws, in fact, not being large enough for them.' Accordingly two
permanent and four milk molar teeth were extracted, and ' on the
same evening the boy could distinguish light from darkness, and on
the following morning could make out objects. From this time his
sight rapidly improved, and he was dismissed cured on the 28th
(eleven days after), the only treatment beyond the removal of the
teeth being two doses of aperient medicine.'
"'Dr. Watson (Lectures on Physic, fourth ed., vol. ii. p 351)
mentions a very similar case. But the blindness was confined to
one eye ; it recurred two or three times, and was on each occasion
cured by tooth-extraction.'
"Deafness from Carious Teeth. — Mr. Cattlin reports the case of
a lady who had for about three months suflTered acute pains in a dis-
eased right lower molar, and in the corresponding ear and side of
the neck, and who had been deaf for four days. ' The inflamed tooth
was extracted, and hearing returned within an hour after the operar
tion.'
"Perverted Nutrition from Dental Nervous Irritation. — Under
this heading three cases are quoted from Mr. Hilton's work (' On
the Influence of Mechanical and Physiological Rest, etc.'), in which
the tongue was decidedly furred only on the side corresponding with
carious or painful teeth ; one in which the hair of the left temple
was bleached by unilateral neuralgia, arising from a carious molar
tooth ; and one in which ulceration of the auditory canal, accom-
NEUBALGIA. 45I
paniecl with offensive discharges from the ear, and enlargement of
one of the cervical glands, vs^as traced to a diseased lower molar on
the same side, and subsided soon after the extraction of the tooth."
From the illustrations given, it will be inferred that the removal of
any discovered lesion of irritation is the primary indication in every
case of neuralgia. The idea has been advanced that there is seldom or
never a neuralgia proper, but that such pain is simply an expression.
It is unfortunately the case, however, that too often we are compelled
to discover our weakness in a search after causes, and are thus rendered
unable to treat a case scientifically, but are driven to empiricism.
Even yet, however, we may render more than an accidental service;
and the principle on which we would found such treatment is that
of soothing and quieting, either as applications would refer to the
system at large, or to the particular part involved. Nervines, where
there is general nervous disturbance, independent, as far as we dis-
cover, of other derangements, will be found to sometimes act very
happily. The tinctures of valerian and gentian, in equal proportion,
given in tablespoonful doses, make a fine combination. Bromide of
potassium, where it seems necessary to keep up a continuous impres-
sion, is given with advantage in doses of ten grains, dissolved in a
wineglass of water, from two to ten times a day. If given, however,
in a paroxysm, forty to sixty grains will be found not too much, and
it sometimes will be well to combine with it small doses of opium
or morphia.
R. — Potass, brom. grs. xx;
Morph. acet. grs. ^ to ^, according to severity of pain ;
Aqua, ^i. M.
To be repeated pro re nata.
Yalerianate of zinc is a favorite preparation with many practition-
ers. It may be made into pills with conserve of rose, or any pre-
ferred vehicle, each pill to contain from one-half to a full grain, to
be given twice or thrice a day.
Tincture of Indian hemp is prescribed in doses of five drops, re-
peated three times a day.
Where there is disturbance of the visceral health, it has been
found occasionally successful to produce rapid but moderate saliva-
tion.
Aconite made into quarter-grain pills, and administered cautiously,
three or four times a day, is recommended.
Digitalis in tincture, or the tincture of veratrum viride, in condi-
452 ORAL DISEASES AND SURGERY.
tions of undue circulatory excitement, exhibited in five-drop doses
until such excitement is subdued, will sometimes quickly relieve the
pain.
Colchicum, where there is a supposed gouty association, may
always be employed. The wine of the root is the best preparation.
In rheumatic neuralgia, or pain associated with a rheumatic con-
dition, the following formula will be found very reliable ; certainly
so, if some other existing lesion is not too antagonistic :
B. — Potass, iod. Iss;
Ext. belladonna, gr. vi ;
Yin. colch. rad. ^ss ;
Tinct. guaiac. ammoniat. ^vi ;
Aqua cinnamomi, ^vi. M.
Sig. A tablespoonful to be taken in a wineglass of water three
times a day ; if it should purge, five drops of laudanum may be
added to each dose.
Arsenic is frequently used with decided benefiL It may be ex-
hibited in granules of the twentieth of a grain three times a day. It
acts well in cutaneous neuralgia.
Donovan's solution — the liq. hydrarg. arsen. et iod. — is a favor-
ite with many practitioners. Dose, five drops three times a day,
avoiding salivation. It is an alterative, having a variety of signifi-
cations.
Iron and bark should be employed in all cases associated with
lassitude and anaemia.
R. — Elx. ferri cinch.
Sig. Teaspoonful four times a day.
R. — Tinct. ferri chl. §i ;
Quinia sulph. 5i- M.
Sig. 15 to 20 drops three to four times a day.
R. — Syrupus ferri pyrophos, ^vi ;
Quinia sulph. 5i- M.
Sig. Teaspoonful four times daily.
Opium and ether, given in full doses before a paroxysm, with ten
or fifteen grains of quinine administered after the pain has ceased,
will, it is asserted, at once make an impression, and frequently
Or,
Or,
NEUBALGIA. 453
abridge the next paroxysm. Success is claimed for the exhibition
of opium to the production of narcotism.
Muriate of ammonia, in doses of half a drachm three or four times
a day, has been given with advantage. A very soothing effect is
produced by placing a lump of the ammonia on a burning coal and
thus impregnating the atmosphere of a room.
Oil of turpentine is frequently applauded by English practitioners.
It may be given in doses of from one-half to a full drachm.
Chloroform, or chloroform combined with camphor, is recom-
mended. A formula used by Dr. Wood is as follows :
R. — Chloroform, f5ij;
Camphor, 5i-
Mix with the yolk of an eg^ and §vi of water, and direct a table-
spoonful to be taken every half hour, every hour, or every two
hours, according to the urgency of the case, until relief is obtained,
or some decided effects are experienced from the medicines, either
on the stomach or brain.
Vermifuge medicines are frequently prescribed with benefit, par-
ticularly in the case of children ; parasites frequently keeping up an
irritation, although presenting no definite signs, •f these medicines,
one of the very best is the combination of spigelia and senna.
R. — Syrupus spigelia et sennae, ^iv.
Sig. Take in teaspoonful doses three times a day. Four ounces
will be enough to destroy any worms which may be present in the
intestines.
Cathartics are generally indicated in spasmodic attacks of neu-
ralgia ; especially is this the case when there is costiveness, furre
tongue, sick headache or stomach, giddiness, etc. It is generally
satisfactory practice to precede the purgation with a few quarter-
grain doses of calomel. The character of the purgative is to be in-
fluenced by the condition of the patient. Sulphate of magnesia is,
I think, generally found applicable. Blue mass, colocynth, and
jalap, or the compound cathartic pill, I have always found objec-
tionable. Where febrile disturbance is present, particularly do I
think these combinations will be found to do much more harm than
good. The ordinary Seidlitz powder, repeated three or four times
within the day, is a very happy and really refreshing medicine. If
it should not do good, it will certainly do no harm.
454 ORAL DISEASES AND SURG ERF.
Strychnine is an antineuralgic medicine of much reputation. It
may be prescribed in quantities of two grains, divided into eighty
pills. One to be taken three times a day.
Of local remedies there are the greatest variety. A formula long
celebrated under the name of Rauque's liniment, is prepared as
follows :
R. — Ext. belladonna, 9ij ;
Ether sulph. §i ;
Laurel-water, ^ij- M.
Sig. Let it be rubbed on the part and saturated flannel be ap-
plied.
The endermic application of morphia is a common practice. The
morphia may be used on a blistered surface, or subcutancously in-
jected, — syringes for the latter purpose being made by all instru-
ment-makers. To make a subcutaneous injection, it is only neces-
sary to thrust the needle-point of the syringe into the rete mucosum,
or it may be passed completely beneath the skin into the underlying
cellular structure.
Hot and moist applications are generally found of much service
in quieting pain — the part to be enveloped in old and loose flannel,
and evaporation prevented by an investment with oiled silk or other
material.
In afl"ections of the fifth pair, Dr. Richab, of Strasburg, attributes
great good to one grain of quinine and two of common snufi", intro-
duced into the nostril of the painful side. It is said in many cases
to act like a charm.
Professor Charles Meigs introduced, several years back, a plan
of treatment with sulphuric ether, which has yielded greater tem-
porary success than anything else I have ever tried. He confused
the nerve currents by taking a piece of sponge saturated with ether,
and, by a continuous but irregular round, would touch, here and
there, difi"erent neighboring surfaces, until the pain would dis-
appear. If, for example, the pain was in the forehead, he would
touch over the supraorbital nerve, over the infraorbital, over the
anterior dental, over the facial, over the cervical, — alternating the
touches to these parts for a period varying from five minutes to half
an hour. In most cases the pain will, for the time, be relieved.
Creasote, much diluted in simple cerate, is sometimes found very
useful as a local obtunder, — five drops of creasote to the ounce of
cerate or lard to be rubbed over the affected part, little by little, until
relief is obtained.
NEURALGIA. 455
Dr. Kirby directs a liniment made of one drachm of tincture of
aconite to seven of fresh palm oil, or with two ounces of camphor
liniment. A half drachm of the former, or double the quantity of
the latter, to be rubbed in twice or thrice a day, according to its
effects. It must be watched, however, as the medicine is cumula-
tive ; if its poisonous effects appear, stimulants are to be given.
Dr. Grave's neuralgic plaster is compounded as follows :
R. — Powder of opium, 9ij ;
Camphor, 5ss ;
Burgundy pitch, q. s. for plaster mass. M.
Stupe the parts with warm water before applying it.
Cazenave's pomade is thus made :
B. — Chloroform, 5i^;
Cyanide of potassium, 5ijss ;
Axunge, giij ;
Wax, q. s. for consistence.
Rub into the part a piece of the ointment the size of a pigeon's
egg, and cover with oilskin.
*^ Neuralgia: Cases treated successfully by the Spine-bag. By John
Chapman, M.D., M.R.C.P., M.S.C.S., Physician to the Farringdon
Dispensary. — The cure of neuralgia, whether the disease be treated
by drugs given internally, or by applications of various kinds at the
seat of pain, or by the two methods conjointly, is confessedly almost
always difficult, and in a large proportion of cases impossible. The
cases reported below have been treated by a method altogether new.
By stating each case with extreme brevity, I am enabled to present
at one view within a small compass the results of several experi-
ments ; and I do this in the hope that they may produce such an
impression on the minds of professional readers as may impel them
to acquaint themselves with the pathological and therapeutical prin-
ciples of which these results are an expression. I shall hereafter
publish an exposition of these principles, illustrated by reports of
cases in extenso, and shall then give a full description of the treat-
ment adopted.
" 1. Facial Neuralgia. — T. H., a gentleman, aged 35, who had
been suffering during the previous fortnight, requested my advice
March 18th, 1865. He was in great pain, which had been con-
tinuous from the previous day, and which had wholly deprived
him of sleep. The pain was chiefly on the right side of the face
456 ORAL DISEASES AND SURGERY.
and head ; but during the morning preceding my visit the left side
had become invaded. The affected parts were very tender, and
somewhat swollen. The head was rather hot, the face flushed, the
tongue thinly coated with whitish fur; pulse 92, full and strong.
Several medicines prescribed by two physicians in succession had
proved of no avail.
"I applied a ten-inch spinal water-bag, containing water at 130°
F., to the cervico-dorsal region, and shortly afterward left the pa-
tient's room. Within half an hour I returned, when I found him
asleep. The treatment was continued for two days by means of
heat; afterward I used ice (at first in the lumbar region), and from
the time he first fell asleep he continued free of pain, which has not
since returned
" 2. Facial Neuralgia. — Fraulein S., aged about 25, consulted me
February 3d, 1867, on account of neuralgia affecting the infraorbital
and dental branches of the trifacial nerve. The pain was not con-
fined to one side of the face, but was sometimes most acute on one
side, sometimes on the other ; it increased at night, and kept her
awake the greater part of each night. She had been suffering in
this way for about three weeks before I saw her. Her general health
was good. The affected parts presented no trace of hyperaemia.
" She was treated by means of ice, and experienced almost imme-
diate relief After three days of treatment she felt and slept very
much better ; and before the end of the fifth day the pain had wholly
ceased. Nearly a year afterward she told me that it had never
returned.
" 3. Facial Neuralgia. — Mademoiselle M., aged 20, consulted me
in August, 1867, when she was suffering from acute facial neuralgia,
the chief foci of which were the infraorbital foramen, and the men-
tal foramen of the right side. The extreme pain came on in fits,
sometimes at 8 a.m., sometimes at 2 p.m., but between the paroxysms
the face continued to ache, and at times the patient had pain at the
back of the head. She had suffered in this way about a fortnight
before coming to me, and had several similar attacks during the pre-
ceding year.
"The treatment consisted in the application of the double-col-
umned hot water-bag. The malady was immediately subdued : no
distinct paroxysm occurred after the first application of heat; all
pain rapidly and completely subsided, and since that date has not
returned.
"4. Dental Neuralgia.— X. W. B., a Russian gentleman, suffer-
NEURALGIA. 457
iug from dental neuralgia, consulted me in September, 1867. The
malady was chiefly confined to the teeth of both upper and lower
jaw, but no particular tooth or teeth seemed to be especially affected.
The pain was intermittent, and so severe as to interfere seriously
with the patient's daily occupation. No cause of the disorder, which
had continued some weeks, could be discovered, and the face, so
far from showing any sign of hypersemia over the seat of pain,
seemed cooler than normal. In the course of the first day of treat-
ment by means of the spinal ice-bag, the pain was completely sub-
dued ; the cold was persisted in for some time, and during the re-
mainder of the patient's stay in England he continued free from
suffering.
"5. Dental Neuralgia. — H. E., female, aged 21, suffering from
violent and continuous pain, spreading over the teeth and gums of
both the upper and lower jaw, consulted me, January 11th, 1868.
The pain was most intense in the lower jaw and on the left side ;
she had intense headache also. The forehead and cheeks were
notably hotter than normal, and she complained of great heat in the
roof of the mouth as well as in the gums — which were swollen and
sore. During the previous week she had had several teeth stopped
with gold : one of them became most especially painful, and there
was threatening of an abscess at its root.
" The treatment consisted in the application of cold across the
occiput, and of heat over the cilio-spinal regioh — in the first instance
separately, and afterward simultaneously. The pain was speedily
and completely annulled; it recurred, and was again annulled by the
same method on several occasions. The patient volunteered the
statement that, during the application of the heat, her mouth be-
came perceptibly cooler.
"6. Facial and Brachial Neuralgia. — Mary A. T., aged 44, first
consulted me at the Farringdon Dispensary, December 28th, 1867,
when she was suffering from neuralgia of the right side of the head,
face, and neck, and along the right shoulder and arm, extending to
the fingers. The right half of the tongue was also affected. The
pain, which was exactly limited to the median line, was described
by the patient — ' like as if something is pulling the flesh off the
bone, it's so dreadful, and sometimes as if the parts were screwed
up in a vice.'
" She was treated by means of ice applied along the whole spine.
She improved immediately and rapidly, and as early as January
15th, informed me that she had not had 'a bit of neuraliga' during
458 ORAL DISEASES AXD SURGERY.
the whole of the preceding week. Up to this date (February 29th)
the pains have not returned."
Facial Neuralgia from Exposed Tooth Pulp. — Mrs. H. had suf-
fered for several years with frequent intense and persistent facial
neuralgia ; had been under the care of four physicians ; taken most
of the sedative, antispasmodic, tonic, and alterative remedies which
could be named ; had been forbidden to go out of the house after
sundown ; was not allowed to put her hands in cold water, etc.
When consulted in reference to her condition, I requested that a
thorough examination of her teeth should be made by a competent
dentist, with a view of ascertaining if the trouble did not originate
there. This was acceded to, but reluctantly, because no pain had
been felt in the teeth. It was, therefore, with some show of gratifica-
tion that I was assured subsequently that the teeth were all sound.
I begged, as a special favor, another and more thorough examination,
which, very much to my gratification, discovered an exposed pulp.
This having been treated, the neuralgia disappeared, and has not
since returned, a period of two years having elapsed. (White.)
Surgical Interference by Operation. — Interference by direct
operation has not, as a general thing, been as satisfactory as could
be desired.
Operative surgery in neuralgia refers to the division or resection
of nerves. In facial neuralgia, where such interference is most fre-
quently practiced, the history of the majority of cases has certainly
not made sufficient offset to balance the risks incurred. It is cer-
tainly true enough that cases occur where it would seem that
nothing else can be done. But when sections are made of healthy
nerve cords one should be well satisfied that he has an otherwise
irremediable condition in the nerve substance external to his line of
section.
For these operations, and the mode of performing them, see
chapter on Resections.
Anomalous Nervous Disturbances from Diseased Teeth. — As a
continuation of the subject of reflex or associate disturbances, it may
not be without advantage to add the following series of clinical ob-
servations, abstracted from various journals, which, from time to
time, have fallen under my observation :
" Dr. B., a dentist, consulted me in reference to his eyes, which
' would not,' as he expressed it, ' focus together ;' could see dis-
tinctly with either eye, but not with both at once ; was unable, in
consequence, to practice his profession ; had consulted several phy-
NEURALGIA.
459
sicians; been blistered, cupped, and had various applications made
to the eye, but it was gradually growing worse. The pupil of the
right eye was very much enlarged.
"I pronounced a carious and diseased first superior molar to be
the exciting cause. It was extracted, with almost immediate relief
and a permanent cure." ( White.)
Facial Pai^alysis. — Dr. Chas. Bacon reported to the New York
State Medical Society the following interesting case of facial
paralysis :
"The paralysis occurred first on the left side, and was caused
probably by irritation of the facial or seventh nerve, by the erup-
tion of the dens sapientiae of the upper maxilla of the same side,
and exposure to cold. The swollen gum was freely excised, mus-
tard pediluvia were employed, active catharsis procured, and the
camphorated liniment with tincture of opium applied to the mas-
toid region and to the angle of the jaw, and subsequently electro-
magnetism to the same region was resorted to, followed by a
blister to the mastoid region, the denuded surface produced by it
being sprinkled, twice a day for two days, with one-eighth of a grain
of strychnine, and then a few doses (fifteen drops) of a solution of
three grains of strychnine in §i of alcohol, were taken. At the end
of some seventeen months the paralysis had entirely disappeared.
For about ten months the patient enjoyed uninterrupted good health,
when he was again attacked with facial palsy of the right side. The
gum of this side was swollen. A treatment somewhat similar to
that pursued in the first attack was directed. At the period when the
report was drawn up, about four weeks from the date of the second
attack, the paralysis was lessened in extent, and the general health
of the patient was good. The gum was less swollen but the tooth
had not yet made its appearance."
"Neuralgia with Deafness, cured instantaneously by the Extrac-
tion of a Tooth. — M. Ed. Yautier records {Gaz. des Hopit.) a case of
this. The subject of it was a very nervous, slender woman, who
had suffered for about four months with intense neuralgic pains,
radiating through almost all the teeth, and also the muscles of the
anterior region of the left side of the head. There was constant
lachrymation of the left eye, and from the moment of the attack
complete deafness in the ear of the same side. A number of phy-
sicians had been consulted, and sulphate of quinia, flying blisters,
and atropia, in succession, tried without giving relief
" When seen by Dr. B. she was suffering severely ; had long been
460 ORAL DISEASES AND SURGERY.
deprived of sleep, and could not chew her food. The teeth were
examined with care, but no one could be found carious. The wisdom
tooth on the left side seemed, however, slightly painful on being
touched, and loose. She was advised to have this tooth extracted,
but with some temper refused. However, some days afterward, her
physician again advising it, she consented, and the tooth was ex-
tracted by M. Yautier. The pains at once ceased, and her hearing
was restored. A month has since elapsed without any return of her
complaint. She seems to be permanently cured." {Dental Cosmos.)
" Cases of Convulsions arising from Carious Teeth. — St. Bar-
tholomew's Hospital. — Notes furnished by Mr. Alfred Coleman:
" Case I. — L. C. G., aged seven years, a moderately healthy-looking
child up to the age of four years and a half, when he had scarlatina
severely, followed by glandular swellings. About four months since
he was observed to avoid using his fingers, and would attempt to
take up a cup between the backs of his two hands, for which his
mother, thinking it was a childish trick, always scolded him and
tried to make him take it up in the proper way, but without much
success. Fancying his right arm was diminishing in size, she took
him to Mr. Coote, who sent him to Mr. Coleman to examine his
mouth. This was on a Saturday. ^ In the afternoon of the same
day, after having been seen by Mr. Coleman, the child was attacked
with a fit of what his mother described as shivering in the right
arm, the arm and fingers being drawn up as well as convulsed ; his
speech also seemed affected. Shortly afterward, this was succeeded
by another fit of the same character, which commenced with a feeling
of pins and needles in the right shoulder, extending to the arm and
hand. From the Saturday to the Sunday evening inclusive he had
ten such attacks. On the Monday he had an epileptic fit, which
lasted two hours, soon afterward followed by another, which did not
last so long.
" Wednesday. — The child has had no more epileptic fits ; but the
lesser seizures still continue, occurring very frequently. He appears
much alarmed at them. His mouth and cheek are drawn up during
a fit, and he cannot speak; but says 'Mother, it is going,' as the
attack is leaving him. On this day Mr. Coleman extracted his four
temporary second molar teeth, all of which were decayed, but had
given him little or no pain.
"May, 1861. — Has remained perfectly free from the before-men-
tioned seizures since the removal of the teeth until within the last
two days, during which he has had seven slight attacks. One of
• NEURALGIA. 461
the first temporary teeth was found to be carious, and it was re-
moved about a week after this. His mother called and stated that
he had one very slight attack since the removal of the tooth ; she
promised to bring him should a second occur, but neither mother
nor child has been seen since that time.
" Case II. — M. J., aged about twenty-three years; is healthy-look-
ing, and enjoys very good health ; suffers much from toothache, and
during the fits has a tingling sensation in the palms of his hands
and soles of his feet, but especially in the left arm. Several of his
teeth were decayed, but not so much so as to require removal ; they
were filled with gold, since which he has had no return of pain or
the accompanying sensations."
"A'mau7'osis consequent on Acute 'Abscess^ of the Antrum, pro-
duced hy a Carious Tooth. — By S. J. A. Salter, M.B., F.L.S., Sur-
geon-Dentist to Guy's Hospital. Read before the Royal Medical
and Chirurgical Society. — The case upon which this paper was
based was one of unusual severity, and of exceptional complications.
The patient, a young woman twenty-four years of age, was attacked
with violent toothache in the right upper first molar, which was fol-
lowed by enormous swelling of the side of the face, and intense
pain. The eyeball then became protruded, and she soon after per-
ceived that the eye was blind. Shortly after the establishment of
these symptoms, ' abscess' of the antrum pointed at the inner and
then at the outer canthus, and a large discharge of pus at both ori-
fices followed ; these orifices soon closed, and the general symptoms
of the part continued unchanged— the swelling of the face, protru-
sion of the globe, and blindness. This state of things lasted for
about three weeks, when the patient was sent to Guy's Hospital, and
admitted.
"At this time the patient exhibited hideous disfigurement from
swelling of the face, oedema of the lids, and lividity of the surround-
ing integument. Upon examining the mouth, it was found that the
carious remains of the first upper right molar appeared to 1 - asso-
ciated with and to have caused the disease. Together with the
other contiguous carious teeth, this was removed, and led, by an ab-
sorbed opening, into the floor of the antrum. The hemorrhage
which followed the operation was discharged partly through the
nose and partly through the orifices in the cheek, as well as from
the tooth-socket, showing a common association of these openings
with the antrum. The condition of the eye constituted the most
important symptom, and the most distressing. The sight was
462 ORAL DISEASES AND SURGERY.
utterly gone ; the globe prominent and everted. There was general
deep-seated inflammation of the fibrous textures of the eye. The
pupil was large and rigidly fixed ; it did not move co-ordinately with
the other under any circumstances. Some abatement of the symp-
toms followed the extraction of the tooth ; but it was soon found that
there was a considerable sequestrum of dead bone, which was re-
moved. The necrosis involved the front part of the floor of the
orbit, the upper cheek portion of the superior maxilla, with the infra-
orbital foramen, and a large plate of bone from the inner (nasal)
wall of the antrum. The removal of the dead boae was followed
by the immediate and complete cessation of all inflammatory symp-
toms ; but the eye remained sightless, and the pupil rigidly fixed.
About five weeks after the removal of the dead b«ne, it was noticed
that the pupil of the affected eye moved with that of the other,
under the influence of light, though vision in it had not returned.
The eye was frequently examined at this stage with the ophthalmo-
scope. All the structures, including the retina, appeared healthy,
except the termination of the optic nerve, which was perfectly white
and anaemic, while that of the other eye was pink and natural.
" The author referred to two other cases essentially similar to his
own. The first (unpublished) occurred in the practice of Mr. Pol-
lock, of St. George's Hospital. The patient had intense inflamma-
tion of the entire maxillary region on one side, caused by a carious
tooth. It implicated the whole face and the contents of the orbit,
but was not attended by ' abscess' of the antrum or necrosis of bone.
The inflammation completely ceased on the removal of the tooth,
but the sight was permanently lost ; the pupil was at first fixed, but
afterward moved with that of the other eye.
"Another example, closely resembling these, was published by
Dr. Briick, in Casper's ' Wochenschrift' for 1851. It was, however,
more chronic, and the loss of vision was only temporary.
" The author concluded his paper by suggesting that the serious
ophthalmic symptoms depended on the nerves of the eye being in-
volved in a plastic inflammation in their course, external to the skull
and before their distribution ; that the optic nerve was permanently
damaged, as shown by the permanent blindness ; and that the third
nerve was temporarily implicated, as shown by the temporary fixed-
ness of the pupil ; and the eversion of the eye from the first seemed
to indicate that the sixth nerve was less or not at all involved.
Finally, the author left it an open question whether the anasmia of
the optic nerve, as displayed by the ophthalmoscope, is to be
NEURALGIA. 453
looked upon as a cause or consequence of its suspended function."
(^Lancet.)
Sympathetic Action. — In the course of an article on "Amaurosis
and other Disorders of the Eye, resulting from Injury of the Terminal
Branches of the Fifth Pair of Nerves," in the Amer. Jour, of the
Med. Sci. for July, Dr. D. Lente gives the following interesting
observations upon the sympathetic relations of the teeth and eye :
" Middlemore says ' amaurosis may arise during the period of den-
tition ; it may take place from the irritation of a carious tooth ; from
laceration or other injury of the supraorbitary nerve.' He relates
a case in which Mr. Howship removed an encysted tumor from the
scalp, which produced 'marked and permanent improvement in
vision.' Another case, in which M. Demours removed a tumor from
the neighborhood of the eye, and thus produced amaurosis. Another
from the Edinburgh Medical and Surgical Journal, ' which would
appear,' he says, 'to prove that wounds of the infraorhitary nerve
may restore the sight of an eye which has long been lost from an
amaurotic affection.' 'A man was affected with perfect gutta serena
of the right eye, and had the sight of the eye restored, he thinks,
in consequence of receiving a smart blow in the neighborhood of the
infraorhitary nerve of the right side of the face.' Another still more
striking case, in which a person received ' a wound just above the
right eyebrow from a piece of glass, which was removed imme-
diately after the accident.' When the wound had healed, 'the sight
of the right eye was very nearly lost ; he has had a painful sensation
in the neighborhood of the cicatrix, and a singular sense of creeping,
and pinching and quivering of the upper eyelid and the integuments
of forehead.' ' I made a free incision of the cicatrix down to the bone,
and all uneasiness at once ceased, and the eye, shortly after, assumed
its healthy character and functions, and vision was loermanently
restored.'' Lawrence; after relating two or three cases of amaurosis
following wounds and the formation of cicatrices over the brows,
remarks : ' It is still a matter of doubt whether injury of the frontal
nerve may cause amaurosis.' And yet, he adds, 'injury or other
irritation of the trigeminus may bring on impaired vision or amau-
rosis.' ' The sympathy between the trigeminus and the immediate
nervous apparatus of vision affords the only explanation of some
apparently obscure cases, in which amaurosis seems to have de-
pended on a carious tooth, or on some other local affection seated
in the head.'
" The following remarks by Marshall Hall were reported in the
464 ORAL DISEASES AXD SURGERY.
London Lancet for 183*7-38: ' These experiments,' alluding to those
made by Magendie, ' are not the only evidence we possess of the
influence of the fifth pair on vision.' ' In an interesting case under
my own care, a partial amaurosis of the right eye has arisen ap-
parently from the caries of the upper canine tooth of the right side.'
It was augmented by unsuccessful efforts at extraction. It has not
ceased, however, since extraction was effected. ' These facts,' says
he, speaking of this and other cases, ' with the similar results from
wounds or tumors of the supraorbitar branch of the fifth, appear to
me to confirm the extraordinary experiments of Magendie.' Hennen
says : ' I have met with one or two cases of amaurosis from wounds
of the supraorbital nerve.' 'Scarpa,' he says, 'doubts of the pos-
sibility of the cure of amaurosis from this cause, and mentions Val-
salva's case as the only one on record.' Mr. Hey, however, states
another in the Medical Observations and Liquiries, vol. v. M.
Larrey mentions another, Vicq d'Azyr, who gives a case of amau-
rosis from a wound of this nerve, in the Histoire de la Sociele
Royale de Medecine, Annee, 1776, says he has 'since divided this
nerve in quadrupeds, but without producing any such effect.'
" That defective vision may result as the direct consequence of
irritation of the terminal branches of the fifth pair may also be in-
ferred from the effects of remedial applications to these nerves, and
from the phenomena observed to follow irritations and injuries of
other branches not so immediately connected with the eye. Some
of these instances it will be proper to mention. A friend of the
writer, a distinguished surgeon of New York City, was incapaci-
tated for business by violent neuralgia of the face ; after having suf-
fered some time with it, he noticed that one of his molar teeth was
defective, and went to a dentist to have it examined ; not supposing,
however, that it had any connection with his neuralgia, since it gave
him no pain. Its removal was advised ; the operation was scarcely
over before the doctor experienced complete relief from his excessive
pain. ' I felt,' he said, ' as if I could have shouted for joy.' A lady,
a short time since, applied to me to extract a tooth for her little
daughter, which, she said, had been causing her excruciating pain
day and night ; but, on examination, I could discover no defect, and
prescribed some anodyne remedy, which gave only temporary relief.
A dentist was called in, who also declined extracting a sound tooth ;
but on a second visit, and a closer examination, detected an unsound
tooth at some distance from the offending one, and extracted it. The
pain instantly ceased, and did not recur. Mackenzie relates a re-
NEURALGIA. 4^15
markable case in point. A man had violent neuralgia of the eye
soon succeeded by amaurosis, and continuing, notwithstanding-
various treatment, from the autumn of 1825 until the beginnino- o"f
1827. At this time M. Galenzowski, to whom he applied, 'found
vision of the left eye lost and the pupil dilated. He extracted a
decayed tooth from the left upper jaw, and, to his astonishment,
and that of the patient, found, attached to its root, a splinter of wood,
supposed to have been originally attached to a toothpick of wood.
Nine days after the patient had entirely regained his sight.^ Mac-
kenzie relates another equally remarkable case, occurring in the
practice of Dr. Tan Zandt, of St. Louis, ' of a young man affected
with complete amaurosis, excited by the persistence of two decid-
uous teeth. As soon as they were extracted, the patient looked up
as if terriiied, and found his vision restored.'' 'Morgagni, Notta,
Deval, Tavignot, and others,' says M. Echeverria, 'have known
amaurosis to be caused by neuralgia, and to disappear as soon as
the neuralgia was cured.' (The italics in the above references are
my own. — L.). Such cases as these might be multiplied, but it is
scarcely necessary." *****
" There are several features in the rather remarkable history of
Antoinette H. which require some notice before concluding this
article. It was objected by a very distinguished oculist, to whom
the case" [one in which part of a gun cap was accidentally driven
into the pericranium of the left side of the forehead, producing
amaurotic and other disturbance] " was related, soon after its occur-
rence, that the wound, being on the left side, the amaurotic symp-
toms should have affected the left eye, and not the right. But this
is not more remarkable than that disease in one tooth should occa-
sion a violent toothache in another perfectly sound ; or that irrita-
tion of the nerves of the stomach by acidity should induce violent
neuralgia of the supraorbital nerve; or that an irritating application
to the mucous surface of the eyelid should determine also an imme-
diate irritation of the Schneiderian membrane, succeeded by violent
sneezing ; or that simply touching the memhrana tympani with a
probe should sometimes give immediate relief to a toothache."'
(Dental Cosmos.)
"Facial Paralysis.— Dv. Coale reports the following case. The
patient was a healthy, w^ell-regulated girl, aged eighteen, who at first
noticed that her face w^as somewhat stiff, and in twenty-four hours
completely paralyzed on the left side. There was great distortion
on laughing or talking, a staring left eye, and tenderness of the
30
466 ORAL DISEASES AXD SURGERY.
whole left side of the face. The tongue was not at all affected, the
disease being confined to the portia dura. No cause could be found
for it, unless it were that she had defective teeth in each jaw, as
much, however, on one side of the mouth as the other. The treat-
ment consisted of leeches to the place of exit of the nerves, strych-
nia, etc., but with no benefit. After the lapse of three weeks, she
was advised to have her carious teeth removed, and thirteen were
accordingly extracted. This was followed by manifest improve-
ment in the course of five da3'S. Electro-galvanism was then gently
employed, and the patient recovered.
" Dr. Tyler said that several years ago he had under his care a
lady with severe sciatica, for which all the usual remedies had been
tried in vain. Finding that she had several decayed teeth, he ex-
tracted four or five of them, with benefit. The remainder were sub-
sequently drawn, after which the patient had no more pain.
" In 1853, a boy, aged nineteen, was brought to the New Hamp-
shire Asylum in a state of mania. Dr. Tyler ascertained that he
had had a tooth extracted some time previous, and that one of the
fangs had broken off, and remained in the jaw. Suppuration took
place, the pus discharging outwardly, and the boy was suddenly at-
tacked with mania. The fang was removed. The fistulous opening
closed, and the patient quickly recovered from his mania.
" In another case of mania, the patient being a young lady, sev-
eral decayed teeth were removed. The patient remained to some
extent under the influence of the ether, which was given at the oper-
ation, for twenty-four hours. After that she was cured of the mania."
Insanity is sometimes caused by Diseased Teeth. — James Tru-
deau, M.D., of Paris, says: " M. Esquirol told me that he had cured
a young lady, who was insane, of her mania by the extraction of
her second molar tooth, which was preventing the growth of a wis-
dom tooth."
Epilepsy from Diseased Teeth. — Dr. Rush ("Med. Inq. and
Obs.") says: " Some time in the year 1801, I was consulted by the
father of a young gentleman in Baltimore, who had been afflicted
with epilepsy. I inquired into the state of his teeth, and was in-
formed that several of them in his upper jaw were much decayed.
I directed them to be extracted, and advised him afterward to lose
a few ounces of blood at any time that he felt the premonitory symp-
toms of a recurrence of his fits. He followed my advice, in conse-
quence of which I had lately the pleasure of hearing, from his
brother, that he was perfectly cured."
NEUItALGIA.
467
Paralysis from Dental Irritation.— The American Journal of
Dental Science, New Series, vol. i. p. 504, quotes from the London
Lancet, as reported by J. L. Levison, of Brighton, the following
case : " Miss , a young lady, was brought in a carriage to my
residence, to have her mouth examined. On being removed, she
was supported by a lady on one side, and a man-servant on the
other, and her entire muscular system seemed paralyzed. Her Ics
trailed on the ground like useless appendages; her arms, when
raised, fell powerless immediately, when unsupported ; and even the
muscles of the tongue were paralyzed, and in her efforts to speak,
this important organ remained in a quiescent state. On examining
the mouth, I perceived a dens sajnentise of the lower jaw very cari-
ous, and deeply imbedded in the temporal muscle, just below the
ridge of the coronoid process, in which locality there was extensive
inflammation. I suggested the removal of the tooth ; and though
I had anticipated some advantage from the operation, the actual re-
sult astonished me. She instantly obtained the free use of her
tongue, which she immediately used to communicate an important
fact, viz., that ever since the tooth I had extracted had been making
its way through the gum, she could date the gradual loss of power
over her limbs, etc. I saw her about a month afterward ; she could
then use her hand and arm — she was writing a letter ! Since then
I have not heard what progress she has made."
Sir Astley Cooper, in speaking of the effects of slight irritation,
says : " M. Toulmin, of Hackney, attended a lady on account of her
suffering unusually from a diseased tooth, and she appeared to be
afflicted with hemiplegia. M. Toulmin extracted the tooth, and in a
short time the paralytic affection entirely subsided."
Catalepsy from Toothache. — The Dental Recorder, vol. viii. No.
1, p. 197 (1854), quotes from The Stethoscope, as reported by Dr.
Huton, the following case:
"Willis, a plowboy (October last), was complaining of toothache
early in the morning ; half an hour after commencing work, was ob-
served lying a short distance from the plow, apparently dead. He
was carried to the house, nearly a mile, and the doctor (five miles
distant) sent for. In the belief that the effect might be produced
through the dental nerve, the tooth was extracted, when the boy im-
mediately got up and expressed himself as well as ever ; and has
continued well since. He had been an unusually healthy boy, and
had never had a physician to see him before."
The following interesting and suggestive cases were collated by
468 ORAL DISEASES AXD SURGERY.
Dr. Abraham Robertson, of Tirgiuia, and published in the Dental
Cosmos :
" Chorea is sometimes caused by Dental Irritation. — The Ameri-
can Journal of Dental Science, vol. vi., New Series, p. 146, quotes
from the Dental Xeics Letter, the following
" Case. Dr. Billard says, after an examination of the case, which
was one of what is commonly called St. Vitus's dance, that he found
several stumps in both jaws, the gums entirely covering some of
them, and on pressure of the same, it caused her great pain, and pus
exuded on the slightest pressure. *****! proceeded to
give ether, and it took a double quantity to make her insensible to
pain. I then took out eight stumps and some small pieces of dead
alveoli, which had caused a continuous irritation of the parts. Since
that time, the author states, the paroxysms grew less frequent, and
now the patient. Miss L., enjoys her usual health."
^' Erysipelas from a Diseased Tooth; Death of Patient. — The fol-
lowing case was reported by Dr. Thompson of the ' Seaman's Re-
treat' (N. y.), and furnished to the New York Medical Gazette, in
which it was published, vol. iii. p. 263 (1852), by Dr. Sayer of
that city.
"Case. — Charles Lunt, aged thirty, Swede, arrived June 28 from
Havre. Admitted into hospital, at the date just mentioned, for an
inflammatory tumefaction of left check and parotid gland, of three
da3's' standing, as patient stated, from toothache, with which he had
been annoyed for several days previous to the swollen face. Patient
otherwise healthy and of a stout, robust appearance.
" On admission, the tooth of which he complained was extracted ;
there discharged, in cutting about the tooth, a considerable quantity
of fetid pus. After extraction of the tooth, a powder of calomel and
rhei was given, and an emollient poultice applied to the face. The
latter was continued, and antiphlogistic remedies pursued, but with-
out much relief to the pain or reduction of the swelling — when, after
several days, the inflammation assumed an erysipelatous character.
The affected parts were now painted with a strong solution of nitrate
of silver, evaporating lotions applied, and the remedies indicated by
the constitutional symptoms administered internally. This treatment
persisted in, the inflammation, in a short time, greatly subsided, and
these promised hopes of a speedy recovery. Suddenly, however,
the erysipelas commenced to spread, and the accompanying symp-
toms to increase in violence, until the palpebra of the (left) eye and
parts adjacent became involved. As the disease advanced, pus was
NEURALGIA.
469
formed in several places, which was evacuated. The conjunctiva,
partaking of the contiguous inflammation, became swollen and oede-
matous. The other tissues of the eye also soon became involved,
and now occurred delirium and other symptoms indicative of the ex-
tension of the inflammation to the brain. This being apprehended,
a vigorous revulsive antiphlogistic course of treatment was adopted,
but without much relief to the patient. The symptoms just alluded
to continuing, and gradually increasing in violence, the disease on
the fourth day of their occurrence proved fatal."
" Vicarious Menstruation from Decayed Teeth. — Dr. Rush, ' Med.
Obs. and Inqrs.,' says, in the second number of a work, entitled
' Bibliotheque Gerraanique Medico-Chirurgicale,' published in Paris
by Dr. Bluver and Dr. Delaroche, there is an account published by
Dr. Siebold of a young woman who had been affected for several
months with great inflammation, pain, and ulcers in her right upper
and lower jaws, at the usual time of the appearance of the catamenia,
which at that period were always deficient in quantity. Upon in-
specting the seats of these morbid affections the doctor discovered
several of the molars in both jaws to be decayed. He directed them
to be drawn, in consequence of which the woman was relieved of
the monthly disease in her mouth, and afterward had a regular
discharge of her catamenia."
"In the Western Journal of Medical and Physical Science for
1838, Dr. S. P. Hullihen reported the following
" Case. — Some time since a young lady, about seventeen years of
age, applied to me with a fungous growth in each of the second molars
of the lower jaw, which had assumed rather a novel character. She
stated that the fungi had made their appearance in both teeth at the
same time, about four years before, and that for the last two years
she had been much troubled Mnth a bleeding from them, which took
place regularly once a month, and continued several days. She
being very anxious to have the teeth saved, I destroyed, to all ap-
pearance, the morbid growth, and plugged the teeth. In a few days
they became sore and painful, the plugs were removed, and a slight
bleeding commenced, which continued three or four days, and then
the tumors entirely disappeared. I was, therefore, induced to plug
them again ; but in about three weeks the teeth became sore, the
plugs were removed, and a bleeding ensued as before. I now sus-
pected it to be a vicarious menstruation, and mentioned the case to
the family physician. At his request I plugged them again, and the
result was precisely as before. The teeth were then removed, and
470 ORAL DISEASES AND SURGERY.
the patient was put under a course of treatment by her physician,
which effected a cure."
"As somewhat allied to this I will here venture the opinion,
although I have no case in mind by which to illustrate the fact, that
other uterine diseases are often greatly aggravated, if not induced,
by this same cause. And, improbable as it may at first seem,
especially do I believe this to be true in relation to one of the most
common afflictions — a very severe affliction, too — of the females of
our country, prolapsus of the uterus.
" This much at least is certain, general debility, however induced,
is a most common cause of this complaint, and I have often ob-
served that when it is not complicated with other diseases, as in-
flammation, ulceration, etc., it may readily be cured, often by topical
applications only, or by topical applications in conjunction with
tonics and healthful exercise in the open air, and sometimes by the
tonics and exercise without any topical treatment, or perhaps by
Dr. Meigs's cure alone, of ' six miles walk a day, commencing with
small doses, and increasing according to ability;' but if from any
cause the general health afterward suffers, and debility ensues, a re-
currence of the prolapsus will also be likely to ensue. And since
diseased teeth, by the nervous irritation they produce, by the de-
rangement they cause in the digestive and respiratory organs, are
most common and potent cause of such debility, they must neces-
sarily be the cause, indirectly at least, of this kind of suffering."
Epilepsy connected with Dental Irritation. — "I. D., aged thirteen,
has had epilepsy eighteen months. Had no fits in infancy, no nerv-
ous affection up to the period of present illness. Family history
good. First attack occurred after eating some crab-fish for supper.
It was long and violent. The second occurred after two months'
interval ; cause of this not known. The third occurred in fourteen
days, and they have recurred at varying intervals, — from one week
to three weeks. They always occur during the night. He screams
sometimes, and not unfrequently bites his tongue. Latterly his
mother has noticed that some days he rubs his left cheek, complain-
ing of faceache, after which the fit follows. He is a healthy-looking
boy; tolerably well-fleshed, although the muscles feel somewhat
flabby. He is intelligent, and does not appear to have suffered in
apprehension or memory ; no headache nor vertigo. Organic func-
tions tolerably well performed ; no inter-paroxysmal phenomena.
On examining the mouth, there is to be seen a molar tooth consider-
ably decayed, with a swollen gum around it, and partly growing
NEURALGIA.
471
over into the cavity ; it is not very tender to touch, and the examin-
ation does not give rise to toothache. On questioning, I find the
sensation which the boy experiences before a fit does not seem to be
one of pain, but rather of an indefinite uneasiness. He always has
a fit tlie night on which this uneasiness comes on. Has never
felt it during the day ; it is always about seven to eight o'clock. I
desired the mother to have the tooth extracted, and ordered a simple
saline, with a quarter of a grain of belladonna, to be taken twice
daily. This was in June. The tooth was extracted next day. I
saw this boy once a fortnight from that time for four months, but he
has had no recurrence of the fit.
" In this case I believe an unfelt aura commenced about the gum
surrounding the tooth, and was not recognized till some degree of
inflammation arose, and thus a modification of pain became asso-
ciated with the aura, and directed attention to it. I have, at the
present moment, another and very similar case to this. The extrac-
tion of the tooth has not yet been performed, so that I cannot give
you the result. When epilepsy occurs in children, I always examine
the mouth, with the twofold view of observing the vault as to height,
narrowness, etc., inasmuch as no observation about the cranial de-
velopment can be complete without such examination, and of ascer-
taining whether any cause of eccentric irritation may spring from
decayed or crowded teeth. I would observe here that, later, the
dentes sapientise often become a source of considerable irritation,
and, therefore, of complication, at least in the epilepsy of young
persons." (Dr. J. S. Ramskill, 3Iedical Times and Gazelle.)
CHAPTER XXXI.
WOUNDS OF THE MOUTH AND ASSOCIATE PARTS.
Wounds of the mouth and associate parts have, of course, the
signification of wounds in general. Thus, some are of an incised
character, being slits or incisions made accidentally or purposely by
sharp-edged instruments ; some are lacerated, contused, or torn,
being made by dull and blunted instruments ; some are punctured,
being made by pointed but not sharp instruments ; some are pene-
trating, as when the offending agent passes through the lip or cheek
into the oral cavity. A wound may be of a compound or complicated
nature, as, for example, in the case of blows or falls, which, while
they cut and contuse the lip or cheek, break, at the same time, the
teeth or fracture the jaw; gunshot injuries, lacerating or simply
puncturing the soft parts, comminuting the hard ; bites of rabid
animals, introducing a virus ; syphilitic inoculations, etc. Compli-
cations may also be considered as embracing hemorrhage and shock
as primary associations ; inflammation, with its varied phenomena,
erysipelas, pyaemia, tetanus, etc., as secondary associations.
Every wound presents a first indication. If an individual receives
a hurt which covers the injured part with earth or other foreign sub-
stance, such substance is to be washed or taken away as the primary
step. If hemorrhage is the feature, arteries are to be ligated, or other
necessary means taken to control such bleeding. If shock be present,
this is the most immediate feature, and is first to be combated. If
a rabid or poisonous animal has inflicted the wound, the destruction
of the virus is a first indication.
Foreign Particles. — To remove earth or similar foreign parti-
cles, no better means can be employed than the simple sponge and
water. Holding the injured part over a basin, squeeze water upon
it from the sponge ; if the particles are not washed away with the
sponge closely applied, let it be lifted aM^ay, and the water allowed
to fall from a distance. It is not, as a rule, at all necessary to per-
mit the sponge to come directly in contact with a wound. Bodies
which may not be washed away, no matter what their character, —
(472)
WOUXDS OF MOUTH AND ASSOCIATE PARTS. 473
splinters, shot, balls, particles of powder, specula of bone, etc.,—
are to be removed with forceps, scoop, or other convenient means
the rule being to allow nothing to remain that may interfere with
the process of repair.
Hemorrhage. — A first matter to con.sider in hemorrhage is its
character. Is it arterial, venous, or capillary ? An arterial hemor-
rhage is known by its scarlet color, and by issuing from the wound
in jets. Hemorrhage from a vein is dark, and has a gradual and
regular flow. Capillary hemorrhage is an oozing. Arterial hem-
orrhage may require that the bleeding vessel shall be ligated. To
do this it is only necessary to sponge away the blood until the vessel
can be plainly seen ; it is then to be taken hold of by the forceps,
or caught in the tenaculum, and a strand of waxed silk thrown
around it. In tying this silk, one must be careful that he shall not
break his strand at either side of the knot, also that the tightening
shall be sufficient to cut the middle and inner coats. To prevent
tearing the vessel from its bed by the breaking of the ligature, the
rule of holding the thumb upon the strands close to either side of
the artery is always to be observed.
After ligating a vessel, one end of the ligature may be cut off and
the other brought out from between the edges of the wound ; this
allows of an easy future removal of the knot.
Torsion of a bleeding artery is a favorite mode of treatment with
many surgeons. The end of the vessel is to be caught by the for-
ceps, and twisted. The author of the mode suggests that the tor-
sion be continued until the end is twisted off.
Acupressure is another, and a very common method of treatment.
A steel or gold needle is passed beneath the vessel in such manner
as to tightly compress it against the neighboring parts.
Pressure by pad and bandage, when a hemorrhage about the face
will not yield to simpler means, is a very satisfactory way of treat-
ment, and one entirely reliable. All the vessels of this region rest
upon a bony floor, and all of them, at certain points, are sufficiently
superficial for the purpose, — the facial, at the notch in the inferior
maxillary, in front of its angle; the temporal, just in front of the
ear above the zygomatic process ; the supraorbital, at the notch in
the orbit ; the infraorbital, at the foramen below the border.
A bandage of common application for any of these vessels is the
crossed or knotted circular. A glance at the drawing will exhibit
the manner of its employment.
It is, however, very seldom that any of these operations are ne-
474 ORAL DISEASES AND SURGERY.
cessary for the arrestation of hemorrhage about the face or mouth.
Cold water thi'own over the bleeding part from a sponge will fre-
quently cause such a contraction, both of vessels and tissues, as to
control it quickly enough. If water alone will not answer the pur-
pose, let alum be added, as much as the water will dissolve. If even
this should not answer the end, use a syringe, throwing a jet from
Fig. 92. — C^os'^ed or Knotted Bandage.
a distance directly upon the part bleeding ; this last will seldom dis-
appoint. Monsel's solutions, so warmly lauded for their styptic
qualities, have exhibited to me more ill results than I have ever met
with from any dozen other articles. If used at all, I think the |
bleeding points should be alone touched ; but of one thing any one i
using them may be assured : if the application does not control the ■
hemorrhage instantly and permanently, he will have increased his !
trouble manifold. !
A hemorrhage that is venous or capillary will seldom require i
more than an application of cold water. If this, or the alum-water,
should fail, astringent medicines may be administered internally.
Of the anti-hemorrhagic medicaments, none has ever stood me in
better purpose than a tincture of the Erigeron Canadense ; one drop
to be given in a teaspoonful of water each minute. This dose seems
like a very small one, but a larger administration has always appeared
to me to do harm rather than good. Opium and lead I have used
with much satisfaction, one grain of the former to two of the latter;
three or four of such pills may be administered at intervals of from
one to two hours each, if found necessary.
SHOCK.
Depression generally attends, to a greater or less extent, the recep-
tion of all wounds. Surgeons divide shocks into primary and sec-
WOUNDS OF MOUTH AND ASSOCIATE PARTS. 475
ondary, or that which is immediate upon the reception of the injury,
and that which does not exhibit itself until some later period.
Shock is prostration;. this may be simply of a nervous nature, im-
plying functional disturbance ; or it may be organic, implying injury
of some vital part; it may again have the twofold relation.
In my own experience I have found few things more important to
observe than the differences between real and apparent shock. One
person, heavy and lymphatic in temperament, shall receive an injury
mortal in its character, and yet, as the immediate or primary shock
is concerned, affords less evidence of such injury than another of
nervous temperament who may suddenly be called to look upon his
wound. Mistakes, in such conditions, have very frequently resulted
fatally to the persons most concerned. An article in the valuable
work* of Prof. H. H. Smith, of the University of Pennsylvania, so
tersely considers this important matter that I am sure no language
could give it better expression.
" In the normal or healthy condition of the body," says Professor
Smith, " each function is so well and accurately performed as to pass
unnoticed by an ordinary observer. The moment attention is called
by marked inconvenience to any one part, that moment its healthy
action is changed, the duration of the disordered action varying
greatly. When only interrupted for a limited period, the function
may be again performed without any appreciable alteration, but when
the interruption is of some hours' duration, the preservative action
' of life may be so impaired as to result more or less quickly in death.
\ " When any injury of a part is of sufficient magnitude to produce
;a marked derangement in the function of the local nerves, reflex ac-
'tion may induce such a depression of the general powers of life as
'will result in the state technically designated as Prostration or
i Collaj)se. This depressed condition is especially noticeable in the
[disturbance of the ganglionic system and its effects on the circula-
Itory apparatus, and is shown either immediately or some hours or
'even days after the receipt of the injury. When apparent within a
i short time after the injury, the condition is designated as Immediate
ior Primarij Shock, but when not developed until several hours or
^days subsequently, it is known as Insidious or Secondary Shock.
I In both there is a common feature of depression, the degree of which
, depends on the violence and extent of the injury, or the character
;and position of the part injured.
Principles and Practice of Surgery, by Henry H. Smith, M.D., etc.
476 ORAL DISEASES AND SURGERY.
" In the lighter forms of primary shock the patient trembles, is
pale, faint, and with an anxious countenance ; and much the same
symptoms are said by Longmore* ' to be witnessed in the horse,
mortally hit, no less than in his rider ; the graver the injury, the
graver and more persistent is the shock.' In marked cases the
pulse is small and feeble or fluttering; the respiration somewhat
oppressed and sighing ; the skin pale and moist, with cold perspira-
tion ; while nausea, vomiting, and hiccough are also seen, and in
some cases there is often well-marked convulsions. The disorder
of the nervous system varies greatly, and is sometimes rather the
result of mental than of corporeal action, as in a pistol-shot in an
extremity not involving important parts, but in which the patient's
mind, having been impressed with the danger to which he was
exposed, continues for some time subsequently to influence his cor-
poreal functions. The violence of the symptoms of primary shock,
in connection with moderate injuries, will depend often on the tem-
perament of the patient, and his mental condition at the time. If
excited by passion, quite severe injuries will often pass unnoticed,
while in cool blood the very idea of a simple operation will suffice,
in some persons, to produce nervous prostration of a marked char-
acter, so much so as readily to induce syncope. In gunshot wounds
of the lower extremities, and in severe railroad injuries, and exten- 1
sive burns, the symptoms of shock are usually most marked. In '
these cases the patient sometimes loses his consciousness entirely, i
and becomes faint, exhibiting great mental disquietude, with absence ;
of thought, and giving foolish answers, or incoherent mutterings.
The skin is covered by a cold sweat, and is pale and flabby; the
muscles are all relaxed; the arm, if raised, drops as if paralyzed;
the sphincters of the bladder and anus permit the escape of urine
and feces, and of this the patient is unconscious. Respiration is
much disordered, and barely perceptible ; the pulse hardly to be felt;
the action of the heart feeble, or sometimes so faint as only to be
heard by applying the ear to the chest; the eyes have a vacant ex-
pression ; the eyelids when raised remain open from want of action
in the orbicularis palpebrarum ; the jaw drops, and the hearing is
temporarily lost, or is stimulated only by loud noises — the patient
remaining in this semi-dead condition for a period which varies
greatly, as from a few minutes to hours, according to the extent of
the shock. In the milder forms, with sufficient consciousness re-
* On Gunshot Wounds, Phila. edit., p. 45.
WOUNDS OF MOUTH AXD ASSOCIATE PARTS. 477
maining, there is only a mental commotion, so as to permit easy
reassurance ; but in the more marked degree this is often difficult
ieath sometimes supervening without reaction, though most fre-
pently a certain amount of reaction is established and conscious-
less returns, or prostration again supervenes and the patient dies.
When a limb is shot or torn away, or the body badly scalded, the
ocal paralysis induced by the injury apparently prevents its imme-
iiate perception by the brain, and in numerous instances the patient
aas been ignorant of the loss of a limb until his attention was called
it. But as soon as the brain becomes cognizant of the injury,
md the stage of depression or shock sets in, these apparently dis-
ant local injuries are attended by the symptoms just enumerated,
hough they are seen less quickly than when the injury involves the
Tunk or head. When the symptoms of shock are marked, serious
nternal injury may be diagnosed even though not apparent at the
noment. In most cases of marked shock the power of deglutition
s more or less impaired for the time, while even in the milder in-
stances the patient experiences such difficulty in swallowing as
vill cause, when the attempt is made, the sudden spasmodic effort
lesignated as a ' gulp,' or the portion partially swallowed is ejected
nth symptoms of strangulation, often evidently of a hysterical
.haracter. When consciousness is not so much impaired the patient
oay be able to control the pharyngeal muscles, yet those of the ex-
remities will be so imperfectly regulated as to cause the limbs to
iCemble as if with fright, or as if exhausted by violent exercise.
1 " Duration. — The duration of the primary shock is very varied.
:n mild cases it disappears rapidly, the patient quickly recovering ;
ihe depression or the disposition to syncope passing away and
[saving him feeble in his circulation as well as in his general
.trength. But in more marked cases, as in the crushing of a limb
|y a railroad train, or by machinery, or a round shot, the collapse
lists for several hours, when the powers of life rallying, reaction
Iccurs, and there is a renewal of the ordinary functions of the
lervous system, noted in the circulation, which now tends to ex-
jessive action as much above the healthy standard as the depression
i^as below it.
i " This reaction after the shock of injury, if not regulated by ap-
propriate treatment, frequently creates a hypersemia or congestion
|f the blood-vessels, and soon develops inflammation and traumatic
i;ver. To prevent this, and keep the reaction from exceeding its
[roper bounds, and yet raise the flagging powers of life, is the im-
[ortant indication to be accomplished in the treatment.
478 ORAL DISEASES AXD SUEGERV.
"Treatment of Primary Shock. — In mild cases of shock, a'
few encouraging words, a mouthful of water, or wine and water,
with judicious explanations of the limited extent of the injury, will
often suffice ; but in marked cases, when the panent's consciousness
is impaired, and his powers of deglutition are temporarily paralyzed
or much weakened, our means of reviving the action of the system
must at first be limited to such remedies as can be applied without
being introduced into the mouth. The best plan of treatment is,
therefore, to dash cold water on the head and face ; to excite arti-
ficial respiration by gently and quickly compressing the costal car-
tilages, or by the ' Ready Method ' of Marshall Hall ; by applying
stimulating vapors, as strong ammonia, to the nostrils ; by exciting
the nerves of the skin by sinapisms applied especially to the epigas-
tric and cardiac regions, and to the extremities ; by applying heat
to the surface of the body through hot bricks, bottles of hot water,
etc., and by rousing the dormant action of the sympathetic nerves,
through the bowels, by administering stimulating enemata, as oleum
terebinthinfe, infusion of capsicum, etc., sufficiently diluted with
water or mucilage to prevent the development of rectal inflamma-
tion. About 5ij of ol- terebinthinae in a pint of soap-suds or salt
water usually suffices.
" When by the continued use of these remedies the patient regains
sufficient consciousness to be able to swallow, or when the depres-
sion has not gone so far as that just alluded to, stimulants may be
cautiously introduced into the stomach. Of these, such should be
selected as are not likely to induce congestion of the cerebral ves-
sels ; hence ten or fifteen drops of the aromatic spirits of ammonia
in a little water, repeated every ten or twenty minutes, answers
better than alcoholic liquors, unless the latter are given in moder-
ate quantities, and their intoxicating tendency carefully guarded
against.
"As the pulse begins to respond to these measures, the use of both
external and internal stimulants should be omitted, the natural tend-
ency being to a reaction that must be restricted to proper limits.
Should the pulse become full, hard, and frequent, so as to indicate
febrile reaction, cold drinks, cold sponging, saline cathartics, and
arterial sedatives, such as five drops of the tincture of veratrum
viride every hour, may be necessary — the powerful action of the
latter remedy requiring its cautious administration, so as to repress
but not depress too much the action of the circulation. The strong
tincture of aconite root, in doses of two drops, or of tinct. of digitalis,
u
WO[T.\WS OF 310 UTH AND ASSOCIATE PARTS. 479
in the dose of ten drops every two hours, for a few hours, may also
be advantageously used, if carefully watched and omitted as soon as
the force and frequency of the pulse indicate their sedative action.
By judicious attention to the proper action of the circulation in these
cases, carefully stimulating the patient when in the collapsed or de-
pressed condition, and inducing sedation when the reaction becomes
excessive, patients may be rallied from the shock of injury and subse-
quently treated as demanded by the peculiar nature of the case. In
that mild degree of shock, sometimes seen in patients who have been
shot by a bullet in the extremities, or struck on the testicles or in the
pit of the stomach, which is characterized by faintness, trembling,
and mental anxiety, a little cold water, or wine and water, with a few
words of hope as to the result of the injury, often suffices.
" In many severe injuries, and especially in those which involve
the main trunks of large nerves, or the spinal cord, or a great extent
of the surface of the body, there is sometimes noted, at varying
periods after the reception of the injury, a train of symptoms of a
marked character, that are very justly spoken of as those of the
secondary or insidious shock of injury.
"Symjjfoms. — The symptoms of insidious shock are often so
masked as to escape the attention of an inexperienced observer,
until they are so far developed as to render it diSicult to rally the
forces of the j)atient. Thus when a limb has been torn off by a
cannon-ball, or in a rolling-mill, or a thrashing-machine, or by a
railroad train, the patient not unfrequently appears to be almost
, unconscious of the severity of his injury, the local paralysis being
' so perfect as to prevent the excruciating suffering that such an injury
! would otherwise create. In the case of the railroad accident, by the
collision of opposing trains on one of our railroads, I saw a young
■ man who had his arm cut off near the shoulder-joint, with so little
j suffering as to be unaware of the extent of the injury till his clothing
I was removed. By great care he subsequently recovered.
! "In numerous instances in the experience of all surgeons, such
; patients have presented the following symptoms : immediately after
i the injury they are remarkably cool, self-possessed, and as if en-
! dowed with indomitable fortitude ; the pulse is often barely acceler-
, ated ; the respiration quiet and natural ; the skin pleasantly warm ;
\ the mind clear, though perhaps a little torpid, but apparently with
i perfect consciousness. In some cases patients have been known to
' walk or ride some distance, evidently unconscious of injury, till sud-
; denly faintness supervenes, and they fall to the ground, and die in
480 ORAL DISEASES AND SURGERY.
the course of an hour, more or less. In other cases, where the ex-
ternal wound or injury is more evident, they will give directions for
their removal, arrange their bed, business, etc.; reply to questions
rationally, and with great composure ; yet, as has been well described
by the late Dr. George McClellan,* they will present a countenance !
that is altogether unnatural, having ' an inquiring, anxious look j
about the forehead, eyes, and upper portions of the face, while all j
about the mouth is smiling and composed.' In addition to which i
'they look with a stare of alarm and suspicion at the surgeon when i
his attention is called to them.' !
"After this period of treacherous calmness has existed from three j
to eighteen hours, the expression suddenly changes; the lips be-
come livid or deadly pale ; the blood leaves the surface of the body;
the pulse flutters and becomes too rapid to count ; the respiration is
short and panting; a great sense of oppression distresses the pa-
tient, and he sinks slowly, as if suffocated, or dies as if struck by
lightning. In these cases the foundations of life are undermined,
and the paralysis, which was at first limited to the part injured,
suddenly extends to the nervous centers, and life is arrested by the
want of proper nervous force.
"Prognosis. — The prognosis in cases of severe injury, in which i
the patient is thus unconscious of suffering, cannot be too guarded, i
the patient not being out of danger from insidious shock until after j
the lapse of forty-eight hours of perfect tranquillity. In the majority ;
of such cases, when secondary shock supervenes, death ensues. i
"Treatment. — The treatment of secondary or insidious shock |
should be chiefly prophylactic, special attention being given to the |
preservation of the powers of the nervous system by the adminis- !
tration of food and stimulants, while all muscular action on the part '
of the patient should be carefully guarded against. I
" In many cases it will be useful to give milk-punch, beef-tea, !
quinine, carbonate of ammonia, chalybeates, etc. as often as possi-
ble, until some evidence is shown of their effect upon the circula- i
tion. Then, while the patient is strictly confined to the recumbent i
position, stimulating frictions should be made along the spine, cold i
applied to the head if it becomes hot, pediluvia or hot bottles applied '
to the feet if cold, and access given to a sufficient amount of fresh j
air in the chamber to favor active respiration, while the patient is at !
i
* Principles and Practice of Surgery, p. 18. Phila., 1848. Edited by Dr. I
Jno. H. B. McClellan.
WOU.\WS OF 310 Um AND ASSOCIATE PARTS. 481
the same time kept warmly covered up in bed. By such means the
occurrence of secondary shock may be prevented; but should it
supervene, nothing but powerful stimulants to the spine, or the ad-
ministration of ether, brandy, tincture of capsicum, etc., with the
free use of beef essence, affords a hope of checking the rapid prostra-
tion that, if not watched, will carry off the patient. In every case
of serious laceration of a limb, opening a large joint, tearing nerves,
etc., cautious watching of the pulse can alone guard against the de-
velopment of insidious shock. If the patient is disposed to sleep,
let the pulse be noted, and let him be awakened every hour to take
nourishment, if the pulse begins to flag. As the symptoms of shock
are usually the result of serious and extended injury, the question
of the propriety of operating for the relief of the injured part will
often arise. Unless in the case of the laceration of blood-vessels
from which the blood oozes, the opinion of most surgeons is adverse
to the propriety of operating until reaction is fully established ; and
since unconsciousness can be readily induced by the use of anaes-
thetics, the supposed advantages derivable from amputating a limb
while the patient was unconscious of the injury, are generally re-
garded as evidence of a want of judgment on the part of the operator.
How soon after reaction an amputation should be performed, will de-
pend on circumstances, and be again alluded to when speaking of
the advantages of primary over secondary amputations.
" Occasionally it happens that after reaction is established and
traumatic fever supervenes, the patient becomes delirious, or trau-
matic delirium or wandering, without fever, is met with. If this
! delirium is an attendant on the febrile condition, sedatives, cooling
; applications, and the judicious use of opiates, with antiphlogistic
I remedies, as antimony, arterial sedatives, and such others as are
adapted to inflammatory fever, will be required; in other cases
I opiates are mainly sufficient. Should delirium tremens supervene,
I the usual treatment, as described in treatises on the practice of med-
j icine, with great attention to the seat of injury, will be requisite.
I Among high livers or in the intemperate, a comparatively slight
• injury will often induce an attack of delirium tremens, requiring
1 opiates and stimulants to counteract it, or, if the pulse is exceed-
I ingly frequent without prostration, the administration of large doses
' of the tincture of digitalis or veratrum viride. In delirium tremens
I supervening on pistol wounds, in many of our volunteer soldiers in
j camp for the first time and deprived of their habitual drams, I have
> 31
482 ORAL DISEASES AND SURGERY.
seen marked benefit derived from the administration of half an ounce
of the tincture of digitalis every four hours until three doses are
taken, this apparently heroic treatment sometimes inducing a per-
fect cure in thirty-six hours. As the dose advised is very large, the
pulse should be cautiously watched before it is repeated."
Virus. If a rabid dog, or other animal, bite the part we are con-
sidering, or any part, — if a poisonous serpent strike its fang, or even
if the loose kiss of the chancrous lip inoculate, — a first indication is
to get clear of the poison. How ? It is now very generally ac-
cepted that the immediate application of solid nitrate of silver to the
parts wounded will neutralize these poisons, or that, at an}^ rate, it
will so alter the condition of the wounded part as to slough ofi" the
oflFending agent, and prevent its absorption. If an escharotic is not
at hand, and this, at the moment, would be not unlikely, such a
wound may be cut away. Suction is also an admirable prophylactic
(not as the chancre inoculation is concerned, there would be here
no immediate hurry) for most poisonous introductions. The danger
to the person sucking such a wound would be very trifling; any
danger at all depending on a casual abrasion that might at the
time be present about the mouth or lips. Excision of bitten parts
is frequently practiced. I recall an occasion, several years ago,
where an enraged rattlesnake escaped from an experimenter, strik-
ing its fangs into a colored assistant standing by. Without a
moment's hesitation, the gentleman excised the part ; no harm ever
came of the matter. Tiding a patient over the depression of rattle-
snake poison by the stimulus and specific effects of whisky, has
received so many confirmations as to have become a matter of
common knowledge. In my own practice I have had on several
occasions to excise poison wounds, and all have been successful.
Without exception, however, the wounds excised have been received
through some intervening substance, and such substances may have
prevented the introduction of any poison.
Healing Wounds. — Primary indications met, the second ques-
tion is the healing of a wound. Every wound heals by granular
tion. The difference between a healing by first intention and a heal-
ing by second intention is only a difference in degree. An incised
wound, delicately and accurately approximated, heals with so little
new inter-tissue that Mr. Paget mentions cases where no line of
difference was discernible even under the microscope. A healing by
second intention, so called, may require so many granules to fill up
a gap that the new or cicatricial tissue is observable at a great dis-
WOUNDS OF MOUTH AND ASSOCIATE PARTS 483
tance, as is frequently witnessed in scars from burns. An indication,
then, of the utmost importance to be met in wounds about the facej
is the avoidance of a necessity for new tissue. To accomplish this'
every wound is to have its parts as nearly approximated as possible^
and the associated vascularity modified, or at least controlled.
How wounds are best approximated is a matter which is always
eliciting discussion. The common methods are by stitches, plasters,
and compresses. An incised wound, of limited" extent, about the
cheek, seldom needs more than that a strip of adhesive plaster
shall be thrown across it. If such a wound occupies the position of
the lips, and shall have made a complete separation, adhesive plaster
will not, perhaps, be found sufiBcient for the purpose. To insure the
least scar, a stitch may be used to approximate the free edges, and
the parts then forced and held together by placing two lateral com-
presses at the sides of the wound, and supporting these with a turn
of the circular bandage ; or it may be found that, after the stitch,
the adhesive strips will answer the purpose. Pins, with a figure-of-8
\ turn about them, make a very nice, reliable, and accurate adaptation,
; and, if not kept in too long, leave very little scar.
A mode of approximation, which will be found very satisfactory,
consists in using a suture of silver wire, and bringing the edges of
I the wound together, as directed in cleft palate. An objection, how-
ever, it must be admitted, to all pins and stitches, lies in the fact of
new wounds being made, — an irritation being begotten by the pres-
ence of the foreign body, which is very apt to provoke more or less
suppuration, thus making other scars, as is witnessed so frequently
in operations performed for hare-lip ; therefore it may be set forth as
the best practice, that any means which breaks the flesh should be
avoided, if any other may be made to answer. Silver or lead wire
is preferred to the waxed silk, only from the fact that these me-
I tallic agents seem to irritate less, and are, therefore, not so likely to
I make points of suppuration, and consequently scars.
j When pins or stitches are used, they are to be left in place only so
i long as is absolutely necessary. This time will, of course, depend
I very much on circumstances. If an incised wound does as well as
it may, sixty to seventy hours will usually be found sufficient for
j the union, while instances enough exist where, in this time, the pro-
, cess of repair seems scarcely to have commenced. A very good way
I to obtain information is to sponge off the wound, and to be instructed
iby the line of approximation ; if this continues to show its incised
nature, the pins are not to be disturbed ; if, on the contrary, it is a
484 OBAL DISEASES A.\W SURGERY.
fleshy line of comparative solidity, the pins may be removed, — the
parts will hold.
The withdrawal of a pin or ligature is a matter demanding- delicacy
of manipulation. It is frequently, and indeed generally, the case,
that more or less blood-rust collects upon a pin, making the removal
a matter of such difficulty that, unless the precaution be taken to
scrape away such rust before making the attempt, a disturbance
of the cicatrix is almost inevitable. In the withdrawal of a pin,
an important matter is the rotation of it ; such rotation facili-
tates the removal wonderfully. Metallic ligatures are generally dis-
turbing ; the proper plan to take them away is to cut the wire at
the side of the spot or knot opposite to that on which it seems
desirable to withdraw it ; the end is then to be carefully straight-
ened, so as to place it on a line with the part in the wound ; sup-
port is to be given the cicatrix by a finger applied on either side,
when, with a rotatory movement, the wire is to be drawn away.
In the use of the pin and figure-of-8, a very excellent plan is, on
the removal of the pin, to allow the blood-matted silk to remain
glued to the wound ; it serves very much to hold the parts together,
and is entirely void of any offense as a source of irritation.
When plasters are used, it is a necessity to have all hairs shaved
away and the parts perfectly dry. The ordinary adhesive kept on
sale by every druggist, composed of resin and lead plaster, is per-
haps open to as little objection as any. It is to be applied in strips
of convenient length and breadth, and rendered adhesive by holding,
for a moment, the back of the strip over a vessel of hot water. There
are skins, however, which this plaster irritates and inflames ; when
cases of the kind are encountered, it is well to employ the isinglass
plaster. An objection to this plaster is its tendency to curl, and
roll up. It is applied by moistening the glazed surface with
water.
In the use of plasters, it is a good rule to allow a space between
each strip; this not only keeps the wound exposed to observation,
but permits of easy drainage. An only exception to such rule is
found in small cuts where it is thought desirable to use collodion.
This mixture of gun-cotton and ether is applied either directly
over a cut — first nicely approximating the edges, and holding the
parts together until the ether has evaporated — or indirectly through
the agency of saturated slips of gauze or other convenient ma-
terial.
The removal of a plaster is to be effected by drawing the strip
WOUNDS OF MOUTH AND ASSOCIATE PARTS 485
from either side toward the wound; such a removal beino- accom-
plished without any strain upon the cicatrix, the line of union beinir
of course, supported by the thumb and forefinger of the other hand.
If a wound seems to be doing well under plaster, there need be no
special haste in its removal. It is usually the case, however, that
such a dressing will not continue to do service longer than two or
three days. In simple incised injuries, this is generally all that is
required, but in lacerated wounds, dressings are demanded an in-
definite length of time, and require continued renewal. In reapply-
ing a dressing of adhesive strips, a good plan is to displace and
replace one at a time.
Complicated Wounds. — The history of a few cases may, per-
haps, best serve to illustrate practice in this direction.
Case I. — Little girl, of remarkably perfect temperament, about
four years of age, brought into the office with quite a gash in the
lower lip, and the six anterior teeth knocked directly back ; consider-
able hemorrhage.
Treatment. — Checked the hemorrhage, and cleaned the parts by
the free use of cold water applied through the syringe ; pushed
the teeth back into their unfractured alveoli, and retained them in
place by laying a delicate roller over them, fixing it beneath the
chin. A single stitch of waxed silk was placed in the wound of
the lip. The case was dismissed for the day, with directions to
keep the parts refrigerated through a continuous application of cold
water.
Second day. Same treatment continued, the band over the teeth
being replaced by a fresh one.
Third day. Wound in the lip healed sufficiently to remove the
ligature. Teeth somewhat tightened ; very little inflammation ;
continued the bandage, but left off the application of the water.
Fourth day. Removed the bandage. Teeth very sore, but doing
well, and quite fast.
Eighth day. Patient dismissed ; some soreness still in the teeth,
but needing only time to bring them to full health.
This case was seen three months after the accident— there was
no discoloration of the teeth, and not the slightest evidence that
any harm had been done them.
Case II.— Child six years of age. Four front inferior teeth
knocked loose by a blow from a ball ; some contusion of the lip,
but no break in the continuity ; very little bleeding.
Treatment.— VxemoYeOi the injured teeth ; absorption having pro-
486 ORAL DISEASES AND SURGERY.
gressed to a considerable extent, applied to the lips dressing of
cold water ; case well enough to dismiss next day.
Case III. — Little boy, five years of age, fell upon a curbstone,
fracturing the superior alveolar process. Examination revealed six
teeth movable in mass, the fracture extending from tuberosity of
right side to canine fossa of left. The accident occurred nine hours
before recourse to treatment.
Condition. — Child feverish and restless ; pulse much excited ;
soft parts about the seat of fracture considerably swollen, and so
tender as to cause the little patient to scream when the parts were
touched.
Treatment. — A Seidlitz powder ; hot pediluvia ; the mouth sy-
ringed with cold water; iced lemonade, ad lib.; spts. Mindereri, 5ii,
y'g gr. acetate of morphia. This was the treatment on the after-
noon and night of accident.
Second day. Hot pediluvia ; iced lemonade, made of crushed
ice ; mustard poultice at back of neck.
Third day. Swelling of gums very much abated. Fed the child
freely with spoon food, then brought the fractured part to its place
by reducing to proper articulation with lower teeth, and retaining in
position by means of the yard strip modification of the Bai'ton
bandage — a fairly comfortable day was passed. In the evening the
bandage was loosened, the child again fed, the bandage tightened,
patient put to bed — a comfortable night was passed.
Fourth day. Doing very well. On loosening the bandage there
was very little tendency in the fractured part to move of itself; child
fed with soup food ; mouth well syringed with cold water ; bandage
reapplied. Patient played about the room most of the day, taking
lemonade and rice-gruel very frequently, by placing the fluid within
the lips and sucking it between the teeth.
From fifth to tenth day did little more than continue the treat-
ment of the fourth.
Eleventh day. Removed the bandage. Fracture fairly solid ; able
to hold of itself; liquid food continued; no other treatment.
Fifteenth day. Patient began to eat solid food ; passing on, with-
out further treatment, to a good cure.
Case IV. — Little girl, three years of age, markedly scrofulous ;
lip cut through; fracture of process of central, lateral incisor, and
cuspid teeth of left side inferior maxilla; cutting edges of teeth
thrown backward.
Treatment. — The wound in the lip being quite extensive, a hare-
WOUNDS OF MOUTH AND ASSOCIATE PARTS. 487
lip pin was inserted, and the parts pushed together and held with a
figure-of-8. The fractured process was restored to position, and
retained by tying the one end of a strand of waxed floss silk around
the last molar tooth of the injured side, bringing it forward, passing-
it between the first molar and cuspid of the fractured part, back of the
three teeth of the broken process, then^out between the central in-
cisors, and back to the first molar, where it was tied. This ligature
supported the part in its place very well. The ferrated elixir of
bark, in doses of twenty-five drops, directed three times a day.
Second day. Wound in the lip doing tolerably well; seat of frac-
ture looking puffy, and asthenic. Very weak solution of compound
tincture of capsicum ordered to be thrown, ter die, over the part.
Third day. Looking worse ; ligatures cutting into the gums ;
patient refusing solid or soft food ; took away the ligature ; tempted
the appetite with ice-cream and jellies ; scarified the puffy gum.
Fourth day. Matter oozing from about seat of fracture ; etherized
the child ; dissected down to the fractured piece, and removed it.
Sixth day. Yery much improved; wound healing fairly; con-
tinued to syringe with the dilute capsicum comp.
Eighth day. Case well enough to be dismissed. The pin in the lip
had been removed on the third day. The wound gaped some little;
but the removal was a necessity, on account of irritation produced
by its presence; support was giv^en by an adhesive strip, after the
taking away of the pin, and the part stimulated with capsicum,
under which it healed very rapidly.
Case Y. — M. L., an iceman, aged perhaps thirty-five, brought into
the office immediately after having been kicked on the mouth by a
vicious mule. Patient very pale and faint. Examination revealed
comminuted fractures of the alveolar process of both jaws, with the
teeth knocked into every position.
Treatment. — First, stimulation with a little brandy. The patient
revived. Incisions on either side of the teeth were made down to
the bone, and some eight pieces removed, with the teeth associated.
No hemorrhage of consequence attended the operation, and in the
course of three or four days the man was going about his business,
—no treatment, outside of the free use of cold water, having been
indicated or employed.
Case YI— C. H., struck over the angle of the jaw l)y a Minie-
ball, which plowed across the face, completely dividing the cheek,
and grooving the right nasal ala. A first treatment employed on
the field, where the injury was received, consisted in associating the
488 ORAL DISEASES AND SURGERY.
severed parts with a series of interrupted sutures, and the application
of a poorly adapted bandage. In this condition the patient was sent
several days' journey, to a hospital in which I happened at the time
to be employed. My first observation of the case exhibited an im-
mense wound, stiches all torn out ; superior maxillary bone exposed,
with groove cut into it ; suppuration most profuse ; patient ex-
hausted, irritable, and feverish.
Treatment. — The weather being oppressively hot, a large basin of
water was brought, in which the head and face were thoroughly, yet
tenderly, washed. The matted hair was combed out and arranged.
This refreshed him very much. Examination of the wound was
commenced. On the groove in the bone was found no splinter, nor
other indication adverse to the direct and immediate overlying of
It by the soft parts. Attention to the line of wound in the soft part
exhibited that the slough, which must necessarily have ensued from
the passage of the ball, had completed itself, and that a process of
repair was attempting to inaugurate itself. Indications thus being
rendered very plain, the whole of the cut and suppurating surface
was slightly stimulated by an application of dilute tincture of iodine,
and then carefully moulded into place and approximated. The main-
tenance of this apposition was accomplished by fitting a compress to
the cheek, and also below the wound, and with a bandage carefully
lifting and supporting it ; no stetchers, pins, or plasters being em-
ployed. The success was perfect, the whole line of the wound being
exposed, permitting the fullest and most frequent examination. In
ten weeks the parts had united so firmly as to allow of the removal
of the compress and bandage. The only medication employed con-
sisted in the administration of an occasional Seidlitz powder, and a
daily glass of porter, with repeated applications to the wound of the
dilute iodine, one part of the officinal tincture to four parts water.
Case VII. — Little girl fell over the shafts of a wagon, cutting her
tongue, in some unappreciated way, directly in twain, for the dis-
tance of an inch down the middle. Hemorrhage very profuse, re-
quiring the ligature of a vessel. This wound was united by two
stitches of the interi'upted suture passed deep in the substance of
the organ ; cold water directed to be held, quite continuously, for the
first day in the mouth ; patient fed on ice-cream and jelly. Third day,
stitches removed, union complete, ligature loosened, and was pulled
away on the seventh day.
Case Till. — Brigadier General D., standing upon an outlook, was
struck by a sharpshooter, the ball passing through the right ramus
WOUNDS OF MOUTH AND ASSOCIATE PARTS.
489
of the lower jaw, shattering the bone, passing forward across and
through the tongue, emerging from and splintering the body of the
bone on the left side. The treatment pursued upon the field had
been to check an alarming hemorrhage from the region of entrance
of the ball, by stuffing the wound with charpie saturated with
Monsel's solution of iron, throwing a baiidage over it, and hurrying
the patient to the hospital.
Condition on entrance. — Patient arrived, and was put under my
care about eleven o'clock at night; complained, by writing on a
slate, of great thirst, with entire inability to swallow, and of the pain-
ful effort it required to breathe; had not been able to drink since the
accident, which happened two days before.
Treatment. — Examination revealed marked displacement of the
middle piece of the fractured bone. This, with the tongue, being
pulled backward by the hyoid attachment of the genio-hyoglossal
muscles, sufficed to explain part of the difficulty in respiration and
deglutition. The tongue itself, however, was much swollen, and had
a ball wound through its base. Two primary indications thus pre-
sented: to keep the body of the bone and tongue in position, and to re-
duce the swelling in the tongue. The external wounds were for second-
ary consideration — the patient had to breathe and had to be nourished.
The mouth was first well syringed with cold water, which was most
refreshing to the patient ; the bone was then brought forward, the
inferior teeth in front of the superior ; the jaws were closed, and
held together by a delicate bandage, the middle fragment being thus
retained even in front of its natural position, and pulling the tongue
forward with it. This accomplished, the patient was propped up in
an arm-chair, and his feet immersed in hot water, the application
being continued until every vein and capillary was engorged. A
local abstraction of blood was not thought desirable, as he had
already lost as much as he could well spare. The result of such a
primary treatment was, that in half an hour the patient was able to
swallow spoonfuls of lemonade. This drink, cold as it could be
made, was continued during most of the night, serving, by its re-
freshment, to give much comfort, and by its refrigeration to abate
the vascular excitement. About four o'clock in the morning the
patient fell into a disturbed sleep, which continued until eight. At
nine o'clock the tongue was examined by separating the lips, and
looking at it through spaces which existed between the teeth ; the
swelling and turgidity had very much diminished. The feet were
again placed in hot water, and the blood held in the parts until a
490 ORAL DISEASES AND SURGERY,
sense of faintness was experienced. This gave increased relief. The
patient thus being over the immediate danger, attention was di-
rected to the state of the external injuries, and the line of passage
of the ball.
The wound at the external angle of the jaw was found to occupy-
quite a space in the parotid fossa, the ball having been received
evidently as the general had turned his head to address some one
behind him. It was stuffed with charpie, looking now a black and
blood-infiltrated mass, and which evidently had been thrust hard and
solidly into the wound, and now had swelled to double its former
size, displacing the parts to a very marked extent. This plug being
firmly fixed, it was left to be removed or not, as circumstances
should seem to direct, at a future time. The wound of exit was
larger than might have been expected, spicula of bone having con-
siderably torn the parts ; from this was removed several small
splinters. The probe, passed into this opening, revealed the line
of the wound, running through the base of the tongue obliquely
across the mouth. An only treatment consisted in the free use of
permanganate of potash and water. The patient passed the day in
a fair degree of comfort.
A sudden secondary hemorrhage being the next thing to fear, it
was determined on the third day to remove the plug ; this was ac-
complished only after a full hour of labor, the charpie having wedged
itself into every imaginable space, the removal being effected by
the very free use of milk-warm water and the most gentle of trac-
tion with the forceps and scalpel handle. The removal was attended
with considerable pain, but without the loss of a single drop of
blood ; the relief from the sense of pressure afforded was so very
great as to change the whole appearance of the patient, he now
breathing and taking his beef essence with the greatest freedom.
The appearance of the wound was really very promising, attempts
at granulation being quite evident, while nothing especially threat-
ening was to be observed. The day after this dressing, the patient,
in opposition to all advice or commands, insisted on being passed
to his family in Washington. All the dangers of secondary hemor-
rhage were exposed and explained to him, but he seemed to be pos-
sessed of the single idea of getting to his home. At five o'clock in
the afternoon he was driven to the steamer plying between Fortress
Monroe and Baltimore, continued in charge of a surgeon who had
been sent with him from the field. At midnight, while on the
Chesapeake, the most profuse secondary hemorrhage came on, which
WOUNDS OF MOUTH AND ASSOCIATE PARTS. 491
was controlled, as best it might be, by masses of ice held continu-
ously to the wound. The patient died during the next day at a
hospital on the wharf in Baltimore — under what exact circumstances
I could not learn ; most likely, however, from exhaustion.
Case IX. — J. B., middle-aged man, gash, from a blow, lacerating
the cheek, opening the duct of Steno.
Treatment. — With a heavy-eyed needle, carried a loop from the
bottom of the wound to the inside of the cheek — the silk, which
was very loose, conducted the saliva into the mouth. Brought the
external wound together by strips of resin plaster; no other treat-
ment required, save an occasional dressing. In a week the loop
had sloughed through into the mouth, preserving completely the
track for the secretion, and the process of granulation had ad-
vanced almost to the stage of cure in the external wound; uo after-
trouble.
Case X. — C. A., young gentleman, twenty years of age, deep
punctured cut in the floor of the mouth just to left of middle line,
made by the slipping of an elevator in the attempt to remove root
of upper canine tooth. Xo hemorrhage, or immediate bad sign of any
kind ; patient very much frightened. Accident had occurred two
days before my seeing the case ; part very sore and tender ; inflam-
mation limited.
Treatment. — Directed arnica water for relief of the soreness ;
nothing else indicated or required ; the wound healing rapidly and
kindly.
Case XI. — Cut received by young lady, exposing and incising
mylo-hyoid artery of left side in the groove ; hemorrhage very great
and persistent.
Treatment.— V^u^hi position ; tiuct. Erigeron as directed; strong
alum solution held to the part on tufts of cotton, afterward thrown
with the syringe ; ice to the part, etc. No result on the bleeding.
The patient becoming affected from loss of blood, enlarged the
wound, picked out the vessel with the Liston forceps, and tied it.
This, of course, controlled the hemorrhage. Patient recovered.
Case XII.— Mr. C. Performed operation on the cheek for erectile
growth ; cut well into the sub-tissue, making quite a deep wound,
just as if the part had been scooped out.
Trea^me?i<.— Cold-water dressing; waiting on nature to fill up
wound with granulations ; nothing else required, nothing done ; the
case progressed to a satisfactory cure, excepting a raised scar.
Case XIII— Young man, shot through the cheek; the mouth
492 ORAL DISEASES AND SURGERY.
beiug, at the time, fortunately open, the ball passed out, doing no
further damage ; no hemorrhage.
Treatment. — Applied cloths wrung out of cold water, for the pur-
pose of controlling vascular reaction; nothing else done; wound
suppurated until the compressed and devitalized tissues were
sloughed ; then kindly granulated, the patient being entirely well
in a month.
Case XIV. — Patient, young lady. In an attempt to extract the
jBrst molar tooth of right upper jaw a flap of gum had been torn,
extending around the mouth to the left second bicuspid ; this flap
had been hanging loose some three hours before the patient pre-
sented herself.
Treatment. — Cut it off, and depended on granulations from the
wounded surface for the filling up ; patient comfortable next day ;
entirely w^ell in a week ; no other treatment of any kind required.
Case XY. — Boy, tAvelve years of age ; playing with powder con-
tained in a bottle, it unfortunately exploded, throwing the glass and
powder into his face. When first seen, an hour after the accident,
the patient was in the greatest distress ; the eyes were completely
closed, lashes entirely destroyed, hair singed, face raw and bleeding,
pulse rapid, and very irritable.
Treatment. — First, Seidlitz pow^der, with half grain of opium;
second, removal of such pieces of glass as could be readily picked
away with the forceps ; third, cold-water dressing. In an hour
the patient was fairly comfortable ; at the end of which time a second
half grain of opium was administered.
Second day. Face very sore, but no burning pain ; picked away
several small pieces of glass and a number of powder grains. Con-
tinued cold-water dressing.
Third day. Reactive inflammation evidently aborted ; water
dressings dispensed with ; used in place
B.— 01. lin.
Aqua calcis, aa q. s.
With this the surface was protected from the atmosphere until it
cicatrized — a period of two weeks. During the time of cure some
little attention was given to the diet, the patient for the first day
craving principally ice-cream, which answered very well, and served
to allay a slight tendency to irritative fever which existed — the
latter four days of the first week stimulating articles of food were
interdicted ; after this he ate what he best liked.
WOUNDS OF MOUTH AXD ASSOCIATE PARTS 493
Case XVI.— Patient, young gentleman. Struck, while on a
gunning excursion, hj a buckshot, which passed through the lower
lip, burying itself in the bone. Patient not seen until the next day;
lip too much swollen to perrtiit of examination.
Treatment. — Cold-water dressing to the lip. Mag. sulph. §ss
internally.
TJiird day. No diminution in sw^elling ; slight erysipelatous
blush ; brushed the parts with the following combination :
R. — Tinct. ferri chl. Jss ;
Quinia sulph. gr. xxx ;
Tinct. cinch, gtt. x;
Aqua, giv. M.
In one hour the blush disappeared — water reapplied.
Fourth day. Inflammation, with the swelling, disappearing very
rapidly ; water-dressing continued.
Sixth day. Probed the wound ; discovered the shot lying near the
root of the first bicuspid tooth ; dissected away the gum from the
inside, and with a very small curved gouge picked the lead away.
Seventh day. Inflammation back again, confined, however, rather
to the inside of the mouth ; reapplied the cold-water dressing, and
directed a Seidlitz powder.
Eighth day. Better; inflammation rapidly yielding ; a little pus
escaping from the shot track in the bone.
Tenth to thirteenth day. Track of wound in the I)one suppura-
ting considerably ; tinct. iodine injected.
Foiu'teenth day. Discharge diminishing; iodine still continued.
Sixteenth day. Discharge entirely ceased ; patient dismissed.
Case XYII. — Patrick T., laborer. While engaged in blasting
rocks the patient was struck with great force, just below the orbit,
by a flying fragment, lacerating, in a frightful manner, the soft parts
of the face, breaking and knocking into the nares the left nasal bone,
and severely concussing the maxillary. No hemorrhage; heavy
shock.
Treatment.— T\iQ patient being a strong, plethoric man, reaction
was allowed to establish itself, and which it did completely only
after the lapse of several hours. Cold-water dressings were, how-
ever, at once applied to the parts, every deduction being in favor of
the inference of severe inflammation. The accident occurred in the
morning. At seven in the evening, a pine stick, whittled, to make
its introduction easy, was coated over the end by dipping it in
494 ORAL DISEASES AND SURGERY.
melted wax, and with this, insinuated into the nostril beneath the
depressed nasal bone, it was thrust out into place, position being
maintained by a tuft of wax-coated cotton, having attached to it a
string for its withdrawal, being pushed up beneath the fracture.
Examination of the injured face and maxillary bone revealed con-
tusion and injury to such an extent as to make it plainly evident
that the process of cure must be that of exfoliation, sloughing, and
repair by granulation ; the only treatment was then the expectant,
and this was met by a simple water-dressing.
Second day. Most decided reaction. Mag. sulph. ^ss adminis-
tered in half a glass of water; water-dressing, medicated with lead
and laudanum.
B. — Plumbi acet. 5'j I
Tinct. opii, §ij ;
Aqua, 3XXX. M.
Cloths wet with this lotion kept constantly upon the cheek.
Third day. Inflammation abating, but patient complaining of
feeling hot and generally miserable. Lemonade ordered as a febri-
fuge, to be made by expressing the juice of an ordinary lemon into
a goblet, sweetening, and filling up the glass with ice broken into a
coarse powder. To be allowed ad libitum.
Fifth day. Wound suppurating ; fever all gone ; dressing changed
to simple water ; waxed cotton changed in nostril, — the replacement
giving much pain.
From fifth to tenth day. Water-dressing continued ; portion of
external plate of the bone apparently dying ; periosteum evidently
destroyed.
Eleventh day. Stimulation commenced ; parts wet three or four
times a day with the following :
R. — Alum pulv. 5ij ;
Tinct. capsicum comp. ^ss ;
Aqua, ^xvi. M.
Fifteenth day. Granulations being thrown out from around the
edges of the wound ; parts brought as closely together as possible,
and retained with adhesive strips ; nasal fracture doing very well.
Tvcentyfifth day. Wound of face entirely healed, with the ex-
ception of a small place in the center, which, when examined with
the probe, discovered a sinus leading to diseased bone.
Thirtyfourth day Piece of bone presenting at the sinus; en-
larged the opening, and withdrew a sequestrum rather larger than an
WOUNDS OF MOUTH AND ASSOCIATE PARTS. 495
ordinary finger-nail. Examination with the probe, after the removal,
gave the fleshy feel indicative of repair. Case dismissed on the
thirty-sixth day.
Case XVIII.— Young man, struck on the side of the face, in a
street brawl, with a slung-shot; face severely cut and contused;
outer boundary of the antrum driven backward into the cavity, not
fractured apparently, but simply bent inward.
Treatment. — Cold-water dressing, — no other application for the
first three days. After this, the patient being compelled to go out
to his work, adhesive strips were employed ; repair progressed
rapidly, without a single adverse manifestation. The depressed
plate of the sinus gave no trouble, soon accommodating itself to its
new position ; all sense of soreness leaving it by the end of the
second week. External wound cicatrized in twenty days.
Case XIX. — A young man slipped while standing on a stall in a
market-house ; falling forward and downward upon one of the hooks,
it entered his mouth, breaking off three of his upper teeth, perfo-
rated his hard palate, and passed by its point into the right nostril.
Treatment. — Seen first one hour after the accident. Pain in the
broken teeth unbearably severe. Examination discovered the en-
gorged pulps entirely uncapped and bulging from their cavities.
The probe introduced through the wound in the palate passed readily
into the nares, giving little or no pain. No fracture of the bone,
save a few trifling spiculse about the circumference of the puncture.
The roots of the broken teeth were at once extracted, and the case,
for the time, left to nature.
Second day. No necessity for any interference ; some soreness,
but no actual pain.
Third day. Nothing required to be done.
Fourth day. Three trifling pieces of bone discharged into the
mouth.
Seventh day. Wound granulating very satisfactorily.
Fifteenth day. Nature unable, evidently, to quite fill up the open-
ing; assisted by scarifying the circumference of the wound, and
touching with tincture of iodine.
Seventeenth, twentieth, and twenty-second days. Scarified, and
touched with iodine.
Twenty-fourth day. Opening completely closed. Case dismissed.
Case XX.— Gentleman. While striking the iron handle of a chisel
in the act of opening a box, a small piece flew off from the hammer,
burying itself in the malar process of superior maxillary bone.
496 OBAL DISEASES AND SURGERY.
Treatment. — With probe, searched in the wound for the foreign
body ; found it in position as described, with very oblique track
through soft parts. Introduced a sharp steel instrument, and, after
some trouble, succeeded in working the piece loose ; could not, how-
ever, get hold of it with forceps without such manipulation as would
evidently enough contuse the parts. Introduced a director down to
the body, and cut to it; removed it in this way without effort.
Wound closed with two delicate sutures, and the cold-water dress-
ing applied; in three or four days the parts were entirely well, with-
out the slightest suppuration having occurred, — no noticeable scar
being left.
CHAPTER XXXII.
OZ^NA.
The term ozsena, like the term epulis, is a somewhat indefinite
one, and is to be first considered in the width of its signification.
Ozsna is from the Greek oZrj, signifying stench, and the terra
is, therefore, in reality and strict justice, applicable to any ill-smell-
ing condition. By universal consent, however, it has been restricted
in its application to foul conditions about the nares and associate
parts, accompanied with offensive discharge. The study of ozaena,
then, it will be seen, is the study of various conditions, and may be
considered under the following heads :
1. Accumulation and degeneration of the common antral secre-
tion.
2. Degenerated pus from tooth-abscess discharging into the
antrum.
3. Ulceration of mucous membrane of the antrum.
4. Deteriorated secretions from constitutional causes.
5. Caries of the osseous walls of antrum of the nares.
6. Ulceration of the mucous membrane of the nares.
7. Caries and necrosis of the osseous boundaries of the nares.
8. Lodgment and retention of foreign bodies.
' The first of these conditions is most frequently observed in con-
' nection with the ordinary cold in the head. The outlet of the antrum,
^ it will be remembered, is by an opening about the size of a goose-
I quill into the middle meatus, which opening is circumscribed by
'mucous membrane, and which membrane, as the result of conges-
|tion, can very well occlude this outlet; the parts being in this con-
'dition, it may happen that the pent-up mucus degenerates and
; decomposes, so that, on the subsi^nce of the swelling, the escaping
! discharges present this ofi'ensive odor. To diagnose this character
[of ozaena, it is only necessary to connect it with the preceding
^inflammation, with the absence of specific conditions, and with
[the readiness with which it yields to simple treatment. Of course
ithere would have been a preliminary feeling of the sense of con-
jgestion on the part of the patient ; he would have had, to express
i 32 ( 497 )
498 ORAL DISEASES AND SURGERY.
it most simply, a cold in the head, and this cold, with its sense
of dryness and constriction, would have grown worse, until, with
the appearance of the discharge, he would have experienced a
sense of relief; the discharge implying the passing away of the
congestion and the restoration of the normal circulation and secre-
tion.
To cure this form of ozaena requires very little treatment, — indeed
in many cases no treatment at all. I am in the habit, when the
discharge continues longer than two or three days, of directing
the sniffing up the nostril of the affected side some such combination
as the following :
R.— ^th. sulph. ^i;
Tinct. iodiuii, ^ij ;
01. juniper. 5i- M.
If this fails to check the discharge, I then employ such constitu-
tional ti'eatment as seems indicated. Patients in whom such dis-
charge exists belong to one of two classes, the plethoric or anaemic.
"With the first, the treatment demanded is depletory: a dose or
two of sulphate of magnesia will generally be all that is demanded;
although in a few instances I have found it necessary to deplete
from the veins. With the second class — and this is by far the
most numerous — we have the mucous membrane of the part falling
into a condition analogous to the urethritis of chronic gonorrhoea :
in these cases tonics are at once to be resorted to, and the common
combination of iron and quinia is perhaps about the best that can
be prescribed :
R. — Tinct. ferri chl. §i ;
Quiniae sulph. 5i- ^I-
Sig. 15 drops in water every three hours.
2. Fetid discharges depending on tooth-abscesses — abscesses
which discharge into the antrum — find their cure, as a rule, imme-
diately on the extraction of the diseased tooth. If this should not,
however, prove to be the case, then injections are to be made
through the tooth alveolus. Iodine is an admirable base for all
such injections. My own practice would be first to control the odor
with the permanganate of potash.
R. — Potass, permang. 5ss to j;
Aqua, ^viij. M.
Inject pro re nata.
OZ^NA. 499
It would most likely be quite sufficient to use this injection three
times a day — after which the following should be thrown in :
B. — Tinct. iodinii, 5i;
Glycerin, gi ;
Acid, tannicum, '^si> ;
Aqua Cologn. |i ;
Aqua pura, ^iij. M.
Or,
Or,
Or,
B. — Tinct. capsici comp. 5ss;
Aqua, 3viij. M.
Chloroform, ^i ;
Spts. aeth, nit. ^ss;
Spts. vin. ^iv. M.
B. — Argent, nit. grs. xxx;
Aqua, 3vi. M.
Indeed, any stimulant preparation may be resorted to, although
I incline to believe that iodine acts the most happily.
3. Ozffina from ulceration of mucous membrane of the antrum is
not, so far as my experience allows me to judge, a condition of fre-
quent occurrence ; without doubt this is the case where no specific
disease, as syphilis, scrofula, or scurvy, exists, so that, meeting with
such ozsena, we naturally at once revert to the constitutional con-
dition. To discover an ulcer within the antrum is a matter for
diagnosis by exclusion, and thus to discover it is not at all a
difficult matter. If there are no diseased teeth or teeth roots ; no
nasal ulceration, no antral dropsy, no acute preliminary conditions ;
if the fetid matter flows most freely when the suspected antrum
overlies its nasal outlet, then Ave will generally be right in inferring
an ulcer of the antrum ; but an ulcer in the antrum is not neces-
sarily a cause of oziena. To give this fetid odor, it must be an un-
healthy ulcer, by which is meant that it tends to degenerate its granu-
lations, rather than to organize them. An ulcer, says Mr. Cooper,
may be defined to be "a granulating surface, secreting matter;" and
this is certainly true of most ulcers, particularly if we replace the
term secreting with the term making; for the matter given off is, 1
imagine, nothing but degenerated lymph-corpuscles, to which the
parts lacked strength to give force of organization. A healthy ulcer
may be seen in any accidental sore tending to rapid self-cure ; there
500 ORAL DISEASES AND SURGERY.
is here little, or perhaps no matter, for the reason that ever}-
particle of the exuded lymph of repair has in it vitality sufficient
for its organization. An unhealthy ulcer, on the contrary, — and
by such an ulcer we mean an adynamic one, — gives off more or
less pus ; it throws out its i-eparative lymph just as does the healthy
one, but the viability of such lymph differs materially from the ex-
udation of the former ulcer. Thus, according to the nature and
character of such degeneration, we have the produced pus: ich-
orous, a thin, watery, acrid discharge ; scrofulous, a cheesy, curd-
like pus; sanious, a thin, sizy discharge; glutinous and viscid, as
in sordes, etc.
Now, whether any or all these kinds of ulcers should give us the
fetor of ozaena, would depend on circumstances ; not the least im-
portant of which would be the state of the atmosphere, and the
cleanliness preserved. Laudable pus, issuing from a healthy wound,
will, in hot weather, become in a very short time quite offensive, as
is, unfortunately, too freely illustrated in hospital practice. Certain
ulcers are, however, in themselves offensive. Every one has had
occasion to observe, at some time or other, the disgusting odor aris-
ing from the saliva of particular persons. I recall, even to this day,
a certain schoolmaster, the odor of whose spittle, employed to rub
sums from my slate, always made me sick. This kind of saliva,
and this odorous ulcer, belong to the alkaline class of people. Give
such persons acid : they always need it ; I never knew an exception.
A simple ulcer of the sinus, that is, one not associated with
osseous diseases, is to be treated in the twofold direction of its con-
stitutional and local requirements. To treat an ulcer justly, calls
for an understanding of the conditions on which ulcers depend ; and
as ulcers of various signification so frequently present themselves
about the mouth and throat, it may not be a digression to make a
hasty review of so enlarged and important a subject.
Ulceration is the absorption or the breaking down of some con-
stituent part of the body. Its great cause is inflammation. In-
flammation is always preceded and excited by irritation. The
term irritation is a comprehensive one, and covers every source of
offense to the human body. Thus one man has an ulcer, the result
of an inflammation excited and perhaps kept up by the presence of
some foreign body, as, for example, a ball, a splinter of wood, a
particle of dust, etc. An ulcer, says Richerand, is from a cause in-
herent in the economy, and differs from a wound, which is always
idiopathic, in being symptomatic. A second man has an ulcer, the
OZJEXA. 50^
result of a localized inflammation, predisposed bj the presence
within his system of some specific taint. These ulcers, a glance
would exhibit, must vary widely in their character, and even more
so in the treatment demanded for their cure. Thus it is that we
speak of, and think about, ulcers in the way of their signification.
We have simple purulent ulcers, venereal ulcers, scrofulous ulcers,
scorbutic, varicose, and cancerous ulcers; the character of each being
expressed by its adjectival prefix. A simple purulent ulcer is a sore,
the result of some local accident, and is, most likely, self-curing; a
venereal ulcer is one excited and kept alive by the presence in the
system of the venereal poison ; the scrofulous, scorbutic, and can-
cerous alike depend on dyscrasic conditions; the varicose on certain
obstructions in the venous system, etc. To secure a cure, in the
first of these classes of ulcers, nothing more is necessary than to
protect them from adverse influences. A varicose ulcer, to be gotten
well, must be converted into a simple one by treatment directed to
the trouble in the circulation ; a cancerous, scorbutic, or scrofulous
ulcer is only to be permanently cured by obliterating the cachexia.
There is nothing obscure in the appreciation of these facts ; any
difficulty is in meeting the indications. Ulcers, it is true, are pre-
sented under a great variety of names ; but these variations have
reference alone to varieties in expression. Thus, the carious
ulcer implies that the condition is dependent on the presence of
dead or dying bone ; a callous ulcer is one having an indurated
circumference ; a fungous ulcer, one where the granulations of repair
are in excess ; a sinuous ulcer is one constituting the orifice of a
canal leading to a deeper than the manifested disease ; an irritable
ulcer is one that, from internal or external causes, has become tender
and excited ; a phagedenic ulcer is one that tends to take on gan-
grenous action ; a sordid ulcer is one discharging a dirt3--looking,
glutinous matter; and so on, each of the many appellations being
simply an expression of some distinctive peculiarity. Now, one
man, having syphilis, gets a rheumatism in his joints, another gets
an ulcer on his tibia. In these two cases the important features
of treatment are, however, to be precisely alike ; both patients must
have an antisyphilitic medication ; the local applications are simply
adjuncts. An ulcer simple in its character, situated over or upon
some part in frequent motion, is apt to assume the irritable aspect ;
an ulcer the result of an idiopathic influence, if occurring on a person
of weak and typhoid condition, is almost certain to assume the
chronic or indolent form ; an ulcer engrafted by external cause on a
502 ORAL DISEASES AND SURGEBY.
depraved constitution is always more or less influenced by the vice,
and such vice must be considered in its treatment; and so, what-
ever may be the extent of the review, this wide collateral relation-
ship keeps itself in the foreground.
To return, then, to ulcers in the antrum. We are prepared to
recognize that such ulcers may be of various signification, and may,
for their cure, demand a various character of treatment. So far as the
odor, however, is concerned, all will benefit by the common primary
treatment of cleanliness and antiseptic injections. To correct the
fetor in a chronic case, it generally becomes a necessity either to
trephine through the canine fossa, or to extract one of the under-
lying teeth and get into the cavity through its alveolus ; the latter
mode is decidedly to be preferred. A plan, however, that may be
tried, consists in keeping a tuft of cotton or fine sponge in the
nostril, and frequently saturating it by the sniffing into it of an anti-
septic. The entrance into this cavity, however, through the alveo-
lus of a tooth is one of the simplest procedures in surgery, de-
manding only that the operator shall recognize the position of the
cavity as influenced by the shape of the jaw. Any spear-shaped
instrument will answer to make the opening ; to keep it patulous,
it is only necessary to introduce, after each operation of injection,
a tent of cotton or sponge. As an injection, the following combina-
tion may be employed :
R. — Acidi carbolici, gtt. xx ;
Glycerin, ^ss ;
Acid, tannic, gr. v ;
Aqua, ^vi. M.
Or,
R. — Spts. viu. 3i ;
Creasotum, gtt. x ;
Aqua, ^vi. M.
Or, as suggested on page 498, the permanganate of potash in the
proportion of from two to ten grains to the ounce of water, as indi-
cated.
Associated with such antiseptic treatment, and which we employ
in every case of ozaena, whatever may be its origin, Ave connect
the specific or peculiar treatment demanded by each special case, —
the understanding of which treatment presupposes and necessitates
the understanding of disease in general, and can conform to no
special rules.
OZ^NA. gQ3
It is true that for certain diseases we have certain medicaments
which we have come, perhaps unadvisedly, to consider too much in
the light of specifics. Thus, in syphilis the mercurials are much
depended on ; so that, having an ulcer of such origin to treat, a
constitutional medicine might be prescribed, as follows :
B- — Syrup, ferri pyrophos. Jvi ;
Hydrarg. bichl. gr. iv. M.
Sig. A teaspoonful three times a day.
Or,
Or,
R. — llydrarg. bichl. gr. ij ;
Potass, iod. 5ij ;
Fid. ext. sarsaparilla, ^viij. M.
Sig. A tablespoonful three times a day.
B. — llydrarg. chl. mite, gr. iv ;
Sacch. alb. pulv. ^ss. M.
Divide into eight powders.
Sig. One three times a day, followed, after each eight have been
taken, by a Seidlitz powder.
Mercury is to be considered as an active force, striking at the para-
site of syphilis, destroying it ; and while it is very well thus to kill such
parasites, it is quite as well to remember that the harm of the agent
employed must be constantly met and counterbalanced ; this we do
by keeping up and supporting the system, so that I think it will
commonly be found that syphilitic ulcers require wholesome food,
fresh air, proper exercise, judicious bathing, — in short, the employ-
ment of every means that tends to the maintenance of the general
health.
In the mercurial ulcer — which is far more common than the syphi-
litic, granting the true syphilitic to exist — the general and local use
of the chlorate of potash is found to act very well. The medicine,
dissolved in water, may be given in doses of ten grains, repeated
four or five times a day ; the injection should be not less in strength
than a saturated solution. The character of a mercurial ulcer is
discovered by associating the local lesion with the existing general
dyscrasias.
Scrofulous ulcers are judged by the appearance of the sore, the
nature of the discharge, and the existence of the disease in the pa-
tient at large. A scrofulous subject, while not always bearing the
clearest general evidences of the disease, yet generally has some one
504 ORAL DISEASES AND SURGERY.
or more features that will allow us to distinguish the condition.
General features associated with scrofula may be enumerated as fol-
lows. The first manifestation occurs generally, not always, at the
period of first dentition, the symptoms being irregular appetite, au
ill-smelling, inspissated mucus, swelling of the superficial glands of
the ucck. Continued manifestations advance with age, presenting
subcutaneous lymph eflTusion, particularly about the calves of the legs
and the outside of the thighs ; various eruptions, inflammation, and
suppuration of joints, especially the hip, knee, and thumb joints ; a
flaccid, enlarged condition of the tonsil glands, susceptibility to at-
mospheric changes, inability to endure physical fatigue, impoverish-
ment of the blood, general asthenia. Scrofulous subjects are gener-
'ally languid in their movements, and without impressibility ; not
always, however, for it is a well-known fact that many of the most
precocious and bright persons end their effulgence in phthisis. In
short, the history of scrofula is the history of phthisis ; it matters
little, so far as a general effect upon an individual is concerned,
whether the tubercle deposits itself in the lung or in the ganglia, or
diffuses itself over the system at large.
Scrofulous ulcers are always unhealthy in appearance, being cov-
ered with a dirty yellowish aplastic matter, irregular about their
edges, generally bluish or purple, more or less undermined, and dis-
charging an ichorous, flaky pus ; local stimulation meets with little
or no response, and, for the reason of the general deficiency in vi-
tality, the parts around ai"e usually indurated from interstitial deposits,
chronically congested, and looking altogether indolent and ill-con-
ditioned.
The treatment of scrofulous ulceration is (in our present knowl-
edge of the disease) simply a treatment of building up. Unacquainted
with the character and causes of the diseases, we direct our aim to
so lift up the life-forces that a sufBcient inherent vitality may be de-
veloped to throw off or overmaster the depressing influence. Exer-
cise, tonic medicaments, cold bathing, salt and mountain air, rare or
raw meats, generous liquors, all are useful means to such an end.
Iodide of potassium has long had a reputation in this disease, also
barium, iodide of iron, syrup of the phosphates, cod-liver oil, phos-
phoric acid, etc. My own individual opinion and experience is, that
wrapping one's self in a wet sheet on getting out of bed, and securing
vigorous reaction by a good hand-rubbing, and, after such operation,
drinking the yolk of a fresh eg^ drowned in good brandy or whisky,
is better than any medicine proper yet prescribed. Certain I am
OZ^NA. 5()5
that I have seen this treatment do such good as warrants the com-
mendation these remarks would give it.
We always, however, do something to a local disease, if for no
other reason, from mere force of habit. We can use with these
ulcers any of the applications referred to a few pages back, and any
one of them is about as good as the other, or we may use them one
after the other.
Syphilitic ozsena from ulceration of the antral mucous meml)rane
must be, as remarked, an exceedingly infrequent affection. Not so,
however, with ulceration from such cause in the nares ; such a con-
dition is quite common. When you have a case in which dirty clotty
scabs are constantly being received into the handkerchief, and much
offensive sanies is discharged from the nose, you may feel well sat-
isfied that you have a case of syphilitic ulceration, and particularly
may you rest satisfied in your diagnosis if any evidences of the dis-
ease exist in other parts of the body. Syphilitic ulceration of the nose
has frequently been confounded with a commencing polypus; but the
conditions are so dissimilar that only the most culpable carelessness
could fail to distinguish them. In the first condition there are the
fetid discharge, and the association with the anterior train of acci-
dents ; a scab soon comes away, and a temporary cessation of the
obstruction ensues In the latter disease the obstruction is gradual
a,nd coutinuous ; there are no fetid clots, and no anterior accidents
of association: blowing the nose, in the one case, most likely re-
lieves for the moment ; in the second, it throws forward the polypus
so that we can see and feel it.
Syphilitic ulcers within the nose attack equally any location,
and possess the most unfortunate tendency to enlarge and bur-
row, so that, if not successfully combated, in a very short time
the bony framework is involved, thus giving the deformities so
common.
A patient with a syphilitic ulcer developing in his nose, com-
plains first of a feeling of congestion. We come to our conclusions
because we observe other certain secondary indications. A few days,
more or less, pass, and he is troubled with a discharge; this, at
first, is very little or perhaps not at all offensive. Very soon, how-
ever, he remarks the odor, and the discharge, which continues to
increase, frequently becomes so profuse that twenty or thirty pocket-
handkerchiefs are necessary for his daily use. Occasionally, and
sometimes very frequently, dirty, gluey clots or scabs come away,
and the ulcer, if seen, is noticed to present a reasonably healthy
506 ORAL DISEASES AND SURGERY.
look, something, for example, as a chancre would look when only
half destroyed and casting oflf its slough. If unconibated and un-
conquered, the ulcer eats deeper and deeper, until the bone is
reached, Avhich, in its turn, succumbs, giving us caries, or, much
more likely, necrosis. Arrived at this stage, we have, indeed, a most
formidable condition, and it is not at all unlikely that, in defiance of
every effort, more or less deformity will I'esult.
An ulcer situated in the anterior part of the nares is indicated by
the forced expirations of the patent. Situated well back, he relieves
himself by forced inspirations ; occasionally, however, from the very
beginning the pituitary membrane becomes so thickened and en-
gorged that the passage of air through the tube is almost shut off:
in these cases the trouble is indicated by excessive restlessness.
It is not by any means always the case that nasal ostitis is
secondary to ulceration: on the contrary, the cases are frequent
enough where the bone becomes primarily diseased and where the
ulcer is simply the associated lesion. Syphilitic ostitis very fre-
quently ends in necrosis; and more particularly is this the case
where the turbinated bones are the ones affected. The vomer, how-
ever, is the one most frequently necrosed in syphilis, — that is to
say, the most frequently attacked ; and this is brought about in
three ways : first, from a primary ulceration of its mucous cover-
ing ; second, by the deposition of submucous tubercles ; third, by
the direct affection of the bone. When ostitis attacks the vomer or
any other bone, our best efforts are to be directed to the resolution
of the inflammation. To secure this end, we resort to such local
means as seem indicated by the peculiar features of the case. The
treatment would be that applicable to inflammation anywhere ; it
could be influenced by the temperament of the patient and the
stage of the disease ; locally we have nothing at this time to do
with its specific character ; we have simply to treat a perverted
condition of the circulation of the part. Constitutionally, however,
its origin is to attract our closest scrutiny ; and, in connection with
the local remedies employed, antivenereals must be depended upon
as our strongest supports.
The diagnosis of inflammation of the nasal boundaries is not diffi-
cult to make out. When the vomer is the bone attacked, the patient
suffers from sharp pains, referred to the root of the nose ; he has
headache, always increased by the recumbent position. If the in-
flammation exists in the anterior part, pressure on the cartilage
increases the pain.
OZMNA. 50y
The nasal bones, when affected, exhibit an overlying congested
skin ; pressure on the bridge is responded to by much pain ; the
lachrymal secretions are affected, and not unfrequently, because of
the congestion in the ductus ad nasum, run over the cheek. The
turbinated bones, when the seat of the inflammation, yield a sore-
ness to the lateral aspects of the canal, and respond quickly to
pressure thereon exerted.
Whichever of these bones may be the one affected, its history, so
far as ozaena is concerned, is the same in signification. If the inflam-
mation is not arrested, necrosis or caries, partial or complete, results.
Soon a discharge makes its appearance, disgustingly foul if the
case is one of necrosis, and more or less offensive, and mixed with
osseous particles, if it is caries.
Antivenereal treatment is a treatment of building up. You can-
not hope to arrest syphilis when it has passed to its tertiary mani-
festations in any other way. Limit and circumscribe the local inflam-
mation as much as you can ; and to do this you will generally find
that stimulants act a better part than depressants. An excellent
injection is a combination of iron, iodine, quinine, and glycerin.
B.— Tinct. ferri chl. 5i ;
Quiniae sulph. gr. xxv;
Tinct. iodinii,
Glycerin, aa |i ;
Aqua, ^iv. M.
Sig. Inject, or brush over and about the parts, three times a day.
Give iron and quinia internally: it is scarcely probable that a
patient having syphilitic necrosis needs a mercurial course ; in-
deed, it is much more likely that he has already been so over-
drugged with this medicine that his trouble is mercurio-syphilitic,
rather than syphilitic alone. Iodide of potassium is recommended
and freely prescribed in these tertiary conditions : it may be given
in doses of from ten to twenty grains dissolved in water or in the
fluid extract of sarsaparilla. But good rare roast beef, poultry, a
daily glass of malt liquor, boat-rowing, wrestling, horseback-riding,
systematic bathing, these are the reliable medicines, and may
elevate the vital forces to an ability iper vias naturales to throw off
the disease. It is confessedly hard to cure syphilis when it has
thus taken hold of the system ; and when it inflames a bone, par-
ticularly a small one, the patient is lucky if he escape without its
complete destruction.
508 ORAL DISEASES AND SURGERY.
Necrosis, partial or complete, implies, of course, the existence
of a sequestrum ; and the getting away of this dead part implies
very generally the cure of the oza3na. Particularly is this the
case when the death is limited to the single bone or piece. To get
away this piece is then one of the most important features in the
treatment. How is it to be done ? Simply wait until the probe
reveals that it is loose ; if it may not be taken away through the
orifice of the sinus it has itself created, we have only to enlarge
in any convenient way such sinus, and then lift the piece away.
If, after the removal of such dead bone, we find the discharge
continuing, but modified as to character and odor, we infer the
necessity for stimulation, and use the iodine, or iodine and iron, or
the combination with tannin and glycerin, as seems to be indicated.
It might be, however, that neither the discharge nor the odor
decreased : in such cases we are seldom wrong in inferring that
more dead or dying bone is in the wound, and the treatment first
employed is to be renewed. When tertiary syphilis has associated
with it severe nocturnal pains, great relief is frequently secured
from the administration of the iodide of potassium, particularly if
combined with minute doses of phosphorus — say five drops of the
acid, phosphoric, dilut.; as a dose it is to be remembered, however,
that, because of the relationship of the potash with the mucous
membranes, in many persons even very small doses will excite much
irritability in the air-passages, thus seeming to increase instead of
allaying the trouble. With such patients we must diminish the
dose of the iodide pro re nata.
Bromide of potassium is now frequently employed to procure rest
and tranquillity. It is commonly prescribed in doses of ten grains ;
but forty or fifty will be found the better dose. It is best given in
a little water just as the patient is about to get into bed.
Lodgment and Retention op Foreign Bodies. — In the use of
cotton or sponge about the nares, care is to be taken that the pellets
do not escape attention and remain lodged in the passages. Some of
the most offensive and resisting discharges occasionally have their
cause in this direction. Rhinolites — calculi varying in size from a
pea to that of a pigeon's %g^ — sometimes form in the canals, and, by
inducing ulceration and collecting debris, become the source of
ozaena. Peas, rags, buttons, and sundry other articles are not un-
frequently found in the nares, thrust there by children of experi-
mental proclivities, any of which may, of course, become a source
of offense.
OZ.ENA.
509
The removal of foreign bodies from the nares is always to be
effected as speedily and with as little injury to the parts as possible.
A plan that may first be tried is to place the patient in a strong
light and search the parts with very delicate forceps: if the body can
be seen, it may thus generally be removed. Another plan consists
in giving a pinch of snuS" and compressing the unobstructed nostril :
the effort of sneezing will not unfrequently throw the body a con-
siderable distance. Still another plan is to compress the unobstructed
nostril and blow into the mouth, thus forcing it out. An annealed
wire, bent into the form of a loop and passed over the body, is very
frequently employed with satisfactory success ; a flexible, blunt,
double hook is also used with advantage. The syringe is some-
times found beneficial, the obstruction being washed back into the
throat.
CHAPTER XXXIII.
FRACTURES OF THE MAXILLARY BONES.
Fractures of the maxillary bones may be divided into two classes,
simple and complicated. The first applies to such cases as are with-
out external or associate injury, implying a simple break in the con-
tinuity of the bone. The second applies to cases associated with
comminution of the bone, to external lesions, injury to vessels, to
teeth, — in short, any and every condition which alters the fracture
from that of a simple to one of a compound character.
The inferior maxilla, from the exposure of its position, from its
shape, and from its office, is much more liable to the accident
of fracture than either of the superior — the accident being com-
monly the result of blows, falls, kicks, etc. These fractures will, in
the majority of cases, outside of gunshot injuries, be found asso-
ciated with the body of the bone, the rami escaping, from the fact
that a force brought to bear upon them slips the articulation easier
than it may break the bone.
The weakest part of a bone would most naturally be the part to
yield in a diffused blow. In most inferior maxillae this weakest
point is found to be the line of the roots of the canine teeth ; hence
the most frequent seat of fracture in the bone is in this line, either to
the right or left, as influenced by the direction of the force. This,
however, as would be inferred, applies to an unbroken dental arch ;
when teeth have been lost, and the process removed, the situation
of this weakest part is materially altered. In gunshot injuries, acci-
dents from the passage of a wheel over the jaw, or similar applica-
tions of force, fractures occur, of course, at the seat of such appli-
cations, and follow no rule. In the work of Prof. Hamilton on
Fractures, in twenty-four recorded cases of breaks in the inferior
maxillary bone, one was perpendicular through the symphysis, twelve
were through the body, five through the angle. Of the twenty-four,
eleven were of a double or triple character, the direction of the
fracture being mostly oblique, both as direction is concerned, and
the face of the break.
(510)
FBACTVRES OF THE MAXILLARY BONES. 511
It is singularly the case that most fractures of the body of the
lower jaw are compound, the opening- existing on the lingual aspect ;
this seems to be the result of the easy lacerability of the gum tissue
combined with the quick displacement inward of the fractured part.
This exposure of the bone seems, in many mouths, to be of no very
material consequence. In others, however, it is quite the reverse
the saliva thus allowed to come in contact with the bone degenerat-
ing and deteriorating the tissue.
Fractures from blows of the fist, or similar concentrated forces, are
apt to be single ; from falls, they are apt to be multiple ; from kicks
of animals, comminuted. A common cause of fracture, familiar to
every dentist, is found in the extraction of teeth having large and
bifurcating roots ; luckily, however, such fractures are not of a seri-
ous nature, generally being confined to the alveolar process, although
cases are on record where such accidents have been so extensive and
severe as to cost the life of the patient. Complete division in the
continuity is, however, rare, very few cases having occurred.
The symptoms denotive of a fracture are seldom or never obscure.
There are, first, the mobility at the break, and the crepitation; second,
when the break exists in the body, there is the loss of harmony in the
line of the teeth, the short fragment being pulled upward. If the
fracture be multiple, irregularities will be produced in the line of the
arch, and in the articulation. If the freed portion be the anterior or
chin part, it will be dragged downward and backward by the action
of the genio-hyoid, byoglossus, and digastric muscles. If it be at the
line of the cuspid tooth and at the upper portion of the ramus, the
fragment will be displaced inward by the action of the mylo-hyoideus,
upward by the action of the masseteric, and forward by the action
of the pterygoidei. If the fracture be single, and beneath the attach-
ment of the masseter, crepitation will be present, but little displace-
ment. If the neck of the bone is broken, the body is dragged forward
by the action of the pterygoid, crepitation and mobility will be very
apparent, and much pain will attend the movements of the jaw, pro-
duced by the displacing action of the temporalis.
Pain, soreness, inability to masticate, inflammatory phenomena,
impediment to speaking or swallowing associate with and charac-
terize the accident, — in short, the history of a fractured jaw is the
history of a fracture anywhere else, allowing for differences in ofiice.
Fractures of the superior maxilla are quite infrequent, and when
they occur, except from extraordinary causes, demand little attention
outside of that which pertains to the injury as a contusion. Of such
512 ORAL DISEASES AND SURGERY.
fractures I have treated a number which surprises me, considering
the rarity of the accident; but in no instance, outside of the alveolar
fractures, have I met with a displacement which required apparatus
for its cure. Indeed, the cellular character of these bones, and the
existence of the antra, permit of such yielding that depression of the
substance of the bone commonly forms the displacement ; hence the
associated frequency of caries with such accidents, the vitality of
the part being lowered or destroyed. It is not, however, to be un-
derstood that displacements do not occur ; the force of an injury may
be great enough, as cases are on record to show, to displace the
bones in mass. In Mr. Heath's work is the record of a case taken
from the Chirurgical Treatise of Richard Wiseman, which is a
marked example of such displacement. The patient was a lad eight
years old, who had received a blow on the middle of the face so
severe that he appeared at first to be dead, and afterwards lay in
prolonged coma. "When," says Mr. Wiseman, "I first saw the
boy, he presented a strange aspect, having his face driven in, his
lower jaw projecting forward. I knew not where to find any purchase,
or how to make any extension. But after a time he became sensible,
and was persuaded to open his mouth. I saw then that the bones
of the palate were driven so far back that it was impossible to pass
my fingers behind them, as I had intended ; and the extension could
be made in no other way. I extemporized an instrument curved at
its extremity, which I engaged behind the palate, and, having car-
ried it a little upward, used it to draw the bone forward, which I did
without any difiiculty ; but 1 had hardly withdrawn the instrument
when the fractured portions went back again. I then contented my-
self with dressing the face with an astringent cerate. I likewise
prescribed bleeding, and some hours afterwards I had an instrument
better constructed to reduce the large mass of displaced bone to its
proper position. I had it held by the child's hand, by that of its
mother or of an assistant, each for a certain time. Nothing else was
done. Thus, by our united attention, the tonicity of the parts was
maintained, the callus was developed, and in proportion as it became
solidified the parts became stronger, the face assumed a good appear-
ance, — certainly better than could have been hoped for after such
marked displacement, — and the child was entirely cured."
A cast in the Westminster Hospital is also alluded to of a fright-
ful deformity produced by the passage of a wagon-wheel over the
face of a man who fell in the street. " Here the bones were com-
pletely shattered, and the maxillae were torn from one another, and
FBACTUBES OF THE MAXILLARY BOXES. 513
death was instantaneous." A case is also recorded admitted into the
same hospital in 1860, resulting from the overturning of a cab upon
the face of its occupant, who at the moment was leaning out of the
window to direct the driver. Here, in addition to a fracture of the
lower jaw, a little to the left of the median line, the nasal bones were
broken, both malars were loose and separated from their attach-
ments, and the left bone was fractured, as also the external angular
process of the frontal bone. Though not positively ascertained, the
vomer was no doubt fractured, and probably the vertical plate of
the ethmoid too. The case is reported by Dr. Fyfes in the Lancet,
July 18th, 18(50. "It was remarkable," says this gentleman, "to
observe how movable the bones of the face were. On watchin*'- the
profile of the patient while he was in the act of swallowing food, the
whole of the bones of the face were observed to move up and down
upon the fixed part of the skull, as the different parts were brought
into motion. It appeared as if the integuments only retained them
in their position. It was a curious feature in the case, that notwith-
standing the very extensive injury done, and the violent character
of the force which caused them, not a single tooth was fractured or
misplaced." This patient is reported as having made a perfect re-
covery.
Of gunshot injuries I have had an opportunity to see some marked
examples. In comminuted fractures it has been my practice to
pick away such pieces as were completely detached, but to leave
and mould, when feasible, all others in place. I never met with
trouble from uncontrollable hemorrhage, and generally found the
reparative energy sufllicient to unite the comminuted parts. In
Circular No. VI. of the Surgeon-General's Departmc^nt, however,
secondary hemorrhage is noted as the principal source of fatality in
the reported cases: 1579 cases of fractures of the facial bones are
reported; and of these 891 recovered, 171 died — the terminations of
517 cases being left still unaccounted for.
The following extract, copied from Mr. Heath's Essay, is from the
Official Medical and Surgical History of the British Army in the
Crimea : " Wounds of the face," says the report, " though present-
ing often a frightful amount of deformity, are not generally of so
serious a nature as their first appearance might lead the uninitiated
to expect. The reason for this, apart from the fact that the face con-
tains no vital organ, seems obviously to be the very free supply of
blood the part receives. From this cause, the fleshy structures readily
heal, and even the bones are so supplied that extensive necrosis
33
514 ORAL DISEASES AXD SURGERY.
rarely happens. The bony tissues, also, are softer than the long
bones of the extremities ; and we therefore here but seldom meet with
long fissures and extensive necrosis as a result of concussion of bone
so often seen in them. This leads us to the very important practical
inference, not in this situation, as a rule, to remove bony fragments
unless the comminution be great, or the fragments completely de-
tached from the soft parts. Even partially detached teeth will often
be found not to have lost their vitality, and, if carefully readjusted,
will become useful. There is, indeed, no great object, beyond per-
haps the present comfort of the patient, to be attained in removing
either fragments of bone or loosened teeth in the great majority of
instances. If the}* die they become loose, and are readily lifted away,
without trouble to the surgeon, and but little pain to the patient.
This observation is especially applicable to fractures of the lower
jaw. Surgeons in this war have seen so many cases of badly frac-
tured instances of this kind unite, and that with a very small amount
of deformity, that men of experience are now excessively chary of
removing any portion of this bone unless it has become dead, or the
fragment is so situated as to interfere considerably with the adjust-
ment of the remainder, or the bone so much comminuted as to give
no probable hope of its becoming consolidated, or so sharply angular
as to threaten further injury to the soft parts or to interfere mate-
rially with their adjustment and retention in situ. In these fractures
of the lower jaw, much less support and adjustment than we are in
the habit of thinking advantageous in ordinary cases of fracture of it,
will frequently be found necessary, or even admissible. A compli-
cated apparatus cannot be borne at first, on account of the condition
of the soft parts, and a slight support by a gutta-percha or Startin's
wire splint, and a split bandage, is all that can be done. Any
attempt at ligaturing the teeth is very generally not only useless,
but injm-ious ; and it is surprising how the parts often, as it were,
adjust themselves, with but little aid from the surgeon."
The treatment of a fractured jaw involves the indications to
be met, and the mode or modes of meeting them. These indica-
tions and modes must of course vary with almost every individual
case. For a simple fracture of the inferior maxillary, or, indeed, as
well for compound fractures, the common pasteboard or gutta-percha
splint will generally be found sufficient and reasonably satisfactory.
To make this splint, take a piece of binder's board, or gutta-percha,
and cut it as designated in Fig. 93.
The board thus cut is soaked in hot water until it becomes suf-
FRACTURES OF THE MAXILLARY BOXES. 515
ficiently softened. The fracture is then set, and the splint moulded
into shape and position. To do this, it is only necessary to lay the
center of the board beneath the chin, one-half projecting; the wings
are now brought up and moulded to the cheeks ; next take the pro-
jecting portion and mould it around the chin and sides of the face.
This makes a complete cap, accurately fitting the parts, and when
dry, is uniform and unyielding. To hold it in position, a bandage
must be applied; the most simple is a modification of Barton's,
which suggested itself to me some five or six years back, and which I
have since used with much satisfaction. The Barton bandage, so gen-
-Fia. 93. — Barton's Bandage.
A. Shape of the piece of gutta-percha for the chin. B. The same moulded to the part
—the ends, 1, 1, being turned upward, and the sides, 2, 2, turned from before backward.
erally employed in fractures of the lower jaw, consists of a roller eight
yards in length and from one and a half to two inches in width —
following in this latter respect the taste and idea of the operator. To
apply this bandage, place the initial extremity behind the left ear ;
carry it around the side of the head, over the right parietal bone;
cross to the right over the neighborhood of the frouto-parietal suture;
carry down beneath the chin ; carry up on the opposite side ; cross
on the forehead ; carry around the left parietal bone, and meet the
beginning of the roller at the occipital prominence, or a little below
it ; continue the turns until the bandage is exhausted.
Gibson's bandage, used in the same and similar fractures, mostly
employed when the break occurs at the angle, consists of three dis-
tinct turns. First. Place the initial extremity in front of the car ;
carry down beneath the chin; pass up on opposite side, and meet the
initial by passing over the fronto-parietal region far enough back to
516 ORAL DISEASES AND SURGERY.
prevent slipping ; repeat this turn three times. Second. Reverse in
front of and a little above the ear, and make three tm-ns around the
Fia. 94. — Gibson's Bandage.
circumference of the vault. Third. End the third of these last turns
at the occiput, and carry three times around the occipito-mental
circumference. This is also an eight-yard roller.
The modification of the Barton bandage, which I find to answer
every purpose in my own practice, and which possesses the virtues
of ease in application, removal, loosening and tightening, is applied
as follows: Take a strip of roller material, one and one-half or two
inches wide, one and one-half yards in length. Standing behind
the patient, rest the chin on the center of this strip ; carry the ends
up, cross on the forehead, carry around the sides of the cranium,
cross again at the occiput ; carry now forward, and tie, or otherwise
fix in front of the chin.
In the application of this dressing or strip, if the parts about the
jaws are tender, it is better to make the termination somewhere on
the side of the cranium. To efiect this, it is only necessary to place
the chin, when first resting the strip, nearer to one or the other of its
ends. The character of this bandage is shown in Fig. 95.
A second method of dressing a simple fracture, one which allows
the mouth to be partially open, consists in making two plates, one
to fit the upper teeth, in part, and the roof of the mouth, the other to
cap a certain convenient number of the lower teeth. After setting
the fracture, these plates are put in position, and attached to each
other by means of a piece of wax ; the attached plates are now re-
moved from the mouth and soldered together. This done, the piece
is replaced, and the teeth are closed into the metal sockets ; the yard
bandage is next applied, and the dressing is completed. This mode
FBACTURES OF THE MAXILLARY BONES. 517
Of treating a fracture of the lower jaw I tbouo-bt ori-inal with my
self, but have found it employed by Mr. Listen, of England, some
Fig. 95.— The Yard Bandage.
twenty years or more back, the splint having been constructed by
Mr. Nasmyth at least five years before the idea suggested itself to
my mind.
In any ordinary fracture of the lower jaw, the mode of dressing
described will be found to meet all indications. In complicated in-
juries, it has been the common experience that rules are of little or
no consequence; the surgeon will find himself governed and directed
by the peculiarities of each case, and will be thrown entirely upon
his own judgment and ingenuity. Perhaps no better exemplification
of this fact exists than was exhibited in the practice of Dr. T. B.
Gunning, of New York, in the case of Secretary Seward. The ideas
of Dr. Gunning are multitudinous in this direction; and while his
professional sense has prompted him to the fullest exhil)it of every
means he has employed, yet I am well satisfied, from what I know
of the profession at large, that the arrangements are too complex to
come into general use. The monograph published by this gentle-
man should, however, be in the hands of every surgeon. I know of
no one who seems to have studied the subject with more care or
wh5 has brought to it a more practiced and matured judgment.
Fig. 96 represents the inner surface of a very simple splint used
by Dr. G., which incloses all the teeth and part of the gum of the
low-er jaw. This splint, as will be seen, would be very applicable
where there were teeth on either side of the fracture, where there
518
ORAL DISEASES AND SURGERY.
was little tendency to vertical displacement, and where there was an
absence of swelling and undue tenderness. The holes marked A are
Fig. 96. — One of Dr. Gunning's Splints.
for purposes of cleanliness, being large enough to receive the point
of a syringe-nozzle. When in position, the jaws are to be closed,
the plate simply resting against the upper jaw or teeth ; the strip
bandage, as described, may be thrown around the jaw and head.
Dr. Gunning uses this splint without fastenings, but not unfrequently
finds it necessary to secure it in place by ligatures, and in some
instances by screws, which are made to pass into or between the
teeth. In cases of much tendency to displacement. Dr. Gunning uses
a splint very much like the one which had previously suggested
itself to Mr. Nasmyth and afterward to myself, — not so good or
convenient, however, I am compelled to think, as it unnecessarily
covers too many teeth, and is thus made cumbersome. This second
splint is shown in Fig. 97.
Fig. 97. — Dr. Gunning's Second Splint.
To secure this splint in place, screws are used. C represents an
opening left between the conjoined splints, for food, speech, etc.; D,
a channel for the saliva from the parotid gland to enter the mouth.
E is a screw used in the retention of the piece.
FRACTURES OF THE MAXILLARY BOXES.
519
The third modification of Dr. Gunning consists in the attachment
to his splint of wings of steel. This is used in cases where the teeth
Fig. 98.— Dr. Gunxixg's Third Splixt.
have been lost in either jaw. F, upper wing; G, lower wing; H,
mental band, to hold the jaw up in the splint ; I, neck-strap, to keep
the band back ; K, balance-strap, to hold the cap in place.
Fig. 99. — Dr. Guxning's Fourth Splint.
This is a splint devised by Dr. Gunning to answer general case.-'.
He suggests, first, the moulding of six or eight size.-^, to be kept ready
for use, from which one is to be selected suitable for any particular
case presenting. The wings are of malleable iron, tinned to prevent
rusting, and for more ready soldering. These sizes, he thinks, would
be sufficient to select from. The splint should have a handle in
front, that it may be used as a cup to take the impression of the
520 ORAL DISEASES AND SURGERY.
jaw, the holes being useful to allow a small probe to be passed
thi'ough the wax down to the teeth, thus allowing air to enter to
facilitate the removal of the in)pression, and, when in use as a splint,
giving entrance to warm water, thrown from a syringe, to keep the
parts clean.
The splint should be made to fit well by bending, cutting off the
edges, and rounding them up smooth. When a tooth projects so as
to keep the splint from fitting, a hole may be cut to let it through, if
the metal cannot be hammered out. This should all be done before
taking the impression, as a well-fitted cup assists greatly in this im-
portant matter.
A splint devised by Dr. Bean, of Georgia, used with decided suc-
cess during the war of the rebellion, among the Confederate troops,
is in its character similar in principle to that of Dr. Gunning. The
interdental portion is almost precisely the same. A modification
consists in the use of a mental compress. This is simply a "piece
of light wood, four and a half inches in length, three-sixteenths of
an inch in thickness, and one inch and a half in width in the middle,
tapering to seven-eighths of an inch, and round at the ends, to each
of w^hich is attached a metallic side piece, four or five inches in
length and from three-quarters to one inch in width, also a shallow
cup, fitting the apex of the chin. Incasing these side pieces are
temporal straps, made of stout cloth, and secured by a strong cord
at the base of each piece.
"A bandage, occipito-frontal, is composed of a band passing around
the head, from the forehead to the occipital protuberance, and se-
cured by a buckle, one inch to the right of the median line behind,
of another strap secured to the band in front and behind, and a third,
extending from the temporal buckles on either side and secured to
the middle strap at the point of crossing."
It is sometimes the case that from comminution, or other causes,
fractures of the inferior maxilla, like fractures of other bones, fail
to unite. Necrosis, intervening, frequently prevents such union.
To treat these cases, the practitioner will find each to have its spe-
cial indications. If necrosis exists, the exfoliation of the sequestrum
must be awaited. In the few cases where the vital forces seem at
fault, they are to be stimulated and elevated. If it occurs that the
ends of the fragments have become rounded, and perhaps tipped with
cartilage, operative means must of necessity be resorted to, — such
means varying with the circumstances. One plan, much approved,
FRACTUBES OF THE MAXILLARY BONES. 521
is to pass through the parts a scton, composed of several strands of
wire, to be removed strand by strand, as inflammation is to be mod-
ified. Or, in place of the wire, other material may be used, as silk,
thread, tape, etc. Another operation consists in boring one or more
holes through each of the fragments, and tying them together with
sutures of wire. Resecting the ends is still another means success-
fully employed by many. Irritating the ends, and thus provoking
the desired inflammatory action, by rubbing the fragments together,
is still another plan.
Attention to the circumstances of a patient sufi'ering from ununited
fracture is important. A case exhibited several years back, at the
clinic of the University of Pennsylvania, l)y Professor Henry II.
Smith, was plainly enough due to the individual having confined
himself exclusively to a diet of potatoes, such diet, in this case at
least, being insufficient to accomplish the repair. The case of Mr.
Seward comes, in many respects, within the category of the un-
uniting fractures, the means to overcome which constituted the skill
employed, the causes here being necrosis and non-fixedness.
Complications, whatever their character, are to be treated on
general principles. It is impossible to direct any special course,
because of such conditions being constant to no rule. Hemorrhages,
so frequently alluded to, I have never met with of any particular mo-
ment. When they do occur, however, they are nearly always second-
ary in character, and it maybe well, where possible, to treat them in
anticipation : for example, an injury which has lacerated the facial
artery would perhaps yield little or no hemorrhage at the time of
accident ; yet, as the process of sloughing should expose the sound
part of the vessel, hemorrhage might be profuse and alarming
enough. In these and corresponding cases, circumstances might,
in special instances, justify one in searching for the ends of the ves-
sels and ligating them. Injuries to the teeth are to receive due
attention : it is not by any means every loosened tooth that is to
be removed, or every displaced one that is to be looked on as lost
to usefulness. Fractures occurring about the neck of the inferior jaw
are to have the displacements corrected by the application of such
compresses as are found to answer the purpose, no matter how closely
such applications follow any special rules, or how far they depart
from them. I do not remember in the course of my professional life
ever having treated two fractures precisely alike.
In fractures of the superior jaw, complications are still more
anomalous. Thus, I remember being compelled in one case to re-
522 ORAL DISEASES AND SURG ERF.
move the whole alveolar process of both superior maxillas, the result
of a kick received from a mule. In this case the patient was a
man broken down by drink and dissipation. I anticipated by-
compulsion a process which I felt sure would have resulted, but
which, to have been accomplished per vias naturales, would have
cost the patient weeks of sufifering, and, not unlikely, life. I have
seen a case of fracture of the right upper maxilla, where the alve-
olar process (the fractured part) hung at least a quarter of an inch
below the common level. In this case the part was moulded back
into its place and supported by a simple strip passing across the
jaw and fixed a little beyond the fronto-parietal suture. In three
days the part became self-supporting, and in two weeks the patient
was eating solid food.
Gunshot injuries of the face and jaw are of every conceivable
variety. The surgeon does primarily, in such cases, all that he can,
and rests his hopes on nature.
With Hamilton, we have to remark that it is " impossible to dis-
cuss in detail all the varieties of accidents to which the complicated
structures of the face are exposed from balls or other missiles."
Certain general rules are, however, to be observed : for instance,
as suggested by this surgeon, " Missiles entering and lodging in the
face ought to be extracted as speedily as possible ; and, whenever
it is practicable, they should be removed through the mouth. If
permitted to remain, they expose to the danger of secondary hemor-
rhage, and increase the chance of subsequent disfigurement.
" Loose fragments of bone should be speedily replaced, unless
very much detached from the flesh and periosteum, experience
having proven that they unite in most cases with facility.
" No piece of skin which is torn up should ever be removed unless
it is absolutely dead ; but it should be laid back carefully in place,
and retained either by a few delicate sutures or by some other gentle
means of support. Tight ligatures and firm straps of adhesive plaster
are apt to bind the tissues and destroy their little remaining vitality.
The best means of supporting a fragment of skin in place, in many
cases, is to lay upon it a thin piece of lint smeared with cerate, and
over this a pledget of cotton-batting, securing the whole with adhe-
sive plaster or a roller.
"As soon as the inflammation and consequent induration have
completely disappeared, and not before, it will be proper to make
the final anaplastic operations."
An addendum to these suggestions of Dr. Hamilton is to be made
FRACTURES OF THE MAXILLARY BOXES. 523
by directing attention to the necessity of controlling and combating
inflammation. To this end cold water is to be freely used locally^
saturated cloths being renewed as the temperature is elevated;
or the water may have to be medicated, lead and laudanum gen-
erally being added. A very admirable antiphlogistic application is
prepared by adding to §xvi of water 5ij of the former and .^ij of the
latter. If a patient should be robust and plethoric, it will in most
cases be advisable to assist the local treatment by cathartics, — mag.
sulph. or the ordinary Seidlitz powder being employed.
CHAPTER XXXIV.
DISLOCATION OF THE INFERIOR MAXILLA.
The frequency of this accident, the terror which it excites, and the
harm resulting when not properly cared for, lend to it an impor-
tance which renders a careful appreciation of it a matter of much
concern.
There are four forms of submaxillary displacement : complete dis-
location, incomplete, bilateral, unilateral. In the first of these, one
or both condyloid processes have slipped fully out of the articulating
fossae and rest entirely in front of the articulating eminence, as ex-
hibited in the view.
Fig. 100. — Complete Dislocation of Jaw.
>-
In the second, the condyle rests upon the inter-fibro cartilage,
directly over the articulating eminence, and will remain fixed, or
may fall backward or forward as directed by accident, not being
retained in its position, as is frequently thought, by the coronoid
process being hooked under the malar bones, but resting, as it were,
upon a point, with complete balance in the muscular structures.
A bilateral luxation is a displacement of both condyles, and is
of somewhat more frequent occurrence than the unilateral, or dis-
placement of one side.
(524)
DISLOCATION OF THE INFERIOR MAXILLA. 505
The diagnosis of a luxation is an exceedingly simple matter. An
open mouth, with inability to close it, the lower jaw thrust forward
in a straight line, or turned to the right or left, according to the acci-
dent, indicates a luxation of a bilateral or unilateral character.
The exciting causes of dislocation are various : yawning, vomit-
ing, putting large bodies into the mouth; blows received upon the
chin from above downward, or in front, while the mouth is open ;
the extracting of teeth, or extending the jaws widely for the conven-
ient filling of them. The first case I ever met with occurred to a
middle-aged man while immoderately laughing.
The predisposing cause of the accident resides in a general or
special laxity of the articulations : thus, all are acquainted witli per-
sons who without effort will dislocate a finger or a toe. I have met
with cases where the operation of removing a tooth was always
attended with unilateral luxation unless a mento-occipital sling was
used.
What is the condition of the parts in luxation ? By placing the
finger immediately in front of the tragus of the ear when the mouth
is closed, and carrying it forward along the zygoma, the surface is
found to be a plane. If the finger is kept on the surface, and the
mouth opened, it is felt to drop into a fossa. This fossa is the glen-
oid ; the concave rim above is the border of the cavity ; the rounded
prominence below is the condyle of the lower jaw. Placing the jaw
of the cadaver in this position, and dissecting down to the articulation,
the condyle is found slipped forward, resting upon the intorarticular
fibro-cartilage, — the fossa has been partially vacated, and the bone
rests against the articulating eminence. If now the condyle is dragged
downward and forward over the eminence, the glenoid cavity will be
found completely vacated, and, unless by manipulation, the condyle
cannot be restored ; laying now back the soft parts, the cavity in
fi-ont of the tragus will be found greatly increased, the finger falling
into the unoccupied fossa. (An added diagnostic sign is then found
to be increa.sed depth and size of the fossa in front of the ear: this it
is desirable to remember, as a fracture of the neck might simulate a
luxation.) Returning to the examination, we find that to reduce
this dislocation it is necessary to depress the head of the bone below
the level of the articulating eminence, which, now being back of the
condyle, serves to fix it in its abnormal position, as originally it
was the means of its retention in place. But we pass to the con-
sideration of the associate parts : the capsular ligament we do not
find torn, as a rule, but stretched and elongated ; the lateral ligar
526 ORAL DISEASES AXD SUEGERr.
mcnts do not seem particularly interfered with, and impress us as
having little influence in the matter, one way or another ; the tem-
poral muscle shows itself stretched and dragged forward, but is
seldom torn ; the pterygoid and masseter are relaxed.
Dislocation is of more frequent occurrence in women than in men,
is uncommon in children, and rare in the robust. When a disloca-
tion has existed for a long time, there seems a tendency on the part
of nature to make some compromise with the condition ; the jaw
will gradually recover considerable of the lost motion, and I have
seen cases where it seemed the patient masticated his food without
the least trouble. The original contour of the face I have never,
however, seen entirely restored.
A luxation of the lower jaw, like the luxation of any other l^one, if
left unreduced, even for a very few days, will be found difficult to
replace ; the muscles become contracted, the condyle settles itself in
its new position, lymph is effused and coagulates, and the general
aspect and relations of the joint are changed. A patient, however, so
situated is not, as remarked by Dr. Gross, to be left unassisted, or
to the relief afforded by nature. In his System of Surgery, this gen-
tleman relates a case in which a Mr. Donovan, an Irish surgeon,
effected reduction ninety-eight days after the occurrence of the acci-
dent. Where ordinary means fail. Dr. Gross recommends that the
efforts at reduction be aided by the subcutaneous section of any
muscles implicated.
Suliluxations are of very common occurrence, particularly among
weak women of easy means and luxurious lives. In England, at-
tention was first directed to the condition by Sir Astley Cooper ; in
this country it certainl}^ has needed no particular one to discuss it, — a
proof, perhaps, of the physical superiority of English over American
ladies. This condition depends, evidently enough, upon a laxity
of the ligaments, and perhaps more particularly on the weakness of
the muscles of the part. In yawning, or not unfrequcutly in ordi-
nary mastication, the condyle will slip forward on the articulating
eminence, and, for a moment, the mouth cannot be closed, requiring,
in many cases, the assistance of the hand to effect it. Depending on
weakness, a permanent cure is only to be looked for as a higher and
stancher vitality is secured. Thus, such a tendency and condition
are to be treated by cold bathing, tonic medication, exercise, etc.
In the case of a lady liable to such luxation, and who Avas made
very nervous by its occurrence, the accident was entirely guarded
against by the patient wearing the occipito-mental caps and bands.
DISLOCATION OF THE INFERIOR MAXILLA. 507
I was once consulted by a lady who was awakened almost every
night by the peculiar and unbearable pain attendant on such slip-
ping of the condyle during the relaxation of sleep.
Dislocations associated with fracture are, happily, of very rare oc-
currence. I myself have never seen a case, unless, indeed, "it existed
in association with certain gunshot wounds, when an appreciation of
the condition, if existing, would have been of very little moment.
Delamotte records a case where, in the person of a girl, double
luxation existed with fracture of the body of the bone. Another is
recorded by Roberts, where the body was broken in front of the
right ramus, and the condjde dislocated outward. A third case
(Heath) is reported in the Dublin Medical Gazette, and " occm-red
in a boy of eight, who suffered a fracture at the symphysis, with
dislocation of the left condyle upward and backward. There was
bleeding from the ear, and the chin was much retracted and turned
to the left ; the mouth was open, but could be closed, and it was then
observed that the lower molars overlapped the upper, but that the
lower incisors were at least one inch behind the upper. Reduction
was easily effected, and the case did well."
Luxations are sometimes congenital. The first case of this kind
was noticed by Mr. Robert Smith, of Dublin, who gives with mi-
nuteness the results of his dissection. The patient, an idiot from in-
fancy, died at the age of thirty-eight. The luxation existed on the
right side, which was remarkably deformed, having a singularly hol-
low appearance, which strikingly contrasted with that of the sound
one, which was unusually full and plump. The extremity of the
finger could be readily pressed between the posterior margin of the
jaw and the auditory canal, owing, as was found on dissection, to
the absence of the condyle of the bone, which was, in fact, greatly
atrophied nearly as far forward as the symphysis. There was no
interarticular cartilage or distinct capsular ligament, and the mas-
seter, pterygoid, and temporal muscles were much wasted. The
temporal, malar, superior maxillary, and sphenoid bones were im-
perfectly developed, and the glenoid cavity existed merely in a rudi-
mentary state.
Treatment o/iu^a^fo??.— By referring back to Fig. 100, it will be
plainly evident that the reduction of a disarticulated condyle con-
sists in getting it back of the emineutia articularis. How best to do
this is the question.
1st. Wrap the thumb in delicate napkins, seat the patient on a
strong chair, and, standing behind him, rest his head against your
528 ORAL DISEASES AND SURGERY.
person ; place now the protected thumbs upon his inferior molar
teeth, and with main strength force the jaw directly downward and
a little backward : the moment you have depressed the articulating
face of the condyle, it will be felt to be dragged into place. The
question of the force required to depress the condyle is the question
of the muscular tone of the individual. In some cases the reduction
is efifected almost before you are aware of having exerted any press-
ure ; in others it cannot be secured without the assistance of mechan-
ical appliances.
Fig. 101.
2d. Failing to reduce a luxation standing behind a patient, reverse
the position, resting the head against an assistant.
3d. Take corks, one or two, according as the luxation is single or
double, force them between the wisdom teeth of upper and lower
jaws as firmly and fixedly as possible; now gradually force the chin
forward and upward, using either the hands, or a tourniquet applied
around the head.
4th. Take a piece of wood about a foot in length, place one end
upon the molar teeth of the luxated side, make a fulcrum of the
molar teeth of the upper jaw of the opposite side, and elevate the
end held in the hand. If the luxation is double, reduce one side at
a time. In the use of this lever, I have secured the result more easily
by resting the center of the piece of wood upon the molar teeth of
the side to be reduced, carrying the end downward. I think it will
be found the most satisfactory application of the power.
The forceps invented by Stromeyer yields a powerful leverage.
This consists of two blades so expanded at the extremities as to fit,
DISLOCATION OF THE INFERIOR MAXILLA.
529
as well as may be, the dental arches, these blades being covered
with leather; a spring between the handles throws them apart,
thus closing the blades. Reduction is attempted in two ways. Intro-
ducing the padded blades so that each shall rest upon its proper tooth
or teeth, — the third and second molars, — the handles are grasped
in the hands of the operator and gradually brought together; when
thus the blades have been so separated that it is inferred that the
face of the condyle is below the level of the obstructing eminence,
the jaw is to be pushed forcibly backward into its place by an
assistant.
Another method of using this instrument is the employment of
a screw and nut which passes between the blades ; a delicate
wrench fits this nut, and through its instrumentality the han-
dles are gradually screwed together, separating of course the blades.
The manipulation of pushing back the jaw, Stromcyer, however,
suggests, should be effected at the same moment with the sudden
closing of the blades.
Fig. 102.— Yertico-Mental Sling or Cap.
5th. Ansesthesia —li^ recent cases the anjesthctic agents may not
be required, although there is seldom objection to their employment.
In cases, however, of any standing, or in muscular persons, it often
34
530 ORAL DISEASES AND SURGERY.
happens that it is impossible to succeed in the reduction without
the aid of relaxating agents; while again, the formation of adhe-
sions will be found to make attempts at reduction both painful and
formidable.
A luxation having been reduced, it becomes necessary to give
support to the parts, and insure against the possibility of the mouth
being too widely oj^cned. This is most comfortably insured by a ver-
tico-mental sling made of elastic straps.
CHAPTER XXX Y.
OPERATIONS UPON THE LIPS AND CHEEK.
Hare-lip. — This defect consists iu a break, single or doul)le, in
tbe continuity of the lip. The deficiency is almost precisely similar
to that which exists naturally in the hare and rabbit, from which
the imperfection gets its name. When congenital, it is always
found associated with the superior lip.
A general view of the operation for the relief of hare-lip, and in-
deed the view which comprises or embraces the principles of the
cure, is, that the margins of the cleft or break are to be pared,
brought together, and held in apposition until nature shall secure
a union. There are, however, nice surgico-mechanical associations,
which are to be studied in connection with such principles of oper-
ation. Cutting manipulations upon the face, and especially about
the lips, claim, it seems to me, more than ordinary skill and judg-
ment. Such skill and judgment the surgeon should be prepared to
exercise, if not for humanity's sake, at least for his own credit and
reputation ; for, as truly remarked by Mr. Skey, " on the more or
less perfect result of such operations depend the appearance and
expression of the patient for life." And surely, just so far as the
surgeon shall beautify or mar, is the comfort of the patient, as well
as his own reputation, influenced.
A proper and comprehensive study of hare-lip divides itself
naturally into three subjects of special signification :
1st. The time of life best suited to the operation.
2d. The condition of the patient.
3d. The mode of operating.
"I advise you," says Mr. Liston, "to defer the operation till the
first set of teeth come in, and I have seen good reasons for adhering
to such rule. When tbe operation is undertaken at an early period,
there is often great diEBculty ; sometimes union does not take place,
the parts turn out again, and the patient is rendered more deformed
than in the first instance. When the features are enlarged some-
what, you have more ground to work upon, you can put the parts
•^ (531)
532 ORAL DISEASES AXD SURGERY.
then neatly together, and you can almost answer positively for the
union taking place. I operated," continues this gentleman, " on a
child, the other day, in whom the operation had been performed
twelve months ago. The parents were anxious to have it per-
formed, but I then refused ; it was done, however ; but the moment
the pins were removed, the lip turned out as before."
" For my own part," says Mr. Bransby Cooper, " I entirely agree
with Sir Astley Cooper, in regarding it as unsafe to operate on
infants before weaning: first, because, from their excessive irrita-
bility, they are totally unable to sustain any loss of blood ; and
.■secondly, because, after the operation, they are rendered incapable of
sucking ; and, indeed, Sir Astley has pointed out, in his lectures,
the frequency of the failures he met with in his own practice, in
operating upon infants shortly after birth. I consider the best time,
under ordinary circumstances, to be soon after the child is weaned,
as it is then capable of receiving nourishment independently of its
mother, and has overcome the distress incidental to the separation
from her."
Dr. Houston, of London, in examining the question as to the
period of life best fitted for the performance of the operation, decides
in favor of the third month after birth ; urging, as his reasons, that
the parts recover themselves better than when the operation is per-
formed later in life ; that the lip, in due time, acquires fullness and
pliancy; the nose is prevented from assuming a spread-out, ugly
appearance; the fissure in the palate, if there be any, closes greatly
with the growth, if supported by a firm and perfect lip; bad habits
of speaking, such as guttural or nasal utterance, which if once estab-
lished become irremediable, are avoided ; and, by removing the dis-
figuration before the child is conscious of its existence, it is spared
the feelings of humiliation which the consciousness of such an in-
firmity necessarily imparts, and which invariably gives a tone to the
character of the individual. He states that he has operated on
several infants three months old, with equal success in all cases,
and has never failed.
Dupuytren recommends the third month; Vclpoau, the first six;
but if that be already passed, he defers operating until the tenth or
fifteenth year.
Skey, differing from Yelpeau, says, " The operation may be per-
formed at almost any age, but should not be undertaken under about
six months."
" The period of life," says Mr. Fergusson, " which I think very
OPERATIONS UPON THE LIPS AXD CHEEK. ^.33
eligible for these operations, is either liefore the teeth begin to show
through the gums, or shortly after the child has ceased to suck, pro-
vided the health seems good. If the patient is allowed to grow up.
he is usually unmanageable until after the age of pul)crty ; but, if
possible, the malformation should always be put right before this
time, as there is a better chance of the gum and nose assuming a
good shape than after they have arrived at their full development.
Indeed," continues Mr. Fergusson, "there are so many advantages
besides these — as to speaking, appearance, etc.— that it is wonder-
derful any surgeon can recommend delay in such cases after the
first or second year of life. I have myself," says Mr. Fergusson.
" operated frequently within the first three months, and in some of
these instances seen the child take the breast readily, Avith the pins
still in the lip."
Dr. J. Mason Warren has operated on infants only a few days
old, with perfect success. Professor P. Dubois read before the
Academy of Medicine of Paris a paper on this subject, and referred
to seven instances which had come under his notice, where the pro-
ceedings had been resorted to, and successfully, within the first few
days after birth; and Malgaigne has followed a similar practice.
" From all my experience and reflections," deduces Mr. Fergusson,
" I am more than ever disposed to recommend a very early opera-
tion. Within the last twelve months I have operated on five infants,
all of them under three months, with the most satisfactory results ;
and these cases, with others I have previously had, are sufficient to
induce me to pursue a similar practice in all instances of the kind
which may come under my notice, unless there be some apparent
indication not to interfere. An erroneous impression, as I suppose,
prevails that children are remarkably subject to convulsions while
undergoing operations ; and this is often urged as a reason for not
interfering with hare-lip in early life. Doubtless convulsions have
occurred in some of these cases ; but similar efiects have been pro-
duced in the adult, and by less formidable means, too. Sir Astley
Cooper has referred to several examples of this kind, but I imagine
they must be rare indeed. I once asked Dr. Abercrombie, of Edin-
burgh, the result of his experience on this point, and he could not
bring a single instance to his recollection where convulsions could
be fairly attributed to an operation."
" At what period," says Colles, the famous Dublin professor,
"should one undertake the operation for hare-lip? No doubt the
earlier you perform it the better chance you will have of a speedy
534 ORAL DISEASES AND SURGERY.
cure; but infants at a very early age do not bear operations well;
many of them will be seized with convulsions, and die, if subjected to
a more trifling operation than this we have been considering. I think
between the second and third year the best period."
"There are," says Professor Gross, in his System of Surgery,
"few subjects in surgery which have been more frequently discussed
during the last quarter of a century than the question of the period
at which the operation of hare-lip may be best performed. My own
opinion long has been that the most eligible period is from the third
to the sixth month, or a short time before the appearance of the first
teeth; the operation is then usually borne well, there is no danger
of convulsions, and the adhesive process generally proceeds most
kindly. In very simple cases I do not hesitate to attempt it earlier ;
and, on the other hand, in double or very complicated hare-lip I
almost always postpone it until the child has attained its second
or third year."
Dr. D. H. Agnew operates at any period ; is influenced onl}",
even during the process of dentition, by constitutional condition.
If dentition is progressing quietly, that is, if there is no associated
irritability, he can see no reason why the operation may not be per-
formed just as well at this time as at any other; has operated in
all the stages of this process. Dr. A. prefers, however, early oper-
ations ; he thinks that his most successful cases have been on chil-
dren who had not attained their tenth day. So far as interference
with sucking is concerned, he remarks that he has seen a child take
the breast almost immediately after an operation has been com-
pleted.
Professor Pancoast entertains about the same views as are ex-
pressed by Dr. Agnew. Dr. Pancoast gives it as the result of his
very extended experience, that the operation may be about as well
done at one time as at another. Does not see why the period of
dentition is to be so cautiously avoided. Operates at any period of
this process, if there are no contraindications of constitutional dis-
turbance. Has operated on many children as early as a few days
after birth, with the happiest results. Does not find the operation
interfere materially with nursing.
Professor Henry H. Smith, of the University, says : "As respects
the period for the operation, the earliest possible time after the
tissues seem firm is to be selected, usually after the third month of
infancy."
Now, although we have here cited such a variety of opinions.
OPERATIONS UPON THE LIPS AND CHEEK. 535
which, to the inexperienced, may seem confusing, 3-et, when we
consider the different circumstances under which these learned and
experienced gentlemen have written and spoken, we are enabled to
deduce from such experiences rules for guidance, in which, if my
observation at all serves me, will be found data as reliable as we
could well expect to possess. The views of such as I have men-
tioned will be found to represent fairly the diversity of opinion ex-
isting throughout the profession. These well-known authorities I
have especially selected, because, being public teachers and writers,
their views in extenso are thereby made the more easy to come at
by any reader specially interested in this subject.
And first, in making up the sum of an operation, we are to con-
sider, regardless of the age of the patient, the amount of shock such
operation is to give, and the ability of the patient to bear this shock.
This at once brings up the character of the defect, and the amount
of operative proceeding necessary to its cure. A bad double cleft
would inflict a much greater amount of pain than a simple single
one, and consequently would inflict a shock double or treble in force
to the last. Now, every man, woman, and child in the world has a
certain amount of physique, and no more. The experience and phy-
siological knowledge of the surgeon enable him to weigh the life-
force. He must then decide, imprimis, whether or not his patient
is equal in such force to the demands of the operation.
He must consider the condition of his patient. This brings up the
second of the special propositions or stand-points from which the
operation is to be studied. The possession of a capable physique
does not imply that the life-force has not, like the tide, its ebb and
flow. A child may have proper development, yet at the very time
when it is presented for operation it may labor under temporary
depression, the result of functional disturbances. A child, for exam-
ple, just convalescent from cholera infantum, or just through with
some of the exanthemata, would certainly not be as fit a subject for
operation as though it had not suffered ; it may have borne the de-
mands made upon it very well, and come out of the ordeal looking
strong ; but then it is the last feather that bends the camel ; the sys-
tem that endured bravely the one demand may not have a residue
of force on hand that will just then meet another. Give such a
system time; get it back to the condition in which the first de-
mand found it, and you then have it certainly capable of the same
resistance and of the same endurance. Again, a patient may not
be up to the required tone, and yet circumstances render a speedy
536 ORAL DISEASES AND SURGERY.
operation desirable. "We can assist nature. Exercise, fresli air, and
proper food can do much. The last may imply that the milk of the
mother, if the child be nursing, be exchanged for that of the hired
nurse. Who has not examined the milk of a mother or wet-nurse
and found it greatly deficient in some important constituent ? I have
seen babes growing visibly weaker and more puny day by day ; I have
seen physicians baffled because they could find no one portion of the
economy less healthy than another. I have seen the microscopist
take the milk on which such a babe has been feeding, and, looking
at it through his glasses, find it half made up of cholesterin. A
change of milk has effected immediate change in the child. A child
may have fibrinous blood to excess, tending to undue inflam-
matory action, or the lymph which such blood would exude might
be so corpuscular in character that a wound would at once take
on suppurative action. Either condition would be adverse to an
operation. Yet we have antiphlogistics for the one and tonics for
the other. A seemingly strong child may be in a typhoid state, and
a blushing cheek may be but the effect of hectic or excitement ;
t3^phoid blood has, comparatively, no fibrin. If you were to perform
an operation on such a patient you w^ould be sure to have a failure
for your pains. I have had under my care patients in just such a
typhoid state, where the pulse would be bounding and the face
always flushed ; such a quick pulse and flush is, however, the result
of the very deficiency in the blood, A child nia}^ be cutting its
teeth, yet this does not necessarily contraindicate an operation. It
is not every child that has convulsions and kindred troubles with
the cutting of its teeth ; many a child goes through the whole pro-
cess of dentition without cause upon which to ground a sob. If a
child is brought to the surgeon, cutting teeth, with an operation for
hare-lip to be performed, and there is associated with the dentition
no general or special local disturbance, why should he not proceed,
caeteris paribus, at once to operate ? I can see, and I have up to
this time met with, no objections to so doing.
The next consideration is the operation itself, — the modifications
of the one principal operation, and the variety of clefts influencing
such modifications.
A basis operation might best be represented by a simple Y-cleft,
having the mesian line of the lip as its center, — the indication being
to restore such lip to a normal contour. On examination with the
glass, we find that the normal lip has no break in its continuity ; we
find what may be termed the center of the lip represented at its free
OPEBATIONS UPON THE LIPS AND CHEEK. 537
margin by a projection of more or less graceful curve. We find, extend-
ing from this free margin up to the nares, and bounded laterally l)y
the ali» nasi, a fossa, — the fossa labialis. From this fossa we find
the lip on either side spreading itself out to be lost in the cheek.
To meet the indications of this case we must remove the break in
the continuity, create a mesial projection, -and give to the center a
fossa. To fulfill such indications requires a study of the conditions
from a surgico-artistic stand-point. We want, first, to remove the
cleft. This in itself is easy of accomplishment ; we have only to pare
the edges and sew, or pin, the raw surfaces together. But in view-
ing this first step a little more closely, we perceive that a C(jninion
V-paring from the edges of the V-break would defeat our purpose in
securing either a center fossa or a mesial projection ; the mode of
bringing the parts together would put on the stretch such fibers of
the orbicularis as are associated with the margin of the lip, while all
that portion farther up would be comparatively relaxed ; thus our
fossa would be a promontory, and our soft median swell would be a
stretched mucous membrane. Such an operation would, then, in
meeting the first indication, destroy our ability to fulfill the two others.
We must, therefore, instead of the Y-cut, seek a better ; for on the
way in which we pare our edges depends the fulfillment of all three
of the indications. An ellipse suggests itself, and such a paring will
meet our wants. 1st. It enables us to bring the edges of the cleft
together. 2d. The center of the ellipse is its greatest diameter, and
this center is the center of the lip. When we bring together this
most widely separated part, it necessarily projects the most yielding
surface — and such surface is the free symphysis of the lip ; thus the
second indication is met. 3d. The greatest stretch on the muscle is
in the site of the myrtiform fossa, with a necessary relaxation above
and below ; and thus the last indication is met ; for, as the result of
such a condition of the parts, we have a fossa formed and a promon-
tory at the free mesial line.
Bemarks. — The paring of a cleft should always be constant in the
one featui'e of being Y-shaped, as reference is had to the base of the
"Y looking toward the throat; this allows for excess in the retrac-
Ition of the skin over the mucous membrane. If this precaution is
I neglected, a difficulty is likely to be experienced in the gaping of the
cutaneous portion of the wound.
i The subject of retaining the parts in apposition, with regard
j to suture material, has elicited much controversy. The ordinary
I operation is as follows. After you have pared the edges of the cleft,
538 ORAL DISEASES AND SURGERY.
take up a needle threaded with the ordinary waxed silk, pass this
through the free marg-ins of the lip and bring the parts together ;
this is to insure a satisfactory approximation at this point. Next
take two ordinary steel pins and pass them at equidistant points on
the lip, — they must go, in depth, at least half its thickness ; these
pins are to enter and emerge at least five lines on each side of the
fissure. Silk ligature stuff, in the shape of the figure-of-8, is now
to be passed about and around these pins. Adhesive strips are next
passed over the pins, a slit being made for their accommodation;
the object of these strips is to press tissue toward the wound, in this
way preventing tension. If blood oozes out and clots upon the liga-
tures, it has been considered rather favorable than otherwise, as it
has been thought to add to the support of the parts. After two or
three days the pins are carefully removed by a rotary motion ; the
ligature material and adhesive strips are allowed to remain from four
days to a week longer.
The ordinary hare-lip pin is objectionable ; it is too large. The
figure-of-8 ligature in connection with the pin is equally to be con-
demned. Wherever we see a case of hare-lip that has been thus
operated on, we see four ugly scars on either side of the cleft : these
are the points at which the pins entered and emerged, and upon
which the figure-of-8 ligature made its greatest compression ; the
parts ulcerated, and the scars are simply the cicatrices from the
healing of such ulcers.
Yarious means have been suggested to be employed in lieu of such
a dressing. Dr. Agnew, in a conversation I had with him lately on
the subject, informed me that he now uses silver wire altogether.
He simply sews the parts together with a greater or less number of
interrupted sutures. He thinks such sutures possess great advan-
tages over the pins.
Another means of bringing the parts together that has been sug-
gested, is the employment of the interrupted suture of silk from the
under surface of the lip. In one case, however, where I tried this
method the result was very unsatisfactory.
Dr. Washington Atlee has suggested a suture which differs only
from the ordinary pin and figure-of-8 in that he employs rings of
india-vuljbcr, which are stretched over the pins. This suture for
many purposes must prove an admirable addition to the armamenta-
rium chirurgicum ; but in hare-lip operations it has no advantage that
I can see over the ordinary figure-of-8, inasmuch as the same strain, if
not a greater, is exerted upon the points at which the rubber is sup-
OPERATIONS UPON THE LIPS AND CHEEK. 539
ported by the pins. The merit claimed for this suture is, that
whether a part swells or remains normal, the compressing force con-
tinues about the same.
A mode of securing the apposition of the parts, which I think will
be found very satisfactory, is to take three, four, or more pieces of
silver wire,— the fewer you can get along with the better, the gauge
being the most delicate that can be procured ; pass these and let
them emerge at lines which shall very nearly correspond with the
commissure of the lips. Next take a strip of common sheet-lead,
and, cutting it to an appropriate size, make in it as many little holes
as you have threads of silk to either side ; pass the threads through
these holes, and compress on each a McLean button — i.e. a simple
flat shot. Now, with the fingers, nicely approximate the wound.
This satisfactorily accomplished, draw up the wires and fix them o;i
a second piece of sheet-lead, as in the first instance. If the center,
which is the point of the wound, tends to bulge forward, a delicate
compress is to be placed over it, and bound to its place by a vcrtico-
labial sling. The advantages of this dressing are, that it may be
retained for weeks, if necessary. It is entirely unirritating. The
wound is perfectly open to examination, and, more than all this, the
threads, being unirritating and very slight, when taken away leave
no sears.
A still happier dressing, but one which can be applied only on
such patients as have reached the age of intelligence, is a modifica-
tion of Dewar. Dewar's compressor may be likened to the ordinary
double hernia truss. It consists simply of a spring which, passes
around the head, having a small pad at each extremity. The piece
is of such circle and character as to bring the pads to the labial com-
missures. The instrument is held in position by any convenient
means. Dewar holds it by what might be termed a fronto-sagitto-
lanil)doidal sling. The process of dressing with this instrument
would be as follows. After making the paring of the cleft, cleanse
the parts well with cold water (controlling hemorrhage by pressure
on the facial arteries) ; next take a strand of the common silk liga-
ture material, and nicely approximate the free edges of the lip, pass-
ing the needle on the under side. The next step is the application
of the compressor. With the thumb and finger force the tissue of
the cheeks toward the mesial line of the lip— this approximates per-
fectly the edges of the wound ; replace your fingers by the com-
pressor, and the parts are held in situ. If the approximation of the
wound thus made should not, however, be satisfactory, secondary
540 ORAL DISEASES AND SURGERY.
compresses of linen may be placed more immediately about the
wound, and fixed by a delicate roller. The advantages of this dress-
ing will be at once apparent. There are no pins or ligatures used,
consequently there is nothing to interfere with direct union ; there
are no punctures made in the skin ; of course there is no risk of
having any but the single linear scar, and even this, if direct union
is secured, must be slight indeed. The parts can be exaniiiied at
any time wnthout important interference with the apparatus.
In some individuals the coronary arteries are quite large. To sup-
press the hemorrhage from these vessels, dependence is generally
placed on the pressure exerted in bringing together the edges of the
wound. If such pressure does not answer, or if we should prefer
some dressing that will not make this pressure, light ligatures may
be thrown around the vessels, one end to be cut off, the other to be
brought out on the back part of the wound. Ligatures, however,
are to be avoided when possible, as they interfere with proper union.
A much better means than the resort to the ligature is compres-
sion of the facial arteries. Such compression needs to be kept up
but for a short time, as the smaller artery soon contracts. Dewar's
compressor controls the hemorrhage by its pressure on the coronary
arteries, and its action may be very readily imitated with the
common compress and roller.
There is a feature associated with the formation of the linear
cicatrix, and the unsightly notch which so commonly deforms hare-
lip patients, that I do not remember to have ever seen alluded to,
but which is of such consequence as to merit the closest scrutiny.
Is it the fault of nature or the fault of the surgeon that the oper-
ation gives any cicatrix at all ? Cicatricial tissue — tissu inodu-
laire, as Delpech more happily terms it — means accidental tissue
— new tissue formed from granulations. The existence of inodular
tissue implies, as it is greater or less in amount, that a wound has
healed either by primary or secondary adhesion, and certainly not
by what Mr. Hunter terms union by first intention, or what Mr. Paget
calls immediate union. If a wound is made to unite by first inten-
tion, there cannot possibly be any observable inodular tissue or scar,
because so little new tissue has been formed, blood-vessels and
nerves have been brought into perfect contact, and the harmony of
the parts has been so completely restored that after a few weeks the
closest observation fails to discover the seat of accident. We have
familiar examples of such union in the slight cuts we are constantly
giving ourselves with the razor, the cuts we get about the fingers,
OPERATIONS UPON THE LIPS AND CHEEK. 541
etc. Some years back I removed from the parotid region of a youno-
man a tumor fully the size of a hen's egg. The flaps were adjusted
with the greatest care, and held in place by compresses of old and
fine linen. I saw this gentleman about ten weeks after the operation
and so immediate had been the union that it was impossible to say
where the cut had been made. Mr. Paget mentions very large wounds
that not unfrequently heal in this perfect manner. One ca'se, that of
a lady who had been operated on for seirrhus of the mammary gland,
might be specially alluded to. Speaking of the operation, he°«ays :
" The flaps, which w^ere very large, had been carefully laid down,
strapped with isinglass plaster, and well tended. After death, whicli
occurred in three weeks, from erysipelas and phlebitis, I cutW the
edges of the wound with the subjacent parts, expecting to find the
evidences of union by organized lymph, or, possibly, blood; but
neither existed ; and the state of the parts cannot be better described
than by saying that scarcely the least indication remained of either
the place where the flap of skin was laid on the fascia, or the means
by which they were united. It was not possible to distinguish the
relation which these parts held to each other from that which natu-
rally exists between subcutaneous fat and the fat beneath it. There
was no unnatural adhesion; but the subcutaneous fat which did lie
over the mammary gland was now connected with the fascia over
the pectoral muscle. The parts were altered in their relations, but
not in their structure. I could find," continues Mr. Paget, "small
points of induration where, I suspect, ligatures had been tied, or
where possibly some slight inflammation had been otherwise ex-
cited ; and one small abscess existed under the lower flap. But, with
the most careful microscopic examination, I could discover no lymjth
or exudation corpuscles, and only a small quantity of what looked
like the debris of such oil particles or corpuscles of blood as might
have been between the cut surfaces when the flaps were laid down.
In short," says Mr. Paget, "this was union by first intention; it
was immediate, at once in respect of the absence of any intermedi-
ate substance placed between the wounded surfaces, and in respect
of the speed with which it was accomplished."
The union of a wound by adhesion or by granulation implies a
certain amount of inflammatory action, and the exudation and or-
ganization of lymph. This is the way in which hai-e-lip wounds
are healed, and this is why we have the linear cicatrix; and not only
the cicatrix, but, according as the union has simulated or departed
from the immediate type, we have a great or small notch.
542 ORAL DISEASES AXD SURGERY.
But how is the notch formed ? The explanation is simple enough ;
but it is not that generally given ; at least, I think not. The notch is
the result of the natural contraction which belongs to fibrous tissue, of
which fibrous tissue the cicatrix is formed ; and if we observe, we
will find that where this linear inodular tissue exists in excess,
a large notch is always associated with it. If we need further
proof to convince ourselves that such contraction is the cause of the
notch, we have only to remark that in cases of lai'ge cicatrices the
destruction of the symmetry of all the surrounding parts has inva-
riably occurred ; the contraction has puckered, as it were, the whole
lip. When the linear cicatrix is very limited, the notch is corre-
spondingly small ; and these conditions could not so uniformly exist
associated, if it was the manner of the paring exclusively that gave
the notch, and not the contraction, as I have described.
The nearer then the approach to a union by first intention we can
make in hare-lip, the better for our success will be the result. But
can we not get immediate union in full ? This would imply that we
have artery to artery, vein to vein, nerve to nerve. Well, the artery
is a prominent point of reference, and the relations of surrounding
parts are in perfect unison. If we can get the mouths of the two
arteries together, will not all other vessels assume, by compulsion,
inosculation ? We may try for this, at any rate ; such care will neces-
sarily insure to us the very nicest approximation of parts, and if
what is termed immediate union cannot be obtained, we may at least
secure to our patient, by such care, the smallest possible scar.
To return now to the modifications in hare-lip, and the oper-
ations.
The first modification of the simple cleft described is where the
break is to the one side or the other, being bounded in either in-
stance by the mesial line. This character of cleft, particularly so far
as the left side is concerned, is by far the most common type; indeed,
it may be denominated the type proper of hare -lip. In operating
here, it is readily seen that the simple ellipse, as practiced in the
previous case, will not answer. Such a cut would give the labial
swell and fossa to the one or the other side of the mesian line,
according as the break extended right or left.
In these cases the indications are met by the operations of Mal-
gaigne. This surgeon makes the one side of a simple Y-cut on the
external flap, while he practices the semi-ellipse on the mesial flap.
This, it is seen, brings up the outside flap, and projects the apex of the
mesial one. A modification of this operation, and a decided improve-
OPERATIONS UPON THE LIPS AND CHEEK. 543
ment, in mj opinion, is one first suggested, I believe, by Dr. Richard
Levis. This consists in making a kind of double V-cut on the mesial
flap. The knife is entered just below the nostril, and the first incision
takes the line of the one side of the Y. On nearing the free surface,
however, this direction is changed, and a second V is cut out of the
substance of the flap. This mode of operating secures a very nice
labial swell, and will be found sufiiciently easy of performance. To
bring out to the level the notch thus made, implies some force ; and
if it should be designed to use Dewar's compressor, it nmst always
be associated with a point of silver suture ; the suture being intro-
duced from the mucous surface.
Another, and the next most common variety in hare-lip, is that in
which the break is double — that is, the single break is divided into
two parts by a teat which starts out from the apex of the cleft; this
teat is seldom more than half the width of the lip. For the correc-
tion of this defect, various means are resorted to. Some surgeons
cut out the teat, thus converting the double into a single break,
making the basis cleft as described. Others, on the contrary, after
paring all the four sides, tease and strain the center piece or teat
until they get it on a level with the rest of the lip. Both of these
operations are veiy objectionable. The first takes away an unneces-
sary amount of substance from the lip, thus giving a tense, stretched
appearance to the part; while the natural resiliency which belongs
to most tissue insures, from the second manipulation, a character of
notch or central depression almost as unsightly as the original de-
formity. In this simple form of double hare-lip, I think it will be
found the most satisfactory operation to pare the lateral flaps in the
elliptical form as described, while the center teat should bo pared
into the Y-form, the base being to the septum nariuni. All the
parts will thus be found capable of a neat approximation ; the teat
doing its share more or less in filling up the break. The approxi-
mation is to be made as in the mode described.
A second form of double hare-lip is that in which the alveolar
process is associated with the teat. This is termed complicated
hare-lip. The portion of process projecting into the cleft is gen-
erally an intermaxillary formation, and holds the germs or de-
veloped incisor teeth— generally the centrals alone. The correction
of this defect implies a somewhat formidable operation. The first
step consists in separating well the lip from its reflection over the
process. Next the gum is separated thoroughly from the projecting
-bone, which bone the third step in the operation removes down to
544 ORAL DISEASES AND SURGERY.
the natural curvature of the parts, either by means of saw, chisel, or
cutting forceps. For myself, I prefer the chisel ; it is certainly a
much more convenient instrument than the Hey's saw so commonly
employed. A straight and curved chisel should always be at hand.
If in this third step of the operation the anterior palatine artery is
wounded, the resulting hemorrhage is easily controlled, either by
taking up the vessel or by touching it with one of the astringents ; or,
if neither of these means suffices for its accomplishment, the artery
may be touched with a red-hot cauterant needle, or it may be plugged
with a point of pine stick. The bone removed, the flaps of gum may
be laid back in the cavity, where they will remain sufficiently approxi-
mated without the employment of any sutures. The operation upon
the lip may now be performed at once in the manner described ; or,
if the force of the patient is too much exhausted, it may be left for a
future period.
These are the two principal forms of double hare-lip. An appre-
ciation of the operations required for their cure will enable the sur-
geon to meet satisfactorily any modifications that may present on
either of them ; and these modifications, it is to be suggested, are
constantly occurring. Let us, for a single moment, refer to an un-
complicated double hare-lip, where the center piece, or teat, as I have
called it, might be found so large and square as fairly to divide the
lip into three parts. Xow, here the mesian line of the lip would be
formed by the center piece ; it would therefore, I think, suggest
itself to any one that either side of the cleft was to be treated as a
separate hare-lip — that is, the whole manipulation might be done at
the one sitting ; but there would have to be symmetrical parings
made of either cleft. In such a case, we have also to take into the
account the concavity made on either of the sides of our fissure, as
reference is had to the influence exerted on the free margin of the
lip ; for here of course we require no swell. Whether, again, in
these really double cases, Ave would first operate on the one side,
and, when this was cured, on the other, is a matter which should
be left to the judgment of the operator. Many surgeons prefer to
correct the whole deformity at once. If we should do this, the
operation would only deviate from the principles laid down, as
regard would be had to approximating the parts. If the center
piece might be small, I think it would be found the most satisfactory
practice to pass the pins, Avire, or whatever suture material might
be used, directly from one lateral flap, on through the center piece,
to and through the other, thus uniting all the parts together by a
OPERATIONS UPON THE LIPS AND CHEEK. ,045
common suture. If, on the contrary, a center piece is broad and
well covered by skin, I think that the greatest good would be found
to be secured by using two sets of ligatures. As regards the single
or double operation, I myself am influenced by the width of the
middle piece, the tenseness or laxity of the tissue of the lip, and the
endurance and condition of the patient. -
Another modification of the double hare-lip is one in which there
is a projection into the cleft of the incisor teeth, the alveolar process
itself being sufficiently normal to allow of non-interference with it.
This modification is commonly met with in the adult alone, or at
least after second dentition. The projection of the teeth is the
natural result of the lack of external support from the labial de-
ficiency; the tongue has actually pushed them outwardly. This
explanation will, I am sure, seem strange only to such as are un-
acquainted with the exceeding mobility of the dental organs under
slight but continued force. It is certainly the true cause of such
projection. In a case of this kind, a preliminary operation is the
removal of the teeth. If, now, six months are allowed to intervene
before attempting the operation on the lip, the alveoli of the ex-
tracted teeth will be found to have receded, through absorption,
quite the eighth of an inch. The second operation is then to be
done secundum artem. This waiting on the process of absorption
will be found greatly to conduce to a successful result.
A still better though more tedious mode of correcting such a de-
formity is by first bringing the projecting teeth back to their normal
place in the arch, through the agency of elastic ligatures. This is a
perfectly feasible operation, and not at all difficult of performance.
By such a preliminary procedure we not only get the teeth out of
the way, but we save to the patient these valuable organs. To
make and appl}" such a ligature, we have only to take a slip of com-
mon india-rubber and attach at either end loops of silk. We next
take these loops and place them over certain of the molar teeth ; it
is entirely immaterial which. The center or rubber part is next
stretched forward and laid over the labial faces of the teeth to be
pulled back. It is astonishing how quickly and powerfully such a
force will act upon the teeth. In two or three weeks, at most, the
teeth may be brought into their proper line. To secure them in
situ, and prevent their being again pushed forward, we have only to
keep them ligatured in any convenient manner until the operation
on the lip is made.
Cleft of the lip, as previously remarked, is common to almost
35
546 OFAL DISEASES AND SURGERY.
every case of cleft of the hard palate. It has always been deemed
very important in these cases that an operation on the lip should
be performed as early as possible ; it is thought to favor the union
of the bony cleft. In these cases the operation differs from that
suited to any ordinary one only when there is projection of one or
both alveolar prominences into the break. In such instances, if the
projection is very marked — that is, so much so as to prevent the
bringing- together of the lips over them — we may perhaps be al)le to
do nothing better than cut away the parts. This, however, is always
to be avoided where possible, — first, because we thus destroy the
germs of the teeth ; and, secondly, because, if by any means we can
get union of the lip, the parts in their development will come mutu-
ally to accommodate each other. In such cases it is recommended
by some authors that we endeavor to bend back these juttings of
bone, turning them in toward the mesial line. Where this can be
done, it answers a very admirable purpose. Still another mode —
after the method which I suggested for the complete relief of this
character of cleft — consists in the employment of the fronto-occipito-
labial elastic sling. This sling is so applied that it pulls upon the
projecting process backward from the occiput. It will certainly
fulfill the indications; but its employment is not unattended with
trouble.
Cases of double hare-lip not uufrequently occur where the center
slip is so associated with the septum of the nares as to make the
parts seem as one. If there was not the loss of material from the
lip, the septum would bear being described as in a state of hyper-
trophy. Again, the lost part from the lip is sometimes found at-
tached to the very tip of the nose, giving to the patient the appear-
ance of laboring under lipoma. These, together with all the anomalies
in this direction, are first to be studied, as regards their cure, from
the artistic stand-point. The surgeon knows where and what he
can afford to cut; he knows what nature will do in the case; it
only remains for him to consider well his incisions — where he shall
make them, and what is to be the result before the' operation is
attempted.
A useful study is found in the examination of examples. If we
familiarize ourselves with all kinds of cases, and if — what is still
better — we represent the morbid anatomy in india-rubber, and thus
devise and try experimental operations, we shall, I am sure, find the
subject of hare-lip grow simple enough.
Excellent studies will be found pictured in the following works :
OPERATIONS UPON THE LIPS AND CHEEK. 547
& Mutter's Surgery, page 1S1 ; Eriehsen's Surgorv, page
Jross's Surgery, pages 611, 612, 617, vol. ii.; Fergusson's
Liston
690; Gi
Surgery, page 494.
Addenda.— In operating for hare-lip, always first dissect the lip
well off from its attachment to the gum.
In paring the fissures, the young sm-geon is much more apt to
remove too little than too much.
In paring out the apex of the cleft, be sure to freshen perfectly
the extreme point of such apex. This is oftentimes neglected; and
an ugly pucker is the result.
The paring for hare-lip is, perhaps, best made on a wooden spatula.
Few instruments are really required in this operation. A scalpel
and forceps, together with such ligature material as it is designed to
employ, will answer the purpose well enough.
The best mode of operating on the infant is for the surgeon to
seat himself face to face with an assistant. The child being ether-
ized, the surgeon lays its body over his own knees, the head being
supported by the assistant. Upon the incision being made on one
side, the assistant grasps the lip between the thumb and finger,
compressing the coronary artery. When the artery of the opposite
side is cut, he secures this. Both are steadily held until the oper-
ator is ready to coaptate the wound.
In operating on the adult, I think it will be found the most con-
venient plan to stand behind the patient ; such a chair being used,
and the head being placed in such position, as recommended in the
operation of staphyloraphy.
Another very convenient manner is to sit in front of the patient,
the head being supported against the breast of an assistant.
When plaster is used to assist the ligatures, silk gauze and col-
lodion are to be preferred ; this leaves the wound constantly ex-
posed to inspection, and is a light and most effective dressing.
CHAPTER XXXYI.
OPERATIONS UPON THE LIPS AND CHEEK.
As the result of disease or accident, persons occasionally suffer
from contraction of the orifice of the mouth ; a most unhappy con-
dition, both as regards the appearance and the comfort of the in-
dividual. Such contractions are represented in the plate, Subfigs.
7, 8, and 9.
Dieffenbach, of Berlin, who interested himself very much in the
surgery of the mouth, suggested and practiced for the relief of these
deformities an operation, which, with occasional slight and unim-
portant modifications, is the one still generally employed.
Dieffenbach's operation is performed on the following principles :
Map out with pen and ink on the tissues such lines and angles as
shall meet your approbation of what the proper mouth should be.
These lines are, of course, to be in conjunction with the existing
orifice or commissure, wherever or however situated, — that is, the
relation of the existing orifice must be studied as it is to have asso-
ciation with the cuts you are to make. Thus, if we glance at Fig. 7,
we at once appreciate the necessity for enlarging the mouth by sec-
tions equilateral to the center, as certainly it is apparent enough
that only by such a form of incision — which I have caused to be
represented by a line — could we secure the end at which we aim.
Fig. 8, on the contrary, would demand an operation exclusively
lateral ; for here the mouth at its right angle is as perfect as we
could hope to make it. Fig. 9 presents us with a complication on
these simple conditions. These complications might be multiplied
almost ad infinitum; for who may say in what condition a wound
or other injury shall leave a part? At any rate, the surgeon is to be
prepared to meet any and all kinds of modifications. These three
figures give perhaps as just an idea of the mechanico-surgical indi-
cations of such cases as any others that might be drawn. Figs, t
and 8 are from life ; 9 is one made up to represent a not unlikely
aspect.* It exhibits, as is seen, a combination of the cicatrix
* Fig. 9 is not correct to the text : add to it the defect in Fig. 1, and it will
be right.
(548)
OPERATIONS UPON THE LIPS AND CHEEK. 549
and hare-lip. In this last case is suggested of itself the necessity
for a double operation. The mouth is to be made smaller before i't
would be at all proper to attempt making it larger. We must
first perform a hare-lip operation. Imagine this "done, and then
further the condition in which such operation would leave the
orifice. If we refer to the drawing, we see that the opening is now
at what is properly the right angle of the mouth, and an operation
for the making of a proper commissure, if there was no hare- or cleft-
lip, would be precisely the same lateral incision as that indicated
in case 8. But then it is to be remarked that, after the first
operation was performed, the orifice would not be, as now, at the
proper right angle. The bringing of the cleft together would pull
it naturally toward the mesial line. Thus, then, it is made a cross
between 7 and 8 ; it is not like 7, because it is not exactly in the
mesial line, and it would not be like 8, because it has been drawn
from the proper right angle toward the mesial line. Here, then, the
complication has materially changed the indications of the principal
operation. The incisions would have to be bilateral, but yet not
equally so as reference is had to the false commissural center, but
only as reference would be made, say to the septum narium or
any other fixed mesial line proper. The space between the central
incisor teeth would be a good mesial center to take.
These features well considered, we take up a pair of sharp-pointed
scissors, and, passing a finger of the left hand into the mouth, enter
one blade of the scissors down through the tissues toward the finger,
sparing alone in the puncture the mucous membrane ; the blade is
now pushed forward toward the mesial line, and the tissues incised,
as indicated by the superior right lateral half of the ellipsis repre-
sented by the line in Fig. 7. The scissors are now reintroduced at
the previous point of entrance, and the cut made on the inferior lip
precisely as was done above. Next dissect out the triangular piece.
Repeat these incisions on the opposite side. The next step con-
siders the incision of the mucous membrane. This is done simply
by dividing it down the center to within two or three lines of the
angle of the wound ; it is then to be brought over the cut surfaces
and attached by means of the interrupted suture to the skin.
This mode of rercstablishing the orifice of the mouth is thought
by many surgeons to be the best that can be employed. Professor
Smith, of the University, reports two cases operated on after this
method, which resulted, he says, to his entire satisfaction.
The late Professor Miitter reports similar satisfactory results.
The following interesting case is from his practice :
550 ORAL DISEASES AND SURGERY.
The patient was a daughter of a respectable practitioner of medi-
cine residing in South Carolina, and, at the time the accident
productive of the deformity occurred, was about eleven years of
age; of fine general health, though of a temperament strongly
lymphatic.
In the commencement of the winter of 1835, while at play with
her companions, she was by some means or other thrust against a
heated stove, by which her hands, arms, neck, and the lower part of
her face were severely burned.
Her wounds were treated in a most judicious manner by her
father; but, in spite of all his efforts, those about the mouth cicatrized
with so much contraction that the entrance into this cavity was
almost obliterated. As soon as the tenderness of the part was
somewhat diminished, he commenced a course of treatment calcu-
lated to restore this orifice to its natural size. He first began by
introducing sponge tents, which Avere allowed fully to distend them-
selves ; but, after repeated attempts with them, by which he caused
the child much suffering without materially benefiting her, they
were abandoned.
He then attempted to dilate it by first making an incision about
six lines in length, extending from each angle of the mouth in an
outward and nearly horizontal direction, and afterward introducing
the tents to prevent the lips of the Avound from uniting. This ap-
peared at first to be productive of some good ; but in a short time
they contracted and cicatrized, and the patient remained in as un-
comfortable a condition as before.
Finding himself foiled in both attempts, he determined to bring
her to Philadelphia for the purpose of consultation. She was ac-
cordingly brought on, and became a patient of Professor Miitter, who
says, "When I first saw her, nearly a year had elapsed since the
occurrence of the accident. Her appearance at the time was very
singular. Firm and dense cicatrices nearly surrounded the mouth,
but were most marked on the lower lip and about the angles;
while the orifice of this cavity was barely large enough to admit
the point of the finger, and presented an oval form. The cicatrices
of the incisions made by her father were also very apparent at each
angle. Her general health was perfect ; and it was only on account
of the deformity and difficulty of taking her food that the operation
was requested. Her speech was not much afifected ; although some
of the labial sounds were imperfectly pronounced. The lining mem-
brane of the mouth was perfectly normal."
OPERATIONS UPON THE LIPS AXD CHEEK. 551
"From the history of the case," says Prof. M., "I concluded it
would be utterly useless to attempt a cure by the repetition of the
measures already employed, and which are the only ones usually had
recourse to. I therefore proposed the operation devised by Dietfen-
bach, and, her father consenting, it was accordingly performed on
the 28th of the month of consultation.
" The operation completed, a common roller bandage was applied,
as in cases of fracture of the lower jaw, in order to prevent any de-
rangement of the wounds. The patient was then placed in bed, with
her head elevated, and as she had just before the operation eaten
freely of some light food, ordered to take no nourishment of any kind
until the next visit, and to be perfectly silent.
"29th. Passed a good night; slept well ; no fever, and complains
of no pain; parts merely a little sore; needles all in place; writes
that she is hungry. Ordered thin oat-meal gruel as diet, which, as
Avell as her drink, is to be given with a small teaspoon.
"30th. Quite as well as yesterday; everything in place; bowels
costive ; ordered an injection of white soap and water ; diet as before.
" 31st. Complains of stiffness in the wounds, but no pain ; dress-
ing all secured ; injection had operated well ; pulse natural ; ordered
chicken soup for diet.
"Dec. 1st. The bandages were removed, and the first dressing
commenced. The sutures, which had been closely bound down to
the parts by blood, were carefully softened with warm water and cut
away. As soon as they were removed, and the parts properly dried,
the most gratifying exhibition of the success of the operation was
afforded. On both sides, union between the everted mucous mem-
brane and the margins of the wounds had taken place nearly through-
out, and the new lips presented an appearance almost natural. Some
of the needles were then removed ; but, as there appeared to be a
feebleness in the adhesion at some points, the needles passing
through them were allowed to remain, and a thread cast loosely
around them. The bandage around the head was also reapplied.
"2d. Second dressing, parts all firm and healthy; the remaining
needles were now removed, and the bandages only reapplied, which
w-as done to prevent talking; no pain in the part, and the patient in
fine spirits. Ordered bowels to be opened with an injection, and the
diet to be more nutritious, but still liquid.
"iS'othing remarkable occurred in the subsequent treatment; all
dressings were taken off on the loth, and the child allowed to pur
sue her ordinary course of life. The mouth presented a very good
552 ORAL DISEASES AND SURGERY.
appearance, though the lips were somewhat thinner than natural,
and there was some difficulty in bringing them in close contact, espe-
cially at the central portions."
Mr. Listen reports a case of equal interest. Mrs. H., aged twenty-
two, was knocked down in a brawl, and a man jumped upon her, lacer-
ating and bruising her cheek and mouth extensively, and fracturing
her jaw. She went to St. Thomas's Hospital, where her jaw was put
up and bandaged. These were not removed for some time ; and, when
taken off, the wound on the right side of the mouth was found healed,
and the cicatrix considerably contracted; since then the contraction
has continued somewhat, and now is so small that she can scarcely
get any solid food to pass her lips. There is a large, dense, white
cicatrix on the right side of the mouth, rather puckered, and sharp
toward the angle of the mouth. An operation was performed on
the 23d. Mr. Listen removed a triangular portion of the cicatrix
on the right side of the mouth, dissecting it off the mucous mem-
brane, which was then divided to the extent of the external wound.
Lint dipped in cold water was then laid over the surface, to suppress
the oozing of blood, which was by no means considerable. About
five hours after the operation, all oozing having ceased, the mucous
membrane was turned over the cut edge of the cicatrix, and united
by three or four points of suture to the skin of the cheek ; by this
means a mucous surface was secured to the newly-formed prolabium,
and the gradual cicatrization and consequent contraction dispensed
with.
History of the case, from notes :
24th. A little swelling around the wound ; not much pain.
25th. The sutures were removed to-day. Adhesion appears to
have taken place between the mucous membrane and skin. Water
dressing to be applied to the lips.
Nov. 1. The water dressing has been continued; union between
the mucous membrane and skin took place to a considerable extent
by the first intention. The remaining parts are granulating favor-
ably. The mouth is much improved in appearance and usefulness.
4th. The lip nearly healed, only a small sore remaining in the
lower lip. Red wash dressing to be applied to it. Discharged much
relieved.
A modification of the mode of Dieffenbach, which I would sug-
gest, and which I am confident will yield still better results, is an
association with these surgical means of a mechanical appliance.
After the operation, as described, has been performed, and time
OPERATIONS UPON THE LIPS AND CHEEK.
553
has been given for union of the reflected mucous membrane, let such
an appliance as I have here figured (mouth-stretcher, it might be
called) be prepared and slip it between the lips. This stretcher
Fig. 103.
represents a properly-shaped mouth ; the lips in the whole of their
, circumferences are caught and held by the gutter of the apparatus,
and thus not only is the healing influenced to a desired shape, but
undue cicatricial contraction is prevented.
If it is objected that such an instrument would look ungainly in
the mouth, I have only to answer that after the first week or two,
there would exist no occasion for its constant wearing; it might be
entirely dispensed with during the day and be worn only at night.
Such use of it, however, should be continued at least six mouths, if
we would have the cure perfect.
An advantage that would be yielded by such an appliance to a
bungling operator would be that it would naturally correct any im-
perfection in his operation ; the character of the apparatus compel-
ling the regular healing of the wound. Indeed, I am not sure but
that in this way a proper mouth might be made if the strictly surgi-
cal part of the manipulation consisted only in a simple incision to
enlarge the parts to a proper capacity. For in the operation it can-
not be said that the reflection of the mucous membrane is an abso-
lute necessity ; whether this membrane should be carried over the
cut surface or not, we would very soon have it clothed with such
tissue, or at least with that which would be found sufficiently analo-
gous to fairly represent it. Dr. Miitter, in remarking on the philos-
ophy of this operation, suggests that the annals of modern surgery
hardly afi'ord an example of greater ingenuity than the procedure of
Dieffenbach. " The great difficulty," he truly remarks, "in all these
cases arises from the constant tendency to contraction manifested by
the cicatrix, which occasionally goes on to such an extent that the
orifice of the mouth is almost closed. At the first examination of
such a deformity, the remedy which seems to promise most success,"
554 ORAL DISEASES AND SURGERY.
says Dr. M., "is mechanical dilatation. Unfortunately, this is pro-
ductive of but temporary relief, and has never, I believe, effected a
permanent cure. Next to this method comes incision of the commis-
sures. We might naturally expect such a course to be sufficient to
effect the ends desired; and in all probal:)ility this would be the case,
could we by any means prevent reunion of the edges of our incisions.
But this, it would appear from statements of the best authorities,
has hitherto been impossible ; for, notwithstanding the introduction
of tents, leaves of sheet-lead, cerate cloth, etc. between the lips of
the wounds, adhesions, more or less complete, are sure to take place."
The instrument which I suggest will, I think, meet indications
which the appliances heretofore used have not been able to meet.
A tent, or cerate cloth, or strip of easily yielding sheet-lead might
not resist the great contractile force existing in these conditions ;
something fixed and immovable is required. One would not be
willing to trust to a less resisting body than the catheter, after
urethral section. I do believe that an instrument such as is here
figured, if properly constructed and justly employed, will as certainly
give a perfect cure as that any indication may be met with a proper
remedy at hand. It will be found reliable if there is truth in sur-
gical principles. It might be asked, " What need of such appliances,
if Dieffenbach's operation will effect a cure ?" Unfortunately, Dief-
fenbach's manipulations cannot in all cases be carried out. If the
mucous membrane, for example, participates in the lesion, the oper-
ation cannot be successfully performed. Or who can say that flaps
of mucous membrane, however nicely approximated with the skin,
will unite ? There are several things which may come between the
surgeon and success. There are, at least, cases which Dieffenbach's
nice operation will not cure.
It seems to me the means suggested will cure them.
The following is an instructive case, reported by Dr. C. A.
Hart :
" Mary Grabau, aged ten years, was brought to me by her mother,
on May 10th, and presented the following appearance: countenance
blanched, body thin and emaciated, the features having a pinched
expression, and the buccal orifice contracted to such an extent as to
only admit the little finger over the first joint with the employment
of an effort. The angles were occupied by dense cicatrices, extend-
ing on to the cheeks and chin. The cheeks were also extensively
adherent to the superior maxilla. The transverse diameter of the
mouth was nine lines.
OPERATIONS UPON THE LIPS AND CHEEK. ^^^3
" The histoiy of the case rendered by the mother was as follows:
at the age of three years, the child was attacked by scarlet fever,'
and during the disease the sloughing of the fauces and cheeks was
very extensive, perforations of the cheeks occurring at five diilerent
sites. The angles of the mouth were also badly involved. Duriu"-
convalescence, the perforations of the cheeks healed, and the cicatriza-
tion of the angles of the mouth closed the orifice to about one-half
the normal size. After the recovery of her strength, an operation
was desired for the relief of her condition, and performed by Dr. E.,
of this city ; the method being a simple incision from each angle of
the mouth, with cold-water dressings applied over the raw surfaces.
" The result of this was of course nil, with the exception that the
mouth became even smaller than before, so that it was with dif-
ficulty that she could take her food with an ordinary-sized teaspoon.
This was followed in the same year by two other operations, whose
only results were retrogressions; but what methods were employed
it was impossible to discover.
" The impression conveyed upon seeing the case was that much
could be attempted, and but little hoped for, though her condition
was one to command sympathy and demand an effort for ameliora-
tion. Before proceeding to any operation, Dr. G. Ceccarini was
called in consultation, and the following method agreed upon,
which, with his and Prof. B. I. Raphael's assistance, I performed
on May 26th. The patient having been placed upon the table
and brought under the influence of chloroform, the little finger was
forced into the mouth, to extend the cheek, and a very delicate
scalpel passed from the angle of the mouth, horizontally, between
the tissues of the lip, to the extent of about three-fourths of an inch;
the point of the blade was then carried up, about five lines, by de-
pressing the handle, and then made to cut obliquely into the cavity
of the mouth, and, in this position, gradually drawn toward the
point of entrance — thus forming a flap from the inside of the upper
Up), lined with mucous membrane.
" The second step consisted in extending the angles of the mouth
about three-fourths of an inch, by incising the skin and other tissues,
anterior to the first point of entrance of the knife.
"The above-described procedure was observed upon the opposite
side of the mouth, and with much greater ease, as the enlargement
of one side afforded more space for manipulation.
" The third step consisted in rolling the flaps which were formed
by the first steps on each side of the mouth, over the raw surface of
556 ORAL DISEASES AND SURGERY.
the new lower lip, from the situations of the old angles to the new
ones, and retaining them in situ by several points of silk sutures,
thus bringing two raw surfaces into apposition, and giving a crim-
son mucous border to the lip. At no period of the operation was
the hemorrhage sufficient to require the aid of a ligature for its
arrest, the coronary arteries both having been obliterated, either by
the disease or the previous operations. The primary dressing con-
sisted of cloths wet with tepid water, and instructions were given
to keep the parts warm to avoid sloughing of the flaps; ordered
morphia3 sulph. gr. ^ to be given in about an hour.
" May 2Tth. Mouth considerably swollen ; with high traumatic
fever ; ordered appropriate remedies.
" May 28th. Fever much decreased; has slept well, appetite good;
the edges of the wounds appear to be united.
"May 29th. Condition much improved; has been playing about
the room.
"May 30th. The union being thoroughly established, the sutures
were all removed.
"May 31st A slight ulceration began on the left side of the
mouth, which threatened to destroy the new lip, but fortunately ex-
tended into the cheek ; this was controlled by the local application
of a solution of tannin and glycerin. After this the case progressed
favorably to convalescence.
" In the method here reported there is no loss of substance, as in
the method of M. Dieffenbach, and a p)erfect lower lip is formed,
the lower lip presenting about the same appearance as after the
method of M. Serre."
Plastic operations about the lips are embraced under the general
name of cheiloplasty ; those upon the cheeks are termed genioplastic.
The necessity for such operations arises from various caases, not
the least frequent of which are sections made by the knife of the
surgeon. Reference to plate exhibits five cases ; the first resulting
from salivation, the second from an ulcer, the third, fourth, and fifth
due to operations for the removal of cancer.
The first of these. Fig. 1, is described as having been a shocking
deformity. The operation for its relief was performed by Prof
Mutter, the practice being as follows : having first extracted the use-
less teeth of the upper jaw, which would have prevented the proper
adjustment of the flaps, or induced their ulceration, the edges of the
ulcer were freshened, and the integuments detached from the side of
OPERATIONS UPON THE LIPS AND CHEEK. 557
the jaw. Two incisions, one above and one below the ulcer, as
seen in the figure, were made, so as to form four flaps. These were
now allowed to fall together, and were united in the line of the teeth
as far forward as the natural angle of the mouth. The result was
entirely satisfactory.
In studying this case, the reader will remark that while the mode
of section, or making the flaps, most happily meets the indications
so far as filling up the seat of the original lost tissue is concerned,
yet that this is only done by making two other defects, one above,'
the other below. Such defects, however, prove, in healthy tissue,
of not so much consequence ; granulations, quickly springing from
the whole circumference of such wounds, supply the lost tissue : in-
deed, in my own experience I have found, as a rule, that the tend-
ency in these fresh parts is to so rapid a granulation and cicatriza-
tion that frequently the line of the artificial union is torn apart.
Fig. 1 may be studied from another stand-point. In a case oper-
ated on by myself, very similar to the drawing, where the neighbor-
ing tissues were loose and free in character, I succeeded in effecting
an admirable cure by simply dissecting the parts from the bone,
freshening the edges, and uniting them by the ordinary hare-lip pin,
supporting the whole by straps of adhesive plaster passed from be-
neath the jaw to the side of the head ; the parts at first looked very
much stretched, but soon accommodated themselves.
Still another mode of performing such operations is after the manner
of Taliacotius. Freshening the edges as before, map out, by means
of a piece of card-paper, the size of a flap required to fill up the gap;
next lay this upon the arm, and, dissecting from the integuments its
size, supported by a pedicel, fix it in the break by means of stitches
of the interrupted suture. To do this, the arm is to be brought over
the head, and thus supported until union is secured, when the pedi-
cel is to be detached, and the parts trimmed to suit.
Subfig. 2, constituting a second study, represents an operation per-
formed by Mott for the relief of an anchylosis of the jaw dependent
on cicatrization of the mouth with the restoration of a part of the
cheek. 1, exhibits cicatrix arising from an ulcer. This was entirely
excised, leaving an opening in the cheek. 2, tongue-shaped flap cut
to fill up the opening by being rotated upon its base.
Subfig. 3 represents an operation performed by Prof. Pancoast for
the removal of an extensive cancer, and the formation of a new lower
lip. The cancer is shown as circumscribed by a curvilinear cut.
A vertical incision in the median line of the chin extended from the
658 ORAL DISEASES AND SURGEBT.
curvilinear cut iiearh" to the os hyoides, and another, which was hor-
izontal and parallel, to the base of the lower jaw, formed four flaps.
The angles of the flaps being removed, the upper flaps (1, 2) were
raised to the proper level, and united by the twisted suture on the
median line, when the lower flaps (3, 4) were also united on the
median line so aato cover the front of the chin.
Sul)fig. 4 represents a similar case, treated by the operation of
Chopart. The lines show the idea of the incisions. 2, 4, circum-
scribe the disease. 1, 5, 3, 6, show vertical cuts. The diseased part,
all above 2, 4, being removed, the integuments are loosened from the
lower jaw, and simph^ lifted up, being retained in the new position
by hare-lip pins, or other convenient form of suture. This operation
occasionally answers very well ; in certain instances, however, where,
for example, it has been necessary to stretch the parts, much cica-
tricial evulsion is apt to occur.
Subfig. 5 represents the same position of the disease, treated
after the manner of Lallemand. 1, the remaining portion of the lip,
which is to be drawn over to the angle of the mouth at 2. A flap,
formed of the integuments of the neck, having been dissected off, is
shown as being partially rotated on its base, and about to be carried
up to cover the deficiency. The wound on the neck may either be
approximated at its edges, or left to heal by granulation.
In epithelial cancers quite as large as those represented in Figs.
3 and 4, I have succeeded in securing the most perfect cures by
practicing the operation of Malgaigne. This consists in removing
the diseased mass by a simple T-incision ; the angles of the mouth
are next enlarged by horizontal cuts, and the V drawn together and
united in the middle line of the face. In my own cases I have al-
ways placed a pin at each corner of the mouth ; as the result of this,
some little puckering is produced, but, in return, it eases the strain
on the middle line, and itself disappears after a very few months.
Plate XI. is one of the most valuable presented by Professor
Smith in his System of Sui'gery, representing a combined operation
in rhino-cheiloplasty, with the original appearance of the patient, the
steps of an operation devised and executed by Professor Pancoast,
and the result obtained as exhibited by an accurate likeness of the
patient taken sixteen months after the operation.
History of the Case. — The history of this case, which will serve
as a type and study of similar cases, is thus described by Professor
Smith. "A man aged fifty-three had lost all the soft parts of the nose
and whole of the upper lip, from the commissures of the mouth to the
PLATE XI.
RHINOPLASTIC AND CHEILOPLASTIC OPERATIONS.
Fig. 1.— Appearance of patient prior to the operations of Cheiloplasty and
Ehinoplasty. — After Pancoast.
Fig. 2.— View of his face with the chin depressed. The mouth, being con-
tracted into a rigid orifice, was enlarged laterallj' by the stomato-
plastic operation of Dieffenbach for atresia oris, after which two
flaps were made, as marked in the lines upon the cheeks, so as to
form the upper lip. — After Pancoast.
Fig. 3. — Appearance of his face after this operation, showing the position
of the sutures and the improvement in the mouth. — After Pancoast.
Fig. 4. — Shows the steps of the Khinoplastic operation performed upon him
subsequently. The edges of the nasal cavity being freshened by a
grooved incision, the outline of the new nose was marked on the
forehead before cutting the flap. The dots indicate the position
of the sutures. — After Pancoast.
Fig. 5. — The wound in the forehead being closed by the hare-lip sutures, the
flap was reverted, and attached in the groove on the edge of the
nasal cavity by three stitches of the interrupted suture, which
were tied over little rolls of adhesive plaster, after Graefe's method.
The edge of the septum is also attached to the upper lip. The twist
in the pedicel is seen in the root of the nose. — After Pancoast.
Fig. 6. — An accurate likeness of patient, sixteen months after the opera-
tion. — After Pancoast.
(559)
I
560 ORAL DISEASES AND SURGERY.
canine fossa of each side, as well as the septum navium and the
turbinated bones, the cavities of the antra Highmorianum and of
the sphenoidal sinuses being exposed. His appearance with his
mouth closed is shown in Fig. 1. The mouth, when opened, pre-
sented a rigid circular orifice three-fourths of an inch in diameter.
" Operation of Pancoast. — The mouth being widened after
Dieffenbach's method (see description on previous page), the free
surface of the gum was freshened, and an incision was then made
obliquely upward and outward for a quarter of an inch from the point
where the gum was covered by integuments, and from the end of
this another cut was made for about the same distance, nearly
parallel with the incisions for widening the mouth, but inclined a
little downward. The cheeks being now loosened from the gum
and malar bone by incisions on the side of the mouth, the flap of
skin and subcutaneous fatty matter was raised from the surface of
the muscle by beginning the dissection at the angle next the nose,
Plate XL Fig. 2.
" The arterial branches, which were divided, having been twisted,
the flaps were drawn downward and forward over the raw surface
of the gum and fastened together with the hare-lip suture, Plate XI.
Fig. 3, the inner edge of the rotated flaps being thus united in the
middle line of the lip. The face being then dressed with lint wet
with lead-water and laudanum, the patient recovered in about two
tnonths. The nose was subsequently formed as follows :
" The hair being shaved from the temple and forehead, the nasal
orifices closed with lint to prevent the entrance of blood, and the
patient lying down with the head supported by a pillow, a flap was
raised from the forehead, as shown in Plate XI. Fig. 4, the skin being
divided at a single sweep of the knife, the blade of which was in-
clined outward so as to cut a beveled edge. The apex of the flap,
which was about five-eighths of an inch wide, rested between the
eyebrows, and the tongue-like portion which was to form the columna
nasi extended up into the scalp. The base of the flap was nearly
three inches wide, in order to allow for its subsequent contraction.
The flap, after being dissected up, was then turned down on the left
side and wrapped in linen, while the wound in the forehead was
closed by four interrupted sutures, after which the flap was applied
to the freshened edges of the new lip and gums, the whole Ijeing
held in position by the plastic suture before described, and tied over
rolls of adhesive plaster, as in Grsefe's method, Plate XI. Fig. 5.
Union having occurred, the pedicel of the flap was divided, five
OPERATIONS UPON THE LIPS AND CHEEK. 561
weeks subsequently, by passing a director under It, after which it
was smoothly fitted down to the roots of the ossa nasi, in a cavity
which was made for its reception by excising a portion of the sub-
jacent integuments. By the twelfth day union was perfect, and the
patient left the hospital so much improved that, sixteen' months
subsequently, his likeness was taken, a^ represented on Plate XI
Fig. 6."
36
CHAPTER XXXVII.
THE TONGUE AND ITS DISEASES.
Whether from infrequency of disease in this organ, or the
diflBculty of expressing its pathological phenomena, we find very
little which might be called systematic, that has been written upon
the subject.
Of medical diseases the tongue has long been esteemed a reliable
sentinel: hence, many and varied are its functional derangements
and expressions. To term, however, such derangements disease
could not by any means be proper, the sympathetic relationship
being evident to the most superficial of observers.
Of organic, or surgical diseases, the tongue has seemed to me to
have its full share. These diseases are of a twofold relation: local,
as reference is had to some direct cause demanding only local at-
tention ; indirect, as constitutional ofi'ense is the agent against which
a treatment is to be directed.
Of local injuries, we may refer to ulcers caused by jagged and
projecting teeth-roots, to cuts and contusions from falls and blows,
to bites inflicted under vai'ious circumstances by the teeth, to papu-
lar hypertrophies, to epithelial indurations and ulcerations, to stings
from insects in fruit-season, to burns, scalds, the incautious or acci-
dental mastication of acrid or irritating substances, to glossitis, from
the excessive use of tobacco, from operations performed on neigh-
boring parts, from mustard administered in strength, in necessity
for sudden emesis, etc.
Of associate or constitutional diseases, we may mention promi-
nently the syphilitic and mercurial impressions appearing in the
form of acute or chronic inflammations, indurations, fissures, ulcers,
and cysts. Malignant diseases, particularly scirrhus, have here
also not unfrequently a first expression.
"In drawing inferences," says Dr. Wood, "from the condition of
this organ, it is important to know whether the appearances it may
present are the result of local disease in the mouth, or of the sym-
pathies which connect it with other parts of the system. In general,
(562)
THE TONGUE AND ITS DISEASES.
563
there is little difficulty in coming to a correct conclusion upon this
point : it is only necessary that the attention should be directed to-
ward it. This organ," continues Professor Wood, " seems to have
been designed as an index, to the eye as well as to the ear, of the
state of the system ; so numerous and diversified are the morbid
affections which modify its healthy appearance. It not only par-
ticipates in all general derangements of the whole system, servin"-
as one of the surest guides to a correct judgment in relation to the
degree, progress, and precise stage of the disease, but especially
also sympathizes with the different parts of the digestive tube, at
one extremity of which it is placed.
" The bulk of the tongue may be increased or diminished. Its
enlargement, when not so considerable as to be very obvious, may
often be known by the appearance of indentations on its sides, made
by the pressure of the teeth. This is occasionally one of the first
■ signs of the mercurial influence. Its contraction, when not the mere
efTect of dryness, is usually the result of a diminished supply of
blood, and indicates either a general deficiency of the circulating
fluid, or great feebleness of the heart's action. Like every other
part naturally moist, it shrinks by drying; and, under such cir-
cumstances, no general inference can be deduced from its mere loss
of volume.
" Its color is often greatly and significantly modified. Morbid flor-
lidness of the tongue is the consequence either of the condition of
the blood, or of its greater abundance in the organ. In the former
case, an unduly arterial ized state of the mass of the blood is indi-
cated ; in the latter, either overexcitement of the circulation gener-
ally, or phlogosis of the stomach. Redness of the tongue, not the
result of local causes exclusively, has been supposed by some pa-
thologists to be an almost certain sign of gastric inflammation or
irritation. But this is far from being the case. It is often seen
when no evidence of gastritis is presented, either by the symptoms
or upon dissection, and is not unfrequently absent when that disease
exists. Serious practical injury may result from this error. The
red tongue can be considered as having special reference to the sto-
mach, only when other symptoms point in the same direction, and,
even then, is by no means a certain sign. A livid or purple color
of the tongue is usually dependent upon an insufficient aeration of
:the blood, and is a valuable sign, in connection with the same color
[Of the lips. Not unfrequently the tongue is morbidly pale; and this
' state is a sign of deficiency of the blood in general, or of its red cor-
564 OFAL DISEASES AND SURGERY.
pusclos iu particular, or of great prostration of the circulating
forces.
"Its condition as to dryness and moisture is often highly signifi-
cant. But caution is necessary not to mistake dryness, from tempo-
rary and unimportant causes, for that which results from general
disease. In persons who sleep habitually with their mouths open,
the tongue is apt to be dry in the morning ; and the same cause
often produces the same effect in sickness. On visiting a patient, we
find the tongue unexpectedly dry, and begin to feel some apprehen-
sion, until we learn that the patient has been breathing for some time
through the mouth alone. A stoppage of the nostrils often gives
rise to this phenomenon. In all doubtful eases, it is only necessary
to request the patient to close his mouth, and then move the tongue
about so as to moisten it. If he succeed satisfactorily, we may con-
clude that the dryness was accidental, and of no account. Another
caution is requisite ; to take care, namely, that a really dry tongue
should not be mistaken for a moist one, in consequence of the patient
having recently taken a liquid into his mouth. Dryness may exist
in different degrees, from mere clamminess to perfect aridity. It de-
pends on a deficiency of saliva, or of mucus, or both, and indicates
a general tendency to diminished secretion. It not unfrequently
occurs, as a sympathetic affection, in ulcerative inflammation of the
small intestine. It affords sometimes the most important therapeu-
tical indications.
" The tempei'atvre of the tongue serves as a guide to that of the
body generally. When cold, it evinces, for the most part, great
prostration of the powers of life. It proves that the process of ca-
lorification is failing at the very fountain ; for the breath must be
cool before the tongue can become so in any considerable degree.
This coldness of the tongue has been frequently noticed in severe
cases of epidemic cholera. But we must take care not to confound
coolness from local causes, as from ice in the mouth, or from the
patient having slept long with the mouth open in a cold atmosphere,
with that proceeding from the state of the system. Heat of the
tongue, except when arising from inflammation of the organ, may
be considered as a sign of a general elevation of temperature.
"But the condition usually denominated a, furred tongue is, per-
haps, the most valuable diagnostic symptom afforded by that very
important little member. In this state, the tongue is covered with
a morbid coating, which adheres so firmly that it cannot be removed
without removing a portion of the surface along with it. Occasion-
THE TONGUE AND ITS DISEASES.
565
ally, deposits take place from the saliva and the mucus of the mouth •
but these are easily removable, and must be distinguished from the
genuine fur. The latter proceeds from a secretory process of the
tongue itself, and seems to be incorporated with the superficial layer
of epithelium. It is almost always confined to the upper surface,
where the structure of the membrane is papillary. Thou"-h verv
generally a sign of disease, it is not always so. Some persons have
a furred tongue habitually, more especially upon rising in the morn-
ing; and, though in the greater number of these there is probably
some chronic disorder of digestion, 3-et in others the health appears
to be perfect.
"A furred tongue almost always accompanies fever, and is one of
the most decided characteristics of that affection. Indeed, when
considerable in degree, and not dependent upon stomatitis of anv
kind, it may very generally be regarded as a febrile symptom. When
the fur is ivhite, thickish, tolerably uniform, and accompanied with
moisture, it usually indicates an open, active state of fever, in which,
though the obvious symptoms may possibly be violent, there is not
apt to be any lurking mischief, nor any malignant tendency. When
short, very adhesive, and rather scanty, permitting the redness of
the tongue to appear through it, and attended with some disposition
to dryness, it is often a sign of a protracted and obstinate form of
fever, which is apt to assume a low, nervous, or typhoid form. A
yellowish hue of the fur is usually indicative of bilious disorder,
being produced either by the vomiting of bile, or, what is probably
much more frequent, by direct secretion from the tongue, consequent
upon deficient secretion by the liver, or an excessive production of
bilious matter in the blood. Not unfrequently, this color of the
tongue is accompanied with a bitter taste. It is common in mias-
matic fevers and hepatic diseases. A hrou-n or black tongue is
usually indicative of a low state of the system and an impaired
condition of the blood. It is owing to the secretion of a dark mat-
ter, apparently identical with that which collects about the teeth and
lips in typhous fevers, and probably consisting of blood modified in
its passage out of the vessels. The same action would seem to take
place in the tongue as that which, in the stomach and bowels, occar
sions the black discharges so common in malignant fevers. It may
depend on an enfeebled state of the secreting tissue, or a diseased
state of the blood, or on both united. Very frequently this dark-
ness of the tongue supervenes upon a previously white coating, and
indicates a deteriorated state of the vital forces and probably of the
566 ORAL DISEASES AND SURGERY.
blood. The caution should be observed, not to confound this discol-
oration with that which may proceed from accidental causes, as from
the chewing of liquorice, tobacco, burnt coffee-grains, etc. In many
instances, the white fur of the tongue is modified by ?^ed points,
which are the tops of the swollen and projecting papillae. This ap-
pearance is not uncommon in eruptive febrile diseases, especially
scarlet fever and measles. When consequent upon a dyspeptic state
of the stomach, the fur is most copious in the morning before break-
fast. In some persons, emptiness of the stomach is said always to
induce this state of the tongue.
" The manner in which a furred tongue becomes clean affords valu-
able indications. When the fur slowly recedes from the tip and
edges, thinning gradually as it retires, it intimates a favorable con-
valescence. A portion of fur often lingers near the root of the tongue,
long after the disease has given way. In another mode of cleaning,
the fur loosens and separates in flakes, often beginning at the middle
or near the root, sometimes in large patches, or over almost the
whole tongue at once, leaving a smooth, red, glossy surface, as
though the papillary structure had been lost. In such cases, if acute,
and if the tongue remains moist, convalescence almost always takes
place, though usually tedious, and sometimes very lingering. In
threatening fevers, it is very desirable to witness this phenomenon ;
and, as it is often preceded by a feeling of soreness in the fauces,
this may be considered, when it occurs in such cases, as an auspi-
cious circumstance. Much stress was laid upon this as a prognostic
symptom by the late Dr. Joseph Parrish, of Philadelphia. Some-
times the fur recurs once and again, before it ultimately disappears ;
and weeks and even mouths are occasionally consumed in the strug-
gling and apparently uncertain advance of the system toward health.
In less favorable cases, the tongue, after having commenced the pro-
cess of cleaning, as just described, or even after completing it, in-
stead of continuing moist, becomes as dry as a chip, with an aggra-
vation of all the symptoms, and no little increase of danger. The
indication is still more unfavorable when, in addition to its dryness,
the surface becomes gashed, chapped, or fissured, or exhibits a rough,
scaly appeai-ance.
" This smooth, red, and glossy state of the tongue, sometimes with
moisture and sometimes with dryness, is not uncommon in chronic
diseases, in which it is generally a bad sign, and is supposed to indi-
cate serious organic derangement of the alimentary mucous mem-
brane. A still worse condition, however, is an aphthous state of
THE TONGUE AND ITS DISEASES. 567
the tongue, which is apt to come on in the advanced stages of chronic
diseases, and is generally to be received, under these circumstances,
as a fatal sign, though of itself, and occurring in ordinary health, it
is in no degree alarming.
"A loss or depraimtion of taste is not uncommon, and is generallv
of little consequence, depending upon a mere derangement of the
surface which receives the gustatory impressions. But when of a
paralytic nature it is much more serious, as it generally indicates
disease within the encephalon.
"The only other point requiring consideration refers to the move-
ments of the tongue. When, in acute febrile diseases, these are not
under the control of the patient, when upon being requested to pro-
trude his tongue he is unable to do so, or when the organ trembles
much in the attempt, the symptom is exceedingly unfavorable, indi-
cating either great prostration, or dangerous cerebral disease. Of
similar unfavorable prognostication, under the same circumstances,
is the occurrence of a difficult and hesitating utterance, like stam-
mering. The inclination of the tongue towards one side, when pro-
truded, usually indicates palsy, and is one of the common attendants
upon hemiplegia."
With these almost exhaustive observations by Professor Wood are
to be associated and noticed the facts that in some nervous, irritable
persons the tongue is found habitually furred, yet without any symp-
toms of gastric or other derangements. Some persons get furred
tongue the moment their stomachs are empty ; others have their
tongues coated always after a meal and while digestion is going on,
the coating passing away as the function ceases. Mental and moral
emotions have a most decided influence. Dr. Wright, in one of his
clinical lectures, mentions the following striking illustration :
" In calling upon a certain patient," says this gentleman, " the
first thing I did was to look at his tongue. I found it as usual, very
pale, flabby, and moist, but without any coating. After having
made other necessary inquiries, I was informed by my patient that
his heart, which had long been disturbed by mental emotions, had
on the previous evening beat with unusual violence and irregularity.
On my asking if he could account for it, he told me that he had just
then received the distressing intelligence that an uncle from whom he
expected a competency, had not left him a shilling. This pitiable
tale, told with much earnestness and visible feeling, occupied little
more than twenty minutes. At the end of that time I again looked
at his tongue, and found it coated with a thick, white fur."
568 ORAL DISEASES AND SURGERY.
It is, however, not with functional expressions of the organ, but
with diseases localized in it, that the surgeon has to treat. These
diseases, by the review made of sympathetic disorders, we are now
prepared to consider.
The most frequent disease of the tongue with which I have met
is syphilis. Syphilitic ulcers, the most common of the manifesta-
tions, appear on any part of the organ, but are most common to the
sides and under surface. Such ulcers are, in my experience, invari-
ably accompanied by associations of its origin, — psoriasis on the
body, nodes, falling of the hair, lymphatic induration of the posterior
cervical ganglia. A syphilitic ulcer on the tongue has the appear-
ance of chancre, hard or soft : we meet with them where the ulcera-
tion is quite deep and the edges heavily indurated. Again, where
there is neither excavation nor induration, we know, however, that
they are venereal from the associations.
A second form of syphilitic disease of the tongue is observed in
the induration and hypertrophy of circumscribed patches of mucous
membrane. The induration in these cases is so markedly localized,
that, if it were not for their varying locations, — being always, how-
ever, on the dorsum, — one might readily believe them to be enlarged
circumvallate papillae ; the patches are quite as large as a dime piece,
are elevated, and are as isolated as one sees a fungiform wart. I
have seen two such patches on the dorsum of a tongue, and at the
same time a large ulcer on its under surface.
Cracks and fissures are other syphilitic indications met with on
the tongue. It may happen in some instances that these fissures are
so deep as to seem to divide the organ into a number of parts ; they
always, so far as I have observed, run lengthwise. These fissures
are at times unbearably sore, denying the patient comfort either in
eating or in rest.
Indurations of the nmcous membrane of the sides of the tongue are
occasionally observed, or it may be that a general thickening exists,
or, indeed, that the whole organ is indurated. In this latter con-
dition the disease has sometimes been mistaken for cancer ; but
such an error could arise only from a failure to observe the associa-
tions of the case.
Sometimes the dorsum presents red patches, the result, evidently,
of a loss of the epithelial covering. These patches are perfectly
smooth, not ulcerated, but are painfully sensitive to hot or cold
impressions. I have met with this condition where the dorsum
seemed literally skinned.
THE TONGUE AND ITS DISEASES. 569
The treatment of syphilis in the tongue has, with one special ex-
ception, the twofold signification of constitutional and local,— the
exception being that of chancre. It has without doubt occurred that
a man has gotten a chancre upon his tongue. Mercury, in some of
its various forms, seems to be looked upon by most practitioners as
having in this direction something specific in its nature; without
doubt, however, it is a greatly abused medicine, and should be used
with more caution and judgment than generally characterize its ex-
hibition.
Where ulcers or other manifestations upon the tongue are second-
ary in their signification, and mercury has not been used upon the
case, it is marvelous how at times, under its influence, such mani-
festations can be made to disappear. How this medicine is to be
used is perhaps best left to be directed by the apparent requirements
of individual cases. Of one thing, however, I am sure : its best
effects are not to be obtained by salivating the patient. Mercury in
the form of the bichloride is a favorite prescription; it may be given
in doses of from the tenth to the twentieth of a grain dissolved in
water or the fluid extract of sarsaparilla, three times a day. The
hyd. c. creta, combined with Dover's powder, is a combination
which may be used with benefit where dryness and other lack of
function are found in the skin. Impression by inunction is another
mode of exhibiting the medicine. A lump of mercurial ointment, the
size of a large pea, may be rubbed into the inner face of the thighs
night and morning. Calomel in quarter-grain doses, combined with
small quantities of sugar to render it palatable, may be given every
two or three hours, until the patient remarks the coppery taste.
Blue pill, in five-grain doses, answers very well if there is no he-
patic disturbance, as manifested by gastric derangement and sick-
headache.
Of the various mercurial preparations, I think, however, the
preference will be found to reside with the bichloride: in this form
the impression of the medicine is gradually secured. If necessary, it
may be given continuously for a month.
Combined with the mercurials, it has been my experience that
tonics are generally found indicated, — a something to counteract the
degenerative tendency which appears to reside in every dose of a
mercurial administered. Iron, quinine, gentian, and bark are excel-
lent preparations. A prescription which will be found to be a very
good one is as follows:
I
570 ORAL DISEASES AND SURGERY.
R. — Hytlrarg. bicbl. gr. iv ;
Elx. ferri cinch. 5vi. M.
Sio". A teaspoonful three times a day.
A second, admirable in cases associated with nervous disturb-
ance is the combination with the mercurial of the pyrophosphate
of iron :
B. — Hydrarg. bichl. gr. iv ;
Syrupus ferri pyrophos. ^vi. M.
Sig. A teaspoonful three times a day.
In syphilitic diseases of the tongue, tertiary in its type, mercury
will seldom be found admissible. The system is broken do\vn: the
process of cure must be one of regenerative repair. These are the
patients for the sea-shore and the hill-side. You will not get them
well if you cannot build them up.
Conjoined with the tonic medication of these cases, very ex-
perienced authorities commend the use of the iodide of potassium.
Whei'e it is thought desirable to use this medicine, ten grains as
a dose may be given three times a day. It is most conveniently
exhibited in water, or, if taste is consulted, in the fluid ext. of sar-
saparilla.
Tertiary symptoms, M. Ricord observes, will not inevitably occur
in the course of syphilis, but they are very likely to do so if the
treatment of the primary and secondary symptoms be not conducted
with the greatest care. As soon as ever the tertiary period has set
in, mercury must be abandoned, and iodide of potassium given.
Xay, further, as mercury taken in time may prevent or retard sec-
ondary symptoms, and so may be regarded as a prophylactic against
them, so may iodide of potassium be regarded as a prophylactic
against tertiary symptoms ; and therefore M. Ricord observes :
"To render the treatment of secondary syphilis complete and
rational, it should always be followed by the exhibition of iodide of
potassium. This substance is, however, not only useless when em-
ployed against secondary symptoms and those of transition, but very
often hurtful ; yet, when secondaries have been of long standing, it
may produce beneflcial eifects; it is also useful as an adjuvant of
mercury in those affections which in some degree lie between the
secondary and strictly tertiary manifestations ; and, finally, it is in-
dispensable for combating the symptoms of a decided tertiary nature.
In order to become well acquainted with the proper manner of ad-
ministering the iodide of potassium, we should take the trouble of
THE TONGUE AND ITS DISEASES. 571
studying its effects, independently of its curative action. First let
us see how it acts on the skin. It may produce on the cutaneous
surface diverse psydracious and acnoid eruptions. The pustules are
generally surrounded by a vividly red areola, and the usual seat of
these eruptions is below the umbilical region, as the nates, thighs,
etc., whereas the common acne (not to mention its other characters)
is mostly situated in the upper half of the body. To these peculi-
arities, it may be added that the pustules will fall in immediately
the administration of the iodide is interrupted. Exanthemata, im-
petigo, and lichen are very apt to be produced by the use of 'this
salt ; and what you ought especially to keep in mind is, that ecchy-
mosis, and purpura in the inferior extremities, are sometimes caused
by the action of the iodide of potassium. The effects of the latter
on mucous membranes should also be carefully observed. It may
cause inflammation of the conjunctiva, the submucous cellular tis-
sue lying under which gets then infiltrated and puffed up ; the eye-
lids turn red and oedematous, and, when the inflammation and effu-
sion are not arrested, the internal parts of the eye become involved
in the affection, and photophobia is the result of this state of thing.s.
The normal mucous secretion is always a little increased, but it does
not take the muco-purulent character, as in the case of catarrhal oph-
thalmia, Coryza, of a more or less severe nature, often exists at the
same time ; it is preceded and accompanied by headache, and a
pretty abundant mucous secretion ; but this coryza never reaches
the suppurative state ; it never produces more than a catarrho-serous
flux. These affections never give rise to any fever, and they disap-
pear as soon as the iodide is given up. This coiyza is an accident
which we should not overlook; for it is of importance to avoid it
when we have to treat a tertiaiy affection of the nasal fossae. As
for the effect of the iodide on the intestinal canal, I have to state that
persons enjoying good health can bear very large doses of it ; I have
given as much as fifteen drachms a day. M. Puche has often given
ten drachms per diem, after commencing with six ; and it has been
noticed that it improves the appetite of the persons who use it.
With some patients a certain pleurodynic sensation, corresponding
to the cardiac extremity of the stomach, is felt after its ingestion ; but
it never causes vomiting. The submucous cellular tissue of the
stomach may, by the use of this iodide, undergo the same modifica-
tions which we have noticed the conjunctiva to be subject to, — a sort
of hyper-secretion and intestinal ptyalism takes place, and much of
the fluid which ought to have been secreted by the skin is rejected
572 ORAL DISEASES AND SURGERY.
by the mouth. This liquid has a slight taste of iodine ; it is not
fetid in the least ; the gums are not swollen, and there is no fetor
in the breath, as happens in mercurial ptyalism. The same effect
may be produced on the other portions of the intestinal canal ; the
patients are then seized with abundant serous diarrhoea. The iodine
is eliminated from the system by the kidneys; half an hour after the
ingestion of it, its presence may be ascertained in the urine, and it
should be remembered that the presence of iodine in the blood in-
creases the renal secretion. I hav-^e even ob,served a case of poly-
dipsia which went on ab long as the iodide was used, but disap-
peared when the latter was discontinued, and gradually sprang up
again as the use of the salt was resumed.
"The effects of the iodide of potassium on the circulation are of
a sedative kind ; it diminishes the number of arterial pulsations,
and lowers their force, but they may regain their normal standard
if the remedy act beneficially on the system ; the same arterial en-
ergy may also reappear when the iodide causes a slight phlegmasia.
This salt is somewhat antiplastic; for it has rather a tendency to
liquefy the blood, and may even produce the peculiar hemorrhages
of purpura. When the effect of the iodide on the nervous system is
carefully watched, it is found to cause a certain excitement of the
nervous centers, followed by a little uncertainty in the movements
and in the intelligence."
A combination much employed by Sir Astley Cooper, in cases
where the iodide of potassium seemed not to favor the patient, was
the liquor arsenici et hydrargyri hydriodatis, — Donovan's solution.
Concerning the local treatment of the venereal affections of the
tongue, with which, in a work like this, we would seem to have
most to do, little is to be added outside of the suggestions offered
on other pages. The treatment is constitutional : direct medication
is perhaps simply to be esteemed as palliative. Lactuca sativa five
ounces, honey one ounce and a half, and alum one drachm and a half,
is a favorite gargle with Ricord in all these cases.
Another consists of a decoction of hemlock, six ounces and a half,
to bichloride of mercury, three grains. From my own experience, I
have suggested the use of acids applied to the ulcers in cases where
the dyscrasis has been corrected or nearly so. It is surprising with
what rapidity a syphilitic ulcer will respond to almost any of the
mineral acids.
In a bad case of mucous tubercles I once treated, I got my patient
well by daily salt-baths and the local use of quinia and iron; twenty-
THE TONGUE AND ITS DISEASES. 573
five grains of the former to two drachms of the mm-iatecl tincture.
The tubercles were painted twice each day for two months.
Borax is a soothing application; it may be rubbed with water
into a cream, and thus be applied ad lib.
A species of local specific, to be used on the part and rinsed away
after a few moments, is compounded as follows :
R. — Aqua destillat. 5ixss ;
Ferri perchl.
Acid, citric.
Acid, hydrochloric, aa Ji- M.
This may be repeated three or four times in the day.
Fissures and fistula are sometimes, in their chronic form, cauter-
ized, nitric acid, pure or dilute, being used for the purpose. In a
case of long-standing fissure of the tongue, I on one occasion cut
out the induration, the patient making a rapid recovery.
Chloride of zinc, twenty grains to the ounce of water, will be
found a useful application in chronic syphilitic conditions, whether
of ulcer, fistule, or fissure.
Mercurial enlargement and induration of the tongue is a condition
frequently demanding treatment. One of the first effects of this
medicine is often seen in the markings made upon the sides of this
organ by an otherwise not observed swelling which has crowded it
against the teeth. The tongue tumefied by the impressions of calo-
mel may become so enlarged as to fill the whole mouth. One par-
ticular case I recall, where, to prevent the patient from being smoth-
ered, I was compelled to drag the body forward over the lower jaw,
and thus fix it until relief could be otherwise secured.
Mercurial ulceration of the tongue is another of the offenses of
this medicine. Such ulcerations are in appearance indolent and irri-
table, are associated with similar conditions of the gums, and with
salivation : their diagnosis is very plainly marked.
The rational treatment of the mercurial conditions refers to the
correction of the local impressions, together with elimination, and
support applied to the system at large. In rapid swellings of the
tongue, it may be found necessary to resort to the use of leeches,
combined with most marked derivation. In the case above referred
to, forty common leeches were applied to the throat, the patient
was profusely sweated, and these applications were succeeded by a
saline cathartic.
Such treatment, combined, if the circulation is sthenic, with some
I
574 ORAL DISEASES AND SURGERY.
arterial depressant, as digitalis, aconite, or veratrum, will commonly
relieve from the immediate danger. Unless, however, the ptyalism
has been acutely excited, and the subject is strong and vigorous,
this treatment will be succeeded by great lassitude and depression ;
such depression is, however, a necessity, and has perhaps saved
the life.
A local treatment in cases of this kind is simply palliative and
soothing. The lactuca sativa and honey, recommended in the syphi-
litic sore-mouth, is an excellent gargle. Sage tea, combined to a
full saturation with chlorate of potassa, is another agreeable applica-
tion. Common table-tea is very grateful to a patient. In combi-
nation with these, or any similar demulcent gargle, I have found
that great relief has been derived from the free exhibition, internally,
of the bromide of potassium.
R. — Potass, brom. 5ss ;
Aqua, ^viij. M.
Sig. Tablespoonful repeated occasionally as the patient is nervous.
Twenty grains, as here directed, may be prescribed three times a
day at the least. I have given eighty at a single dose.
The acute conditions of a mercurial glossitis combated, the prac-
titioner may find it desirable to attend to the more general require-
ments of the case. The system is to be protected against further
impressions of the agent, while at the same time it will generally
be found that a present support is demanded. Chlorate of potassa,
the antagonist of the mercurials, has now obtained in this direc-
tion an almost universal use : it may be administered in full satu-
ration, in tablespoonful doses, three or four times a day. A very
good way to prescribe this salt is to order one ounce placed in an
eight-ounce bottle, which is to be kept filled with water until all is
dissolved. As each dose is taken, the patient replaces it Avith fresh
water.
In the treatment of the mercurial ulcer, the local applications
suggested have been various. Bismuth, red bark and borax, in
equal proportions, act sometimes very happily. Chlorate of potassa,
tannic acid, and glycerin is another excellent combination. Solu-
tions of sulphate of copper or zinc, one grain to the ounce of water,
are cleansing and stimulating applications. Iron, opium, chalk-
powder, aromatic powder, are all, in their turn and place, useful.
If phagedena intervene or threaten, the potassio-tartrate of iron, as
recommended by Ricord in the similar ulcers of syphilis, is not to
THE TONGUE AND ITS DISEASES. 575
be omitted : it may be used in the strength of thirty grains to the
ounce. It should also be administered internally in doses varyin"-
from five to ten grains repeated every two hours.
Chronic phagedena, which in some degree associates itself more
or less frequently with mercurial ulcers, is best treated by the
potential cauterants. Of these, a favorite is creasote : it is to be ap-
plied with care, however, as it may provoke secondary inflamma-
tion. Carbolic acid is a useful article, and will sometimes prove
very reliable. Nitric acid is highly recommended by many practi-
tioners : when applied, every recess of the sore should be burned,
and this should be repeated daily until healthy granulations are
provoked.
SciRRHUS. — Of the third form of constitutional impressions,
scirrhous carcinoma may now engage our consideration. This
scirrhus of the tongue, from the circumstances of its association
and position, is to be assumed a necessarily dangerous, if not fatal,
disease. Scirrhus in other parts may be cured ; that is to say,
being removed, it may not reappear in the part of removal, — although,
being, as is most likely, a constitutional condition, it is perhaps sel-
dom that the disease is permanently destroyed. That scirrhous car-
cinoma is not, however, at least in its incipiency, so formidable a
condition as encephaloid, seems to be the universal impression :
there is a fixedness, an apparent isolation, about it, which always
invites operation.
Situated in the tongue, such isolation is, unfortunately, not so
marked as when found in other parts : it appears as an induration
rather than as what might be termed a lump, and this induration
has not commonly a definite boundary to its stroma: hence, if re-
moved by operation, one is at a loss to say whether such removal
is complete.
A carcinomatous scirrhus is to be distinguished from ordinary
scirrhus principally by the peculiar darting, lancinating pains
which, sooner or later, always appear in it; these pains are
markedly diagnostic. Again, a scirrhous carcinoma is apt to have
a hereditary history: a generation may have escaped, but it will be
discovered somewhere in the family. In this respect, my experience
leads me to infer that it is really a more persistent type of carcinoma
than encephaloma. Encephaloma is more quickly fatal, Init is less
persistent.
All local medication to a carcinomatous scirrhus is worse than use-
less. If it is not widely cut away, it is better, a hundred times, to
576 ORAL DISEASES AND SURG ERF.
do nothing at all to it. Many a tumor of this class that would
have remained dormant for years has been excited to the most de-
structive malignancy by overofficious meddling with it. If a prac-
titioner does not know the character of a tumefaction upon a tongue,
he cannot act more wisely than to do nothing at all, until, at least,
time and continued observation have made plain to him the diag-
nosis.
At a period very various as to time, a scirrhous carcinoma ulcer-
ates. If the tumor has attained any size, fungous granulations sprout
forth, giving that expression known as fungus haematodes ; if, on
the contrary, the tumor ulcerates while small, it is irregular, puck-
ered, everted in its edges or elevated, and covered with abundant
granulations: the discharge maybe thin and sanious, or purulent,
the latter character being, however, rare : it differs from the syphi-
litic sore in its granulative bottom.
A section of scirrhous carcinoma presents a stroma dense, abun-
dant, and closely meshed. A fibrous structure is always more or
less marked, particularly in its occult state, such structure assimi-
lating both the white and yellow tissues, being perhaps really these
tissues. A diagnostic sign is a peculiar creak or cry given under
the knife. Another is ^ shrinkage or contraction in the center of a
section. Still another is a creamy juice, which may often be scraped
from it.
In looking at a microscopic slice of scirrhous carcinoma, the
Fig. 104.
A microscopic view of the cancer-cells filling the interstices among the bundles of the
fibro-cellular tissue in the skin of the breast. Magnified about two hundred times.
(After Paget.)
areolae existing in the stroma are found filled with granules, nuclei,
and nucleated cells, these cells being of most diversified form, and
THE TONGVE AND ITS DISEASES.
01 i
common to no tissue: the term heteroclitic is justly applied to them
The appearance of such a section is exhibited in the eno-ravin-r"
Fig. 104. ''
" It is well known that whenever a special predisposition to al)-
normal action exists in the vital economy, a very slight thing is suf-
ficient to act as an exciting cause of disease. This is especially the
case in many affections of both an organic and dynamic character,
examples of which we have occasionally presented, among which
was the apparent development of cancer from the irritation pro-
duced by rough or decayed teeth. Additional evidence upon this
point is furnished by the following cases from the clinical report on
epithelial cancer, by Mr. Jonathan Hutchinson, in the Medical Times
and Gazette : ' George P., aged thirty-six, a dark, sallow, but health}--
looking man, was admitted, December 29, 1853, into St. Bartholo-
mew's Hospital, under the care of Mr. Stanley, for a cancerous ulcer
in the middle of the right margin of the tongue, ahout an inch in
length, half an inch in width, and half a line to a line in depth. The
base was irregular, not granular, nor distinctly nodular or warty; it
was clean and moderately florid, and while in the hospital, and being
guarded from the teeth by an ivory cover for them, it became level,
and skinned over very thinly, yet enough to prevent its bleeding
when lightly rubbed. The borders of the ulcer were upraised, with
a somewhat lobed or glandular surface. This was especially the
case with the upper border, which, occupying a portion of the dorsum
of the tongue, overhung a little the adjacent mucous membrane.
The elevated border felt firm, tense, and nearly hard ; the base of
the ulcer was equally so, and these characters were evidently de-
rived from morbid deposits at and for about two to three lines beyond
the ulcerated surface. At the border this deposit did not involve the
very surface layer of the mucous membrane, which was tensely
stretched over it, but discernible with its small vessels. The rest
of the tongue appeared to be all healthy. One lymph-gland by the
side of the facial artery was slightly enlarged, firm, but not hard.
The teeth by the side of the ulcer were not rough, but neither were
they clean, and, as already said, the ulcer became smoother and
skinned over when protected from them.
'"He said that nine months jireviously his tongue had become
sore through the " fretting" of a decayed tooth at this part. He
allowed the tooth to remain for six months, the sore extending all
the time until it had reached its present dimensions. At length,
three months ago, the tooth was drawn ; the sore remained, and he
37
578 ORAL DISEASES AND SURGERY.
was not aware of any change in its character. It was always very
painful, and the pain extended from it over the whole cheek and the
side of the head and jaw. Many of the cervical lymphatic glands
under the right side of the jaw had been enlarged, but they had
subsided two months previously ; and the one by the facial artery
had only in the last week been enlarged. His great-aunt died of
cancer of the throat (sufficiently proved) ; but no other relative was
known to have had cancer. He never had any syphilis or well-
marked struma.'
"After an ineffectual effort to remove the disease by constitutional
treatment with iodide of potassium, the part was excised, the trou-
blesome symptoms subsided, the patient recovered, and is still in
good health, — eleven years after the operation.
" ' Caroline C, aged thirty-five, a married woman, and the mother
of three children, was admitted, February, 1855, into Middlesex
Hospital, under the care of Mr. De Morgan. She was subject to
dyspepsia; but during the last few years she had been in rather
better health. She had broken teeth on the right side of her mouth,
which had irritated the tongue. Tw^o years before her admission
she noticed that her tongue was sore, and a year ago a lump began
to form in it. Mr. De Morgan removed the right side and tip of the
tongue by ligature. He made an incision in the median line beneath
the jaw, and dissected his way upward, and then, having passed the
ligature, tied it over a wooden bridge, which was fixed as a sort of
tourniquet. In ten days or a fortnight it had separated. On March
19th both the wound below the jaw and that of the tongue were
quite healed. There was then, however, suspicious hardening about
the cicatrix. The disease soon afterward returned in the stump,
and in the course of a few months the woman died.'
"'Daniel H., aged forty-six, was admitted, November 2d, 1860,
into St. Thomas's Hospital, under the care of Mr. McMurdo. He
stated that twelve months ago he experienced a soreness of his
tongue on the left side, which he imagined W'as due to irritation of
some decayed teeth. Several had been removed in consequence, but
nothing was done for the tongue. The ulcer in the latter grew more
painful, and five months ago the glands below the jaw began to en-
large. There is at present an ulcer on the left and under side of the
tongue. This half of the tongue is hardened, swollen, and very
painful ; and he speaks with great difficulty, from pain in moving
the tongue, which is also not able to be much moved, from being
swollen, and tied down bv the ulceration and induration. He suf-
THE TONGUE AND ITS DISEASES. 579
fers a great deal of pain. His health has generally been good, and
he says that, except for the local distress, he feels well. He is, how-
ever, very sallow, haggard, and emaciated.' "
Purely benign localized tumors of the sarcomatous class, as the
fibrous, the fibro-plastic, and the cartilaginous, are those with which
scirrhous carcinoma is most apt to be confounded.
As scirrhous carcinoma always begins upon the sides of the
tongue, jagged and sharp teeth irritating the parts may l)e su[)posed
to have some influence in its localization ; such teeth, under all cir-
cumstances, should be removed or smoothly dressed. I have seen
many an epithelial carcinoma so located.
In the treatment of scirrhus of the tongue by amputation, several
modes have been employed. One, that of the French school, is by
means of an instrument known as the ecraseur of Chassaignac.
This is simply a delicate chain arranged from a handle, which little
by little crushes off the part. Another mode, that of strangula-
tion, consists in the introduction of circumscribing ligatures, which,
being drawn tightly, cut off all circulation from the diseased part,
thus compelling its separation. Still another is the use of caustic
remedies ; of these there is a great variety, — arsenic, however,
forming the base of most of them. No remedies require to be used
with more judgment and caution. If the practitioner desires to try
a caustic, my own experience would suggest chloride of zinc :
R. — Zinci chl.
Alum pulv. aa gr. v;
Acid, tannic, gr. ij ;
Ferri persulph. gr. iij ;
Glycerin q. s. for a paste. M.
To apply this paste, draw the tongue forward, hold it, and dry it
carefully in a napkin. Lay some crystals of zinc on the part and
cover over with the paste. This may be allowed to remain as long
as the tongue can be kept dry. Finally, wash the debris away, an.l
the application is completed.
It may happen, after such an application, that severe general glos-
sitis will supervene; this will be unfortunate, and will imply that
much more harm than good has been done. In making a caustic
impression under such circumstances, the parts should be quickly
killed, not excited and provoked.
The knife, the best instrument, removes, as is seen in the plate,
all the parts supposed to be involved. Whether such knife be in the
580 ORAL DISEASES AND SURGERY.
form of the scalpel or scissors, it is, I think, the best instrument at
our command, at least in the present state of our knowledge of such
disease.
Injection of persulphate of iron is a means much employed and
commended. My own experience with it, however, has not led me
to look upon it as a specific.
The arrows of Maisonneuve, tipped with zinc, may be used by those
who do not fear a resulting inflammation. Two, thi'ee, or more of
such arrows may be made to circumscribe the tumor, precisely as
practiced by this surgeon in his operations upon the mammary
gland.
Benign Scirrhus. — Scirrhus of the tongue, purely fibrous or car-
tilaginous in character, is frequently met with. Such tumors appear
in the form of lobules, or isolated masses. They are painless, with
the exception of a soreness, the result of their interference with
function ; they do not tend to ulcerate, and when removed by the
knife, do not return. Section of them by the knife, and examina-
tion under the microscope, show their relationship with normal tis-
sues, and thus dissipate apprehension. These tumors, however,
belonging to the sarcomatous class, may degenerate.
Encysted Tumors. — Cystic tumors of the tongue are not unfre-
quent. That known as meliceris is round, free from pain, and filled
with a glutinous, honey-like substance. A peculiarity of this cyst
is found in the fungiform character of its bottom, this portion look-
ing pyogenic. A second order of cysts contains lymph, sometimes
colloid in consistence and appearance, at others flaky, or, it may be,
puriform.
Says Sir Benjamin Brodie. "There is a disease of the tongue
which I have seen every now and then, and which I am sure is very
often mistaken for cancer, though it is of a different nature. It is a
curable disease, although it looks like a malignant one in many re-
spects. The first thing of which the patient complains is enlarge-
ment of the tongue, with some pain. On examination, you find a
tumor in one pa^rt of it, not very well defined, nor with any distinct
margin. It is a softish tumor, and increases in size, and perhaps
another tumor appears in a different part of the tongue, and that in-
creases also. There may be three or four of these soft elastic tumors,
with no very defined margins, in various parts of the tongue. This
is the first stage of the disease.
" In the second stage there is a small formation of matter in one
of these tumors, — a little abscess, which breaks externally, discharg-
THE TONGUE AND ITS DISEASES. 5S1
ing two or three drops of pus. When the abscess has burst it does
not heal, but another forms in one of the other tumors. These al)-
scesses may assume the form of ulcers, and the ulcers have a par-
ticular appearance. In the first instance it is a very narrow streak
of ulceration, but on introducing a probe you find that the ulcer is
the external orifice to a sort of fissure- in the tongue. The probe
passes in obliquely ; the tongue is, as it were, undermined by the
ulcer, a flap of the substance of the tongue being over it.
" The disease now becomes more painful, and at last the ulcers
may spread externally. In some instances they occupy a very con-
siderable portion of the surface of the tongue, but generally they
burrow internally, and do not spread much toward the surface.
This is a very distressing state of things, and a man may remain
in this state for a long time. The glands of the neck do not Ijo-
come affected, nor does the general health suffer, except from the
difficulty of swallowing food. This is one inconvenience experienced
by the patient ; and he also labors under a difficulty of articulation.
The tongue, from its enlarged state, may become stiff, not sufficiently
pliable for the purposes of speech, and the patient either speaks thick
or lisps.
" In some instances the disease may be relieved by a course of
sarsaparilla, with small doses of bichloride of mercury. A strong
decoction of sarsaparilla, with from a quarter to half a grain of bi-
chloride of mercury, may be taken in the course of the day. Of
course, if there be anything wrong in the general health, you should
endeavor to get that corrected, and attend especially to the state of
the bo^vels and the secretion of the liver. If the secretions of the
digestive organs be unhealthy, a dose of senna and salts may be
given every other morning, and blue pill every other night. When
the patient is brought into this state, one remedy, as I have said, is
sarsaparilla with bichloride of mercury ; but, according to my experi-
ence, this is not the best remedy. The remedy best adapted for
these cases is a solution of arsenic. Give the patient five minims
three times daily, in a draught, gradually increasing the dose to ten
minims. It should be taken in full doses, so that it may begin to
produce some of its poisonous effects on the system. When it be-
gins to act as a poison, it will show itself in various ways. Some-
times there is a sense of heat, a burning pain in the rectum ; some-
times griping, purging, and sickness, and nervous tremblings. A
patient who is taking arsenic, especially in pretty large doses, ought
to be carefully watched. At first you may see him every two or
582 ORAL DISEASES AND SURGERY.
three days, and then every day ; and as soon as the arsenic begins
to operate as a poison, leave it off. "When this effect is produced,
the disease of the tongue generally gets well ; but at any rate leave
off the arsenic, and the poisoning will not go too far; it will do no
harm. If, after a time, you find that the disease is relieved, but not
entirely cured, you may try another course of arsenic. Perhaps it
may take a considerable time to get the tongue quite well. Sarsa-
parilla, with the bichloride of mercury, may be given at one time ;
and at another, arsenic. You cannot give either of these remedies
forever, and indeed the arsenic can only be given for a very limited
period ; but it is astonishing what bad tongues of this description I
have seen get well under these modes of treatment, especially under
the use of arsenic."
A form of cystic tumor, being a cystiform hypertrophy of a cir-
cumvallate papilla, is met with occasionally on the back part of the
dorsum. These tumors have attained the size of a walnut. To the
touch they are very solid, the walls being veiy much indurated. If
convinced that there is no malignant association, the practitioner
may puncture the sac and introduce a tent. Iodine may be used
both externally and by injection.
Acute Glossitis. — Acute inflammation of the tongue, whether of
idiopathic or of traumatic character, is always to be looked on with
concern. The causes inducing this condition are various.
Viewed as a distinct condition, and this view, no matter Avhat
the cause, will always force itself on the attention of the practitioner
when called to a case, the most urgent necessity will nearly always
be felt for a treatment that shall abort or resolve the phenomena as
quickly as possible. It is true that all glossal inflammations are
not dangerous ; but all inspire Avith a sense of danger.
Acute glossitis, idiopathic in form, commonly begins with a sense
of enlargement and stiffness of some part of the organ, generally the
anterior part ; this soon becomes red, painful, and perceptibly
swollen. At this stage the condition may rest, and after some
little time commence to decline. On the other hand, a single hour
may witness the extension of the inflammation to an extent which
shall threaten or perhaps produce suffocation. In still other in-
stances the advance is gradual ; the circulation sympathizing, the
pulse grows rapid and irritable, the skin becomes hot, only to de-
cline to the cold sweating stage ; and suppuration or perhaps gan-
grene terminates the action.
The dangerous character of glossitis demands the most energetic
THE TONGUE AND ITS DISEASES. 583
treatment. Leeches direct to the organ or beneath the jaw, bleeding
from the arm, catharsis, diaphoresis,— any or all of these means are
successively to be brought into requisition. A plan of treatment,
reliable as any in character, may thus be pursued: place on the
back of the neck a cataplasm of mustard and red pepper; put the
feet in water as hot as can be endured y give a full dose of sulphate
of magnesia. If now the disease does not seem to be immediately
held in check, put the patient in bed and administer spirits of Min-
dererus until full diaphoresis is secured. If even yet control is not
secured, let fifty, seventy, or a hundred American leeches, or a
third of the quantity of Swedish, be placed beneath the jaw. If
the action is still unconquered, blood pro re nata is to be taken from
the arm, and the tongue itself is to be freely incised. If yet the
swelling goes on, and suffocation be threatened, laryngotomy or
tracheotomy is made a necessity. (See these operations.)
A case presented before the North London Medical Society will
be found interesting and suggestive in this connection :
" Mr. J. Z. Laurence exhibited the tongue of a woman who had
died of acute inflammation of the organ. She had been under Mr.
Laurence's care for acute rheumatism, when, on the evening of the
5th November, he was called to her, and found her sitting up in the
bed, with a countenance expressive of the greatest anxiety, her face
pale and bedewed with sweat; she breathed at long intervals, and
laboriously; pulse 130. The cause of this was evident; she could
not open her mouth to speak, for a swelling of the left half of the
tongue, which was red, dry, and glassy. On the night of the 2d
and 3d she had had severe rigors. Mr. Laurence at once made three
free incisions into the tongue, and about half a pint of blood escaped.
About two hours after the bleeding had ceased, the submaxillary
region began to swell, twelve leeches were applied, and on the follow-
ing morning the right half of the tongue began to swell, and by the
afternoon it had attained full as great a size as the left. With this
was a corresponding engorgement of the tissues about the jaw ; the
local depletion had had very little effect in reducing the swelling of
the left side of the tongue ; generally she was worse ; rigors now
came on, and the pulse intermitted three or four beats. Mr. Quain
saw her, and proposed incising the right half of the tongue, but
both patient and friends objected. Mr. Laurence saw her the la^t
time alive the same night; her surface was deadly cold; pulse not
perceptible at the wrist, yet, strangely enough, the respiration went
on tranquilly, though feebly. Mr. Laurence at once perceive.l that
584 ORAL DISEASES AND SURGERY.
she was dying of slow asphyxia, and that her only chaace was in
tracheotomy; this was proposed with more impressive force than
a surgeon almost dare do. She and her husband doggedly refused ;
next morning she was dead.
"Autopsy. — Xo organic disease was discoverable. The whole of
the tongue was swollen, pale, and soft from maceration in a puro-
serous fluid, which infiltrated the substance. The superior aperture
of the larynx was greatly narrowed by serous effusion ; the rima
glottidis to a less extent; below this point, the whole of the trachea
was perfectly unobstructed ; the submaxillary region and anterior
triangles of the neck were infiltrated Avith a serous fluid, which,
among the suprahyoid muscles, had assumed a purulent aspect.
The lungs were singularly healthy ; the heart, kidneys, and bladder
presented no signs of disease.
" From the above facts, it follows that tracheotomy would in all
probability have saved the woman's life ; and Mr. Laurence believes
he proposed it at the proper time. It is true there was, throughout
the case, not one fit of suffocation. On the contrary, she died choked
in the most gradual conceivable manner ; and were he to meet with
another case, he would not defer the operation until the patient was
in his last gasp, as was too commonly the case, but resort to it as
soon as he saw the patient sinking, previous measures not having
ameliorated his condition. A curious pathological fact, which Mr.
Laurence noticed and pointed out to Mr. Phillips, who attended the
case with him, was the successive and separate invasion of the two
halves of the tongue by the inflammatory action, offering a remark-
able instance of the dependence of pathological changes on the ana-
tomical distribution of the blood-vessels."
Abscess. — In depraved and tainted conditions of the system, ab-
scesses, of what might be called a cold character, occasionally form
among the deeper muscles of the tongue ; such abscesses arc not
necessarily associated with any marked inflammator}'" phenomena,
but may have attention first directed toward them by the swelling
which appears on the under surface.
The proper treatment in these cases will be found in voiding the
matter through puncture as soon as fluctuation is perceived ; other-
wise it has happened that the pus has dissected its way down the
neck, pointing in front of the hjo\& bone, creating much derange-
ment, and threatening even a fatal result. Treat these cases by
local stimulating injections and the internal administration of tonic
medicines.
THE TONGUE AND ITS DISEASES.
585
The following suggestive case of abscess of the tono-ue enclino-
fatally from hemorrhage, is related by Mr. Ward, being presented
before the London Medical Societv :
"E. T , aged seven, was born with a slight red enlargement
in the center of the tongue. No inconvenience or difficulty in the
ordinary motions of the tongue, or in swallowing, had ever been ex-
perienced ; the general health had always been good. In the night
of Sept. 2Uh, 184T, having been in her usual health at bedtime, she
was attacked with pain and swelling under the chin and both sides
of the lower jaw ; slept very little, and the following morning had
pain in the tongue, with great difficulty in speaking, or swallowing
anything but liquids. She had an aperient powder at night, and the
lower jaw was fomented frequently. In this state she continued for
two or three days, and was visited by me on Oct. 1st, when the fol-
lowing appearances were noted :— Face flushed ; eyes very bright ;
countenance anxious ; great swelling, redness, and extreme tender-
ness of the parts under the lower jaw ; very slight swelling of the
tongue itself, which is covered with a thick, brown fur ; is unable to
open the mouth wide, or move the tongue beyond the teeth, or
to speak, and has great pain in the mouth ; pulse very quick and
sharp ; great heat of skin, and thirst urgent ; bowels confined.
Ordered eight leeches to be applied under the chin ; to take, at bed-
time, four grains of calomel ; James's powder and sugar, of each
three grains; a saline mixture, containing a scruple of nitrate of
potash ; one tablespoonful every three or four hours.
" Oct. 2d. Slept more last night than since first attacked ; fever
great; pain slightly relieved; swelling and redness less; mouth
I nearly closed ; was able to swallow the powder in jelly, but refuses
the mixture, of which very little has been taken ; bowels freely re-
lieved, evacuations dark and offensive ; to take calomel and James's
powder, of each three grains, and jalap, five grains, at bedtime ;
use a chloride-of-soda gai'gle, warm, to the mouth, by means of a
syringe. Fluids taken in the mouth I'eturu by the nose.
"4th. Less fever; rests better at night; difficulty in swallowing
or speaking the same; can open the mouth sufficiently to allow the
tongue to be seen, which is nearly fixed, very little swollen, and still
1 thickly coated; the breath extremely fetid; external redness and
■swelling still considerable; the tenderness great ; pulse soft, quick,
and weak; the bowels act freely; was able to pass my finger into
the mouth ; under each side of the tongue distinct fluctuation can be
•felt ; while pressing on the left side the lining membrane gave way,
586 ORAL DISEASES AND SURGERY.
and was followed by a profuse discharge of fetid pus, mixed with
blood ; the point of the finger passed easily to the depth of the first
joint, under the tongue, giving the sensation of a large pulp cavity;
the tongue not very tender, can be moved from side to side by means
of a small teaspoon, but not voluntarily. Apply strong poppy fo-
mentation frequently, and linseed poultice ; continue the chloride-of-
soda gargle under the tongue, with the syringe, and take, of a mix-
ture consisting of six grains of quinine, a teaspoonful every four
hours; give a little port wine and water frequently, and milk or thin
arrowroot for drink.
." 6th. The pain less since the use of the poppy fomentation, gen-
erally sleeping for some hours after using it; the discharge of pus
and saliva very copious and offensive ; lies with the head on the left
side to allow the free exit of the discharge, otherwise the mouth is
constantly filled ; fever less, as also the swelling and tenderness ;
redness gone ; great debility and considerable wasting of the body
already ; can swallow fluid, and is eager for the wine ; very little
quinine has been taken ; bowels act twice a day ; can open the mouth
wider, but is still unable to protrude the tongue, which is cleaner
and moister; on slightly raising it by the handle of a spoon, a large
jagged opening may be seen on the left under side of the lower jaw,
from which, by gentle pressure under the chin, a profuse discharge
of thick pus wells up, of which I pressed out at least two ounces ;
pulse soft and weak. Continue the external applications ; apply the
chloride-of-soda gargle frequently to the mouth and under the
tongue, with the syringe ; take a mixture consisting of two ounces
and a half of decoction of bark, syrup of orange-peel, and tincture
of bark, of each two drachms, a fourth part three times a day ; con-
tinue the wine, and give strong beef-tea and arrowroot frequently.
"9th. Altogether improved; discharge less, but still fetid; takes
fluid nourishment frequently, and the wine; the general swelling and
the tenderness reduced ; more on the left side under the jaw than
the right, and is unable to protrude the tongue further. Continue
all the applications and the mixture.
" 11th. Has not rested so well the last two nights, and has had
more pain, particularly on the right side, which is more swollen
and very tender, the left side being almost in its natural state ; the
discharge has been profuse, but thinner ; the tongue is moist and
clean; not very tender, but less movable; the opening under the
left side of the tongue smaller ; fever returned ; has constant hack-
ing cough ; not able to swallow so well, or to speak so as to be
THE TONGUE AND ITS DISEASES.
587
understood. Apply six leeches under right side of loAver jaw;
continue the fomentations and poultices; also, bark mixture and
port wine.
" 12th. Has slept very little from the frequent coughing, which
tires her very much; discharge from the mouth less and thinner,
but still fetid; emaciation extreme; has changed the position of
lying to the right side ; left angle of the mouth drawn down ; the
swelling and tenderness on the right side very much increased since
yesterday; feels soft; is more prominent in the center, and appears
pointing here ; the finger in the mouth can detect very distinct
fluctuation under the tongue, which is thickly coated and very
tender ; takes very little nourishment, only a tea.?poonful at a time :
prefers wine to other things. Continue the fomentations and
poultices.
" 13th. Has had a bad night ; is very irritable and feverish ;
mouth nearly closed ; unable to examine the tongue ; the swelling
about the same ; the right cheek and under side of the jaw of a
dusky red color, and very shining; so tender that she has again
changed the position ; lying on the left side ; cough less, pulse very
small and weak ; takes scarcely anything ; discharge more copious,
thicker, and slightly tinged with blood ; it now appears to come
from the right side. In the evening, while coughing, a large gush
of blood took place from the mouth, mixed with pus, and flowed
freely for more than ten minutes. By applying ice internally and
externally (which I had directed to be in readiness), the hemorrhage
was arrested. A cold lotion was applied externally, and an alum
gargle frequently to the mouth.
" 14th. Has slept very little; unable to lie down, from the con-
stant discharge of fetid pus and saliva from the mouth ; the swelling
of the right cheek and side of the jaw less ; very tender, of a dull,
yellowish color; able to open the mouth so as to examine the
tongue, which does not appear enlarged ; no power of moving it
herself; is thickly coated with a dark fur, and when pressed upon,
a profuse discharge of thick pus fills the mouth immediately ; no
return of the hemorrhage; is very pale and faint; pulse very small
and weak; has taken more nourishment since last night than
for some days before, such as port wine, isinglass in milk, beef-tea,
jelly, etc. Continue the lotion and alum-gargle to the mouth with
a syringe. At half-past seven p.m., in the act of swallowing a small
piece of bread and butter, profuse hemorrhage occurred from the
mouth, and more than a pint of blood was lost before it was again
588 ORAL DISEASES AND SURGERY.
arrested by the free application of ice ; it was of a bright arterial
color. She became faint, and expired at nine p.m.
" On the day following I made a post-mortem examination of the
parts affected. The parotid, submaxillary glands, and other parts,
having been brought into view, were found (on the right side) so
much softened, decomposed, and mixed with coagulated blood and
pus, as to be recognized with diflBculty, and it was impossible to
trace from what vessel the hemorrhage proceeded, such was the
destruction of the parts. On the left side, the glands were of a
greenish color, very much softened, and bathed in pus A probe
passed readily by the side of the jaw into the mouth. I divided
the trachea just above the sternum, and dissected the larynx and
tongue carefully out. The morbid state of the tongue is shown in
the preparation before the society."
In the discussion which ensued, the case was considered a
very remarkable one. The remarks chiefly had I'eference to the
cause of the disease, respecting which various opinions were ex-
pressed.
Effusions. — The tongue is occasionally the seat of most formida-
ble congestions or effusions. In the space of a single hour I have
known an inflamed tongue so swell as almost to prevent respira-
tion. The organ, in these cases, looks so vascular that one hesitates
to use the knife, when enlargement arrives to an extent which
threatens suffocation. I am sure I suggest the very best practice
when I say incise freely — cut deeply from behind forward, either
side of the median line, avoiding, however, in the depth of the cut,
the ranine arteries. The wounds thus made will bleed for a time
freely, indeed, alarmingly ; but the common experience is that they
soon close, and need give little or no anxiety. Yelpeau has recom-
mended the opening of the ranine veins in congestion. Leeches are
also applied direct to the tongue.
Erysipelas. — A formidable danger in the tongue is the presence
of erysipelas: this may be idiopathic, but is most frequently trau-
matic, operations about the jaws being, unfortunately, liable to pro-
voke this condition. The treatment of erysipelas in the tongue
is the history of its treatment elsewhere. Iron and quinia, inter-
nally and locally, should be freely employed. If this should not be
found effective, then make incisions. The practitioner is never to for-
get to extend his observations over functional disturbances which
may exist.
Bites of Insects. — The most severe and threatening glossitis I
THE TONGUE AND ITS DISEASES.
589
ever met with was the result of a sting of a wasp taken into the
mouth while eating blackberries. The tongue in these accidents
swells enormously, yet, happily, tends to a rapid self-cure. If seen
immediately, the very best application is dilute ammonia ; later, we
can only treat such an inflammation like any other of the sthenic
type. It is well, however, to remember ^that the swelling is from
effusion rather than a congestion ; incisions, if necessary, may always
be freely made. Iodine, in these instances, acts sometimes very hap-
pily ; paint the tongue thoroughly, and hold cold water in the
mouth. If, unfortunately, erysipelas should supervene, the iron
and quinia combination is at once to be resorted to. In these cases
the pain becomes excessive, the parts may change to a livid hue,
and there seems to be a decided tendency to gangrene; particu-
larly is this the case in depraved and broken-down persons. Free
incisions are never to be neglected: the erysipelas in these cases
depends upon the separation of the molecules — if the expression
may be used — from their base of supply; the incisions, draining the
organ, allow contraction of the parts, and thus restore the circu-
latory relationship.
In ulcers, or in tumefactions of the tongue, provoked by irritating
teeth, it is seldom necessary to do more than remove the source of
offense. Cases occur, however, where some after-treatment is de-
manded, the provoked ulcer being indolent, or, in some instances,
even semi-gangrenous. For all such ulcers, the best wash that I
have ever used is water, changed in color to a milky blue by the
addition of the compound tincture of capsicum. Where a part is
simply indurated and not ulcerated, it is better, for a time at least,
to leave the case to nature. My own rule is, never to meddle with
an induration but from necessity. In all these cases injudicious med-
dling will be found very bad practice. I recall an instance coming
under my observation a short time since, in which, while in the act
of filling a tooth, a practitioner had thrust an instrument quite deeply
into the tongue; severe inflammation was the result, the eflfoct, I
imagine, of uncleanly rust or blood-stain. On the subsidence of the
swelling, the wound, being found to discharge, was injected with
strong solutions of nitrate of silver. A week of this treatment re-
sulted in the formation of a tubercle as large as a hazel-nut ; the
injection was now ordered to be discontinued, and in two weeks the
tubercle had disappeared.
Erectile Tumors.— Of the erectile growths I have never personally
met with a case situated upon tbe tongue ; instances, however, are
590 ORAL DISEASES AND SURGERY.
reported. The history and treatment of such tumors would be pre-
cisely that of other naevi.
Fatty Tumors. — These, like the erectile, are uncommon. A case
which I once saw exhibited the tumor looking like a mass of very
smooth fat, encysted by the mucous membrane : the situation was the
inferior left surface of the organ. As the man spoke, the tumor would
bulge out over his lower teeth, presenting a most unsightly appear-
ance. The patient would not submit to an operation, and it was
with a feeling of disappointment that I afterward found myself un-
able to follow the history of the case.
Metastatic Disease. — The example herewith given explains, with-
out other remarks, a character of trouble rare, yet sometimes met with,
upon the tongue. We may recognize in the disappearance and reap-
pearance of the various exanthems an explanation of the condition.
" I have been consulted," says Mr. Wm. McClure, in a paper read
before the Harveian Society, " by a young married lady, for rather
a curious affection. She informs me that her tongue becomes occa-
sionally bestudded with small ulcerations, and afterward, when
these get well, the palm of her left hand becomes affected with a
sort of psoriasis palmaris. The tongue is at present quite well, but
the palm of her hand is covered with the eruption. When this gets
better, however, she expects her tongue to become again the seat of
disease, for thus they have alternated for a considerable time past —
she says about two years. The chief reason for which she consults
me at present, however, is that she has gout in one of her feet. I
believe that the whole series of her complaints depends on some
derangement of the digestive organs, though that is not made very
apparent by external symptoms. I gave her an alterative pill, and a
tonic mixture, combined with colchicum and an alkali. The gout has
already disappeared, and even the hand is much improved. As soon
as the gout was got rid of I substituted for the tonic mixture — in
which, as I have just said, were wine of colchicum and carbonate of
soda — a mixture composed of the extract of sarsaparilla combined
with the iodide of potassium. As a local application to her hand I
prescribed an ointment composed of pure iodine, iodide of potassium,
and hog's lard ; but this was found, upon trial, to give her so much
pain, and produced so much irritation, that I was forced to abandon
its use after a few days' trial. For it I substituted the following
ointment, viz. : white oxide of mercury four grains, and extract of
conium a drachm, rubbed up with seven drachms of prepared hog's
lard. This ointment was ordered to be rubbed into the palm of her
THE TONGUE AND ITS DISEASES. 591
hand every day, both morning and evening. Besides those reme-
dies, local and general, she took occasionally an alterative and aperi-
ent pill, made up of blue pill and the compound extract of colocynth.
The consequence has been, after a month's steady use of the reme-
dies, that the hand has become quite well, the skin being now, for
the first time these two years, soft, whitQ, flexible, smooth, and com-
pletely free from itching, heat, and every unpleasant appearance and
feeling. Jv^or has the tongue as yet shown any tendency to alternate
disease, as before ; so that we have reason to hope— the constitution
having been set to rights by the means employed— the former chain
of morbid sympathy between the distant organs of which we have
been speaking, and by which a metastasis of the psoriasis, from the
one to the other alternately, took place so often, for so long a time,
has been at last broken and destroyed, permitting both to remain in
their healthy condition."
Urticaria, a very common skin trouble, I have myself met with as
having a similar metastatic relation. In this case a wheal would
appear either upon the cheek or the tongue whenever ice-cream was
eaten.
Hypertrophy. — This condition has been met with and described
by various writers. Hypertrophy may be complete, involving the
whole organ, or the enlargement may pertain to particular tissues
alone. A case is described by Mr. Paget, involving the muscular
substances exclusively, the primitive fasciculi being found to divide
in a dichotomous manner. The epithelium is another of the tissues
most frequently found affected, instances being on record where this
structure has thickened so as to resemble a coat of mail. Granular
hypertrophy, a condition of enlargement of the papillary structure,
is sometimes seen in the form of a mass of warty excrescences cover-
ing the whole body of the tongue ; at other times it is confined to
some portions, more or less limited in extent.
The treatment of a hypertrophied tongue must be governed by the
circumstances and character of each particular case. In epithelial
hypertrophy the best results seem to have been secured through the
use of arsenic, — from the thirtieth to the twentieth of a grain being
administered three times a day, its efiect being carefully noted.
Donovan's solution, the liq. hydrarg. arson, et iod., given in five-
drop doses, has been highly commended.
In granular or papillary hypertrophy, the use of chromic acid will
be found desirable, touching the various excrescences daily with the
crystals. Another excellent application is the solution of the per-
I
592 ORAL DISEASES AND SURGERY.
chloride of iron. Cvitting the warts away in mass, by the use of a
pair of scissors, may be practiced where the parts are not too vascu-
lar. Pyroligneous acid is another favorite means of cure.
In a true hypertrophy of the organ — that is, where the body has
enlarged, as a result of congenital impressions — medicinal appliances
are of little service. This disease is markedly one of young life,
commencing generally very soon after birth, and progressing tardily
but surely until death or an operation gives relief. Unaccountable
though it may seem, hypertrophy is confined almost exclusively to
female children, — this sex being affected in the proportion of five to
one.
As may be inferred, hypertrophy of the tongue .presents various
degrees of enlargement, — cases being on record where the organ has
hung from the mouth, resting upon the breast. In the cases of ele-
phantiasis, the raucous membrane looks more like the bark of a tree
than anything else, being rough, dry, and crusted.
In the treatment of hypertrophy, we consider the character of the
trouble from the twofold aspect of activity and chronicity. Where
the first of these characters exists, much may be hoped for from medi-
cation ; where the latter obtains, little may be expected except from
operation.
Compression, as recommended by Lasser and indorsed by Prof
Syme, it may not be amiss to try before proceeding to excision ; but
the treatment will certainly be found to have much more of failure
than of success in it.
Excision of the Tongue. — From surgical necessit}^, or from
accident, it sometimes becomes necessary to amputate a part or
even the whole of the tongue. Surprising as it may seem, such
amputations, even when of the complete organ, interfere very
little with the speech, and do not entirely obliterate the sense of
taste. Mr. Xunnely, an English surgeon, lately exhibited to the
Pathological Society of London a patient from whom he had re-
moved the whole of the organ ; this being effected by a submental
opening ; the patient, a man aged thirty-five, never having a bad
symptom. The disease, which had existed sixteen or eighteen
months, became worse two months before the operation, and from
the pain and difficulty of speaking, the impossibility of mastication,
and difficulty of deglutition, was fast wearing the patient out. When
shown to the society, the patient had recovered strength and flesh ;
Indeed, said that he felt as well as ever ; he talked with great dis-
tinctness, and swallowed with facility.
THE TONGUE AND ITS DISEASES.
593
A second interesting case is reported by James Syme, F.R.S.E
Surgeon-in-Ordinary to the Queen in Scotland, and Professor of
Clinical Surgery in the University of Edinburgh :
"About twelve months ago," says Mr. Syme, "I communicated
a case in which the tongue had been completely removed by exci-
sion, on account of extensive disease that threatened to prove fatal
by preventing the admission of nourishment. This account was
necessarily limited to the operation and its immediate effects, as
sufficient time had not elapsed for determining whether or not the
relief afforded would prove permanent, or how far the powers of
deglutition, articulation, and taste would be restored. After his
return home to Manchester, the patient sent me favorable reports of
his progress, but certainly not such as to convey any adequate idea
of the improvement that had taken place since he came under my
care. He was then emaciated and bent down by long-continued
suffering, unable to articulate, so as to require a slate and pencil for
expressing his wishes, and swallowing even fluids with such ex-
treme difficulty as to feel on the point of starvation. My surprise
may, therefore, be imagined when, on the 10th of September last, he
unexpectedly made his appearance, erect and vigorous, and, seeing
that I did not recognize him, announcing his name in a loud, clear
voice. The feeling thus excited was not lessened by learning that,
while traveling in the Highlands, he had dined at table-d'hotes, and
entered into conversation without betraying the deficiency under
which he labored. Very much astonished by a result so much better
than could have been anticipated, I requested a number of my medi-
cal friends to join me in examining the state of matters. Professor
Goodsir and Mr. Nasmyth having satisfied themselves that no
vestige of the tongue remained, various observations were made
with regard to articulation and other functions of the absent organ ;
and Mr. Annandale afterward instituted a more particular inquiry,
of which he has given me the following report:
" ' The lips and jaw-bone, where divided, were soundly united
without any deformity. The opening between the mouth and
pharynx was much diminished in size and irregular in shape from
contraction of the fauces and soft palate, which were drawn downward
and forward more to the right than the left side, from the mucous
membrane at that part having participated in the disease and been
removed along with the tongue. Mr. W says that he can
swallow as well as ever, provided that the food is either finely
divided or fluid. He is also able to masticate solid substances,
38
594 ORAL DISEASES AND SURGERY.
although difficulty is sometimes experienced from their getting into
awkward parts of the mouth. In ordinary speech his words are
wonderfully clear and distinct, and he can sing without any diffi-
culty. All the vowels and words composed of them are articulated
perfectly, and also the following consonants : B, C, F, H, K, L, M,
N, P, q' R, Y, W. D is pronounced "dthe," J "the," G like " sjee,"
"S" is a lisp. His taste is impaired, but still enables him to dis-
tinguish different articles and their respective qualities, as grouse
from partridge, bitters from sweets, good beer from bad beer, etc.
He has remarked that the seat of sensation lies somewhere in the
throat, since there is no recognition of taste previous to the act of
swallowing ; and, in order to ascertain the truth on this point more
precisely, the following experiments were made :
" ' 1. A strong solution of salt was applied by means of a camel's-
hair brush to the fauces, palate, floor of the mouth, lips, and inner
surface of the cheek, with the result of something being felt in the
mouth ; but no idea formed as to its nature.
" '2. About a quarter of a teaspoonful of finely-powdered sugar
was placed on the floor of the mouth, and, having been allowed to
remain there a few seconds, was then brought thoroughly into con-
tact with every part of the cavity without any recognition of its
nature ; but when a little water was added and swallowed, the taste
was immediately perceived.
" ' 3. The same experiment was repeated with another substance
(salt), and with the same result.'
" It has long been known that large portions of the tongue may
be removed without destroying or materially impairing the power
of articulation ; but I am not aware of any case on record in which
it has remained so perfect after complete removal of the organ. Of
the facts above mentioned, the one that seems most curious is the
connection between taste and deglutition; from which it appears
that the latter is essential for the full perception of the former. If
the pleasure of taste could be perfectly gratified by mastication
without deglutition, there would be no limit to the consumption of
food; but the instinctive desire to swallow an agreeable morsel
affords a check to any such abuse."
Mr. Paget reports the following case :
" On the 20th of February a little girl, about three years of age,
was brought into the operating theater of St. Bartholomew's Hos-
pital with hypertrophy and prolapsus of the tongue, which com-
menced when she was some six months old. It now protruded
THE TONGUE AND ITS DISEASES. 595
nearly two inches, and hung- downward, completely filling the circle
of the lips ; its end was dry, and excoriated with hardened epi-
thelium, a sort of crust having formed of the size of a shilling;
several of the papillae also were enlarged, and in places gave to the
tongue a warty or granular appearance. The lower jaw had already
begun to be deformed, and expanded downward and outward ; the
teeth were gi-adually separating from one another in the mental por-
tion of the jaw ; and there was dripping of saliva. An examination
of the tongue by Mr. Paget showed that the organ was truly hyper-
trophied, and the part not prolapsed completely filled the cavity of
the mouth.
" Chloroform was carefully given to the child, and the chain of an
ecraseur was passed around the tongue within the mouth, the jaws
being kept open by a metal gag. The chain was slowly drawn
home, and the prolapsed and hypertrophied portion was detached
with little or no bleeding.
" On examination of the piece removed, its structure was found to
be similar to that of the natural organ, both in texture and color; it
was simply a redundancy of growth, from hypertrophy.
" The subsequent progress of the case was reported as most satis-
factory, a good recovery being recorded."
Partial amputations of the tongue have been very frequent. Union,
in many of the cases, is very rapid and perfect. In one case, that of
a child, where a kind of a flap operation was made, I got reliable
union in a single day, and never had trouble with it afterward.
Subfig. 1, in plate, is a front view of the anatomical relations of
the parts about the fauces as shown with the mouth widely open. 1,
the dorsum of the tongue; 2, 3, the tonsils; 4, the uvula; 5, the
anterior half arch; 6, the posterior half arch, with the tonsil between
it and 5 ; 7, the soft palate.
Subfig. 2 represents a side view of a vertical section of the mouth
and tongue, showing the relations of the vessels and nerves of the
tongue. 1, the lingual artery; 2, its sublingual branch, — the veins
accompanying the arteries; 3, the hypoglossal nerve; 4, the ranine
terminations of the lingual vessels.
Subfig. 3 represents the situation and associations of a disease
compelling amputation of a section of the tongue. The lines, 1, 2,
3, form a Y, which is to circumscribe the groAvth; it should, how-
ever, have been placed much farther back.
Subfig. 4 exhibits the operation of excising the tongue, as prac-
ticed with scissors. When the knife is used, the sections are similarly
596 ORAL DISEASES AND SURGERY.
made. If, in such an operation, the hemorrhage is threatening, it is
better to quickly ligate the vessels of one side before making the
section of the other ; this suggestion, however, only holds good when
the bleeding orifices are freely exposed, and can be reached without
effort or difficulty.
Subfig. 5 shows the preceding operation completed, and the flaps
united by ligatures. 1, 2, represents the sutures, — wire pins or waxed
silk may be used. Let them be left in only long enough to secure
the union; this, if no undue inflammation supervenes, will be ac-
complished in from twenty-four to forty-eight hours.
Subfig. 6 is the lingua vitula, or lingual hypertrophy. The par-
ticular case here represented was a patient of Dr. Harris, of Phila-
delphia, and was the first operation performed in the United States.
The case is thus described by Prof. Smith in his System of Surgery.
"The patient, aged nineteen, had the tongue enlarged at birth. A
short time previous to the operation it projected beyond the upper
incisors at least three inches. Its circumference was six inches, and
its vertical thickness one inch and a half; it filled up the jaws so
completely that it was necessary to have his food cut into small
pieces and introduced at the side of the tongue."
The operation practiced by Dr. Harris was accomplished as fol-
lows: "The tongue being elevated, a strong ligature was passed
through its top so as to control its movements. The under surface
was then dissected from the floor of the mouth about three-fourths
of an inch behind the anterior part of the jaw, and a strong, straight
bistoury introduced into the organ at a point where the dissection
terminated, whence it was pushed through between the median line
and the left ranine artery, and, being drawn laterally and forward,
was made to cut a flap, which terminated near the first bicuspid
tooth. The left ranine artery being then secured with a ligature, the
bistoury was again introduced in a corresponding position on the
right side, and the opposite, or right flap, made in a similar manner.
The artery of this side being now secured, and the space interven-
ing, or central portion, divided by strong scissors, the incisions or
flaps resembled the letter V, and, being approximated by these in-
terrupted sutures, made a pointed, well-formed tongue of the ordi-
nary length. A year subsequently, the patient articulated distinctly,
and was relieved of all deformity."
In another case, somewhat similar to this, under the care of the
same surgeon, a ligature was applied to the enlarged portion, in
order to cause it to slough oS"; but the irritation. Professor Smith in-
THE TONGUE AND ITS DISEASES. 597
forms us, was so great that Dr. Harris found himself subsequently
compelled to amputate the end of the tongue with a catlin. In this
patient the organ protruded four inches ; its circumference was over
six inches, and its vertical thickness nearly two inches.
The subfigures 1 and 8 represent the "amputation of the ton.«il
gland with the knife, and with the tonsiflotome. (See Tonsil Gland.'^.)
ToNGUE-TiE.— The condition denominated tongue-tie is frequently
met with in young children, and, indeed, occasionally in the adult.
Tongue-tie is simply a shortening or curtailment of the anterior
mucous fraenum. A tongue that cannot be projected beyond the
teeth is tied, and a tongue so tied cannot perform its various offices
comfortably and naturally. In examining the mouth of a child thus
afflicted, the tip of the tongue will not unfrequently be found drawn
down and fixed to the floor of the mouth, incapable, indeed, of anv
movement. These, however, are extreme cases, the usual condition
being simply curtailment of natural motion.
Tongue-tie is of two kinds, adventitious and congenital. Of the
first, that arising from ulceration is the most common. A person
having a bad ulcer under the tongue, particularly if on the side of
the fraenum, is almost sure to have this fold shortened as the result
of cicatrization.
A second form is one described by Professor Dewees, exceedingly
rare, I imagine, but worthy of note.
"Very frequently," says Professor Dewees, "there is attached to
the fri"enum of the tongues of new-born children a nearly transpa-
rent, whitish membrane, Avhich pursues the natural frsEnum through
its whole course, continues beyond the point where the frajnum stops,
and terminates near the extremity of the tongue itself; so that the
tongue is tied down, as it were, to its proper bed.
" In consequence of this disposition of the frgenum, the cliild can-
not elevate the tongue or protrude it beyond the lips ; and in its
attempts to suck, it cannot apply it with sufficient force or cer-
tainty to the nipple to make a complete exhaustion ; therefore it
can suck but imperfectly; and this is accompanied by a clucking
kind of noise. Whenever this is observed, the mouth should be ex-
amined, and it will almost always be found in the situation just
described ; but not necessarily, as there may be clucking without
this membrane ; but this membrane, we believe, is never without
the clucking.
" This membrane is easily discovered by provoking the child to
cry, or by elevating the point of the tongue by the extremity of the
698 ORAL DISEASES AND SURGERY.
little finger. In making the attempt to raise the tongue, the child
is almost sure to cry ; and then this membrane is readily discovered,
as it is now fully upon the stretch.
" This defect is easily remedied. It should be done in the follow-
ing manner : let the child be laid across the lap of the nurse, with
its face toward a proper light, and the operator stand behind the
head, so that he does not intercept the light. The chin of the child
must be gently depressed by the forefinger of the nurse. When the
chin is thus depressed, the little finger of the left hand of the
operator must be insinuated between the side of the tongue, near its
tip, and the inner corresponding portion of the jaw, until it can lift
up the point of the tongue ; which being done, the membrane is im-
mediately brought into view, and upon the stretch ; or, should the
child now begin to cry, as it almost always does, the operator can
easily place his finger under the tongue, and keep this false fraenum
tense, while, by a single stroke directly across it by a sharp gum
lancet, he divides it to the true fraenum: the operation is then fin-
ished. We have never known it necessary to repeat this operation.
The incision through the membrane never yields more than a small
drop of blood ; no hemorrhage can ensue, as this tissue is but very
slightly vascular."
A third of the adventitious forms is the result of the induration
of the fraenum. This is occasionally venereal in character, but more
frequently carcinomatous. In these cases the band gradually thick-
ens until the motion of the tongue is markedly impaired. The can-
cerous is distinguished in its incipiency from the venereal disease
by the greater pain associated with the movements of the parts : in
the first, the pain is acute and sharp ; in the second, it is soreness
rather than pain. If the induration is malignant, the parts may be
excised, but a hope of cure is very slight ; if venereal, we pursue
the specific treatment conjoined with such general and local combi-
nations as may seem demanded by the particular case. Donovan's
solution, given in five-drop doses, is quite reliable ; the practitioner
is to avoid overirritation to the fraenum.
Congenital tongue-tie is quickly appreciated by lifting the tip of
the organ. These cases differ very much, the fraenum, at times,
being observed to run as in the normal course, except that it is
much shortened. In other instances the fold passes forward almost
to the apex. This fold may be free or tight. If the former, it forms a
septum between the lateral aspects of the floor of the mouth, but is
THE TONGUE AND ITS DISEASES. 599
not otherwise inconvenient; if the latter, it ties the tongue more or
Jess closely.
The relief of a congenital tie consists in nicking or cutting the
contracted franum. This operation, although of the simplest nature
requn-es to be performed with some care. A frseuum too freely cut
will permit of the tongue being pulled quite far back into the fauces •
cases being on record where suffocation has nearly resulted from'
such accidents. Again, it is not to be forgotten that the ranine
vessels inosculate just in front of the frsenum on the under surface
of the tongue, and might very easily be divided in an operation,
many children having lost their lives from such an accident.
A proper operation consists in making a simple nick midway Ijc-
tween the tongue and the floor of the mouth : a rupture of the'part
thus secured, the motions of the tongue will quickly secure all the
latitude required. Should an operation, unfortunately, open a ves-
sel, the best practice would be to secure it with a ligature : this,
unfortunately, is not always easy to be accomplished, the artery
retracting within its loose sheath. A mode devised by M. Petit to
control such a hemorrhage consists in taking a piece of ivory, cut
fork-shape — the prongs, of which there are two, passing on either
side of the fraenum, the short handle resting against the inside of
the jaw. To apply this instrument, introduce against the bleed-
ing vessel a tuft of lint saturated with alum-water, or other astrin-
gent ; place now the fork about it, and secure it in place by pressing
it down with the tongue, over and around Avhich, and the jaw, a
roller is to be thrown.
Swallowing the tongue, as it is called, is a disagreeable accident,
and may occur without section of the fraenum. Dr. Dewees men-
tions one case in which a child became choked several times a
day from such a recession. It was always, however, relieved by
the nurse, w^ho would press the organ down with the handle of a
spoon and then draw it forward. A second case, reported by Pro-
fessor Gross, resulted in the death of the child at eighteen months.
To operate for tongue-tie, it is best to place the body of an infant
upon the lap of the nurse, the head being received upon or between
the knees of the surgeon ; the tip of the tongue is now raised, and
the cut, or nick, made with a pair of curved scissors.
CHAPTER XXXV III.
THE APHTHiE.
Aphtha is a term which every reader must have remarked to be
associated (like the word epulis) with some degree of confusion.
In the Greek, from which the term is derived, there are two
verbs with the same spelling — a--io. The meaning of the one is
"to set on fire;" that of the other, "to bind to" or "to fasten
upon."
The mouth presents ulcers or sores of various signification, —
some which are characterized by pain of a burning, inflammatory
character; others, chronic, or cold in nature, furnish an inviting
soil to a very persistent and almost omnipresent parasite — the
oidium, — this fungus fastening upon and binding such sores in its
necklace-like embrace. It has thus very naturally occurred that
pathologists, seeking an expressive term by which to designate
these varying conditions, differently employed the common name as
it happened to them to observe or adopt the one or the other of the
roots from which the expressions were derived. That such uses of
the dissimilar verbs on the part of various authors must have been
made, is necessary to be inferred to explain the differences which
characterize their descriptions.
With such examples of libert}', intentional or unintentional, I
may be excused in presenting to my readers the subject after my
own manner and views
For the reasons of the double derivation, and for others which I
shall proceed to present, the term aphthfe cannot, injustice and patho-
logical signification, be applied to a particular species of sore, but
must, as a noun of multitude, apply to a class — which class has
many species. Thus we may accept as explained and dismissed the
various questions of ulceration and non-ulceration, exudation or non-
exudation, the oidium or no fungi.
The type of aphthae is as follows : An aphtha or aphthous patch
is a degenerate sore, to be seen, under varying circumstances, upon
the mucous surface of the mouth, the fauces, the oesophagus, and,
(600)
THE APHTHA. gQj
quite likely, upon any part of the alimentary canal, and perhaps as
well the respiratory tract. The most common seat of this patch is the
uvula ; next to this the lower lip ; next the tongue. The sore varies
in size, from the smallest point to a confluent mass which may
cover a large surface ; looks pasty or exudative, is generally ob-
long in shape, and varies in color from the misty white of hoar-
frost to the dirty-yellow of scrofulous pus. As most frequently
seen, such a patch is one of perhaps several similar sores.
This, as described, is the type case. From it we are prepared to
pass to the general view of the subject.
An aphtha is a canker ; nothing more, nothing less. Thrush, fol-
lieular inflammation, cancrum oris, gangrsena oris, are all species of a
cancroid class, of the class aphthse.
What, then, is aphthse ?
The modern microscopist exhibits and describes aphthse as patches
of a fungoid excrescence — the oidium albicans. A pot of paste, a
papered wall, a section of apple or other fruit, the leather back of a
book or chair, exposed to a confined atmosphere, hot and moist,
quickly enough produces, or rather gives attachment to, the oidium.
Oidium albicans is not a disease, is not aphtha ; neither is it the
expression of disease. It is merely a fungous growth, accidentally
associated with a soil and circumstances favorable to it as a
habitat.*
Aphthae is, without doubt, the expression of a cachexia, and is
* Parasitic fungi (Hogg on the Microscope), vegetable blights as they are
commonly called, have of late years become objects of earnest attention, on
account of the enormous damage done to our growing crops, and also of the
many curious facts in their historj'- which have been brought to light.
Oidium is a common mildew.
It appears that at particular periods of the year the atmosphere is, so to
speak, more fully charged with the various spores of fungi than it is at others.
In 1854, the Eev. Lord Godolphin Osborne, during the cholera visitation,
exposed prepared slips of glass over cesspools, gully-holes, etc. near the dwell-
ings of those where the disease appeared, and caught what he termed
aerozoa, — chiefly minute spores and germs of fungi.
From this same year (1854) to the present time, we have amused ourselves
by catching these floating atoms, and, so far as we can judge, they are found
everywhere, and in and on every conceivable thing, if we only look closely
enough for them. Even the open mouth is an excellent trap. Of this there
is ample evidence, since we find on the delicate membrane lining the mouth
of the sucking, crying infant, and on the diphtheritic sore-throat of the adult,
the destructive plant oidium albicans.
602 ORAL DISEASES AND SURGERY.
not likely to be a merely local disease. Neither, I conceive, is it
possible for the fungus to be peculiar to a sore, as a something
specific, any more than it is peculiar to the paste, the fruit, or the book.
It depends in the one instance, as in the other, upon an accidental
association. This accident, in the case of the sore, is the absence of
a sufficient vitality to enable a part to resist the "fastening upon
itself" of ever-present parasites. The microscopist, if I may be
allowed to suggest it, has, in his examinations and conclusions,
accepted the accident and overlooked the true disease.
Thrush or miiguet, one of the species, is an erythematic inflamma-
tion, degenerating after a few days into a condition of curdy exuda-
tion. The inflamed surface, after a longer or shorter time, presents
small whitish points ; these coalesce, forming the exudate patches.
These patches vary in color ; as they remain moist and clear, they
are considered with least apprehension ; as they grow dry and
brown, they are esteemed possessed of dangerous import.
Dissections of the cadaver have exhibited aphthae not only upon
the oesophageal mucous membrane, but also on other parts of the
alimentary canal. They have not as yet, so far as I am aware, been
met with upon the respiratory tract ; but there is no good reason
why they should not have here a like existence.
In an acute attack of thrush the mouth is hot and the general
condition feverish. Milder cases, or those of easy progress, seem —
so far as any observable constitutional sympathy is concerned — to
have alone a local signification.
But, if thrush is a distinct disease, could it be possessed of a dou-
ble signification ? Could it at one time be strictly local, at another
systemic ? Thrush is common to children prematurely born or
nursed by unhealthy women. It belongs to hot, moist climates, to
the situations of uncleanly hospitals ; in fact, to any and every con-
dition deemed to be depressive of the life-force ; it is, in short, a sys-
temic adynamic expression, seated on a mucous surface. That it
differs from carbuncle or cancrum oris is not the case in fact, but
only in degree ; it is, in other words, one expression of a common
condition, — a species, and not a class.
Follicular inflammation — another form of stomatitis very likely
to be asthenic — is a term used to signify that the abnormal vascu-
lar change is seated in the mucous crypts or follicles. In passing
the finger over a surface so inflamed, the studded irregularity pro-
duced by the engorgement of the glands is plainly evident. As
such inflammation progresses, the bodies become recognized by the
THE APHTHA. g^^
eye as papular eminences standing out from a common erythematic
surface. In color they are of a varying red, such variations in shade
expressing the constitutional conditions.
Follicular inflammation terminates either bv resolution or ulcera-
tion ; when in the latter way, the follicles soften in the center, sup-
purate, and have the bottom filled with a whitish, pasty mass ; when
in this condition, they are the aphthiB of M. Billard.
Follicular inflammation appears most frequently in the infont
during the dentitional period,— an explanation existing in a quickly
and easily recognized combination of a predisposition and an exci-
tant. In its most simple form,_that is, where there is no marked
dyscrasis, or where the excitant is not of sufficient intensity to irri-
tate to any extent,— the lancing of the gums, or the application of
cooling local remedies, may be sufficient to combat or control the
manifestations. Where, on the other hand, the conditions predi.s-
posing to the disease exist in a state of balance, as it were, with the
natural resistive forces, the addition of a second depressant influ-
ence, as that resulting from the irritation of dental development,
may very well be understood as giving the mastery to an agent or
condition otherwise controlled or held fully in check. Thus we
explain to ourselves the real and apparent connection of dental irri-
tation with the aphthas.
From a simple form, or the inflammation of isolated follicles, the
condition, in some ill states of the general system, becomes conflu-
ent, such extreme form being most frequently noticed in the typhoid
exanthems, or in destructive organic diseases. In confluent follicu-
lar inflammation, a prognosis can only be justly made when every
associate and collateral influence has been appreciated. The condi-
tion will nearly always be found an occasion for anxiety.
Caucrum oris, a species of stomatitis, generally accorded a special
classification, differs in no wise from that just considered, except in
being more localized, as if the force of the influence had concentrated
rather than diffused itself.
The complaint known as cancrum oris is an asthenic, spreading
ulcer. In appearance this ulcer differs from what has been given
the special definition of aphthae by most writers, only in being more
depraved and threatening. It has the same pasty bottom of vary-
ing shades of white, the same association of pain, the same variation
in persistence. Like other aphthas, cancrum oris seems to be, and is,
associated with dyscrasis, appearing most commonly in the infants
of ill-conditioned charities, in the ill housed and poorly fed,— having,
604 ORAL DISEASES AND SURGERY.
in all systemic associations, the precise history of the species alluded
to as thrush and glandular inflammation.
This form of stomatitis, although confined to no exact locality, is
yet most commonly met with on the checks or gums. It may com-
mence with a phagedenic impression, and very quickly destroy the
patient ; or a slight vesicle or pustule may fir.st appear, to be fol-
lowed bv varying inflammatory associations, precisely as if some
local poison was the source of the trouble.
The history of cancrum oris difi'ers from that of other cancroid
affections alone in degree. This is fully proven in the facts that it is
associated with the same causes ; that any ordinary canker sore is
capable of taking on an ulcerative action ; that the fungus oidium is
quite as common to the seat of this as the other affections. In fact,
every analogy will demonstrate that the relation is like that which
associates the phagedenic with the simple venereal sore, being the
difference of degree and not cause or character.
Gangragna oris, sloughing phagedsena, is another degree or species
of the common class. It may commence as an acute inflammation,
quickly deteriorating, as a species of fatty degeneration of the epi-
thelial tissue, as a submucous effusion, or as an eschar which falls
from its relations with a rapidity which leaves us at a loss for an
explanation, except on the inference that the materies morbi have had
the most special concentration. The eschar, formed sooner or later,
is ashy in color, or a deadish brown, while the still living parts,
particularly the external cheek, if this part should be the seat of the
ulcer, has an erysipelatous blush, — white, semi-livid, and threaten-
ing in appearance.
Gangrsena oris is markedly a disease of the dentitional period,
occurring in ill-fed, ill-clothed, or ill-housed children, between the
first and second dentitions. Most conspicuous is the constitutional
nature of this affection. It is, it seems to me, a general febrile or
inflammatory disturbance, concentrating its greatest force upon some
part of the oral cavity, invited or directed, without doubt, by the
irritability therein existing, — proof of which inference lies in the
fact that in nearly every case we find inflammatory complications,
such associated inflammations being most frequently found in the
lung-tissue. I take it for granted that the oral concentration saves
some other more important part.
Gangrgena oris, where it does not too quickly kill and separate
its eschar, affords support to parasitic fungi ; the oidium albicans, as
in the other forms of aphthae, being that most frequently met with.
THE APHTHA. ^^^
Oral gangrene varies, as would be inferred, in degree ; thus, com-
mencing as a single canker sore, or epith(!lial degeneration, and
terminating with no very serious result, it might be described as
the follicular, or other of the simple species. Concentrated, or in
its malignant form, it destroys life without affording the physician
any extended chance to combat with it. In healthy children gan-
grene is very uncommon, the ordinary canker being generally the
worst manifestation. In children exhausted under the exanthems,
in those maltreated with mercury, or laboring under a syphilitic de-
generation, the marked or destructive type is exhibited.
The decomposition of mucus, or the debris remaining from the
food, when lodged upon an aphthous sore, forms the best nidus for
the development of fungi — it is, as it were, a soil — and it is unde-
niable that epithelial scales in varying states of abnormal degenera-
tion, inspissated mucus, and particles of decomposed food arc
common to all such sores. Thus, in sickly children, the fungoid
association is most common from the fact of the weakened energy
of the parts afflicted ; this, favoring decomposition and the reten-
tion of the debris in the cavity of the mouth, and consequently pro-
ducing the required soil or habitat of the oidium, as alluded to.
In foundling hospitals, where the sucking-bottle is used, the spores
of fungus find an easy passage to the mouth, being in this way
located and developed. In the nursing infant of an uncleanly
mother, the accumulation and retention of the milk will, with
favoring atmospheric influences, quickly develop fungi. It is the
fungus and not aphthae that is contagious, as must be plainly seen ;
hence one can but wonder at the disputes of Guersant, Billard,
Yalleix, Duges, and others.
Review. — Having thus expressed my own views of aphthae, com-
mitting myself to the admission that I fail to distinguish it as any
special disease, I may, with perhaps a greater justice to the sub-
ject, present the opinions of others whose extended observations
and judgment have long held them in the light and i)osition of
authority. Trousseau and Delpech both describe the aphthte as being
sores with the raateries morbi deposited beneath the ei)ithelium.
Bamberger {Krankheiten der Mund und Mundlwle : see Virchow,
Archives) controverts these views, and explains the presence of the
soormasse by the fact that it has insinuated itself between, among,
and below the epithelial particles.
If we take, says Professor Bamberger, the soormasse, and place
it under the microscope, we find it made up almost exclusively of
606 ORAL DISEASES AXD SURGERY.
epithelial scales, old and young, the debris of the food, and of in-
spissated mucus, which last is probably only a condition of epithe-
lial formation. The color of the mass is not to be hastily judged,
as this might have been influenced by the debris of the mouth.
"Upon these sores, however, very quickly appear a peculiar
organization, which consists of round and oval spores which stick
to each other, and in this way form a more or less ramifying series
of threads. The longer the sore continues, the more marked is its
penetration by these threads or spores. This new organization, or
fungus, can never, however, originate or be generated by the oi'gan-
ism itself, but is always the result of germs coming from outside
sources. It is not peculiar to a particular sore, though it occurs most
frequently on those of a certain order. Besides the two constituent
parts, epithelial scales and fungus, there appears sometimes a third
constituent, in the form of granules or granulated matter.
"From this," continues Professor Bamberger, "we see that aphthae
cannot be counted among the products of inflammational and exuda-
tional processes, as so frequently considered ; the microscope has
failed to discover an exudational appearance; also, there is wanting
the anatomical and clinical appearances of inflammation. True, it
may be that it is found in association with a catarrh, but this is an
accident, just as one may not say that the diarrhoea so frequently
found in connection with the sore in the infant is the cause of the
sore, as he might not say that the sore is the cause of the diarrhoea.
There is, in aphthae, no ulceration, the soormasse being capable of
being peeled from the surface."
Professor Dewees thus refers to the aphthae as exhibited in the
infant :
"This complaint is generally called the baby's sore-mouth: it
consists of a greater or less number of white vesicles on the inside
of the mouth. It very generally begins on the inner part of the
lower lip, or corners of the mouth, and much resembles a small
coagulum of milk. Prom this point it sometimes spreads itself
very rapidly over the inside of the cheeks, tongue, and gums ; and,
at others, it will appear in the same form, and at the same time, on
several portions of the mouth ; as inner portions of the cheeks, etc.
The French, especially M. Billard, make it a different disease from
what they term 'muguet.' But, from a careful examination of the
two diseases, I believe them to be the same, differing only in in-
tensity. I think we have not the disease which he terms ' muguet,'
or I do not understand his description : as far as I have been able
THE APHTHA. g^^
to compare them, they are identical. The difference may consist in
the modification which a hospital may give it; if there be a dif-
ference, I think it must be owing to this cause. When this efflores-
cence is extensive, the child slavers very much, and is frequently
embarrassed in its sucking; it cries, and evidently betrays that it
is in pain; it is very restless and very thirsty, as it evinces by its
frequent stirrings, and its disposition to be continued at the breast
The eruption in its mildest form is very white, and looks as if a
stratum of milky coagulum were spread over the mouth. It some-
times confines itself to the center of the cheeks, at others to the
lower lip, or one side of the tongue. In its severer forms the ap-
pearance of the eruption is of a dark-brownish color or extremely
red, owing, most probably, to minute portions of blood ; but both
are evidently grades of the same affection, changed either by mis-
management, constitution, or the force of the remote cause.
"This affection is thought to be altogether of a symptomatic
kind— or very rarely idiopathic. It is almost uniformly preceded
by a deranged condition of the stomach and alimentary canal, and
always, we believe, by some disturbances of the stomach itself. The
brain always shows signs of participating in this complaint, as there
is almost always an unusual inclination to sleep, though the child is
frequently disturbed in its nap by some internal irritation, perhaps
of the bowels themselves. This disposition to sleep is so well known
to nurses that they will frequently tell you ' the child is sleeping for
a sore-mouth.' The bowels are often teased by watery, acrid .stools,
of a greenish color ; their discharge is frequently attended with the
eruption of much wind, and, to judge from the noise, it would be
supposed there was a very large discharge of feces, though, upon
examination, it is found to be very sparing.
" The alvine discharges are frequently very acrid, so much so,
sometimes, as to excoriate the verge of the anus and nates very
severely; especially when due attention is not paid to cleanliness
or to the frequent changing of the diapers. But this never takes
place until the disease is pretty well advanced, and has made some
progress; it is generally pretty well spread over the mouth, and
always shows a violent disease. The stomach is also sometimes
much deranged ; vomiting the milk very soon after it is received
into the stomach, in the form of a dense curd, mixed Avith a porra-
ceous mucous substance. If the milk be not voided by vomiting,
the stomach constantly discharges, by eructations, a gas with a
very sour smell. The child, when the disease is severe, soon be-
608 ORAL DISEASES AND SURGERY.
comes debilitated, and rapidly emaciates ; it is almost constantly
harassed by severe colics and profuse diarrhoea; its stomach will
scarcely retain the little it can swallow ; and the oesophagus some-
times becomes so loaded with aphthae that it can no longer transmit
the small quantity which is reluctantly admitted into the mouth ;
and the child dies, either from the exhaustion consequent upon the
profuseness of the discharges from its bowels, or from inanition.
" It is a popular belief that this aphthous efflorescence passes from
the mouth through the whole tract of the alimentary canal to the
very termination of the rectum ; and the excoriation at this part is
offered as evidence of the fact. Whether this be true or not we do
not know, for we are not in possession of any facts from dissection
which decide the point. We once examined a body which certainly
died from aphthae, the examination of which would by no means tend
to confirm this common belief A child, on the tenth day after birth,
was observed to have a number of white spots upon several different
portions of its mouth, which rapidly spread over its whole surface.
It had the usual premonitory and accompanying symptoms, which
increased daily in severity, in spite of every effort to oppose them.
It was a feeble, weakly child, of a consumptive, feeble mother. Its
sufferings were very great, though under some control from lauda-
num, so long as it could be taken by the mouth, or retained by in-
jections — coat after coat of aphthae was thrown off, and each new
crop appeared to be more abundant, and less amenable to remedies,
until at last, at the end of two weeks of severe suffering, the poor
infant could not swallow a drop of the thinnest fluid. Injections of
bark and mutton-tea, in conformity with popular opinion, were re-
sorted to, but all in vain ; the child, in a few days more, died from
absolute starvation, or, at least, the catastrophe was certainly hur-
ried by the impossibility of receiving nourishment.
"We examined the body after death: we found the whole tract of
the oesophagus literally blocked up with an aphthous incrustation,
to the cardia, and there it suddenly stopped. The inner coat of the
stomach bore some marks of inflammation, as did several portions
of the intestines ; but not a trace of aphthae could be discovered
below the place just mentioned. This case would, therefore, create
a doubt whether this affection besieges any other parts of the body
than those just stated, namely, the mouth, posterior fauces, and the
oesophagus to the cardia, since, perhaps, none could have been of
greater severity ; but it is with us a solitary case, and should not be
received for too much. Dr. Heberden says, ' The aphthae are sup-
THE APHTHA. q^^
posed not only to infest the mouth and fauces, but to be continued
down through the whole intestinal canal. In two who died of lin-
gering fever, and whose mouths were covered with aphtha; which
hung in rags all over it, there was not the least trace of them that
could be found in dissection beyond the fauces.'* The excoriations
about the anus can certainly be accounted for, without the presence
of aphthae to produce them; in bad cases, the stools are always ex-
tremely acrid, and the parts over which they constantly pass and
spread are, at such a tender age, very delicate, and very readily ex-
cited to inflammation.
" Dr. Good seems to admit, without hesitation, the transmission
of aphthae through the intestinal canal ; for he says, without reserve,
' The fauces become next affected, and it descends thence through
the oesophagus into the stomach, and travels in a continuous line
through the entire course of the intestines to the rectum, the feces
being often loaded with aphthous sloughs.'f
" We are afraid there is too much taken for granted in this ac-
count; we know of no decided evidence of the fiict, nor does Dr.
Good name any authority for the statement. The case alluded to
was certainly one of death from aphthae ; but in it the aphthous
efflorescence stopped at the cardia. Is it probable that any child
could survive this affection did it travel the whole course of the in-
testinal canal ? We think not — yet aphthae is rarely a dangerous
disease in infancy. Dr. Good's description of this affection would
certainly lead to the conclusion that it is the ordinar}^ march of the
disease to pass through the bowels and manifest itself at the verge
of the anus. This point is far from being settled in the minds of
pathologists: even the French are far from having ascertained it
with certainty — it is true, M. Billard says he has seen evidences of
it in the large and small intestines, as well as the stomach ; but
there is no mention of it lower than the ileum.
"Now, this cannot be so ; since it is in violent and long-protracted
cases alone that the anus discovers any signs of irritation from this
cause, which would not be the case were Dr. Good's account cor-
rect.
"Dr. Good and others suppose that aphthae communicates itself by
* Commentaries, p. 31. " It is well known, too, that in small-pox no pus-
tules are traced beyond the pharynx and larynx, even in the most severe
cases, when the mouth and tongue are thickly covered with the eruption." —
Tweedie's Illustrations, p. 65.
t Study of Medicine, vol. ii. p. 391.
39
610 ORAL DISEASES AND SURGERY.
a specific contagion,* and gives as evidence, the excoriations of the
nurse's nipples. We do not hesitate to believe there is a discharge
from these little pustules which may be highly acrimonious to the de-
nuded skin, but we think this is perfectly innoxious to a sound one.
For we have never seen sore nipples produced by aphthae, where the
skin of these organs was perfectly sound. That they aggravate the
tenderness and inflammation, when these parts are tender and abraded,
we admit, and so would any other acrid substance, without having
recourse to the belief of a specific contagion. If this were the case,
why do not the lips of children laboring under this affection, betray
its influence?
" That this complaint is occasionally epidemic, there is every rea-
son to believe ; and this circumstance, among some others to be men-
tioned, renders the opinion so commonly credited (of its being a sym-
pathetic affection), very questionable. We have always considered
aphthae as arising from some peculiar condition of the stomach ; but,
from some late cases, and more mature reflection, we think it maybe
otherwise. Our reasons for doubt are, —
" 1. We have recently seen this affection in two cases where the
stomach and bowels were in the most perfect order before the erup-
tion, but became disturbed a little during the progress of the disease.
" 2. That this complaint has been very often removed by topical
applications alone, where the efiiorescence has been very consider-
able, and where there was no remedy of any kind addressed to the
stomach and bowels. f
" 3. That we do not uniformly see this complaint where there has
existed great disorder of both stomach and bowels, and these of a
permanent kind.
" 4. That, however the stomach and bowels may be disturbed by
acidity or other inconvenience, or however long these may continue,
if the child has had this complaint, it is not renewed, though the
individual is not exempt from a second attack, like measles or small-
pox; for, in certain chronic affections, they may be again visited by
aphthae.
" 5. That this affection is sometimes epidemic, as stated above ;
for Dr. Good informs us that not only all the children of the same
family, however cautiously separated from one another, but many of
* M. Billard declares it not to be contagious.
f Query. — Is then the unconquerable diarrhoea, sometimes present, a mere
accident, or would it not be more easy to account for it by the presence of
aphthae?
THE APHTHA. ^^^^
those of the same neighborhood, have been known, at times, to suf-
fer from it simultaneously. (Yo\. ii. p. 391.)
" 6. That this disease is almost always ushered in by some cere-
bral affection, as great drowsiness or watchfulness; the first is by
far the most common.
"7. That other portions of mucous membranes are liable to the
same kind of eruption, without the condition of stomach or bowels
being instrumental in its production ; for we have seen it most plen-
tiful within the labia pudendi, as well as on the internal face of the
prepuce.
"These facts have made us lately question the sympathetic origin
of aphthae; yet we admit they are not altogether conclusive in our
own mind ; but we thought it proper to suggest the possibility of
its being an idiopathic disease of the mucous membrane.
" This aifection is not confined to early infancy ; it shows itself in
the more advanced periods of childhood, and from that to any period
of human life. It is sure to attend the last stages of almost every
long-protracted disease, especially those which may have wasting
discharges; such as phthisis pulmonalis, dysentery, or diarrhoea;
and when it does appear, it is almost sure to be a fatal harbinger.
" This disease is not essentially accompanied with fever ; if it ac-
company any chance affection which is attended by fever, we do
not find it to heighten the existing one.
"Weakly children, and especially those born before their full
period, are more obnoxious to this complaint than the robust and
those who have tarried to their full time in the uterus — the children
of weakly women, and particularly those who make bad nurses from
scarcity of milk, or from its not being of a sufiBciently nutritious qual-
ity, are more disposed to this affection than the children of hale
women, who have plenty of nourishment of good quality. The
children fed much upon farinaceous substances are especially ex-
posed to the attack of this disease, particularly when their food is
sweetened with brown sugar or molasses."
In the work by M. Jourdain " On the Surgical Diseases of the
Mouth " is a chapter on aphthge, so unlike all that precedes it, as
connected with modern pathology, that I cannot but think the book
owes the presence of the chapter to the translator rather than to the
author.
" The term aphtha," says this work, " is used alike by ancients and
moderns, but in quite a different acceptation. The former define
aphthifi as superficial malignant ulcers, attended with heat, occur-
612 ORAL DISEASES AND SURGERY.
ring especially in infants, and not confined to the mucous membrane
of the mouth. It is at the present day universally applied to those
whitish pustules which appear on the mucous membrane of the
mouth, and sometimes of the adjoining parts. Inattention to this
difference has led many to apply to the latter disease a treatment
based upon the definition of the ancients, whereas the two are pal-
pably different.
" AphthiB have been regarded as ulcers ; but ulceration implies
solution of continuity, whereas in true aphthae there is no erosion
or decrease of substance, but, on the contrary, an increase ; desqua-
mation of the aphthous crust leaves no trace of cicatrization. Theo-
rists speak of white, red, and black aphthae, according to the nature
of the generating humor ; but during a long practice I have never
seen them of any other color than white, whitish, or, especially when
of an unfavorable character, ash-colored.
"They commence by small white spots, usually on the uvula,
thence spreading, sometimes over the veil of the palate, sometimes
over the tongue, gums, and inside of the lips and cheek. Often they
spread still further into the pharynx and oesophagus. Of their ex-
tension beyond this we cannot, of course, have the evidence of sight;
but we have other and unequivocal symptoms, which prevent us
from regarding as an absurdity the idea of their presence in the
oesophagus, stomach, and smaller intestines ; as, for instance, in the
difficulty of breathing and deglutition; also in the appearance of the
discharges from the stomach and bowels, so frequent in aphthous
disease.
" The description of aphthae is easier than their etiology. We
maintain that they depend in all cases upon the same cause, differ-
ing, indeed, in degree of intensity, but never in its nature. We
therefore differ from those who assign one cause in adults and an-
other in infants. Nor can we agree with the many who make them
to arise from excess of serum or of acid in the milk or nourishment
given to the infant. The depleting, purging, and starving treat-
ment based upon this hypothesis is most pernicious ; moreover, expe-
rience tells us that this very acidity or astringency of aliment will
frequently cure aphthous eruptions, or prevent them from coming to
maturity ; and a serous flux, determining to the mouth, has caused
the complete disappearance of existing aphthae.
" What, then, is the true origin of this disease ? We believe it
to be found in the existence of a slow and imperfect crisis, and to
arise from a sulphurous humor generated in the larger vessels, and
THE APHTHM. gjg
determining to such parts as are, by position or structure nio.t
impressible. Observe for a moment the circumstances and charac-
ter of aphthae. In all fevers, in the young and in the vigorous, their
appearance is ever preceded by a crisis more or less distinct, and,
according to the violence of the primary disease, marked by more or
less severe symptoms. In one case nature struggles successfully
with the acrimonious morbific principle, a favorable crisis occurs,
and an aphthous eruption brings great relief to the patient; in an-
other case this morbific principle is too abundant, obstinate, or nialiir-
nant,— no crisis occurs,— no aphthte,— nature succumbs, and the
patient dies. Again, we have aphthae through the critical transfer
of morbid action from some more or less vital and important organ.
In some cases the change proves salutary ; in others there is a reac-
tion, the aphthae disappear, and if the vis vitse be not destroyed, it
is often greatly endangered.
" Aphthae rarely occur in a perfect and favorable crisis, but rather,
as we have before said, in those which are slow and imperfect, such
as are met with in a great number of diseases. Thus we find some
aphthous eruptions of not only days', but weeks' and months' contin-
uance. When, for instance, necessary evacuations have been neg-
lected in the onset of disease, and a cachectic plethora has super-
vened, the cure is slow and incomplete without the occurrence of
aphthae. Diuretics and gentle enemas aid the recovery; blood-let-
ting and purgatives retard it : the aphthee disappear after fulfilling
their sanative purpose, and the patient feels perfectly relieved. Ex-
perience, however, shows that the danger is not quite over ; some
lurking matter may take fresh increase, give rise to new aphthae, in
default of other means of escape from the system, and greatly endan-
ger life ; this may happen twice, thrice, or oftener.
" The causes or antecedent symptoms of aphthae may be mild, and
recovery take place without any or with very simple treatment ; or
they may be severe and lamentable, ending in suffocation, delirium,
or obstinate diarrhoea. This difference we find explained by the
varying state of the humors ; at one time being crude, and by con-
sequence irritating, at another time matured or concocted, by which
process of concoction the more hurtful principles are expelled, — a
process aided in some inexplicable manner by the continued circu-
lation of the animal spirits. Thus it happens that the aphthae of
seventh-day crises are usually more unfavorable than those which
follow crises of a later date, when the morbid matter has had time
to undergo a thorough concoction.
614 ORAL DISEASES AND SURGERY.
" Although aphthae are most generally preceded by febrile mias-
mata, they are not necessarily so. I have seen cases, both among
adults and infants, in which they have been neither preceded nor
attended by fever. In infants we may properly suspect impurity
of the mother's blood.
" Certain evacuants have been found more hurtful than beneficial
in the treatment of aphthae. This comes from a forgetfulness of the
excellent advice of Hippocrates, who tells us to have regard, in the
choice of depleting agents, to the channels of evacuation which na-
ture points out in any given case. Now, the vessels concerned in
the critical discharge of an aphthous eruption are the lymphatic
rather than the venous or arterial vessels. Therefore to the changes
of the lymphatic fluid, rather than to those of the blood, is our atten-
tion to be mainly directed in the management of this disease. We
have frequent evidence of serous or lymphatic engorgement at the
outset of aphthous eruptions ; in the fever, stupor, and restlessness
during sleep, — indicating a fullness of the head and an acrimony of
the humors.
" Aphthae are more common in some countries than in others,
which explains the almost total silence of some writers respecting
them. This depends upon difference in climate and mode of living.
In warm countries their course is rapid, from the increased perspira-
tory action of the skin. But in colder latitudes, where the food is
coarser, the habit of body denser, and the humors thicker, their
progress is slower, because the secretions of the system generally
are more liable to obstruction. In these countries, especially, all
discharges which tend to arrest perspiration, such as hemorrhoidal,
intestinal, or uterine, whether occurring spontaneously or artificially
provoked, are very unfavorable in the treatment of aphthEe. On the
contrary, a copious cutaneous or urinary secretion forms often a favor-
able crisis. This agrees with the doctrine that aphthae are essentially
serous, and most readily cured by a free discharge of serum or lymph.
The cause of endemics we leave others to explain ; each country
bears in its womb the seeds of its own diseases, aud also the means
for their cure. External agencies may cause aphthae, not, as the an-
cients supposed, by their direct action on the mouth, but indirectly,
through the mass of the circulating fluids.
" The diagnosis of aphthae is easy ; not so the correct interpreta-
tion of their premonitory symptoms. Painful deglutition, dryness
of the mouth, a thick, husky voice, heat of the stomach, with rum-
bling noises, disturbed, unrefreshing sleep, — these often precede aph-
THE APHTHM. gl5
thous eruptions. Urinaiy symptoms are not to be relied upon, though
often useful in prognosis after the appearance of the eruption. In
the different forms of fever, the obstinacy of the disease is often a
precursory symptom; when, notwithstanding the intestinal, uri-
nary, and other evacuations, there still exists great depression and
embarrassment of the vital functions, the appearance of aphtha will
often in a single night bring calm and relief to the patient, as expe-
rience has abundantly testified. The physician should follow na-
ture's hint, and seek to aid in the cure of the disease through the same
channels. The above symptoms, be it understood, are by no means
necessarily followed by aphthous eruptions.
"We should be careful in our prognosis : where the system is not
weakened, the pre-existing morbid matter w^ell concocted, or the
extent of the eruption limited to the palate, we may anticipate a
favorable issue. But if the patient be in a reduced and weakened
condition, the morbid matter crude, or the aphthae covering the entire
membrane of the mouth and pharynx, the disease is much more to
be feared. Again, suppression or derangement of the menstrual flux
is unfavorable, from its tendency to draw the eruption from the
place where alone it can properly mature. Profuse alvine or hemor-
rhoidal discharges are also hurtful; also any catai-rhal attack falling
upon the throat, causing the sudden disappearance of the aphthae.
Aphtbse occurring in diseases, at the onset of which there was in-
sufficient evacuation, are grave and dangerous. The disease may
occur in persons of either sex, and be of tedious duration; but when
the appetite returns, not only is the food highly relished, but it gives,
by its new nourishment, relief and salutary benefit."
" The^term aphthae," says Prof Wood, in his Practice of Medicine,
vol. i. page 501, "was employed by the ancients to signify various
inflammatory affections of the mucous membrane of the mouth.
Willan proposed to restrict it to a peculiar vesicular eruption upon
the membrane, but committed the error of confounding with this
affection the thrush of early infancy. The two complaints are quite
distinct, and should not be similarly designated. Aphthas, in com-
pliance with very general custom, is extended to all those small
ulcers, with whitish surface, which so frequently appear in the
mouth, whatever may be their origin. The most frequent source of
aphtha; is probably the vesicular eruption occasionally present in
erythema. The vesicle is small, oval, or roundish, white or pearl-
colored, and consists of a transparent serous fluid under the elevated
epithelium. In a few days the epithelium breaks, the serum escapes,
616 ORAL DISEASES AND SURGERY.
and a small ulcer forms, more or less painful, with a whitish bottom,
and usually a red circle of inflammation around it. The vesicles are
sometimes distinct and scattered, sometimes numerous and confluent.
The distinct variety, though painful, is a light affection, continuing
in general only a few days or a week, and is usually confined to the
mouth. It produces little or no constitutional disorder, though it
may be associated with fever and gastric irritation as an effect. It
attacks equally children and adults, but is said to be very common
in early infancy. In adults it is frequently occasioned by the irrita-
tion of decayed teeth. The confluent variety is much more severe
and obstinate. This frequently extends into the fauces and pharynx,
and is said to reach even the intestinal canal, though it may be
doubted whether the affection of the stomach and bowels is identical
with that of the mouth."
The French fail in distinguishing, with Prof Wood, the difference
between the pultaceous inflammation of thrush, or muguet, and the
aphthae, calling muguet the " aphthes des enfans." They recognize
also that there are variations in the expressions of the condition,
making a distinction between the viuguet henin ou discret, and the
confluent, muguet malin ou confluent.
In Clymer's Aitken's Science and Practice of Medicine, the subject
is thus alluded to: "Follicular inflammation of the mouth, follicular
stomatitis, aphthous stomatitis, or aphthae of the mouth, is a disease
which usually commences as a simple stomatitis ; but very soon
small, round, transparent, grayish or white vesicles appear, and at
the base of each is an elevated marginal ring, which is pale and
firm. Fluid soon escapes from the ruptured vesicle ; an ulcer
forms, which spreads, bounded by a red circle and an elevated
border. In some forms of the affection microscopical parasitic
plants appear."
Treatment. — If we are content to view aphthae simply as a fun-
gous sore, originating from and maintained by the presence of a
parasite, — the oidium albicans, — we would find a most admirable
application in carbolic acid, admitting that the parasite had an ex-
ternal relation only; if, however, these spores come from within
and are exudational, such local treatment would stand us alone to a
very temporary end.
Viewing the fungus simply as an accidental parasite external in its
relations, our attention is directed primarily to the necessity for
cleanliness, and the avoidance of all positions, locations, and circum-
stances favoring the development of fungi; carbolic acid, acid nitrate
THE APHTHA.
617
of mercury, sulphuric acid, nitrate of silver, or chloride of zinc, will
be found destructive to the parasite, and, of necessity, if the circum-
stances are changed, equal to the production of a permanent change
in the appearance of the part ; that is to say, the application is equal
to the removal of the envelope or cover of the disease, but, except bv
a happy accident, will not beneficially affect the underlying condition
or the disease proper.
In the treatment of aphthae, the practitioner finds himself com-
pelled, at the very outstart, to consider the constitutional associa-
tions. Occurring in connection with acute diseases, it is generally
the case that the local expression is found to disappear with the
condition exciting it. Thus, in febrile attacks attended with stoma-
titis, we direct our remedies to the causes inducing such attacks ;
as the functions become harmonized and regulated, the expressions
of the irregularity disappear.
Aphthae, whatever its form, appearing in connection with the
dyscrasic diseases, gives to the practitioner the greatest anxiety and
trouble. In our anticipations of what we are to do, we are not to
forget that the task before us is the removal, or, at least, the marked
amelioration, of the constitutional disease. If this should be syphi-
litic, tubercular, or cancerous, the magnitude of the task is evident :
hence it is that patients are allowed so frequently and so unneces-
sarily to find themselves subjected to a series of disappointments.
Acute aphthae, as manifested in cancrum oris, gangraena oris, and
follicular inflammation, demands not unfrequently the most attentive
local treatment. This treatment has, however, nothing particularly
special in it, and, without doubt, must be appreciated from the
general expressions of the subject. Alteratives and soothing ap-
plications are such as would naturally commend themselves. Sul-
phate of copper, in proportions varying from five to thirty grains to
the ounce of water, is an excellent application. Iron and quinine
in combination is used to great advantage, twenty-five grains of the
latter to one drachm of the muriated tincture. A powder made by
combining equal parts of red bark, chalk, and tannic acid is fre-
quently found very serviceable. Solutions of alum, and the tinctures
of capsicum and myrrh, are useful in their places ; also borax, oxalate
of cerium, powdered chlorate of potash, sulphate of iron, etc.
Where the parts seem angry and irritable, or phagedenic, com-
bined with these applications are to be employed the more soothing
means : starch, gum, and slippery-elm water are very serviceable.
Tincture of hamamelis, much diluted, is a good preparation. It is
618 ORAL DISEASES AND SURGERY.
to be understood that while the principles which govern the treat-
ment of the aphthae are common to the species, the applications
must vary to meet peculiar indications. The ordinary white sores,
for example, need little more in the way of a local treatment than
the continued application to them of some of the agents mentioned :
which one would be best, or, indeed, what would be best, we could
not well say, unless considering a particular case. The local treat-
ment is not, however, in any of these cases urgent, and it is the
general experience that we find ourselves trying first one thing
and then another ; indeed, it is unfortunately too common that we
are soon brought to the conviction that any local application is
unreliable enough, — not that we cannot cause a sore to disappear,
but that to-day, to-morrow, or next week, another comes to take its
place. Canker sores seem periodic in some persons ; they come
without perceptible cause other than what seems a persistent con-
stitutional condition, defy all treatment, and finally disappear of their
own accord.
Of the special conditions, thrush demands that the bowels should
be kept free from costiveness, — oil, the saline cathartics, or aloes
being employed as indicated. Where fever attends the local mani-
festation, it is well to prescribe the neutral mixture made by fully
saturating lemon-juice with the carbonate of potassa; or, if more
agreeable to the patient, the ordinary lemonade may be used. In
diarrhoea, which is so frequent an attendant on thrush, some such
combination as the following may be used :
B. — Hydrarg. chl. mit. gr. ij ;
Pulv. opii,
Pulv. ipecac, aa gr. i ;
Mag. carb. gr. xii. M.
Ft. chart. No. xii.
Of these powders, the infant may take one, mixed in molasses or
other vehicle, every two hours, until the discharge is checked or
until the twelve are taken. In diarrhoea with green discharges it
may be sufficient to use the magnesia alone, or lime-water, which is
more convenient of exhibition, may suffice for the correction of the
acidity : this latter can be rendered palatable by combination with
some of the aromatic waters. In cases associated with much in-
testinal disturbance, it will in most instances be found satisfac-
tory practice to combine laudanum or paregoric with olive or cas-
THE APHTHM.
619
tor oil, administering in such doses as accords with the age of the
patient. A child one year of age may take three drops of lau-
danum or twenty of paregoric, combined with a teaspoonful of
the oil ; for an adult a dose would be twenty-five or thirty drops
of laudanum to a tablespoonful of the oil. It is also found use-
ful to drink freely of the demulcent waters, marshmallow and gum
arable being among the best of these. In debility— and this is by
far the most frequent of the conditions — combinations of iron and
bark, conjoined with the most nutritious articles of diet, will be
found indicated : ferrated elixir of cinchona is a pleasant and very
reliable preparation, and is freely taken by children. The dose far
an adult is one teaspoonful, repeated three or four times a day ; to
an infant a year old, ten drops may be given.
Concerning the diet, if the patient is beyond the age of infancy, it
will be found that the richest food is most advantageously received ;
juicy beef, oysters, malt liquor, wine, etc. being freely allowed. In
the infant, the character of the milk of the mother is to be examined:
in many cases it will be found needful to furnish a different nurse,
or, otherwise, wean the child. Many cases of persistent thrush in the
infant have quickly disappeared after a change of nurses.
Gangraena oris, the most degenerative and destructive of the aph-
thae, requires the most persistent vigor in the treatment, both as
regards systemic and local conditions. Sulphate of quinia and the
muriated tincture of iron are, in the first direction, most to be relied
on. This condition occurs most frequently between the periods of
1 first and second dentition, and is, without doubt, more common to
I the miasmatic than to other regions, excepting always the location
of ill-kept and ill-ventilated charities. Gangraena oris may have a
local excitant, but it is never without a constitutional predisposition :
it may commence as a simple sore, gradually degenerating, or, as in
carbuncle, destruction may reside in the primary impression. A
common form of sloughing stomatitis is its appearance as a whitish
or ash-colored eschar situated upon the gums, lips, or cheeks. This
eschar quickly falls out, being followed by degeneration of the asso-
ciate parts; the breath becomes offensive, the saliva flows as in
ptyalism, while, to add to the discomfort, the ulcer pours out an
acrid, corrosive fluid, which not only excoriates the mouth, but
seems to provoke the extension of the mortification. If not checked,
the ulceration extends to the bone, quickly involving it in the gen-
eral destruction, and bringing on the condition of necrosis,— necrosis
620 ORAL DISEASES AND SURGERY.
infantilis, as the disease is, unfortunately, so frequently compelled
to be named.
The treatment of gangraena oris is precisely that of a carbuncle.
We endeavor to circumscribe the action by sloughing out the af-
fected part with the aid of caustic ; this accomplished, we stimulate
the general system, correct, where possible, all functional disturb-
ances, and use for the relief of the local sore such soothing means
as seem indicated.
CHAPTER XXXIX.
RANULA.
The subject of ranula is one easily compreliended. A ranula is
the analogue of the sebaceous tumor, being simply a collection, the
result of the closure of a tube of outlet. The tumor thus designated
is found principally beneath the tongue: it is generally a translucent
swelling, varying in size according to the length of time it has
existed, at times being observed when not larger than a pea, at
others so great in bulk as to throw the tongue back into the fauces.
I have seen a ranula which filled the whole oral cavity ; but such
dimensions are uncommon.
Recalling the anatomy of the salivary glands, we remember that
the submaxillary, situated beneath the jaw, has the outlet for its
secretions in a tube opening at the side of the fraenum lingure, — the
duct of Wharton, as it is called. The lingual gland empties itself on
the same line. The parotid, by its tube, the duet of Steno, opens
upon the mucous face of the cheek opposite the superior second
molar tooth. While patulous, these tubes convey into the mouth
the secretions of their respective glands, and thus the saliva, passing
'to its recremental purpose, is disposed of
If we were to tie or otherwise obstruct one of these tubes, it
would be natural to expect that the secretion accumulating back of
the ligature would expand and bulge out the duct into the form
of a tumor. This is the very simple history of the formation of a
ranula.
Ranula, thus provoked and thus formed, varies much in appearance
and character. In one case it will look and feel almost precisely like
the belly of the frog, the enveloping cyst being thin and attenuated.
In another instance the walls are thick. The contents present vary-
ing characteristics, being watery, or semi-solid, or solid, even to
the hardness of stone, as illustrated in the very instructive case cited
in the chapter on Salivary Calculus.
] A ranula, the contents of which are waterv, implies, as a rule, that
I ( 621 )
622 ORAL DISEASES AND SURGERY.
the disease has been of short existence, the contents being simply
the secretion from the gland unchanged in character. In the ranula
of semi-solid consistence an explanation is found in the partial
absorption of the more fluid portion, leaving an inspissated mass.
In the solid ranula the encystment is the common salivary calculus,
— precisely the same as is found upon the sides of the teeth, ex-
cepting in the absence of the common debris of the mouth. Such a
ranula Avill be found to be of long standing: absorption of the
watery portion has gone on until what remains is the lining portion
of the secretion.
A thin cyst implies a rapidly-formed tumor unattended by vas-
cular excitement, the envelope being a simple attenuation of the
walls of the duct and overlying parts. This form of ranula very
frequently ruptures and thus effects a self-cure. Cysts, thickened
and hard, imply a tumor of slower growth and the association of
vascular changes resulting in the effusion within the cyst-wall, and
the organization of a greater or less amount of lymph. Cysts thus
thickened may compose the principal bulk of a ranula, the cavity
being very small in comparison.
A ranula gives trouble from its bulk and location alone, seldom or
never degenerating. It does not seem true, either, that harm results
to digestion from the loss of the secretion, such loss, indeed, being
more apparent than real, the associate glands performing excess of
work. A ranula attaining great size would necessarily intrude upon
all the surrounding parts, thereby provoking secondary lesions which
might very well prove of more serious character and consequence
than the original disease : thus, cases are on record where the teeth
have been forced from their sockets, where large ulcers have been j
formed against the inner face of the lower jaw, where necrosis of ex- ;
tensive character has been provoked, etc.
Treatment. — This, in principle, consists simply in opening the
tumor, evacuating its contents, and so conducting the cure of the
wound that it shall not entirely close, securing and preserving, in '
this way, an orifice of exit for the secretion.
In the rana, or frog-belly tumors, it is found sufficient to catch up
with the tenaculum or forceps a portion of the sac, and with the i
scissors or bistoury cut it off: the edges are then to be cauterized, j
and the case left to nature. I
In the thickened cysts, such an operation as just suggested might '■
not be easy to accomplish. In such a case, take a strand of ligature '.
wire (silver is to be preferred), double it upon itself some half-dozen i
RANULA. g23
times, to the extent of the supposed thickness of the sac of the tumor
to be operated upon. Take next the continuation of the length of
the wire, and closely, yet spirally, bind with it the thickness just
secured by the half-dozen reflections. Next take a curved needle,
and thread the wire to it. Now pass it through the tumor, entering
at the center. When the thickened part of the wire— which is to
be bulbed by a perforated shot compressed on its extremity— is
brought in contact with the cyst, it is to be let in by an incision
just large enough to allow the passage ; pull it now in, until checked
by the shot ; fix the needle-end so as to retain the thickened end
in place, and the operative part of the proceeding is completed.
If, when making the little section for the passage of the wire, the
contents should not at once escape, they are to be pressed or syringed
out. If the parts seem particularly indolent, there is no objection
to the introduction of a stimulating injection. The presence of the
wire will, however, in ordinary cases prove sufiBciently provocative
of the desired action. Iodine in tincture may be used externally
over the face of the tumor. As the size of the tumefaction gradually
diminishes, the thickened end of the seton is to be kept in place by
attention to the fixing, or single-strand, end.
In a ranula holding a calculus within the cyst, nothing is to be
done without using the knife, except, indeed, in certain occasional
cases where the orifice of the duct has become patulous and the
stone can be seen or felt. In these cases the operator may succeed
in drilling or breaking them in pieces, and thus securing their re-
moval. It is much easier, however, even here, to incise down to
the stone, and thus take it away. The case alluded to as mentioned
in the chapter on Salivary Calculus is as good a study as could be
. given in the direction.
All cysts or tumors found beneath the tongue are not, however,
to be esteemed as being of the character just described. Inflamma-
tion of the sublingual gland is not unfrequently met with, and the
tumefaction is, at times, so considerable as to very closely simulate
ranula. Cysts within the substance of the glands, not salivary in
[■character, are other of the conditions met with, and these more
closely simulate the ordinary ranula than the first ; particularly
j'when the cyst is simple. Papillary indurations are sometimes met
i»with in the same situation.
i A singular case operated upon by myself, and where I very nearly
j lost the patient, occurred in the person of a confectioner, and has the
[following history:
624 ORAL DISEASES AND SURGERY.
First it was noticed that the parts beneath the chin began to
soften and grow broad, freedom of motion was lost in the jaw,
and a slight sense of difficulty was experienced in speech, as the
result of stiffness about the tongue, the mucous floor of the mouth
being quite indurated. In the course of four months a tumor, evi-
dently cystic, and fully the size of an ordinary orange, occupied the
front of the neck, but happily concealed by the long and heavy beard
of the patient.
Presenting himself for an operation, a diagnosis was secured
through the aid of an exploring needle. This valuable instrument
revealed not only that the tumefaction was a cyst, but gave some
idea of its contents.
The operation for the cure was performed by making a reasonable
incision directly in the median line of the neck, passing into the
cyst. The contents, a great mass of lymph-like matter, filling a large
glass, issued as a continuous rope; in color and consistence it was
like thin calves'-foot jelly. Washing the cavity thoroughly with
warm alum-water, compresses were carefully adjusted to the parts
and sustained by a bandage passing over the forehead. In two
weeks, and without any trouble, the parts seemed to have united,
and the cyst to be obliterated.
One month later the patient again presented himself. The tumor
was rapidly reforming: the cyst had evidently not been destroyed.
It was now the size of a walnut. A few days later a second opera-
tion was performed, precisely as in the first instance. The contents
of the tumor differed, however, at least in color, having the same
colloid consistence, but being blood-red. After an incision, deter-
mined on obliterating the cavity, I syringed it with the officinal tinc-
ture of iodine, undiluted, stuffing the cyst loosely with cotton. I this
time succeeded in producing a perfect cure ; but the swelling result-
ing from the inflammation was so great that it was only by leeches,
cathartics, and diaphoretics, conjoined with the closest attention,
extending over a period of four days, that I succeeded in saving the
life, — for two whole days the patient being unable to swallow even
teaspoonful measures of water, and breathing with the greatest
difficulty.
What was this tumor? Evidently a hydro-hem atocele, the start-
ing-point of the lesion being, I think, in a sublingual gland. It might
be suggested that, had it belonged to this gland, the swelling would
have exhibited itself more in the mouth. My reason for inferring that
it was so situated lay in the fact that a blunt probe passed into the
BANULA. g25
cavity could readily be felt in the position of the ri^irht of these
bodies on the floor of the mouth.
A case very similar to this, and of great interest, is recorded in
Bell's Principles of Surgery :
"A young woman of Berwick whose native peculiarity of accent
had received a singular aggravation by such an uncouth obliquity
and imperfect motion of the tongue as conveyed the notion of her
attempting to chew and turn each vocable with her tongue before
she proceeded to swallow it, in place of uttering it.
" This was produced by a tumor of very great size, and of an
appearance so peculiar as plainly to denote its character. It con-
sisted in a vast collection of matter in the sublingual gland; and as
that gland is covered by the whole thickness of the tongue within,
and by the mylo-hyoidei muscles without, and bounded by the line
of the jaw-bone, it had the following singularities of character. It
could not be distinguished as a tumor, but had rather the appear-
ance of a general swelling of the lower part of the face, jaw, and
neck, such as often accompanies severe toothache or mumps. Upon
laying the hand upon the outside of the neck, below the lower jaw-
bone, the whole hand was filled with a swelling, apparently solid,
but so little convex or circumscribed as to resemble in no degree the
tumor of any particular gland, and yet so limited and so firm as not
at all to resemble the general tumefaction proceeding from tooth-
ache. Upon introducing the finger into the mouth, you found the
tongue raised, turned edge uppermost, and pressed entirely toward
the left side of the mouth, the external tumor being upon the right
side. Upon pressing the fingers very firmly down by the side of
the tongue, and reaching from without, you could sensibly perceive
not so properly a fluctuation as an elasticity, which implied the
presence of a fluid ; the tumor seemed elastic like a foot-ball, but
with a degree of tension which made it seem almost solid. It was
by comparing a variety of circumstances, especially the original
place and slow growth of the tumor, that I confidently referred it to
the sublingual gland. In this I had the advantage of the surgeon
under whose particular care she was ; but I did him the justice to
send her back to him, again and again, expressing my opinion and
my wish, at the same time, that he should do whatever he might
suppose right. By good fortune, she called upon me the day she
was to return home, nothing being as yet done to the tumor, but
supplied with abundance of blisters and plasters to apply at a fit
40
626 ORAL DISEASES AND SURGERY.
opportunity to her throat. I felt now that professional ceremonies
should give way to essential charities. I placed her in a chair, and
almost without her consciousness, at least before she was aware, I
struck a fine bleeding-lancet deep into the tumor by the side of the
fraenum of the tongue, when, from the firm compression of the sur-
rounding parts, the matter, though too gross to pass freely through
such an opening, was spewed out from the orifice, in a manner ex-
pressly resembling that in which yellow paint is squeezed out from
the bladder upon a painter's pallet. It was of a deep-saffron color,
thicker than mustard, mixed like gruel with seed-like particles, and
exceedingly fetid. I knew that the tumor was not emptied, though
the outward swelling was almost gone ; but I also knew that though
I should not enlarge the opening, the second secretion from the sur-
face of the sac, which is in all cases thin, would dilute and wash out
whatever viscid matter remained ; and when she saw how suddenly
my prognostic was fulfilled, she expressed a perfect confidence in
whatever I predicted, and a perfect willingness to submit cheerfully
to whatever I proposed to do. Next day I introduced the point of
a probe-pointed bistoury into the orifice made by the lancet ; and,
knowing that the lingual artery lies on a lower level, imbedded
among the muscles, and running along the lower surface of the
tumor, while I had over the point and blade of my bistoury nothing
but the inside membrane of the mouth, much thickened, I ran it
fearlessly and at one stroke, as the less painful way, along the whole
length of the tumor, when the thickest of the yellow mucus flowed
freely or was raked out with the points of the fingers and the handle
of the bistoury; and the tongue, descended now to its natural level,
was in a capacity once more of delivering the peculiar dialect of her
native city in all its purity.
" So tense and apparent!}' solid was this tumor, in consequence of
the compression by so many surrounding muscles, that her surgeon
mistook it for a solid and strumous swelling. I reckoned that in
this, as in all cases of sacculated tumor, the second secretion, which
was thinner, would wash out the thicker mucus, and I was not de-
ceived ; but she left me too early for me to witness the obliteration
of the sac.
" I find it, in all such cases, a matter of some importance, especi-
ally in a girl, to anticipate the outward suppuration of any saccu-
lated tumor, by puncturing it, though to a great depth within the
mouth and under the tongue, and equally necessary to be at pains
in preserving the opening and obliterating the sac ; a slight miscon-
RANULA. g^y
duct in this respect occasions much distress to the patient and
much superfluous labor to the surgeon." '
The salivary glands become occasionally the seat of inflammatory
swellings, which are quite as apt to become indolent as to resolve.
I have within my own observation several of these cases, and have
been as many as six months in reducing such an induration. The
submaxillary, however, seems the gland most disposed to take on
these conditions, and the tumefaction thus produced is without
rather than within the mouth, although it not unfrequently hai)p('ns
that it is first observed by the patient as a hard body on the inner
side of the jaw.
Another form of tumor which might here be alluded to is found
in the submaxillary triangle.
In dissecting down to the su))maxillary gland, there will be ex-
posed, when the body is uncovered by removing the superficial leaf
of the triangular fascia, two lymphatic ganglia. These ganglia arc
very apt to indurate, forming sometimes a tumor of considerable
size. I have met with them as large as a walnut. It is most com-
mon to mistake such indurations for hypertrophy of the gland itself
Two diagnostic signs distinguish them : they are not triangular, and
they are not so solidly fixed as when the gland itself is the seat of
the enlargement.
Illustrations. — By looking over and studying the clinical cases
following, I think the general character and manner of treatment to
be pursued in ranula and the kindred conditions must be fully appro,
ciated.
" Ranula. — Operation by Dr. Hamilton. P. R. Cortelyou, House
Surgeon.
"Dec. 13th, 1867. II , of X., aged 10 years, private patient.
admitted to Bellevue under Dr. Hamilton's care.
" Soon after birth his father noticed a swelling under bis chin, near
the median line, which has continued to increase ever since. Now
the size of a large orange, nearly in the center, but inclining a little
to the right side. It is not painful or tender ; its surface is smooth and
elastic. On exploration it was found to contain a thin yellowish fluid.
" Examining within the mouth, it was found to have lifted the
tongue considerably; but its walls did not present the translucent
appearance sometimes seen in ranula, nor could it be decided posi-
tively whether the orifices of the ducts, or the right side, were still
open. It became a question what was the source of this enlarge-
ment or tumor.
628 ORAL DISEASES A.\W SlfRGERY.
" The term ' ranula' has been applied by some surgeons to obstruc-
tions of the sublingual ducts ; by others to obstructions of the sub-
maxillary ducts; and by most surgeons to obstructions of either the
one or the other indifferently. Certain writers, also, have extended
the term to all encysted tumors in this region, whether occurring in
the areolar tissue or in muciparous glands, which present a common
external appearance, like the throat of a frog.
" It was not very clear from which of these several sources this
tumor had originated. It was decided, therefore, to proceed as if it
were an obstructed duct. Accordingly, Dr. Hamilton made a small
incision into the tumor beside the tongue, on the right side, avoid-
ing carefully the ranine artery. This opening was at once enlarged
by introducing a pair of bullet forceps and expanding them, so as to
tear the wound larger. The sac was emptied, and a piece of lami-
naria digitata introduced. On the third day considerable inflamma-
tion existed, extending to the root of the tongue and side of the face.
There had been also, up to this time, a constant but slight hemor-
rhage. Both the swelling and bleeding abated from this time. The
contents of the sac were examined under the microscope, but not
with sufficient care to determine their character.
"Feb. 1st, 1868, nearly two months after the operation, the father
reports that the sac has almost disappeared. A little pus continues
to discharge, and there is no tenderness or swelling. The laminaria
is taken out daily, and replaced with ease. It is probable that the
complete cure will not take place under several months.
" Dr. Hamilton mentioned that a ranula was said to form occa-
sionally in a bursa outside of the genio-hyoid muscle ; but he had
searched for this bursa and could not find it."
" Swelling of Suhmaxillary Gland from Inflammatory Obstruc-
tion of its Duct. — Charles D. Hoyt, of Middlesex, Yates county,
called upon Dr. Hamilton, December 29th, 1846, with a moderate
enlargement of the right submaxillary gland, it being apparently, as
felt beneath the jaw, of the size of a large Lima bean. He stated that
this enlargement occurred about one week before, while eating his
breakfast, and that in five minutes it attained the size of a ' walnut
with its bark on,' and that it prevented his opening his mouth freely.
After leaving the table he rubbed it for some time, and in half an
hour it was reduced to its present size.
"From that time the same enlargement occurred every time he
ate, and without any reference to what he ate. It enlarged most,
however, while eating his first meal in the morning. By rubbing
RANULA.
629
alone could it be reduced. Chewing tobacco seemed rather to dimin-
ish than to increase its size. It was not tender, nor red, but when
enlarged to its utmost it caused a severe pain, which extended to
his ear.
" Tinct. of iodine externally was first employed by Dr. H., but, no
result being obtained, he directed him to take a full dose of Epsom
salts. This had the desired effect. The enlargement disappeared
very quickly, and did not return."
" Obstruction of both Submaxillarij Ducts.— Decemhev ITth, 1847,
John C. Lyons, aged 20, Benton Center, Yates county, consulted
Dr. H. He stated that in the latter part of July, while harvesting,
the weather being very warm, he discovered in the morning a sore-
ness under his tongue upon the left side, and before night he found
there was a tumor at this point. It was oblong and only about half
an inch in length. His physician. Dr. Wolcott, opened it the fol-
lowing day, and it discharged a glairy matter. Since then it had
been opened four times; but, a few days before calling on Dr. H.,
he discovered that there was a swelling on the opposite side, exter-
nally, in the region of the submaxillary gland. When seen by Dr. H.
the gland was of the size of a pullet's egg, oblong, not painful or
tender. It was increasing in size, but he noticed that it was larger
in cold and damp weather. His health was good. He was advised
to submit to a low diet, take physic, and apply externally the tinct.
of iodine. He was never seen again, and the result is not known.
During the winter of 184*7 and '48, two similar cases of enlargement
of the submaxillary gland were presented in Dr. Hamilton's Surgical
Clinic, at the Buffalo Medical College, one of which had resulted in
an external salivary fistule.
"In a I'ecent report of one of Professor Jarjavay's clinics, copied
into the number of the Gazette des Hopitaux of November 23d, 1867,
similar enlargements of the submaxillary gland arc mentioned as
occurring in connection with obstructions of Wharton's duct ; but
he restricts the application of the term ranula to obstruction of some
one of the tweuty-eight or thirty excretory ducts of the sublingual
gland."
Ranula.— In one of a series of interesting papers on "Anatomy
in its Relations with Medicine and Surgery," Dr. D. Hayes Agnew
makes the following remarks on this subject : " A tumor is met with
beneath the end of the tongue, rising from the floor of the mouth, to
which the name ranula has been applied. It involves the ducts of
the sublingual glands, the excretory orifices of which here open.
630 ORAL DISEASES AND SURGERY.
These become obstructed by some substance, either mechanical or
inflammatory, the secretion accumulates behind, distending them
finally into a semi-transparent tumor. Sometimes they are found to
be firm and resisting in the texture. In such cases the distention
has provoked an inflammatory exudation and its organization into
fibrous tissue. The transparency will depend upon the attenuation
of the mucous membrane. The same morbid condition maybe pres-
ent in a very limited degree, confined even to a single duct, so as
to resemble a little vesicle. The cure of such can rarely be accom-
plished by puncture and evacuation of the contents : the wound you
make will soon heal, and, as the duct or ducts ai*e not restored to a
previous condition, the swelling will be reproduced. No treatment
short of that which contemplates the destruction of the glandular
tissue will prove effectual. This is best attained either by injection
or excision ; the latter 1 think the preferable, which is readily done
by including the mass within two elliptical incisions, and then allow-
ing the wound to heal by granulation or stitching the edges together
with the finest silver wire. If it be a small cyst, after clipping it
away, the point of a stick of caustic may be carried into the wound
for a moment or so.
"Another tumor is found in this same locality, and which is pro-
duced by a salivai-y calculus becoming arrested near the outlet of
the submaxillar}" duct ; and, last, another variety of tumor, w^hich I
am disposed to believe is rare, and being connected with the under
surface of the top of the tongue, rather than the floor of the mouth,
must be referred to the cluster of glands there situated. The sides
of the tongue may be bound down by cicatricial tissue, so as to inter-
fere with its proper functional movements. Should a nerve-filament
happen to be included, it may give rise to a very painful condition.
This is best remedied by incisions or exsection of the diseased struc-
ture."
Lately, at the Imperial Society of Surgeons there was exhibited
by M. Paulet two salivary calculi found by him in Wharton's duct.
In connection with the presentation was reported the unique fact —
for such it was thought to be — that the submaxillary glands of both
sides were found stuffed with calculi. M. Pana, however, presented
at the same meeting a single calculus taken by excision from this
gland. It happens, also, that at the present time I have under treat-
ment a similar case, the first ever met with by me. The stone is
situated on the inside of the mouth, just anterior to the ramus of
the left side.
RANULA. (331^
PMUula treated by 3Iechanical Pressure. — "Xearly seven years
ago," says Dr. Wm. Macdonald, "J. F , aged twenty-two years,
and residing in M Street, in this city, consulted me in consequence
of being much distressed with a ranula, or a large tumor under her
tongue, arising from an accumulation of saliva and mucus in the
ducts of the sublingual gland. For two years after the period this
person consulted me, she was attended both by my professional
friends and myself, and that without success. During these two
years that this patient was under the surgical and medical treatment
both of my medical friends and myself, the following methods of
cure were adopted in succession : the ranula was very often opened
with a lancet, and injections of rose-water and sulphate of zinc (five
grains of the sulphate to the ounce of rose-water) injected by means
of a syringe, night and morning, into the cavity of the emptied ranula.
Occasionally, when the ranula burst of its own accord, and left an
ulcer, considerable portions of the sublingual gland were dissected
out ; and on one occasion the actual cautery was proposed to be
employed ; but the patient would not consent to the employment of
this method of treatment. During the two years the patient was
under treatment she took occasionally tonics and alteratives, to-
gether with laxatives, as the nature of her case seemed to require,
but without any good effect.
" In these critical circumstances it occurred to me, about five
years ago, that, if the fluid contained in the ranula were completely
evacuated, the employment of pressure over the tumor might cause
adhesion of almost all the internal surfaces of the tumor, except a
fistulous aperture or apertures, analogous to the sublingual duct,
through which the saliva would necessarily flow, and by necessary
consequence a radical cure would be produced, provided that a per-
manent adhesion of both surfaces of the ranula could be effected.
" In order to produce such a result, I proceeded to perform the
following operation. (I must remark that the size of the tumor at
this period was such as to preclude the possibility of swallowing
any fluid or solid kind of food.) I introduced a bent needle, armed
with a ligature, into the ranula, with the view of enabling me to
render the tumor steady while I was opening it with the lancet, and
also in order to direct me afterward in injecting the ranula ; this
being done, I procured a common musket-ball of lead, a little flat-
tened, and having a perforation through it, and through this per-
foration in the bullet I introduced a yard or so of common tape,
which was loosely tied around the neck of the patient, while the
632 ORAL DISEASES AND SURGERY.
bullet remained in the patient's mouth and pressed by gravitation
upon the upper covering of the ranula. It is obvious that the tape
fixed to the bullet served only the purpose of preventing the patient
from swallowing the bullet while it remained in her mouth. The
bullet thus kept in the patient's mouth night and day for two weeks
produced union by inflammation (caused by mechanical pressure) of
both surfaces of the ranula, except two fistulous apertures analogous
to sublingual ducts, through which saliva has flowed on each side of
the fraeuum of the tongue ever since ; and this patient has happily
had no return of her troublesome complaint from that period to this
date. Now, as nearly five years have elapsed since the cure of the
ranula, we may hope that the disease will not again return."
CHAPTER XL.
PALATINE DEFECTS AND THEIR TREATMENT.
In the treatment of any palatine defect, the first consideration is
to be of its cause and condition. Thus, it will be found that such
defects or deficiencies may, by influencing circumstances, require
treatment so modified or changed as to seem, in cases apparently
similar, quite at variance with each other.
For example, let us takfe two perforations exposing the narcs ;
one congenital, the other the result of disease. Now, in the first of
these cases we might adopt any operation or appliance which would
seem to promise relief; while in the second we might justly pause
at any interference. No one in his senses would attempt the opera-
tion of staphyloraphy on a patient laboring under acute syphilis, or
where a mercurial course had so broken down the crasls of the blood
as to make union by the first intention impossible, or even doubtful.
No more would he be justified in attempting this or any other of the
operations of expediency, with the constitutional conditions adverse
to success, than he would be justified in avoiding the responsibility
where such influencing associations were favorable.
Cleft Palate. — The condition known as cleft palate, to which
we at once pass, may, from its exceeding frequency, be the first to
claim attention. A cleft may be partial or complete ; that is, there
may be a simple lengthwise division in that portion of the mouth
known as the soft palate, or the cleft may be so extensive as to ex-
tend from the uvula to the lip, a fissure separating both hard and
soft parts. The first of these two conditions is found perhaps most
frequently as the result of disease ; the latter is nearly always con-
genital. Indeed, I do not recall a single case where I have met
complete fissure as the result of disease. I have treated fissures
produced by syphilis where there was a break both in the bone
and in the soft palate, but never that I remember where a coexistent
break existed in the continuity of the lip.
Fissure of the hard palate the result of disease, differs, however,
from congenital fissure in a particular which I think would scarcely
(633)
634 ORAL DISEASES AND SURGERY.
allow of the surgeon being deceived. A fissure the result of dis-
ease exhibits a break in the continuity of one or both palatine bones;
a fissure having congenital origin exhibits, so far as my experience
goes, the deficiency at the line of contiguity or in the palatine raphe
— this at least as the rule.
Let us first consider the condition and treatment of the congenital
cleft. A child is born, toward whose mouth attention is first di-
rected either by the nasal character of its cry, or a little later, by its
inability to take the breast properly, or, what is by great odds much
the most frequent case, the condition is marked by the break con-
tinuing through the lip, giving the deformity known as hare-lip.
When a child is thus, unfortunately, born, and the attention of the
surgeon is called to the case, it seems to me but a single question
presents itself for his consideration, namely, how the deformity
may be corrected: suffered to exist, every day will increase the
difficulty of the cure, that is, so far as the most formidable part of
the operation is involved, while if at once attempted, the prospect
of complete success is very great.
Fissure of the hard palate has generally been deemed irremedi-
able, so far as operative means are concerned, and the surgeon has
learned to consider his whole duty done in describing to the parents
the mechanical method which in after-life is to conceal and correct the
trouble of his patient. Now, in this chapter I shall present a i-emedial
surgery which is as practicable and feasible as any other of the oper-
ations of expediency, and perhaps I am justified in going so much
further as to say that the modes of procedure will be found much
more promising than the majority of such operations. Through the
proper application of mechanical allied with the more strictly surgical
means, I have not unfrequently succeeded in effecting changes in the
young maxillary bones, a simple description of which might cause
my veracity to be doubted ; and yet this ability to effect such changes
must become very plain to us, if for a single moment we pause to
consider the difference between the composition of the young and that
of the old bone. Young bone, or bone at birth, as is well known, is
almost if not quite half made up of animal material ; while in the
osseous structure of the adult there is an excess in the limy, or unyield-
ing material, of from seventy-five to perhaps quite eighty-five per cent.
Let me refer to the old experiment of the maceration of bone in
dilute muriatic acid, to illustrate more farailiai'ly this yielding con-
stituent of bone. We know that if we subject a bone to the action
of this acid for one or two weeks, we may tie a rib like a whip-cord.
PALATINE DEFECTS AND THEIR TREATMENT.
635
Now, we do this simply by reducing an old bone to somewhat the
condition of a young one. I have removed a rib from a living youn«-
cat, and played with it in this same whip-cord manner. I have per-
ceptibly bent the femur of a young child ; but no one, I imagine,
ever performed such a manipulation on the healthy femur of the
adult. You may take an inferior maxillary bone, even in the child
of fifteen years, where the projection of the chin is so great as to pro-
duce deformity, and with a properly-constructed vertico-racntal elas-
tic sling you may, in a period varying from three weeks to as many
years, so change the angle of the bone as to do away entirely with
the deformity. You may take the projecting myrtiform border, and
through the instrumentality of the oceipito-alveolar sling you may
in quite a short period compel it to a natural articulation. On this
known yielding character of the young bone, therefore, operations
for the correction of congenital fissures of the hard palate may be
founded.
A congenital fissure of the hard palate may be corrected instantly,
or the cure may be effected slowl3^ The first of these procedures is
applicable to such cases as present but a limited separation of the
bones; the latter, when the fissure has considerable width.
The operative procedure for the immediate cure is as follows: an
instrument, a modification of the Hoey clamp, or the ordinary arte-
rial compressor, is to be made by so arranging the pads that they
shall apply to the sides of the jaws and allow of the force being so
directed that the pads can be approximated without undue facial
pressure. The clamp of Hoey, it will be seen, needs alteration only
so far as the pads are concerned, and is quite easy of adjustment to
this purpose.
The instrument ready (the patient being in proper condition), the
operator commences by paring the soft parts and bone on both sides
of the fissure, beginning on the approximal faces of the palate-bones,
and cutting forward to the alveolar face of the chasm. This part
of the operation completed, the little patient may be allowed to
rest until the bleeding ceases. The next step is to re-etherize and
apply the compressor, the curved pads embracing the buccal faces
of the alveolar arch ; by now gradually turning the screw of the
instrument, the yielding bones are brought together. The next and
last step in the operation is to retain the parts in position by the
use of compresses placed upon and below the malar bones, and
secured by adhesive strips applied as in the occipito labial cravat
of Mayo.
636 ORAL DISEASES AND SURGERY.
It may be urged against these manipulations that they are formi-
dable and too heroic ; that fractures may result, etc. On these points
the surgeon must decide for himself. I can only answer that, if care-
fully performed, it is not a dangerous operation ; fracture of the
bone, even if it should occur, would be of little consequence, as the
parts have to be kept, as it were, in splints, and consequently the
treatment of the one would be the treatment of the other. The most
marked risk would be from inflammation that might be provoked ;
but a surgeon not unfrequently has to run far greater risk for even a
less result.
Another mode of securing the same end, which is entirely di-
vested of formidable risk, is as follows : take a circle of india-rub-
ber tubing, the circumference of which shall be about one-third or
one-half that of the child's head ; next prepare two firm compresses,
of a size adapted to the case under treatment; place these pads or
compresses one on either cheek, in such position as will give them
their rest on the buccal faces of the alveolar arch. These being se-
cured in place by one or more delicate strips of adhesive plaster,
take up the ring of rubber and pass it around the cervico-labial di-
ameter of the head. Passing over the compresses, it will thus exert,
as is seen, a gradual pressure, serving to push the bone toward a
common center, this center being the mesial line of the palatine arch.
This process is a gradual one; but, if the patient is young, I think
it will be found to succeed ; the only real objection to the manipu-
lation is the constant care necessary to prevent excoriation of the
tender skin.
When, by this procedure, the bony parietes have been brought
into contact, the operation, so far as the hard palate is concerned, is
completed by simply paring the folds of the mucous membrane. It
may or may not be necessary to coaptate them ; if the bones have
been brought very closely together, the granulations will alone be
sufficient to bridge the slight remaining chasm.
In either of these operations it is seen that the break, both in the
soft palate and lip, is not remedied. It is well, I think, not to at-
tempt the cure of the lip until the patient has entirely recovered
from the foregoing operation. It may then be performed, and, if done
according to a rule, hereafter suggested, will secure to the patient a
lip so perfect that, in adult life, little or perhaps no mark of an opera-
tion will exist. The operation for the cleft in the soft palate must
be left to a period later in life, for reasons presently to be alluded to.
These suggestions for the cure of cleft in the hard palate were, I
PALATINE DEFECTS AND THEIR TREATMENT. 637
thought, original with myself,— though it is of slight consequence
who invents an operation, so that it is good ; but in the periscopic
department of the Dental Cosmos I find the following extract, made
by Dr. Ziegler, from the Australian Medical Becord and Dublin
Medical Press, which shows that the operation was conceived by
another before it presented itself to ray mind. The extract is a short
one, and so apropos to the matter that I shall take the liberty to pre-
sent it entire :
"Pressure in the Treatment of Cleft Palate. — I am not aware,"
says the author, "that the subject of using pressure in treating fis-
sure of the palate has been before suggested. I am inclined to think
that it has not ; for when the plan first presented itself to my mind,
in 1851, I carefully examined French, German, English, and Ameri-
can works to see whether it had. I was first led to try it on the dead
body of a child, which had died three weeks after birth. The fis-
sure was longitudinal, and large enough to admit the extremity of the
little finger; fissure of the lip also existed. By means of a pair of
clamps, the sides of the fissure were brought readily in contact,
without any fracture or displacement of the bones ; the only fault
was that the gums of the upper jaw were within those of the lower;
but nature would modify this as the living child grew up ; the use
of pressure on the lower jaw would remove a great deal of this de-
formity ; of course the amount of deformity would depend on the
size of the fissure in the palate. I several times repeated the exper-
iments on young dogs, removing a piece of the palate-bone by means
of Key's saw, and then applying the pressure. The animals did
well.
"The operation should be performed as early as possible after
birth, when the bones are in their softest condition. The following
is the plan which I would suggest : the edges of the fissure having
been pared, the superior maxillary bones should be embraced by a
horseshoe-shaped clamp, with a shelf on its lower border to receive
the gums and prevent it slipping. It should be padded with india-
rubber or some other material to prevent the germs of the teeth bemg
injured. The clamp should work on a joint, and possess arms. It may
be said to resemble a large pair of pincers with horseshoe-shaped
blades. A screw may be attached at the extremities of the handles,
for the purpose of bringing the blades in contact, or the hands may
be used : the former would be, I think, preferable, as the force could
be applied gradually, and not be likely to be carried too far. It may
also be employed in grown-up children, when the bones are so widely
638 ORAL DISEASES AND SURGERY.
separated as to render it difficult to get soft parts enough to close the
opening, but in a gradual manner and at intervals more or less pro-
longed, according to the amount of pain it excites. If it were used
suddenly it might produce inflammation, and subsequently abscess,
which would prove troublesome to treat. From the foregoing it
will be, I hope, understood that the younger the child the safer the
operation is likely to prove, and that even in grown-up children it
may be adopted, with precaution, with decided benefit.
" The pads and the ledge to rest the teeth upon should be made
to slide in the sides of the clamp : the former, that the pressure may
be directed on any part of the bones ; the latter, that the edges of
the teeth may rest on it, without the pressure being directed either
too high or too low, but at the point where the palate-bone joins the
superior maxillary."
"We pass here to the consideration of the treatment of the fissure
in the soft palate. This operation is known as staphyloraphy, a
term derived from two Greek words, which signify suture of the
uvula. As generally practiced, it is rather difficult of performance,
and so frequently unsuccessful that surgeons seem disposed to avoid
the responsibility of it. I propose here to suggest for consideration
a new mode of performing the operation, which renders the manipu-
lations as easy of accomplishment as by the old mode they are
tedious and difficult.
Prei^aration of the Patient. — For weeks before it is designed to
perform this operation, preparations are made for it, by subjecting the
parts to such daily manipulations as shall educate to forbearance
the natural sensibility of the fauces. Without such preliminary
manipulation, the retchings and spasmodic twitchings would be
such as to render a proper performance of the operation almost an
impossibility. With such education, the parts will be found to
assume, in a reasonable time, a stoical indifference to even quite
severe irritants. This forbearance is secured by roughly fingering
the part daily. I think it is not amiss to occasionally pass the
point of the tenaculum through the parts to be operated upon. I
never knew the trifling wound to give any trouble ; and the double
advantage is gained, if the part be put on stretch, of securing an
estimate of the capability of the velum to be brought to the mesial
line, — an important item in the operation, as will be easily appre-
ciated. Some surgeons are in the habit of daily tickling the parts
with a fine brush ; this, I should suppose, would answer a very
PALATINE DEFECTS AND THEIR TREATMENT. 639
good purpose. A very admirable idea, and a most successful one,
is to have made an obturator,* which shall extend back to the palate
border, or nearly to it. This is to be placed in the mouth, and as
soon as the irritability it produces is so far overcome as to permit
of its permanent retention, the bands attached to it are to be clasped
firmly about the necks of the teeth, and it is worn continuously for one
or two months. When the parts have thus submitted to the presence
of an obturator, they will be found quite ready for any operation.
On the evening before the day of operation let a saline cathartic
be given the patient — particularly if he is robust and strong. The
meal immediately preceding the performance should, I think, always
be a substantial one, for it is to be remembered that the patient is to
have little to eat for some time.
In operating on the depressed and anaemic patient, let his defici-
ency in vital forces be first considered, and, as far as possiljle, let it
be corrected. If such attention is neglected, we will be almost sure
to make a failure : the parts will not unite. Exercise in the open air,
generous living, and the iron tonics may be prescribed. To sum all
up in a single sentence, the preliminary treatment must meet the in-
dications of each particular case. If, for example, you should operate
on a scorbutic patient, or a patient disposed to purpura, without cor-
recting such dyscrasis, you would be no more likely to gain union of
the parts brought together than in an operation on the cadaver.
The surgical anatomy of the part is required fully to Ijc under-
stood. So much of success depends on a thorough knowledge of the
muscular relation to the cleft that such acquaintance would give a
success where otherwise a failure would be sure to result. This
anatomy we may study before taking up the steps of the operation.
To get a correct idea of the soft palate, we should commence the
study of it, by first carefully examining the parts on the living sub-
ject. When we look into a living mouth, we see an arch stretching
from every portion of the alveolar edge backward and inward, to-
ward the fauces, terminating in a tongue or uvula, pendant in a
horizontal direction from its center. One-half of this arch is seen to
be fixed, the other— the posterior half— is seen to be in almost con-
stant motion. If, now, the finger is carried into the mouth, the
fixed part is found to correspond with the boundaries of the palatine
faces of the maxillary and palate bones ; that is, for a certain ex-
A description of tliis instrument and of its proper use will hereafter be
jTiven.
640 ORAL DISEASES AND SURGERY.
tent, you feel that the parts are solid, as if the fing-er passed over an
arch of bone which might be covered alone by mucous membrane ;
and this is in fact about the case. The finger traverses the anterior
bony border of the mouth, or the hard palate. As now the finger
is passed backward, it falls over a hard ridge upon parts that are
soft and yielding ; this hard ridge is the posterior face of the palate-
bone, and terminates the hard palate. The part upon which the
finger has fallen is the veil or soft palate, the part that was observed
to be movable. This is the part in which occurs the rent, or cleft,
for the cure of which is demanded the operation we are about to
consider.
The mobility of this part, which pertains to its function, depends,
as may be anticipated, on an associated muscular structure. To
study properly this structure, which is all-important to be practically
understood and appreciated, the student should take up the scalpel
and pass to the cadaver ; it is, perhaps, only by dissecting that a
really satisfactory idea of these muscles can be secured, — that is, as
pertains to that kind of knowledge which gives confidence when we
come to perform operations upon the part.
The external coat or covering which we see on every mouth,
living or dead, is the mucous membrane ; simply the continuation of
that which covers the hard palate ; but while in the case of the hard
palate we find all the underlying structure osseous, in the soft palate
we discover this deep tissue to be made up exclusively of muscular
tissue — at least as far as a surgical anatomy is concerned, or as it
alone serves our purpose here to study it.
Commencing with the mesial line, we can dissect out the attach-
ment of five muscles, each of which is of course duplicated on the
opposite side, and each of which has such relation to this mesial
line that, in case of cleft or split, it serves more or less to draw away
the parts postero-laterally.
These muscles, mentioned in the order of their signification to this
lateral displacement, and consequently in their relation to the opera-
tion of staphyloraphy, are tensor palati, palati glossal, levator palati,
palati pharyngeal, motores uvulse. But of all these muscles the tensor
palati plays the most important part, and is therefore entitled to
closest consideration.
This muscle arises from the scaphoid fossa at the root of the in-
ternal pterygoid plate, from the anterior surface of the Eustachian
tube, and from the spinous process of the sphenoid bone. If you
carry your finger (in your own mouth) back to the wisdom tooth of
PALATINE DEFECTS AND THEIB TREATMENT. 641
the superior jaw, and let it drop over and back of this tooth, it will
fall on the tuberosity of the maxillary bone ; carry it now half an
inch farther back, and it will come to a second prominence ; this is
the haniular process of the pter^-goid plate of the sphenoid bone.
Now, the tensor palati muscle descends from the origin of which we
have just informed ourselves, and meetijig this hamular process, it
winds— as a tendon — around it, and then, by a fanlike expansion,
spreads itself over the soft palate. Its action is evident: it expands
the palate laterally.
To perform successfully the operation for cleft palate, it is per-
haps desirable, in every case, that the strain made by this muscle
should be taken off. A moment's reflection will show us that the
action of the muscle, in case of a cleft, would, when the parts were
brought together, be much increased over its natural capability, not
only because it would be put considerably on the stretch, but be-
cause such stretch would, more than likely, excite it to a spasmodic
contraction. The muscle of course is then to be divided ; and we
may as well here, as anywhere, consider the easiest point at which
such preliminary operation can be done.
We remarked of the muscle that it would be found winding — as
a tendon — around the hamular process. It winds from the back,
and outwardly, inward, and forward, so that just in front of the
process, between it and the tuberosity, is the place at which its
section may be best performed ; there are here no important vessels
to be wounded, if we except the posterior palatine artery and nerve,
and they hug the base of the tuberosity so closely that it would, I
think, have to be a very badly managed knife that should interfere
with either of them. The cut should be a little oblique. The inter-
ference with function, as in most cases of myotomy or tenotomy,
would be of course but temporary. The action of the muscle would
be found recovered quite as soon as our cleft operation would be
ready for it.
The next most important muscle is the palato-glossal ; this is sim-
ply the anterior half arch, the constrictor isthmii iaucium. It arises,
as will be seen, from the soft palate on either side of the uvula, and,
passing outward, is inserted into the sides of the tongue, blending
with the fibers of the stylo-glossus muscle.
The palato-pharyngeus arises from the soft palate, by an expanded
fasciculus, and, passing outward, goes to be inserted into the poste-
rior borders of the thyroid cartilage. These muscles constitute the
posterior half arches. Section, both of the palato-pharyngeus and
41
642 OEAL DISEASES AND SURGERY.
the palato-glossal, is to be made through the substance of the
muscle, and is accomplished simply by nicking, somewhat deeply,
the arches — four cuts, one to each arch. These nicks are best made
with scissors.
The Levator Palati. — This muscle arises from the petrous portion
of the temporal bone, passes into the interior of the pharynx, and
then descends obliquely downward and inward, spreading its fibers
out over the posterior surfaces of the soft palate as far as the raphe.
The action of the fifth and last muscle, the azygos uvulae, it is per-
haps not absolutely necessary to consider — its influence, for separa-
tion of the wound, being very trifling.
Section of the levator palati is thought to be easiest of perform-
ance after the manner suggested by Mr. Pollock. This gentleman
first puts the flap on stretch, and then, with a double-edged knife,
makes an incision through the soft palate just on the inner side of
the hamular process. The handle is now alternately elevated and
depressed, a sweeping cut being made along the posterior surface of
the soft palate.
The other anatomical elements of the soft palate are glandular
structures, vessels, nerves, etc., all associated, more or less inti-
mately, by connective tissues ; but these need not be particularly
referred to, as one could not well dissect out the muscles without
necessarily familiarizing himself with them. Thus, then, we under-
stand the surgical anatomy proper of the parts — the anatomy as it
has relation to cleft palate.
The operation of staphyloraphy was first practiced by a dentist of
Paris, La Monier, — if I remember the name rightly. It has for its
object the bringing together of the separated portions of a cleft soft
palate, and the retention of the parts in apposition until nature shall
unite them.
The operation consists of four difi'erent stages, with an object to
be attained by each stage :
1st. The paring off of the edges of the cleft.
2d. The introduction of ligatures.
3d. The bringing together of the freshened edges, and fixing the
ligatures.
4th. The relief of any tension on the ligatures that may attend the
approximation of the parts.
These are the steps or stages, and to accomplish them various
means and instruments have been devised — some good, some bad,
some indifferent. The reader curious in such matters will find an
PALATINE DEFECTS AND THEIR TREATMENT. 643
admirable and most instructive chapter on the subject in the System
of Surgery, published in 1851, by Professor H. H. Smith of the
IJniversity of Pennsylvania. In the chapter therein devoted to
staphyloraphy is given a synopsis of the operations as practiced
by surgeons whose names have been and are particularly associated
with the subject.
An epitome may be made of this chapter by noticing that the oper-
ation first suggested by La Monier, in 1764, was revived by Graefe,
of Berlin, in 1817, but first methodized and puldished, with the rules
for its performance, by Roux, of Paris, about 1819. In 1820 a nearly
similar operation was performed by Dr. John C. Warren, of Boston,
he being at that time ignorant of the views or operations of other
surgeons. In many respects the steps proposed by Drs. Warren and
Eoux correspond, though the means suggested by Dr. Warren are
simplest — the operation of the latter being, however, generally re-
garded as the basis of the various modifications that have since per-
fected the proceeding.
The instruments prepared by Roux for performing the operation
are alluded to as being sufficiently complicated. To execute the man-
ipulations, he seated his patient before a strong light, with his head
thrown back and supported against the chest of an assistant— the
mouth being kept widely open by means of a cork placed between
the molar teeth. The surgeon then placed himself in front, and,
with forceps held in the left hand, seized the right lip of the fissure.
With his right hand armed with a needle-holder, he next introduced
the point of the needle from before backward behind the uvula, in
order to traverse the flap from behind forward, at three or four lines
from the free edge of the fissure. The needle, being thrust in as far
as its head, was then freed from the needle-holder, and seized at its
point by forceps, which drew it and the ligature through into .the
mouth. After permitting a few minutes of rest to the patient, the
same manoeuvre was practiced on the left side of the fissure with the
other needle of the same ligature, the two ends of which were thus
brought out into the mouth. In passing these ligatures, M. Roux
commenced with the lowest, next passed to the highest, and ended
with the middle.
The next step in the operation of Roux was to freshen the edges
of the fissure. This he accomplished by seizing the margins, as be-
fore, with his forceps, and paring from behind forward.
To tie the ligatures, this surgeon commenced by knotting the mid-
dle one with the fingers, and, after making a simple knot, confiding
644 ORAL DISEASES AND SURG ERF.
it to an assistant, wlio hold it with an instrument termed by the
French a serre-noeud (knot tier) ; he then passed on to the second
ligature, and from that to the first, drawing them tighter than is
necessary to approximate the edges of the wound, in order to pre-
vent any separation. Eating, drinking, and speaking were inter-
dicted the patient for from two to three days, the ligature being
removed on the third or fourth day, excepting the lowest one, which
was allowed to remain twenty-four hours longer than the other.
Dr. John C. Warren performed the operation as follows. The
patient being well supported and secured, a piece of wood, an inch
wide, a little curved at the end, and with a handle to be held by an as-
sistant, was placed on the molar teeth of one side, to keep the mouth
open. A sharp-pointed curved bistoury was then thrust through
the top of the palate, above the angle of the fissure, and carried down
on one edge of the cleft to its extremity, and the same was done on
the opposite side, so as to cut out a piece in the form of a letter Y,
including about a line from each edge. Next a hook, or curved
needle, fastened in a handle, with an eye on its extremity, and a mov-
able point, armed with a triple thread of strong silk, was passed
doubled into the mouth through the fissure behiud the palate, and
the latter pierced by it one-third the length of the fissure from the
upper angle of the wound, so as to include about three lines of the
edge of the soft palate. The eye, with the ligature, being seen, was
seized with a common hook and drawn out. The eyed hook was
then drawn back, turned behind the palate, and the other edge trans-
fixed in a similar manner. A second and a third stitch was now passed
in a similar manner, the third being as near as possible to the lower
end of the fissure. Then, seizing the upper ligature with the finger,
the knot was tied without using a serre-nceud, and placed on one
side of the wound in order to prevent its pressing on the fissure, the
other being tied in like manner, and the fissure closed.
After the first operation of Dr. Warren, Dr. A. H. Stevens, of
New York, September, 1826 — see North American Medical Jour-
nal, vol. iii. p. 233 — operated successfully, by first inserting the liga-
tures and then paring the edges.
In 1827, Dr. Mettauer, of Yirginia, operated for staphyloraphy,
and in 1837 published an excellent essay. Dr. M. employed leaden
ligatures : see American Journal of Medical Science, vol. xxi. p. 309.
Allusions are made in this chapter to other operators and opera-
tions; but, as they are all only modifications of the methods of Roux
and Warren, it is not necessary to refer to them.
PALATINE DEFECTS AND THEIR TREATMENT.
645
Several years back I remember having in my possession a mono-
graph on the subject of staphyloraphy, from the pen of the late Pro-
fessor Miitter. I regret that I cannot now lay my hands upon it.
Dr. Miitter was much interested in the operation, and his pamphlet,
as I recall, abounded in cases illustrating his success in this direc-
tion.
To Mr. Fergusson, of England, however, more than to any other
man, are we perhaps indebted for a scientitic appreciation of the re-
quirements in staphyloraphy. The cutting and sewing parts of the
operation are simple mechanical manipulations, which are of conse-
quence only as they tax the ingenuity of the surgeon. The proper
surgical understanding of the subject consists, as we are prepared to
see, in a just acquaintance with the muscular relations of the parts.
These relations we have already studied. To Mr. Fergusson belongs
the credit of first making these demonstrations. It is very true that
before his time incisions in the soft parts had been advised. Roux,
Dieffenbach, Mettauer, Liston, and Warren all practiced them where
difficulty was met within approximating the fissure; but the incision
practiced by them, as remarked by Mr Fergusson, seems to have
been without reference to the anatomy of the parts, and, as a conse-
quence, rendered success somewhat a matter of accident. The oper-
ation of Mr. Fergusson, so far as the paring and bringing of the
fissured parts together are concerned, is about the same as that prac-
ticed by Dr. Warren. He pares the cleft before inserting his sutures,
and his knots are made about as Dr. Warren's.
In looking over the history of staphyloraphy, the reader will be
struck with the likeness in complaints, the three principal of which
seem to be — the difficulty in tying the ligatures, the great tendency
of the ligatures to slough out after they are once nicely secured,
and the concealment of the parts during operation, both because
of deficiency in light and the accumulation of the viscid muco-saliva
which in mouths thus affected is secreted in such abundance.
Now, in the direction of operations in and about the oral cavity
I have had that experience and that practice which will, perhaps,
justify me in asserting that there is an easier and more philosophi-
cal mode of performing the operation of staphyloraphy than has yet
been practiced. To sit in front of a patient and operate in the mouth
is most unhandy. The operator is in his own light; besides, it is
certainly much more difficult to operate sitting than standing— mo-
tion is cramped, freedom is interfered with. To operate on the
mouth of a patient, when the surgeon is seated in front, makes
646 ORAL DISEASES AND SURGERY.
necessary an assistant, whose office it is to manage the head. This
has a twofold objection. In the first place, the assistant cannot fol-
low in all those little changes which are so necessary to success.
He docs not see quickly the shiftings and turnings which so assist
in the manipulations. Again, one is more naturally ambidextral
when the arms are supported than when they are unsupported. In
operating by sitting in front of a patient, the surgeon must work at
arm's length ; he has nothing to steady him — no guard which shall
enable him to shield himself against any sudden awkward movement
on the part either of the assistant or the patient.
To make a knot in a deep canal, such as the mouth or vagina, is
not easy. To fix a ligature by compressing something upon it
is very simple. Silk acts as an irritant to human tissue-^silver
or lead does not ; therefore, where it is desirable to retain a liga-
ture for several days or weeks, without irritation, metal is best
adapted.
Instruments perfectly suited to an operation simplify it greatly.
Predicating an operation on these self-evident truths, I commend
the following as the best and easiest mode of manipulating, believing
that where once practiced it will take precedence of all other modes.
The instruments required are those belonging to the ordinary
vesico-vaginal case, — the long-handled knife, needles, and needle-
carrier, shot-carrier and compressor, tenaculum, cutting forceps, sil-
ver or lead wire, the little perforated flat shot of McLean, and mop
sticks. Better instruments than these for the operation of staphylor-
apby will not, I think, ever be devised. The instruments arranged on
a tray in the order in which they are to be used, the patient, having
the steps of the operation explained to him, — for much is expected
from him, — is seated on a chair having a movable head-rest ; it is well
if this rest moves in a ball-and-socket joint — at any rate, it must be
movable backward and forward. The ordinary dental chair answers
the purpose admirably. When the head is placed on this rest the
mouth will be found to look directly upward. The surgeon now
takes his position back of the patient, standing on a footstool of
such height that his breast shall be brought on a level with the
head of the patient. If the reader is disposed, he can thus seat a
friend, and, taking a position back of him, by leaning over his head
he will find that when the mouth is opened he not only has a most
perfect view of a thoroughly lighted cavity, but by leaning against
him, and passing his arms around the head so as to bring the hands
to the mouth, he will recognize that, besides having h-is own arms so
PALATINE DEFECTS AND THEIR TREATMENT. 047
steadied as to allow of the easiest manipulation, he has the move-
ments of the patient completely under his control.
Now, this relative position of the surgeon to his patient gives him
not only the advantages enumerated, but he is out of the way of all
expectorative efforts. If saliva and blood should accumulate about
the parts at which he is working, he -can and will, almost uncon-
sciously, and certainly Avithout effort, so turn the head that, while
he does not at all interfere with his own manipulations, he throws
the fluid into some more convenient part of the mouth. This, I
know, can be done so readily that each step of the operation may
be accomplished without the annoyance and delay experienced in
using the mop. Certainly, a patient so held cannot make any move-
ment too quickly or too unexpected for the surgeon. True, he might
be so obstreperous that the operation could not be accomplished ; but
he could not make any movement which the knife of the operator
could not naturally follow, and, therefore, any accidental harm could
not be done.
Patient and surgeon thus in position, the tenaculum is taken up
and carried through the very point of the cleft pendulum. The
part is then put on stretch, and a paring of about a line taken from
the whole of that side, cutting from behind forward. The manii)u-
lation is Repeated on the opposite side. The first stage completed,
tincture of iodine, diluted to about one-tenth its officinal strength with
wine or water, is given the patient with which to gargle and wash
the mouth. This I find to cleanse the mouth adniira])ly ; besides, it
is a fine healthy stimulant.
The bleeding arrested and the patient a little recovered, the second
step of passing the ligature may be attempted. Take up one of the
curved needles, and, threading it with the silver wire, fix it in the
needle-carrier. Passing now the instrument into the mouth, thrust
the needle through one side of the cleft, about three lines from the
margin and about half an inch from the apex of the cleft or hard
palate. After passing it to the point at which it is held by the
carrier, it is to be caught by the forceps and brought through, the
slide of the porte being loosened so as to permit of such withdrawal
of the needle from its beaks. This accomplished, the needle is to
be replaced in the porte and carried through the opposite side ; re-
lieving it from the grasp of the carrier as before, the two ends are
brought from the mouth and their relation secured by one or two
twists. This completes the first ligature. A second is now passed
half an inch farther on, also a third, or more, as may seem needed.
648 ORAL DISEASES AND SURGERY.
The manipulations required are of course the same as for the first.
This completes the second stage, and the patient is allowed to rest
as before. If he needs to wash his mouth, the surgeon must look
carefully after his ligatures.
The third stage, or approximation of the edges, is next to be
accomplished. Take up the shot-carrier, and, slipping through its
fenestra the twisted ends of the first ligature introduced, push the
carrier down the wires, and you will find, as it approaches the palate,
the edges of the cleft approximate. This I think will always be
found to be the case wnth the ligature nearest the hard palate : the
parts come together very easil}^ You now slip off the carrier and
take up one of the perforated shot ; put this on the wires, and with
the carrier force it down to the palate. Holding it now in place,
which is done simply by laying the wires against the carrier and
shifting your finger over it, take up with the right hand the forceps,'
and compress the shot tightly upon the wires. The parts up to this
ligature will now be found nicely approximated and fixed. This
completed, repeat the operation on the second ligature. But this
will be found, pcrhajjs, impossible, without greatly overstraining
the parts and risking the tearing out of the wire.
If this is the case, you at once desist from the attempt, and make
the section as described of the tensor palati muscles on either side.
Now most likely the parts will come together comfortably: if so, fix
them with the shot as before ; if, however, an approximation has
not yet been secured, nick the anterior half arch ; and if this does
not suffice, cut the posterior and the levator palati ; the ligature may
then be fixed, as well as those still farther back. Each shot firmly
compressed, the wires are to be cut off as closely as possible. Thus
the third and fourth steps of the operation are completed, and
nothing remains but to enjoin on the patient the most perfect rest.
Herein lies half the secret of success : the patient should scarcely
move for two or three days; certainly he should not be permitted
any food that would demand for its comminution the slightest effort
of mastication. He should be directed to allow the liquids he may
take to trickle down his throat, rather than to attempt to swal-
low them. These restrictions need not, however, be made quite
.so strict, if in the operation myotomy of the half arches has been
performed.
In the old mode of performing the operation, it was found neces-
sary after the first one or two days to remove the ligatures because
of their tendency to slough out: the use of silver wire obviates this
PALATINE DEFECTS AND THEIR TREATMENT.
649
necessity, as the metal seems to provoke no iiiflammation. These
ligatures may therefore, if they seem useful, be allowed to remain
from one to three weeks. This non-irritating quality of the metal
ligature is so marked that I have seen them, when applied on vari-
cose veins, as firmly fixed after four months as the first day they
were put on. This is the feature which adapts them so admirably
for sta])hyloraphy.
The wounds made in dividing the muscles may be left to nature.
If the patient is in condition for the principal operations, he is
in a condition which does away with any necessity for care in
trifling flesh-wounds ; if, however, any trouble should arise in such
a direction, the practice would be that which would apply to similar
wounds, however made.
It is seen that the manipulations here suggested for the cure of
cleft palate are precisely the same as those practiced in vesico-vaginal
fistula, and that the instruments adapted to the one are exactly suited
for the other.
The position in operating is, I think, a new suggestion, and is
founded on a somewhat extended experience in manipulating upon
and about the mouth. To me it seems the most proper position for
performing the operation easily and comfortably ; the advantages
which it possesses over the old mode of sitting down in front of the
patient are so easily studied upon the person of any one, that I trust
the suggestion will receive the attention I think it will be found to
merit.*
With this consideration of cleft palate proper, we may pass to the
study of other defects of the parts.
Holes in the Palate. — Breaks in the continuity of the palate
maybe treated in two ways: either by an operation strictly sur-
gical, as reference may be had to the use of the knife, or by means
which might be denominated surgico-mechanical. If the knife is to
be exclusively used, we have simply to pare the edges of the break,
and then get the parts in apposition as best we can. Herein con
sists the difficulty of such operations; and the tact and knowledge of
the surgeon will prove his best guides. If the breaks are in the
soft palate, any resistance that may be met with is to be overcome
precisely as we would overcome it in staphyloraphy: let the sur-
geon consider what muscle or muscles oppose him, and divide them
as before suggested ; or, if myotomy seems scarcely necessary, he
* These manipulations were first practiced and described l»y mo in 1801.
650 ORAL DISEASES AND SURGERY.
can in all probability accomplish his purpose by making lateral slits
through the raucous membrane alone, or otherwise he may go a
little deeper, making a kind of semi-myotomy.
If the break is small, one ligature will perhaps be all that is neces-
sary to secure the approximation of the pared edges; this suture
is to be made and fixed precisely as in the previous operation If
more than one suture seems indicated, of course, two, three, or more
are to be employed.
Defects in the hard palate are also amenable to surgical skill :
they may be remedied by the use of the knife and stimulating local
applications, or, if these fail, an artificial palate, properly constructed,
will so admirably supply the deficiency that the patient is rendered
almost as well oif as his fellows.
Using the knife alone, most successful results are frequently at-
tained by first paring the edges of the break and afterward dis-
secting the parts freely from the bone. This mode of operating is
admirably suited to such hard palates as have a thick, soft, mucous
membrane. By such a mode of operating, and with such a mucous
membrane, quite wide chasms may be easily spanned.
With mucous membrane of this character, plastic operations will
be found to answer very well. It is quite easy to get a flap without
disturbing the periosteum, and such a flap may be twisted on its
pedicel without any special interference with its function. The
pedicel, however, should be as wide as possible, remembering that
the circulation pertains to the basement membrane alone. An" ob-
jection, however, to such operations in the mouth is the difficulty
that attends the fixing of the flap in its new place.
The next mode of relieving these defects that may be alluded to
is that originally suggested by Dieffenbach. This surgeon com-
mends the penciling of the edges of the break with tincture of can-
tharides, hoping thereby to excite granulation to an extent that shall
fill up the cleft.
Now, while this does very well for small holes, it seldom succeeds
with the larger. The granulations, having nothing to support them,
break down before connecting in the middle.
This defect in the treatment can be remedied, and success almost
warranted, by the following modification : make a simple obturator
or artificial palate ; the mode of doing which is described in the^
following chapter. After fitting this so as to cover accurately every
portion of the hard palate, it may be removed, and the cleft pared ;
next touch the parts with cantharides or tinctm*e of iodine — the latter
PALATINE DEFECTS AND THEIR TREATMENT. G51
I prefer. The plate is now to be replaced, and will be found to act
most completely as a support to the granulations which will be
formed. The process of freshening the edges is, of course, to be fre-
quently repeated ; but after the first paring the cuts may be made
from the circle on, and not around, the cavity.
The next class of palatine defects which claim our attention are
such as require for their relief a surgico-mechanical treatment. This
brings us to the subject of the Obturator, — an instrument whose
style, form, and manufacture are of the same interest to the surgeon
as are those of the Pessary to the obstetrician.
I
CHAPTER XL I.
OBTURATORS.
The instrument, or plate, called an obturator, gets its name from
the Latin verb ohturo, and signifies a something that shall close
or stop up an entrance or break. Thus, after the operation of tre-
phining, it is not uncommon to shield the exposed brain against risk I
of accident by fitting a silver plate over the site of the removed bone ;
and this shield is, to all intents and purposes, an obturator ; it closes
the break in the continuity.
In the treatment of palatine defects, obturators may be employed j
with the greatest success ; the range of their application is really I
wonderful. I have seen one case, at least, where the whole side of
a face has been so completely restored through such instrumentality, ,
that a passing observer would scarcely, I think, have remarked any- I
thing amiss with the wearer.
In the consideration of the more strictly surgical treatment of pala-
tine defects, we studied the operations which suggested themselves
as being the most effective and promising. It is not, however, as
we will find, every patient who is willing to submit to an operation;
and it is not, on the other hand, as we are prepared to understand,
every case that is fit to be operated upon. To leave either class of
persons to their fate would be as cruel as it would be unnecessary ;
it is here, therefore, we may so happily resort to the means known
as the surgico-mechanical.
As obturators are to fulfill various indications, so, of course, do
the}" vary in form, style, and method of manufacture. The simplest
obturator is one made to cover a break, more or less extensive,
in the hard palate proper, — that is, a break which does not impli-
cate either the alveolar borders or the soft palate. Such an obtu-
rator holds the same relative position to obturators in general that
the Physick-Dessault apparatus holds to all apparatus for thigh-frac-
tures. Both may be termed principals, and all variations are but
modifications of these principals. Thus, if we appeciate the style,
indications met, and mode of manufacture of a simple obturator, we
( 652 )
OBTURATORS.
653
understand fully the genius of the instrument, and are thus enabled
so to appreciate the mechanism of the piece that we will be prepared
to diminish or enlarge its capacity jwo re nata.
A patient presents himself to us suffering under a deficiency in the
hard palate. We examine the case, and find the walls of the break
so heavily and solidly indurated that we perceive at once that any
attempt to pare and bring the parts together would be futile. Palato-
plasty at once, and naturally, suggests itself, but observation of the
surrounding parts convinces us that the risks are too great for the
good promised. Such is a case that not unfrcquently offers itself to the
surgeon's judgment. Dieffenbach, whose name is so honorably asso-
ciated with oral surgery, evidently found himself much embarrassed
with just such cases — cases which I would here present as the easiest
of remedy by use of the obturator. It was Dieffenbach, it will be
remembered, who suggested the stud of india-rubber. Two pieces
of rubber the thickness of pasteboard were cut three or four times
larger than the opening to be closed, and between these was placed
a small round piece ; the whole was then securely fastened together
by means of waxed thread ; one of these pieces was intended to rest
on the posterior and the other on the anterior surface of the opening;
the small middle piece was for the intermediate space.
A moment's reflection will exhibit the inconveniences as well
as the more striking faults of such an appliance. The rubber, unless
it was vulcanized (and to be so applied, it could not be vulcanized),
would soon become very offensive. It would act as a continual
source of irritation, and particularly so far as the posterior base of
the cleft is concerned. The center piece, which, to hold the parts
with any degree of steadiness, would have to fit the opening with
some degree of accuracy, would, because of the presence of moisture
and heat, soon expand, thus enlarging the canal. It would be very
inconvenient to remove for the purpose of cleansing, which cleans-
ing it would certainly demand daily.
A case amply illustrative of the inefficiency of this mode of
treating palatine defects, and, indeed, of the absolute harm resulting
from it, is recorded by Dr. J. H. McQuillen, in the Denial Cosmos.
The patient, who had an opening in the palate, the result of syphilis,
was treated by Dr. Xeall, who employed, in the first instance, india-
rubber as a substance from which to construct an obturator. This
was cut somewhat in a button shape, being large above and l)elow,
and contracted in the center, thus constituting an apparatus which
was retained in position by resting on the floor of the nares, sur-
654 ORAL DISEASES AND SURGERY.
rounding the orifice. After it had been worn a week or two, the
patient returned, when it w^as found quite loose and the orifice some-
what enlarged, the rubber having acted as a source of irritation and
induced absorption. Another apparatus was formed from the same
material, and, after being worn a week or so, the orifice was found
much larger than at the previous meeting. The rubber was also
found considerably affected by the fluids of the mouth. Satisfied
that it would not answer the purpose intended, this material was
abandoned, and a simple obturator of silver was constructed, cover-
ing the orifice and roof of the mouth. This was found to fulfill every
indication.
There is another, a somewhat domestic treatment for these defects,
which I may here allude to. This consists in stuffing the break with
cotton or wool. The cotton not unfrequently escapes into the throat,
or, passing into the nares, it has sometimes produced ozasna by lodg-
ing among the turbinated bones : quite extensive necrosis of these
bones has also been provoked in this way. The practice is not
without its danger.
A case of a different class, yet belonging to the same category so
far as treatment is concerned, invites, in connection with the consider-
ation of simple obturators, a moment's attention. This is the existence
of a cleft or break associated with subacute or chronic disease — the
cases to which we allude as not being fit for operation.
Some time since, Mr. , a French teacher of this city, had ne-
crosis of the palatine arch, the result of venereal disease; the se-
questrum that came away was quite large, producing a break in the
continuity of the hard palate at least an inch in diameter, of course
freely exposing the nares. The result was, as might be anticipated,
that his vocation as a teacher had at once to be relinquished.
I saw this case, in consultation with the attending surgeon, about
a month after the patient had resigned a situation which he held in
one of our principal private schools, and upon which, up to this
time, he had mainly depended for his income. The necessities of
the man w^ere, of course, immediate, and any operation for the resto-
ration of his speech was out of the question. I had the happiness
of relieving him of his trouble so perfectly after three days, by the
use of an obturator, that every time he has since met me he has
laughingly assured me that he speaks much better English than
before his accident. It is certainly true that he speaks quite as
well.
The obturator for these cases consists simply of a metal plate
OBTURATORS. 555
that shall fit accurately eveiy part of the hard palate, tiie regu-
larity of the arch to be restored by carrying the plate over the cleft
or break. Such a plate should fit with the greatest nicety, and is to
be held in place either by bands placed around certain of the teeth, or
otherwise by means of atmospheric pressure. The first plan of fast-
ening the piece should be employed when disease is associated with
the cleft. The latter is well adapted when the break is not too large,
and where all disease has long passed away. To make such an ob-
turator, first take an ordinary impression cup, such as is employed
in taking casts of the mouth. This cup is filled with ordinary bees-
wax, softened before the fire to the consistency of dough. Thus pre-
pared, the operator takes his position behind the patient, as recom-
mended in the operation of staphyloraphy. The cup is now to be
introduced carefully into the mouth, and carried just so far back as
will allow of the teeth being included within the arch or rim of the
cup. This accomplished, cup and wax, in a body, are to be pressed
firmly up into the roof of the mouth and around the neck of the
teeth and alveolar border. The patient holding the mouth very
wide open, the mass is to be removed even more carefully than it was
inserted. This manipulation, if properly executed, gives us the
exact impression of the mouth. The next step is to make a model.
To do this, we take the impression we have just obtained, and, sur-
rounding it with a rim of paper, the rim to be, say, one and a half
inches in height, we stir into water the common calcined phistfr —
sulphate of lime — until we have a very thick, creamy paste. This
paste is poured into the impression, and should be enough to fill
from the wax, which lies at the bottom, up to the top of the rim.
The model thus made is not to be disturbed for three or four hours ;
it must have time to set.
The next step in the operation is to remove, from about the plaster
cast we have just made, the paper and wax. This is accomplished,
first, by heating gently the cup in which the wax lies, which per-
mits of its easy removal ; and next carefully trimming from about
the necks of the teeth, by means of a knife-blade kept constantly
warm, the wax which so closely surrounds and imljcds them; in
this way the wax may all be safely taken away. The paper is, of
course, simply to be torn away, and this is done before removing
either cup or wax. Comparing the face of the model thus made
with the mouth from which the impression was taken, we shall find
we have its counterpart to the minutest particular.
As the model contains the break in the urch, and it is our inten-
656 OBAL DISEASES AND Si^EGERY.
tion to restore this arch to its original and natural contour, so is it
at this step in the procedure that we can best secure our object.
This, I think, is most easily done by taking a little ball of warm wax,
and filling with it the hole or break in the model. The natural con-
cavity of the arch is in this way restored. Of course this is not at
all difficult, nor is there any guess-work about it, as we hare the in-
clinations of all the surrounding parts to guide us, and all we have
to do is simply to model this wax to the proi)er curve.
The cast is finished by beveling.the portion which rested against
the paper ; this beveling to be so done that the greatest diameter of
the model shall be its base.
This completes the model to which the obturator is to be made.
The next step is the preparation of dies. These are to be made,
one of zinc, the other of lead ; and the process of getting up such
casts is precisely the same as that adopted by the dentist or the
moulder.
Procure a circle of tin: a common tin cup, with the bottom broken
out, answers the purpose well enough. Lay the model you have pre-
pared upon the table, the palate face looking up. Now place the
circle of tin over it, and with some moulder's sand, veiy fine, which
you have previously moistened and tempered, cover in the model,
packing and filling the circle completely. Now turn the circle or
cup so that the base of the cast looks up. Next a penknife-blade or
small gimlet is to be inserted into the plaster, and by striking it
several light taps the cast will be loosened. It is now to be lifted
from the sand by means of the knife-blade. Thus we have a mould
for a metal casting. The next step is the making of such a cast.
To do this we have only to melt one or two pounds of common
zinc, in any convenient vessel, and pour it slowly into the mould.
This done, let the whole remain undisturbed until completely
cold.
Tims, it is seen, we have prepared, with little or no labor, a cor-
rect model of the mouth in metal. It is to this zinc model we are
to fit and adapt our obturator. Now, this latter process is easy or
difficult, according as one goes about it. One method is to take
hammer, files, and pliers, and cut, file, and mallet, until the adapta-
tion is secured. Such a task is almost as hard as was the cleaning
of the Augean stables ; besides, it is next to an impossibility to
accomplish it properly. A second plan, and one which is as easy,
simple, and interesting as the other is difficult, perplexing, and
annoying, consists in making a counter model in lead, between
OBTURATORS. 657
which and the model, or male cast, the plate or obturator is to be
struck up. This counter model is very easily made, as follows:
Take the zinc cast and lay it upon the table, with the face or pal-
atine surface looking up ; lay over it the cup or circle, precisely as
in the case of the plaster model. Now, with the sand moistened as
before, fill up the cup covering in the cast — packing the sand as solid
as possible. Next, without disturbing the cup as it rests upon the
table, take a knife and dig away the sand until you expose the face
of the cast. You are now prepared to make the counter model.
Take a vessel, not the one in which you melted th(! zinc, and place
in it two or more pounds of lead; when melted, pour this over the
face of the zinc cast, filling up to the very top the hole which you
have dug out in the sand. When the lead has become cool, take the
castings from the sand, and, with a hammer, the two can be easily
knocked apart.
To make the obturator, by means of these dies, we next proceed
as follows : a piece of thin sheet-lead is forced with the fingers over
the face of the zinc cast; with a sharp and delicate-bladed knife this
lead is cut so as to cover accuratel}^ the hard palate, being even fes-
tooned so as to adapt itself accurately about the necks of all the
teeth. This palate of lead being thus nicely and correctly fitted to
the parts, it is taken off the casts and carefully spread out. Next it
is laid on a piece of gold or silver plate, and the outlines distinctly
marked with cutting forceps; the shape of the arch, as marked
from the lead, is then cut out from this second piece of metal. The
next step is the process of annealing, or softening the metal, so that
it shall be as malleable as possible. This consists in subjecting it to
a red heat, which may be done in any convenient manner. The
dentist lays the piece on charcoal, and throws over it, by means of
a blow-pipe, the flame from his alcohol soldering-lamp. This does it
very nicely.
It is next to be taken up, and bent with the pliers so as to fit
the cast tolerably; it is not, however, at all necessary, in this
procedure, to give one's self much trouble. Next take up the coun-
ter model, and lay it carefully over the zinc— the plate being be-
tween the two. With the hammer the casts are now to be driven
together. In this step of the operation it is rather desirable that
we should feel our way,— that is, hit the models a few slight taps,
and then, taking them apart, see if the plate is going as we wnnt
it. If all is right, the casts may be driven into each other w.tl.
all reasonable force. If, on the contrary, the plate is not takuig
42
668 ORAL DISEASES AND SURGERY.
a proper direction, it must be so inclined by means of the pliers.
To complete the finish of the plate itself, it may, perhaps, require
that the festoons, which are to embrace the necks of the teeth, be
cleanly cut out by means of the ordinary round file.
Thus we have our obturator completed. If we place it in the
mouth, we will see that we have restored the arch, by our con-
trivance, to its original condition, at least so far as the purposes of
speech and mastication are concerned.
Nothing now remains but to secure the piece firmly to its place.
And this brings us to the consideration of modifications of the
instrument.
If a patient, for whom we had made such an obturator as that
the manufacture of which I have just described, had certain good
sound teeth, we might proceed to fix the piece in the mouth as fol-
lows: going back to the plaster model, we would fit around such
teeth as might seem to us best, delicate bands of metal — gold should
always be preferred ; these bands should fit the teeth with great
accuracy, and are to be fixed to their places while the obturator is
lying on the model. Take next a particle of wax, and stick the
plate and bands together. Now carefully lift all from the model,
and set in plaster. This last manipulation is accomplished by
laying the piece on charcoal, and pouring over all, the wax alone
excepted, the creamy plaster, before alluded to. When this plaster
sets, the wax is taken away, and there is exposed a small portion,
both of obturator and bands. These parts are to be soldered to-
gether.
This last process fits the piece for the mouth. In placing it in
position, we have only to slip the bands over the teeth, and we will
find that it is held with all security.
Another plan of securing the apparatus to the mouth is by means
of atmospheric pressure. To accomplish this, a cavity is to be made
in the piece. This is done by placing on the plaster model, before:
making the castings from it, a piece of wax ; its shape may repre-'
sent, in diameter and thickness, the ordinary half dime. Or per-
haps we cannot find a surface on the arch for a suction of such size
and shape ; if so, it may be lessened, or the shape may be modified
so as to suit any case. What we want is a cavity in the plate ; the
size and location are not of so much consequence. Such a piece of
wax will, of course, be represented by zinc in the casting, and by a
depression in the counter cast. In forcing the plate between the
dies, the portion represented by the wax is thrown up; thus, when
I
OBTURATORS.
659
the plate is in the mouth, a cavity is formed. The obturator is held,
in this case, by making an air-pump, as it were, of the tongue, au(l
sucking the air from the cavity. I have seen obturators, thus de-
pendent on atmospheric pressure for fixedness, held so tightly that it
required quite an amount of force for their r<iraoval. The principle
is the same as that employed for holding artificial teeth in place.
The whole modus operandi will be perfectly understood at a glance
by looking at any set of teeth made for the superior jaw.
Another modification of the obturator is that in which the piece is
held to its place by a bulb or rim, which passes into the cavity of
the break. This adapts the instrument to such cases as have neither
teeth nor site for suction, where, for instance, disease has destroyed
the whole of the hard palate, leaving alone, as boundaries of the
cleft, the alveolar processes and soft palate. Such an obturator,
and the character of cleft for which it is adapted, are happilv and
truthfully exhibited in the accompanying drawings. Fig. 105 repre-
sents the mouth. Fig. 106 the obturator. This case, together with
others which represent various modifications of the apparatus, are
from life, having occurred in the practice of prominent dentists of
this city. The models, with an accompanying history of the cases,
were presented to the Pennsylvania Association of Dentists, at a
meeting held by that Society, October 9th, I860.*
" The first case, as seen in Fig. 105, from the practice of Dr. McGrath
& Son, was that of a female over fifty years of age. In this instance
the fissure was confined to the hard palate, and was undoubtedly
the result of syphilis. Of the history of this case, all that could l)e
obtained was such as was derived from answers to indirect ques-
tions which were put to her. They learned that the defect was the
result of a disease which commenced as sore-throat and continued
its ravages for over three years before it was arrested ; this, together
with the appearance of the pharynx and uvula, — they being covered
with cicatrices, the result of old ulcers, — ^left them without any doubt
as to the true nature of the complaint. The parts which had been
destroyed during the progress of the disease were the palate-bones
and the palatine processes of the superior maxillaries (making an
opening into the nose nearly two inches in length and one inch in
breadth), the turbinated bones (with the exception of the middle one
on the left side, which is represented in the cut as projecting from
the side of the cavity) and the vomer, producing an enormous irregu-
* Keport by Geo. T. Barker, D.D.S.
600
ORAL DISEASES AND SURGERY.
larly shaped cavity, extending as high up as the nasal bones, which
latter, however, bore no traces of ever having been affected by the
Fig. 105.
disease. The patient, in order to prevent the passage of the food
into the cavity during mastication, had been in the habit of filling
the opening with a fold of muslin, which answered the purpose to
a certain extent ; the velum was entire ; the patient had also lost
all the teeth of the upper jaw.
" The kind of obturator employed in this case was simple and
uncomplicated in its mechanism, Fig. 106. A plate was made to
fit accurately to the alveolar ridge, extending about one-eighth of
an inch beyond the posterior margin of the opening; also passing in
to a distance of nearly an inch, and fitting as closely as possible to
the anterior and lateral sides of the cavity. The object of this latter
arrangement was to render the plate firm in its position. From the
posterior margin of the opening, and extending forward about half
the length of the alveolar ridge, was a fold of mucous membrane
projecting inward and upward, over this fold ; that portion of the
plate which was opposite to it was bent. This, together with the
suction obtained by the plate fitting closely to the alveolar ridge,
OBTUBATORS. ,3g^
enabled the wearer to keep it in its place. The openin.^ was then
covered, by soldering to this a second piece of plate, so fashioned as
to represent as nearly as possible the form of the lost palate The
object in not extending the plate into the cavity on the posterior
edge of the opening was to prevent a lodgment for the nasal secre-
tions, which by their accumulation would prove offensive to th(>
patient. The artificial teeth were then fastened in their proper
position, and the apparatus was complete. This obturator the pa-
tient has been wearing for about three months; it remains in place
Fig. 106.
and fulfills the office of mastication as well as any ordinary suction
plate in a mouth where no defect of the palate exists.
"The second case. Fig. 107, was also that of a female, but the
fissure was confined to the soft palate. This, as in the former case,
Avas the result of syphilis. The fissure extended from the posterior
opening of the nares through the velum to the palate-bones, and was
nearh^ an inch in breadth. The uvula was entirely gone, as well as
the lateral half arches, and along with them the palato-pharyngei
and constrictors isthmi faucium muscles. In this case deglutition
was impaired to a great extent ; the food would pass into the nares,
and the fluids would also pass into the nasal cavity and out through
their anterior openings. The disease had not confined itself to the
palate, but, extending to the nasal organs, had completely destroyed
their internal structure, as well as a portion of the nasal bone, to
such an extent as to materially change the external shape of that
organ. The obturator. Fig. 108, constructed for this case, was of
662
ORAL DISEASES AND SURGERY.
one piece, and made to cover the hard palate completely, extending
from the central incisors to the posterior wall of the pharynx, and
Fig. 107.
passing a short distance beyond the edges of the opening on each
side. The plate was made to press firmly against that portion of
the soft palate which remained, yet not so firm as to be the cause of
irritation, the edges of the plate being slightly bent downward for
the same reason ; the object being to prevent the possibility of the
soft parts being drawn above the palate, which would afford a com-
munication with the nares. The posterior edge of the obturator Avas
bent downward at a right angle with the body of the palate, and
curved so as to form with the posterior wall of the pharynx an oval
opening sufficiently large to permit the patient to breathe freely
through the nostrils. In the act of deglutition, the muscles would
contract and press against this portion of the plate, thereby cutting
off the communication with the nares. To this plate were attached
three artificial teeth, — two lateral incisors and one molar, — the whole
being retained in position by means of clasps around the teeth.
OBTURATORS.
663
"This obturator the patient has been wearing a little over two
months, and, like the former one, has proved successful, deglutition
being restored, and the speech considerably improved."
Fig. 108.
Dr. T. L. Buckingham, Professor of Chemistry in the Pennsyl-
vania College of Dental Surgery, presented the following cases:
"The first ease," he said, "he had anything to do with was that
of a gentleman who had an opening through the hard palate, in the
center of the arch, about as large as a ten-cent piece. This gentle-
man had worn an obturator with a sponge attached to it, made in
the following manner : a plate was struck up to fit the roof of the
mouth, and a piece of sponge was sewed upon the palatine surface
to fill the opening, and to hold the plate in its place. Some of the
objections to this obturator were that the opening became enlarged
from the absorption occasioned by the pressure of the sponge upon
the sides of the cavity; it would also become very offensive, and re-
quire frequent removal. In this case a plate was struck up to fit
the mouth, and attached to the teeth by means of clasps. This
simple appliance answered better than any other that had been made
for him.
"The second case was a gentleman who had an opening into the left
antrum, at the point where the second bicuspid and the first molar had
been, but on the outer surface of the alveolar ridge, or rather where
664
ORAL DISEASES AXD SUBGERT.
the ridge had been — for the alveolus was entirely absorbed opposite
the opening, which was about half an inch in length by a quarter in
width. The nasal bones were diseased, which caused an almost
intolerable odor.
" He made for this case a small obturator to close the opening.
This was left open at the top to allow him to place in it a small por-
tion of chloride of lime. His intention was to correct, if possible,
the oflfensive smell, but the patient did not live long enough to give
it a fair trial ; he remarked that while any of the chloride of lime
remained in the obturator there was no unpleasant smell; but, unfor-
tunately for the experiment, the gentleman had lost nearly all the
sense of smell, and therefore could not tell when it had evaporated.
"He made for this case an upper set of teeth, to which the obtu-
rator was secured, it being held in position, to a great degree, by the
plate and teeth.
"In the two preceding cases the voice was not altered when the
appliances were in the mouth.
" The third case was that of a gentleman who, on a previous occa-
TiG. 109.
sion, had a tumor removed which covered a portion of the posterior
surface of the hard and the anterior surface of the soft palate. The
surgeon, on its removal, had divided the velum and uvula, so that the
OBTURATORS.
665
case resembled a congenital deformity. The attempt had been made
twice to bring the soft parts together again by a surgical operation,
which bad failed.
" Fig. 109 shows the appearance of the parts very clearly— the
letters A and B showing the thickened muscles as they hung down
on the side of the pharynx.
" He made for this case an obtm-ator, Fig. 110, the plate of which
Fig. 110.
covered the whole of the roof of the mouth, with a bulb attached, to
extend up into the posterior nares and well back toward the antero-
posterior walls of the pharynx, leaving but a small space between
them. This obturator enabled the patient to eat and drink without
annoyance ; without it food would pass into the nares and occasion
much inconvenience. It also greatly assisted his voice, as many of
his words could not be understood when it was not worn, but he
could articulate them with great distinctness when it was in place ;
remarked that he had been more successful in restoring the voice in
this case than in any other he had treated, and attributed it to the
fact that this person, having once had his voice perfect, was always
endeavoring to speak as he had formerly done, while in the congeni-
tal cases they did not try to overcome this difficulty.
" The fourth case was that' of a lady who had an opening in the
anterior part of the hard palate, a little larger than a ten-cent piece,
and also a small one exposing the left antrum. All the teeth in the
superior arch had been removed, and absorption of the alveolar pro-
cess, opposite the smaller opening, had progressed to such an extent
as to present at that point a deep depression ; the remaining part of
the alveolar ridge had not been absorbtnl more than is usual where
the teeth have been lost.
"Fig. Ill shows the appearance of the different parts — C repre-
senting the smaller opening, and D the larger one; between these
two points was the depression referred to.
666
ORAL DISEASES AND SURGERY.
" This lady had never worn any mechanical appliance, but had
been in the habit of closing the larger opening with loosfe cotton or
pieces of linen. Without having it filled, she could scarcely be un-
derstood when speaking. He made for this case, first, a plain plate
to extend over both the openings, but not into them ; upon this plate,
at the point where the process had been absorbed, he arranged wax
so as to restore the alveolar ridge to its natural fullness. By using
the plate with the wax attached for a mould, he was able to obtain
metallic dies. A second plate was then made to fit over that part
of the first one which was covered by the wax ; these two plates were
then soldered together. The object in forming a double plate was
to fill up that part where absorption had taken place, so that the
Fig. 111.
plate when worn would resemble the roof of the mouth, and not be
deeper on one side than ou the other.
" This obturator was very successful, the voice was much im-
proved, and she could eat and drink as well as persons ordinarily
can who wear upper sets of teeth ; and, what was more remarkable,
she could wear it without springs or any assistance whatever to
retain it in position.
" He stated that he hardly knew whether his fifth case should
come under discussion at the present time or not, as it could hardly
be termed a palatine fissure ; but, from its exceeding interest, he
would now present it.
OBTURATORS.
667
"A gentleman was handling a gun loaded with l)uckshot, when
it was discharged in his hands. The gun being pointed toward his
head at the time, the load struck him at the angle made by the ramus
and the body of the inferior maxillary on the right side, passing up-
ward and outward on the opposite side of the face. It must have
been a terrible wound, and should, frorfl the representation given,
have caused almost instant death He, however, recovered, after
being confined to his bed for more than a year, and during that time
he had to be fed with a spoon. The only way he could eat or drink
was to lie on his back and let the food run down his throat, and it
was a long time before he found he could swallow.
" The teeth in the upper jaw were all gone excoptingthe left second
molar and wisdom tooth ; both antra were fully exposed, the re-
maining roof of the mouth being left almost flat. The lower jaw-
bone was gone on the right side, from the second bicuspid back, and
also the condyloid process ; but about three-quarters of an inch of
the coronoid remained, which was drawn in so as to partially cover
the roof of the mouth. The molar teeth were lost on the left side,
and also all on the right side from the symphysis. In taking hold
of the lower jaw it could be moved either backward, forward, or
laterally, to a considerable distance.
Fig. 112.
" Figs. 112 and 113 show this case— the letters A and B the open-
i ings in the antrum, and C the end of the lower jaw-bone. The dis-
668 ORAL DISEASES AND SURGERY.
tance between the points A and C, when the mouth was closed, was
just two inches.
Fig. 113.
1^ %
" This gentleman had been wearing a partial set of upper teeth
which had been attached to the molars, but the clasps of the artifi-
cial teeth had loosened them, and it was therefore necessary to re-
place this piece of work with a set that could be supported in some
other way.
" This was the most difficult case be had ever treated. One of
the greatest obstacles he encountered was the obtaining of a correct
impression. To accomplish this, he first filled the antra with loose
cotton to prevent the wax from passing into them ; he then took as
good a Avax impression as he could of both the upper and lower jaws ;
from these he made impression cups to be used in taking the plaster
impressions. There was very little difficulty in obtaining an impres-
sion of the upper jaw with plaster (the antra being filled with cotton
as before), but it was far more difficult to take a good one of the
lower jaw. The distance from the points of the teeth down to the
point marked C, as shown in Fig. 112, was so great that when any
material was pressed down to take the impression, it was almost
impossible to remove it from the mouth without altering it so much
as to render it of no value; after several trials he succeeded in getting
a very good one with plaster. It had to be broken before its removal
from the mouth ; but, by carefully putting the pieces together, a good
plaster cast was obtained.
" He then made a plate to extend over the roof of the mouth and
cover both of the cavities opening into the antra ; on this plate he
OBTURATORS.
669
arranged wax, briuging it clown as far as the alveolar ridge should
have been; then made a metal cast and struck another plate to fit
over the first, soldered them together, and placed upon these single
gum teeth as he would have done had there been no more aljsorp-
tion than is usually found in upper cases.
" There was nothing peculiar in the formation of the lower case,
except that the teeth had to be very long on the right side (for this
a block was made), and the plate was not allowed to extend farther
back than to the position once occupied by the second bicuspid tooth.
The under teeth were put in more for the purpose of attaching
springs for the support of the upper ones than for use.
" He could not say what success had attended this case, as the
gentleman left the city immediately upon their insertion, and he had
not seen him since that time."
Other cases of equal interest are found in the report; but, as they
are unaccompanied by models, I omit them.
A material for obturators is fast winning its way to professional
favor in the article known as Yulcanite. This is the base now so
extensively used in the manufacture of sets of teeth. Its merits
and demerits are widely discussed in all the dental publications of
the day, and from these journals everything pertaining to it may be
gleaned. The advantages claimed for it are : its cheapness, its
lightness, its capability of being moulded into the most irregular
positions, and its similation in color and feel to the natural parts.
The objections are its liability to decompose and become oS'ensive.
The manipulation of the material is so easy that the surgeon at-
tempting the manufacture from it of surgical appliances, would give
himself a source of recreation rather than work. To make an ob-
turator from vulcanite, you take an impression of the mouth in wax
and make from it a plaster model precisely as before described.
Prepared gutta-percha is now moulded over this model to the form
required. Plaster is next run over this first model, the gutta-percha
plate being between. The model and counter model thus made are
separated, and the place of the original plate supplied with fresh
vulcanite. The models are now put together,- and the vulcanite be-
tween subjected to pressure. The whole is then placed in an ap-
paratus termed the vulcanizer, and this being filled with water the
temperature is raised to about 325 degrees. When taken from the
steam-bath the plate is found to be as hard as bone. The last pro-
cess consists in the polishing of the piece ; this is a simple manipu-
lation, and requires only one or two files, a burnisher, and some
patience.
670 OFAL DISEASES AXD SURGERYi
M. Desirabode, a French surgeon, proposes a palatine obturator
for congenital fissure of the palate (see Harris's Dictionary), by which
he thinks the sides of the alveolar border may be so appi-oximated
as to favor a union of the divided parts. It consists of a platina
plate fitted to the vault of the palate and fastened to the teeth by
means of three clasps soldered to each side, so asJ;o cap the canine
teeth, the bicuspid, and two of the molar teeth, bent upon the
alveolar border in such a manner as to maintain the whole pressure.
After the plate with these appendages has been well adapted, it is
to be divided from before backward along the median line, and then
a piece removed from either side so that the two edges may be sepa-
rated about half an inch from each other. The two plates are now
united by means of a thick and resisting band of caoutchouc, made
fast by riveting. The plates thus united form a smaller obturator
than the plate before it was divided, so that it can only be applied
l)y putting the caoutchouc on the stretch, which is effected by means
of two sticks so contrived as to force the two plates asunder. After
the plate is properly adjusted, these are removed, when, by the con-
traction of the caoutchouc, the sides of the alveolar borders are
gradually approximated.
This contrivance of Desirabode looks very plausible, but, unfortu-
nately, all experience is against its employment.
In the first place, to correct by pressure a fissure in the hard
palate, implies the very earliest use of such force. A child is some
five or six years old before its first dentition is properly completed ;
and even at this period one would not dare to apply any such ap-
paratus, because of the physiological process of absorption which
has already commenced in certain of the teeth. Then if, on the con-
trary, he meant his instrument to apply to a more advanced period,
he would have to wait until at least the' sixteenth 3'ear, as before
this age the fangs of the molars are not perfected. The bones by
this time have, as a matter of course, become much less amenable
to treatment. And, again, even besides this, as I know from prac-
tical teachings, his apparatus would in less than a week's time pro-
duce such periosteal trouble about the alveoli that no human being
would, or could, bear the continuance of the pressure ; or, even ad-
mitting there should be found a patient heroic enough to bear the
treatment, the apparatus would have its usefulness destroyed in less
than two weeks by the teeth, to which it was attached, coming
away. In other words, the instrument is useless, because the teeth,
being the weaker and more yielding, would give way first.
OBTURATOBS.
G71
In Listen and Mutter's Surgery is an engraving of an obturator
made to supply the loss of both hard and soft palates. The con-
trivance, which is a simple plate such as I have described, is seen
to extend from the teeth back to the fauces. Attached to the back
portion of the plate representing the soft palate, is a metal pendu-
lum working on^a hinge — this pendulum is much better omitted, for,
while it cannot possibly answer any useful purpose, it must cer-
tainly be much in the way. In making so extensive an obturator,
it must not be forgotten that the part which represents the soft
palate is to be given the double curve which is seen on looking into
any healthy mouth. To get the impression for such an obturator
we have only to employ a deeper impression cup.
Dr. E. Wildman, of the Pennsylvania College of Dental Surgery,
kindly furnishes me with a description and cuts of a case, which, as
a study, could scarcely occupy too much attention. The patient I
have myself seen.
Fig. 114. — The Face without Nose.
Fig lU will convey an idea of the external appearance of the pa-
tient, but not fully, a"s the whole upper lip was cicatrized, and the
left cheek depressed near the border of the cavity.
672
OBAL DISEASES AND SURGERY.
"In May, 1863, a young man," says Dr. Wildman, " aged 26
years, presented himself for the purpose of having an appliance made
to repair a loss sustained by disease. Upon removing the black patch
which he wore upon his face, and the cotton with which the cavity
was filled (without the latter he could not articulate a word), I found
that the entire external nose was gone ; that the nasal bones, the nasal
processes of the superior maxillary, also a large portion of their pal-
atine processes, the approximal parts of the palatine processes of the
palatine and the turbinated bones had ])een destroyed. The soft
palate, the uvula, and the tonsils were uninjured.
" In looking into the nasal cavity, the walls of the antrum on the
left side were found deficient, and ends of the roots of the incisors
exposed and decayed. The tongue was visible through the opening
in the palatine arch. The size and shape of this orifice are repre-
sented by the outer central line in Fig. 115.
Pig. 115. — Internal View of Superior Arcu.
"Although desirable, it was deemed unsafe to remove the diseasec
roots, owing to the yielding nature of the superior maxillary bonesJ
The disease appeared to be arrested, and the parts in a sufficiently
healthy condition to warrant the application of the substitute ; anc
time has verified this, as, with the exception of the exfoliation of
OBTURATORS. 673
small scale from one of the superior maxillary bones, aVjout nine
months since, no change has taken place up to this date.
" The first step in the operation was to procure an impression that
would enable me to make a perfect model of all the parts involved,
and their surroundings, in their relative positions. For this purpose
plaster was best adapted, but its use was precluded by the acrid se-
cretions in the nasal cavity; wax and paraffin was considered the
best substitute, and used. Owing to the rigidity of the upper lip,
I was unable to use the ordinary impression cup with success,
and was obliged to take a rough impression of the palatine arch,
from which a model was made, and a metallic impression cup
swaged.
" A sufficient quantity of paraffin and wax was placed in warm
water, and, with an assistant to keep it at the proper temperature, the
mode of procedure was as follows : a proper quantity of the com-
pound was placed in the cup, introduced into the mouth, and pressed
up firmly against the arch ; the part forced into the palatine fissure
was at the same time pressed with the finger, introduced through
the nasal cavity, so that it should give an accurate impression of its
lateral boi'ders. A groove was then cut in this to serve as a key,
and, after oiling it, a piece of the compound was introduced through
the orifice of the nasal cavity, and passed down to make the impres-
sion of the floor of the nasal cavity. When sufficiently hard it was
carefully removed, the upper surface trimmed, placed in cold water
to give it its greatest firmness, then introduced into the cavity, and
pressed into its proper position. The metallic cup containing the
impression of the palatine arch was then removed. The next stej)
was to take an impression of the sides of the cavity, then the top,
using a curved wooden spatula to press the compound in proper posi-
tion, being careful to mark or key the parts that came in contact,
and have their surfaces oiled, to prevent adhesion; and also that the
pieces should be thinner in front than in their posterior parts, so that
when the four pieces forming the impression of the base, sides, and
top were in their proper position, they would leave a tapering cavity,
with its largest diameter at the front orifice. Into this orifice was
forced a plug or cone of the compound, filling it completely ; in the
front of this piece were inserted pieces of match sticks, to cause it to
adhere to the next piece or mask. The head was now thrown back
to nearly a horizontal position, wet tissue paper was placed over the
eyebrows and lashes, the face oiled, and plaster mixed thick was
batted on with a brush. When set, this was removed, drawing with
43
674
ORAL DISEASES AND SURGERY.
it the central plug or cone ; the dififerent parts were then carefully
removed, and thrown into cold water to give them a consistency to
bear handling without danger of injury. On this central cone all
the parts were placed in their proper position, and the impression of
the palatine arch was adjusted in its proper place. From this a
plaster model was made, giving the upper part of the face, cavities,
palatine arch, all correctly in their relative positions.
" Of the different substances — leather, wood, wax, metal enameled,
and porcelain — used for making artificial noses, I gave the preference
to hard rubber in this case, on account of its rigidity, strength, light-
ness, and less liability to injury by accident.
" To prevent derangement, it was necessary to make the appliance
as simple as possible ; it consisted of two pieces : the external nose,
septum, and floor of the nasal cavity constituted one, having a pro-
jection passing downward into the palatine fissure, as represented in
Figures 115 and 116, A; and the other, the obturator B, Fig. 117,
with a projection rising upward into the palatine fissure. These
Figs. 116 and 117. — Nose, with Attachments.
projections were made hollow, so that when the two parts were
placed together, as in Fig. Ill, there would be a cavity or box
wherein the attachments could be placed.
"Models were made of the compound of paraffin and wax, which
OBTURATORS. 575
were strengthened in the weaker parts by imbedding small strips of
metal in their substance to give sufficient firmness to admit of the
necessary handling without injury. The model was applied to the
patient, and the nose trimmed so as to harmonize with his features.
They were then imbedded in plaster in the usual manner for vulcan-
ite work, with the exception that a stout curved wire passed through
the artificial nasal cavities, extending beyond their borders, to give
strength to the rods of plaster forming these cavities in the matrix,
and thus to prevent their fracture in packing.
" This appliance was vulcanized four hours, consuming one hour
in attaining 280° F., at which point it was held one hour, and occu-
pying the third hour in elevating the temperature to 320°, where it
was retained one hour. The work was rather overdone, but not so
much so as to injure it.
" The two pieces were retained in position by a staple and slide
bolt. In the recess of the part of the floor of the nasal cavity pro-
jecting into the palatine fissure (A, Fig. 115) was inserted a gold
staple. In the recess of the projection of the obturator passing into
the palatine fissure (B, Fig. 117) were the gold catch and shield of
the slide-bolt. The object of this shield was to prevent any foreign
substance entering the slot and obstructing the movements of the
bolt, also to give a base of support to the catch. The rectangular
upright of the catch was soldered to the shield, passed through it
and a longitudinal slot in B, and securely fastened to a rubber slide
inlaid longitudinally, and moving freely in the lingual surfiice of the
obturator. On the anterior end of this slide was a small rounded
projection, which enabled the patient, when the two parts of the
appliance were placed in their proper position, with the point of a
finger introduced into the mouth, to force the slide backward, thereby
to pass the catch into the staple and firmly secure the apparatus, or
by drawing the slide forward, detach the parts when desirable to
remove them.
" The external nose was painted with oil color, to give it as nearly
a flesh tint as possible, although this is not attainable upon an opaque
ground. Flesh being translucent, a true imitation can only be made
upon a translucent ground.
" The apparatus was introduced on June 30th, 1863, giving to
the patient great satisfaction and comfort. His appearance was
much improved, as may be judged by comparing Figs. lU and 118,
which were engraved from photographs. He breathes freely through
the nose, and speaks with ease ; the only imperfection in his speech
676
ORAL DISEASES AND SURGEBY.
is a nasal twang, and this is less now than when the instrument
was first applied. The obturator at first extended too far back, and
¥iQ. 118. — TuE Face, with Nose.
caused some irritation of the velum ; this defect was readily
remedied.
"The operation proved entirely satisfactory, with two exceptions:
first, the color of the nose was not as natural as desirable, for the
reason already stated ; second, in deglutition and speech, when the
tongue pressed forcibly against the posterior part of the obturator,
an unpleasant vibratory movement of the apex of the nose was
noticeable. This could have been remedied by an elastic attach-
ment coupling the two parts of the apparatus, but this mode was
objectionable by reason of its producing constant pressure upon the
delicate parts, and thereby endangering absorption. A safer plan
was adopted by inserting a small steel pin in the nose as near as
possible to its apex, to which was attached the bridge of a pair of
spectacle frames, these being retained in position by an elastic cord
attached to the bows and passing around the head. This arrange-
ment answered the double purpose of counteracting the vibratory
I
OBTUBATORS.
677
movement, and the bridge of the frames concealing the upper part
of the joint where the nose came in contact with the face, which
was most conspicuous.
" This apparatus is worn with ease and comfort by the patient."
The obturator, although employed by the ancient Greeks, and
by every succeeding generation of civilized men, seems to have
attained to its wonderful completeness only in our own age. Be-
fore the time of Ambrose Pare, the appliances were all of a tem-
porary nature, if we except mention of one suggested by Petro-
nius, in the sixteenth century, although whether this surgeon ever
really made such a plate as he described, we are not informed. To
Pare, however, we are indebted for a written description of the
metal obturator, crude, without doubt, but embracing the principles
of the present instruments. " Made," says this surgeon, " like unto
a dish in figure, and on the upper surface, which shall be toward
the hair, a little sponge must be fastened, which, when it is moist-
ened with the moisture distilling from the brain, will become swollen
and puffed, so that it will fill the concavity of the palate, that the
artificial palate cannot fall down, but stand fast and firm as if it
stood of itself"
Garangeot, in ltl5, makes an advance on the idea of Pare —
although, it must be admitted, a very slight one. He describes his
instrument as having a stem in the form of a screw, upon which
ran a nut. To make use of it, he cut a piece of sponge in the form
of a hemisphere, with a flat surface ; through this sponge the stem
was passed, the nut holding it in place. When about to introduce
it, he wet the sponge, then squeezed it dry, and forced it through
the aperture or break.
After the period of Garangeot, no special advances seem to have
been made until 1828, when obturators were constructed by a Mr.
Snell, prepared on casts, which were correct representations or im-
pressions of the special cases. In a monograph published by this
writer, he says: "My method of constructing an obturator is with
a gold plate, accurately fitted to the roof of the mouth, extending
backward to the os palati, or extremity of the hard palate ; a part of
the plate, about an inch in length, being carried through the fissure.
To that part of the plate which answers to the nasal fossae are sol-
dered two plates, meeting in the center and carried upward through
the fissure to the top of the remaining portion of the bones, to which
it should be exactly adapted, and made to the natural shape of the
678 ORAL DISEASES AND SURGERY.
nasal palatine floor ; thus the fluids of the mouth will be carried
backward into the fauces. A piece of prepared elastic gum is next
attached to the posterior part of the plate where the natural soft
palate commences, extending downward on each side as low as the
remaining part of the uvula, and grooved at its lateral edges to re-
ceive the fissured portions of the velum; a movable velum is placed
in the posterior center of the elastic gum. That these may partake
of the natural movements of the parts during deglutition, a sponge
is aSixed behind them, one end of which is attached to the posterior
and anterior surfaces of the principal plate, and the other end rests
gently against the posterior face of the india-rubber: this keeps
it always in close apposition with the edges of the fissure during
deglutition.
"It is requisite to mention," he says, "that the elastic gum
should be placed in a gold frame, and not merely fastened to the
posterior part of the plate, as it would shrink up by remaining in
the mouth. This frame should pass round its edges only, leaving
the center upon, etc."
In 1845, Mr. Stearn, a surgeon of London, conceived the idea of
an obturator, the principle of which has been brought to such per-
fection by Dr. Norman W. Kingsley, of the Dental College of New
York.* This appliance, as made by Mr. Stearn, consisted of a gold
plate fitted to the hard palate, having attached to it, by means of
two spiral springs, an artificial velum of elastic rubber, consisting of
a body, wings, and grooved edges, to receive the margins of the
cleft. The conception of this obturator reflects the greatest praise
upon Mr. Stearn, an honor which Dr. Kingsley may feel it no
detraction to share with him.
The perfected instrument of Dr. Kingsley, though greatly differing
from that of Mr. Stearn, consists likewise of a body with movable
wings. These wings, made of soft rubber, fill up the break in the soft
palate, being moved by the lateral remnants of the defective parts.
With respect to this obturator, so much experience seems to have
accumulated that its great usefulness can no longer be doubted.
Concerning the mode of manufacture, taking the impressions, and
a])plying the piece, full details can be found in Harris's Principles
and Practice of Dental Surgery, edition of 1863.
* Dupuytren, the eminent French surgeon, is not, as it seems to me, with-
out same claim to a share in this invention ; his idea, however, was very
crude.
CHAPTER XLII.
RESECTIONS OF THE MAXILLARY BONES.
The history of experimental surgery upon the bones of the face
furnishes one of the most interesting of the chapters in surgery.
The formation upon and within these bones of such diseases as
seemed to make desirable their removal, necessarily directed, from
a comparatively early period, the attention of surgeons to the feasi-
bility, propriety, and promises of such operations.
It is not at all unreasonable to infer that surgery gained its first
lesson in this direction by observing, through the results of acci-
dents, how extensive could be an injury done to these parts without
fatal, or, indeed, even threatening consequences. Hence, as early
as 1693, Acoluthus, a surgeon of Breslau, attempted the removal of
a portion of the upper jaw for a tumor, in which operation he suc-
ceeded very satisfactorily. Jourdan, according to his translator, re-
moved, at various times during his century, portions of the jaw.
To Dr. Jameson, an American surgeon, however, most are agreed,
belongs the credit of having made the first complete resection or
removal of the upper jaw, — this having been done in 1820. Prof
Gross gives the credit to Lizars, of Edinburgh, believing him en-
titled to the merit of having first suggested the possibility and
advantage of the operation. In 1824, four years later. Dr. David
Rodgers, of New York, resected both superior maxillae. Afterward
this was attempted by Lizars, and in the same year by Gensoul, of
France. After this the operations may be esteemed as having
become commonly recognized, surgeons of ability performing the
various sections throughout England and France, and especially in
the United States.
While the operation of resection has been frequently performed,
it cannot but surprise the surgeon of to-day to notice how slowly
its lessons were learned. At present it is practiced with little
preliminary caution, being esteemed an operation that may be per-
formed with really little danger to the patient, and even without
much damage to the appearance. Formerly, and, indeed, not very
( 679)
680 ORAL DISEASES AND SURGERY.
far back, it was considered only safe to ligate, as a preliminary step,
the primitive carotid artery ; and when, as experience advanced,
this was seen not to be a necessity, the actual cauterants were
always held in readiness, a practice which, much to the detriment
of a happy cure, obtains in some sections even to the present day.
Resections of the maxillary bones are practiced for various dis-
eases, the principal of which are the malignant tumors. That such
resections are so often reported as unfavorable, has not been from
shock, or any local injury done, but from the fact that the disease
for which the operation was performed was in itself fatal.
" Excision of the upper jaw," says Mr. Syme, " when performed
for the removal of tumors which are confined to that bone, is a most
satisfactory and successful operation ; but if the operation be at-
tempted for the removal of a disease which has originated in the
base of the skull, and grown downward, it not only, as is well
known, fails in its object, but speedily ends in a fatal result. In
diagnosing between a tumor of the upper jaw which admits of re-
moval and one that does not, Mr. Syme directs special attention to
the appearance of the face. If the eyeball be displaced, and the
position of the bones of the nose be altered, the case is one which
does not admit of operative measures ; but if these signs are absent,
and if the history of the case shows that the disease began in the
jaw itself, then the disease will most likely admit of complete cure
by the excision of the affected bone. The soft nature of some of these
tumors is no hinderance to the performance of the operation, for Mr.
Syme has excised the upper jaw with a good result in many cases,
where the consistence of the tumor was quite as soft as that of a
malignant growth."
In looking, after an interval of months, and, in a few cases, of
years, at individuals upon whose jaws I have personally performed
resections, I have been astonished at the correction on the part of
nature of deformity. The little German boy, alluded to in the
chapter on Necrosis as having lost the left half of the inferior max-
illa, without at the time any reproduction, looks to-day as though
no such loss had ever occurred ; his face is exactly as it was before
the operation, and, as far as I can see, the ability to masticate, al-
lowing for the loss of the teeth on that side, is about as good as
ever. This, however, is an uncommon case, the result without
doubt of the youth of the patient.
Oilier, by his experiments upon the osteogenetic properties of the
periosteum, has done good service to oral surgery. It is now a
RESECTIONS OF THE MAXILLABY BONES
681
common practice in all resections to spare and save all the tissue
possible. I have, in the chapter on Necrosis, spoken of my own
success in this direction, having replaced entirely, with the exception
of the alveolar process and teeth, the whole of the body of the
lower jaw through the process of enucleation.
It is not to be forgotten, however, that the seeds of a disease, so
to speak, may be left in a part by an attempted preservation of peri-
osteal tissue. This fact is always, in all classes of resection, to be
borne prominently in mind : periosteal tissue is not to be saved
unless healthy.
To make a complete resection of either maxilla implies, ordinarily,
a preliminary uncovering of the affected bone. The incisions to
such ends are necessarily various, being influenced by the condi-
tion of the parts beneath. They are not, however, always necessary.
Prof. Horner, as exhibited in Plate XIII., has removed the upper
jaw of the left side without preliminary incision; and in two favor-
able cases I have myself succeeded, without the slightest difficulty,
in doing the same thing.
In the case of tumors of magnitude and importance, these subin-
tegumental operations, in my opinion, are not to be commended.
A wound, or incision, made to expose such tumors, may be united
by the first intention, leaving little or no scar, while certainly the
exposure obtained through such incisions compensates by the liberty
and rapidity of movement allowed in the subsequent steps of an
operation.
Subfig. 1 exhibits the mouth of the patient of the late Dr. Horner,
immediately after the removal of the superior maxillary bone with-
out external incision ; Fig. 2 is a side view of the bone removed ;
and Fig. 3 is the likeness of the patient taken three years after the
operation. The operation, as practiced by Dr. Horner, is thus de-
scribed by his son-in-law, Prof. Smith: "Having determined to
avoid cutting through the cheek, as commonly practiced, the patient
was seated in a chair, with his head well supported, and partially
etherized. The assistant, supporting the patient's head, then raised
the angle of the mouth on the left side,* and held it widely open, while
the upper lip and cheek were dissected from the superior maxilla as
far back as possible, in a line parallel with the superior margin of the
buccinator muscle. The two incisor teeth on the left side being then
drawn, the corresponding alveoli were cut through in the middle
* The figure, by an error, is made to show the operation on the right side.
682 ORAL DISEASES AND SURGERY.
line by a narrow saw, which worked its way from the mouth into
the left nostril ; then a pair of strong hawk-bill scissors, such as are
used by gardeners for lopping off twigs, took out the two vacated
alveoli at a clip.
" A thin, flat, well-tempered knife, with a strong, round handle,
was now struck through the roof of the mouth into the nose, at the
junction of the palatine processes of the palate and superior maxil-
lary bones (posterior middle palate suture), so as to cut forward and
separate the maxillary bones from each other in the middle, when
the narrow saw was again used to cut through the root of the nasal
process of the maxillary bone, and strong scissors, curved on the
flat, made to cut through the orbitar plate at its margin, the inci-
sion being carried back to the pterygoid process of the sphenoid,
around and below the malar bone.
" The base of the soft palate being then detached by a short, trian-
gular knife, curved on the flat, so as to leave the soft palate attached
to the palate-bone, a few touches of the knife freed the remaining
attachments.
" The pterygoid process, malar bone, and the orbitar plate of the
upper maxillary were not disturbed. The tumor, — which was scir-
rhous, — besides its bony connection, was also attached to the poste-
rior part of the cheek, and to the external pterygoid muscle. The
gouge and scissors, however, sufficed to remove every part that
could be detached.
" The bleeding was profuse, especially from what was believed to
be the posterior palatine artery, but the vessel was readily secured
by means of a ligature and Physick's needle, and a few other liga-
tures, with charpie, arrested the remainder of the hemorrhage."
The ordinary operation for the removal of the superior maxillary
bone I may now proceed to describe in detail.
If the disease for which such an operation is to be performed is a
tumor of moderate dimensions, say scirrhus, as in Prof Horner's case,
which seldom attain to large size, — the uncovering of the part is
to be effected by dividing the superior lip in the middle line, carrying
the incision upward along the base of the ala of the diseased side to
the inner canthus ; the flap thus secured, which is triangular, is dis-
sected off as far as possible. Now remove the central teeth, and,
with a scalpel, make an incision along the middle line of the hard
palate as far back as the palato-maxillary articulation ; at right an-
gles with this incision make a second, extending to the tuberosity of
the maxilla, the cut to be as nearly as possible on the line of the
RESECTIONS OF THE MAXILLARY BONES. 683
articulation. Examining at this stage a skull,— which it is never
amiss to have by,— take up a Hey's saw, and cut across the nasal
process, leaving, if possible, the orbital plate. Next, with the same
saw, cut across the maxillo-malar articulation; this completes the
two upper sections. The third, the intermaxillary, is quickly effected
by introducing within the nostril one blade of the large cutting for-
ceps, the other being placed on the line of the articulation within the
mouth, as far back as the point of union with the palate-bone ; the
incision is now made, and the separation, so far as cutting is con-
cerned, is completed. Take now a pair of strong forceps, and, seiz-
ing the bone, twist it from its bed.
The hemorrhage, the matter next demanding attention, varies very
much with circumstances. It may be that twenty arteries will jet
their blood into the face of the operator, or, on the contrary, only
two or three may require artificial means for their control. One
need neither be hasty nor timid about this bleeding. Water, fully
saturated with alum, simply squeezed into the cavity from a sponge,
will oftentimes control it. If this should not answer the purpose, a
syringe may be used, throwing the water against the vessels from
some little distance. The casting of a ligature around a vessel is,
however, a matter as easy as it is simple. Wash away the blood
until the orifice of the bleeding artery can be seen, catch it with the
tenaculum, or forceps, draw it thus a little from its sheath, and tie it.
Repeat this with each vessel until all are secured.
That proper form and support may be given to the integuments,
the next step in the operation is the stuffing of the wound. To do
this, take a number of pieces of old linen, or patent lint, fold them
into small squares, saturate these freely with alum- water, and, one
by one, pack them into the cavity until the contour of the part shall
correspond with that of the other side. The surgeon is to remem-
ber how many of these squares he has used, that thus he may have
the assurance at a future period that all have been removed.
Rotundity and form secured, the flap is next laid carefully into
place, and closely, yet not tightly, approximated by a sufBcicnt num-
ber of stitches of the interrupted suture. It is generally the best
plan to put a pin or stitch first in the lip, thus insuring correct ap-
proximation at this most important point.
•'As a dressing, simple cold water may be used, keeping the parts
constantly cool by its continuous renewal ; or, if water alone is found
insufficient to control vascular excitement, it may be medicated with
lead in the proportion of 3ij to ^xvi ; cold water, however, will gen-
erally be found all-sufficient.
684 ORAL DISEASES AND SURGERY.
Concerning the pads or squares inside, I am confident it will be
found the very best practice never to allow them to dry from the
time of their first introduction. This is easily prevented by repeated
syringing with pure water, or water medicated with stimulants,
astringents, sedatives, or antiphlogistics, as indicated.
The stitches used in approximating the external wound are to
be removed as soon as possible, — three or four days will generally
allow of such removal. It is well to remove them gradually, taking
away intermediate ones.
The removal of the squares is to be effected leisurely — indeed, the
principle is to consider them as a tent, to be thrown out as the
wound granulates and fills up below them ; pick out the top or mid-
dle ones, as the irritation produced by their overretention compels
you. Or, if it seems necessary, after the first three days have '
passed, they may all be removed and renewed, in lessening numbers,
daily.
This completes the surgical proceedings of such a resection. .
Many cases, however, occur where the external incision here I
suggested might not be the best one, and, indeed, where it might
not be sufficient to uncover the disease. Certain surgeons prefer to
expose the bone by an incision, commencing at the angle of the |
mouth, and passing obliquely upward over the Stenonian duct to
the center of the malar bone, throwing thus the flap upward and
inward from below. Another favorite mode is to use both these
incisions upon the same subject, a necessary proceeding, in many
cases, where the tumor is large.
" Mr. Fergusson, who is particularly successful in oral surgery,
in remarks after an operation for the removal of disease affecting
the alveolus and antrum, made some important and interesting ob-
servations, having reference generally to the exposure of such parts
prior to the removal of the actual disease. He said that formerly,
and even now, some surgeons were in the habit of freely dividing
the integument of the cheek, lip, etc., trying to get at the disease
from various points. Mr. Fergusson said that one method he pur-
sued with advantage (as in a case of removal of malignant disease
of the upper jaw), was to divide the upper lip in the median line,
and then by carrying the incision on one or both sides, as the cir-
cumstances of the ease required it, into the nose, to dissect back**he
upper lip, ala nasi, and cheek, and thus expose the parts freely,
avoid the deformity of scar on the cheek, or, to use his words, ' to
leave as few mai-ks of the surgeon's doings on the face as possible.'
RESECTIONS OF THE MAXILLARY BONES
G85
lu a case then before him— a young woman— he was able to remove
the disease without interfering with the lip. It affected the alveolar
ridge of the right side, extending from the second incisor to the
second molar, and was continued into the antrum ; but whether it
first arose in the antrum or the alveolus, he did not know. Mr. Fer
gusson attributed the success attending this method of removal, in
a great measure, to the instrument he used, viz., a pair of clipping
forceps. He first clipped away the alveolar ridge, and then attacked
the portion of disease situated in the neighborhood ; by this means
freely laid open the antrum and nostril. He alluded to a case in
which Mr. Bowman successfully removed a large tumor from the
antrum extending into the mouth, without dividing the lips."
Such a mode of uncovering a tumor of limited size is admirable :
the section will be found to make a large exposure, and the scar left
will scarcely be remarked.
Operation for Resection of both Superior Maxilla. — It has
never fallen to my lot to resect, or to see resected, both maxillary
bones. Several such operations are, however, on record ; and from
them I select that of Heyfelder, as being the one I myself should
perform should such a necessity arise.
The patient is to be seated in a chair, with his head supported
by an assistant, or, better, he may lie down. An incision is made
on each side of the face, from the external angle of the eye to the
labial commissure ; the included parts are now reflected upward
toward the forehead until the infraorbital ridges are exposed. This
uncovers the whole of both bones. The chain saw is now passed
through the spheno-maxillary fissures, the malar bones are divided,
the maxillse separated from the ossa nasi, and the vomer and thinner
bones are cut wuth strong scissors. These steps complete the
separation, when the bones are to be pried from the cavities with
elevators or twisted away with the lion forceps of Liston. The re-
sult of an operation thus performed by Heyfelder is thus described :
"Very little blood was lost, torsion and compression sufficing to
arrest the hemorrhage. Two hours afterward, the edges of the
wounds, from the angles of the eyes to the corners of the mouth,
being united by twenty-six stitches of the interrupted suture, cold
lotions were applied : there was no reaction or swelling, and the
patient could swallow water and broth. Four days subsequently,
the wounds had nearly healed by the first intention, and in six weeks
the patient was exhibited to the Medical Society of Erlachen. At
this time there was no deformity of the features : a fissure, thirteen
686 ORAL DISEASES AND SURGERY.
lines long and three lines wide, was seen along the median line of his
mouth; the soft palate and uvula were in their natural place; deglu-
tition was free ; the nose had resumed its original form and direction;
and the face, which, before the operation, was like that of a monkey,
again possessed a human expression; a firm and solid tissue re-
placed the extirpated parts."
Professor Gross, while commending that any operation for the
removal of the upper jaw should be preceded by a careful inquiry
into the history of the case, is not, from his experience, inclined to
admit that encephalomatous tumors are to be esteemed as always
hopeless to operative interference. " If the tumor," says this gen-
tleman, " be large in size, rapid in its development, dipping into the
surrounding structures, and attended with contamination of the
neighboring absorbent glands, failure of the general health, and a
sallow, cadaverous countenance, all manual interference is out of the
question. On the other hand, however, there is no reason, in my
opinion, for refraining from the use of the knife, even in this form of
disease, provided the morbid growth is comparatively small and
tardy in its progress, and the surrounding parts and constitution
are perfectly sound." Professor Gross thinks the propriety of such
a course is sanctioned by the experience of the best surgeons.
Concerning hemorrhage, this same gentleman gives it as his expe-
rience that there are no organs in the body of the same extent in
their natural and diseased conditions, the removal of which is at-
tended with less trouble in this direction. " I rarely, if ever," he
says, " stop to tie a vessel during any operation, however extensive
or complicated." My experience has taught me that there is, in
general, no necessity for such a course, which is always attended
with vexation and delay. The deep-seated arteries involved in
tumors of the upper jaw seldom bleed much, if care be taken to
keep beyond the limits of the diseased structures. If this precau-
tion be neglected, the hemorrhage may be copious and even ex-
hausting.
Kesections of the Inferior Maxilla — in whole and in part.
— Partial resections of the lower jaw have become so common as to
elicit little attention. I have myself certainly made such sections in
as many as fifty cases. The causes necessitating such operations are
considered in other parts of this work. (See Chapters on Tumors.)
Subfigures 6, Y, and 8, Plate XIII., exhibit various steps in such
resection, and are photographically true, allowing for the absence of
the blood.
RESECTIONS OF THE MAXILLARY BONES. 687
Complete section of the lower jaw is one of the most disfi-urin-
and comfort-destroying operations that can be practiced on thHivin^
being, and is never to be performed without the existence of a well-
recognized or proven necessity. Any partial section anterior to the
rami may generally be easily accomplished without external wound
the hps being held out of the way by the mouth-stretcher used in
the performance of dental operations.
Fig. 119.— Mouth-Stretcher applied.
it^.SCBALD.
In cases where section of the lip may be thought desirable, as
when the practitioner, from inexperience, may not be able to accom-
plish the section without the exposure, various cuts are proposed and
required. These cuts may be fully understood by the studies pre-
sented. Subfigure 8, Plate XIII., represents exposure of the mental
portion of the bone. The flaps, 1, 2, are made b}' a single vertical
incision through the median line of the lower lip, crossed by a
688 ORAL DISEASES AND SURGERY.
second at right angles at the base of the jaw, extending on either side,
laterally, as far as the bone is required to be removed.
Subfigure 7 represents the exposure of the whole left half of the
jaw. To accomplish this, make a first incision in the median line
to the under border of the bone. From this carry a second under
the jaw — although along it — to the temporo-maxillary articulation.
Dissect now the flap upward. In the horizontal cut here made it
will be perceived that the facial artery is divided ; this is a large
vessel, and requires a ligature. It will be found, I think, the better
practice to tie both ends before proceeding to the operation upon the
bone. The coronary artery cut in the vertical incision will often
compel a ligature.
Subfigure 6 exhibits an exposure of the whole body of the bone.
This is accomplished, as in the drawing, by a simple horizontal in-
cision along the base of the jaw, carried from angle to angle, and the
flap, including the mouth entire, thrown up ; or it may be secured
by joining the horizontal to a vertical incision made from the angle
of the mouth ; or, as in Fig. 8, by the median, vertical, and horizon-
tal incisions. These sections understood, any required modification
will suggest itself
Subfigures 4, 5, 6, represent an operation practiced by Dr. J.
Rhea Barton : 4 exhibits the tumor, which will be seen to be of
great bulk, being described as having complete possession of the
mouth, forcing the tongue into the pharynx, and stretching the jaws
widely apart. It also rose up outside the superior maxillary bone,
protruding the lips, cheek, and neck on the left side.
Finding, by examination, that the base of the bone might be left
with promise, Dr. Barton made the resection as exhibited by the
lines in 5. This was accomplished by sawing horizontally from
without inward, commencing at the middle line below the canal,
and extending the section bilaterally. The removal of the bone,
in this particular operation, gave no hemorrhage requiring attention.
The flaps being replaced and stitched, the patient was well in a
month.
Complete section of the jaw, as exhibited in Fig. 8, after the prac-
tice of Dupuytren and many successors, destroys forever the articu-
lation of the jaws, and interferes not only with mastication, but seri-
ously with deglutition and speech. Exposing the bone as directed,
the section is most easily made with either the Hey, metacarpal, or
chain saw. Before, however, shaving the bone from its inner attach-
ments, a loop of waxed silk, or silver wire, is to be passed through
BESECTIONS OF THE MAXILLARY BONES.
G89
the tip of the tongue, that it may thus bo prevented from being drawn
back into the pharynx by the g-enio-hyoid and stylo-hyoid nmseles.
Subfig-ure 1 exhibits the removal of one-half the maxilla. Expos-
ing the bone as directed, remove one or more of the center teeth ;
next, from without inward, saw through the bone, or, if preferred,
use the chain saw, carrying it around the bone by the aid of a curved
needle. Catching now the bone in the gra.sp of the forceps, or using
the fingers, as preferred, detach the inner soft parts, twisting the
bone outward and downward. Arriving, in the dissection, at the
coronoid process, the temporal tendon is to be detached by a chisel-
shaped knife, care being taken not to wound the maxillary artery or
internal carotid. This process freed, the condyle can be twisted
from its ligaments, or, better still, twisted and cut away. This
operation, apparently so formidable, I once succeeded in doing with-
out external incision. With the section as represented in the figure,
it is not at all difficult. A diseased bone is not, I am convinced,
nearly so difficult to disarticulate as the sound one.
Prof. Smith, in his System of Surgery, gives the credit to Dr.
Geo. McClellan of having been the first to attempt more than a lim-
ited section of this bone, — this surgeon, in 1823, removing all the
parts anterior to the angles. In this, however, he was preceded l)y
Deaderick, of Tennessee, who, in 1812, made a resection which ex-
tended from the symphysis to the angle. Mott, of New York, is
also referred to as having made an operation similar to Deaderick's,
in 1821. Dr. Ackley, of Cleveland, Ohio, is reported as having, in
1850, removed the bone entire. In Europe, priority of the operation
performed first by Deaderick is awarded to Dupuytren. Mott, ac-
cording to Prof. Smith, disarticulated the bone, — Deaderick and Du-
puytren did not. Prof Mott thought it necessary to ligate the
primitive carotid artery a few days before making his resection, a
step long since proved to be entirely uncalled for, complicating and
increasing the dangers of the operation.
The operation of Dr. Deaderick, deservedly famous for its priority,
was done on the person of a lad fourteen years of age. The operation
was performed for the removal of a cartilaginous tumor on the left
side of the jaw, filling up nearly the whole of the mouth, causing the
greatest difficulty in swallowing, and, at times, even in breathing. To
accomplish his resection, Dr. Deaderick commenced an incision under
the zygomatic process, and carried it across the tumor, downward
and forward, to nearly an inch beyond the middle of the chin. From
the center of this first incision, and consequently at right angles with
44
090
ORAL DISEASES AXD SURGERY.
it, au incision was extended a short distance upon the neck. The
flaps thus secured were dissected from the diseased mass, and the
bone next sawed off at the angle and sj'mphysis. The flaps were
now laid back in the usual way, and the boy made a speedy recovery.
Nerve Section. — A most interesting department of resective sur-
gery — for thus it may be termed — is found in the operations required
to expose nerves involved in neuralgic lesions. It is certainly no
longer a question that sections of nerve-cords may be made without
special danger or risk, — the greater question being always the estab-
FiG. 120.
,jj, "-— 1^|_-,._
lishment of a coi'rect diagnosis. In the chapter on Neuralgia I took
occasion to remark that such operations were far from being satis-
factory ; but that remark is here to be modified by pronouncing the
fault, in many of the cases, to be rather with the surgeon than his
case. Section of a nerve is only justified where on the peripheral
side there exists a lesion which may not otherwise be cured ; and of
such cases there are, without doubt, many.
RESECTIONS OF THE MAXILLARY BOXES
691
Section of Inferior llaxillary Nerve.— While I am very well
convinced that in many of the reported cases sections of the inferior
maxillary nerve have been made without necessity, yet it is certainly
an operation to be practiced and commended.
In looking at Fig. 120, the nerve, which is a cord of some size, is
seen to pass v^ithin the substance of the jaw midway to the thick-
ness, and on a line which would be well enough marked by taking
the center between the base of the bone and the cutting edges of the
teeth. Approaching the ramus, it ascends obliquely upward and
backward, escaping operative proceeding at the posterior dental for-
amen.
To expose this nerve, if within the ramus, begin an incision at the
sigmoid notch, and carry it carefully downward through the integu-
ments, avoiding with all care the wounding of any overlying part of
the parotid gland; the gland discovered, push it carefully backward,
and complete the incision down to the bone, scraping aside, rather
than removing, the periosteum. As the next step, take a small tre-
phine, and cut out two sections, or rather cut, with the trephine,
sufficiently deep to reach, or very nearly reach, the nerve canal.
Take now the chisel, and with gentle cuts remove the intervening
portion of bone. If the operation is carefully performed, the nerve
can be uncovered without the slightest wound. Reaching the ves-
sels, isolate the nerve from the artery and vein by lifting it upon
the tenaculum. It is now to be divided, removing as much as is
thought desirable, never less than half an inch, and if more, cer-
tainly the better.
If the operation is to be performed within the body proper of the
bone, the uncovering is even more simple : use still the straight line,
cutting midway upon the bone, separate the lips of the wound by
delicate retractors, securing a free exposure of the bone (with the
periosteum scraped away, as before suggested), trephine, and re-
move the section.
The facial artery, it is not to be forgotten, passes in front of the
masseter muscle; if it is necessarily cut, the operator must stop and
throw a ligature about it,— it is better to tie both ends. Cuts into
the muscular substance are to be avoided as much as possible ; such
incisions add to the trouble of an operation by the free hemorrhage
provoked.
A section of the nerve cord secured, the surgeon carefully lays
back the flaps and watches the result. It has been thought well by
some to give large doses of some opiate immediately after such
692 ORAL DISEASES AXD SURGERY.
operations; but when this is required I infer the operation will be
found to prove a mistake, as in such successful cases as have occurred
in my own experience, the relief from suffering experienced has acted
a!3 the profoundcst of opiates, — the patients sleeping for the first few
days almost continually.
Among the recorded cases of section of the inferior dental nerve
where complete success has attended the operation, are four by Prof.
Gross. In these cases all known remedies for the relief of the dis-
ease had been employed without avail.
Inversion and Eversign of Lip. — It sometimes happens that
from accident or congenital defect the lip — generally the lower —
is inverted or everted. When turned inward, the part is shortened,
and not unfrequently permits of the escape of the oral fluids. In-
version, while generally the result of some cancroid affection which
has produced considerable cicatricial tissue, is yet occasionally ob-
served associated with some perversion of the frsenum, this fold being
unduly short, or running too near the free edge of the lip. A case of
inversion, the worst I have ever met with, resulted from a gunshot
wound, involving both lip and jaw. In this case that surface which
was the free edge had become involved in reparative material near
the base of the alveolar process, and had thus become tightly bound
to these parts ; the teeth and face of the gums being exposed. To
prevent the dribblings from his mouth passing to the neck and breast
the patient had constructed for himself a species of tin cup, which
he constantly wore bound to his chin, and which was concealed
from observation by a large neckkerchief.
Eversion, the more common condition, depends, like inversion, on
a variety of causes. A burn received about the chin, contracting
the part, has frequently produced it. Hypertrophy of the mucous
membrane is an occasional cause; preternatural elongation of the
fraenum permits such falling outward. Any loss of substance ex-
ternally, contracting the parts, necessarily tends to eversion.
Treatment of inversion or eversion varies, of course, with the
various causes. In the inversion of the lip where such cause lies in
the existence of cicatricial tissue, it will be found easier to imagine
than to secure the means of cure. If the lip has length, a cure may
be attempted by an elliptical portion taken from the outer surface,
the parts being brought together and an immediate union secured
through the use of the hare-lip pin or common interrupted suture;
if, on the contrary, the lip has been shortened in its bulk, as is fre-
quently the case where the ulcer has been deep, we must depend for
BESECTIONS OF THE MAXILLARY BONES. 693
relief on aplastic operation: such an operation consists in cutting
away the cicatrix and transplanting to the scat of removal a pcdi-
celed flap taken from the inner face of the cheek; this, however, is
always more or less unsatisfactory, such inversion being the worst
form to treat.
A shortened or improperly attached frtenum is, generally, most
easy of correction, — a section, yiore or less extensive, assisted bv a
frequent turning outward of the parts by the patient, quickly result-
ing in the cure.
Inversion from gunshot injuries classifies itself with contraction
from ulceration ; each case is a study in itself, and will be found to
have its own peculiar demands. Many of these conditions have no
cure, the patient being doomed to drag through an undesirable ex-
istence. Others will be found very easy of remedy, some attached
point requiring, perhaps, alone to be freed. Ah intermediate class,
and this is by far the most common, demands a combination of oper-
ations, — such requirements suggesting themselves to the ingenious
surgeon. .
Eversions are treated on the same general principles. An ellipsis
from the mucous face of the lip is the most common mode of cure
resorted to. A second mode is a double V-shaped incision, the cen-
ter of the cut being the center of the lip; the space within, being
wider than that without, naturally draws the parts inward and down-
ward. In preternatural elongation of the fraenum I have secured
satisfactory results by cutting out a limited portion of the bridle
and producing an eschar by the use of nitrate of silver. Or, if the
operator prefer, he may stitch the parts together after the abbrevia-
tion, securing the continuance of an approxinuition by the use of a
turn or two of a bandage.
INDEX.
Abscess, alveolar 140
abortive treatment of 141
anomalies of 142
associations of 143
local features of. 140
Absorption of gums 212
Acute inflammation of tongue... 582
Adenoid tumors 409
Air tubes 277
Alveolar process 19
relations of teeth to 20
uses of 22
weakness of 19
Amalgam 193
Anaesthesia, general 242
age, its connection with 259
cerebral disease 263
chloroform 253
disease of heart 261
effects of a bad article 249
ether 243
hysteria 260
induction of insensibility.... 257
insanity 264
manner of exhibition 253
mode of exhibition of 244
nitrous oxide gas 265
quantit}- to be given 249
relations to atmosphere 250
strength and debility 260
test of purity 253
use of in oral surgery 253
Anaesthesia, local 288
apparatus of Richardson 239
" for foot 241
«' for hand 210
" of Thornwaite and
Home 238
electro-galvanism 239
ether spray 239
rhigolene 241
use of ice bags 238
Analvsis of Indian-corn 183
6{ milk 178
of oatmeal 179
of potatoes 179
of wheat 182
Angina simplex 97
chronic 99
Anomalies of dentition 116
illustrations of 127
varieties of 116
Antrum of Highmore 21
distention of 422
dropsy of 424
general consideration of 419
■ indolent tumor of 420
mercurial troubles of 433
purulent condition of 425
relations of temperaments to 425
scorbutic troubles of 433
surgical features of. 22
syphilitic troubles of 433
tooth abscess of 422
tumors of 371
Aphtha 600
definition of by Prof. Wood 615
diagnosis of 614
forms of 601
general consideration of 602
prognosis of 615
review of 605
type of 600
Arterial tumors 411
Arteries of face 46
branches of facial 47
facial 47
features to be noticed 48
of tongue 57
Articulation, temporo-maxillary 61
Associative lesions of dentition... 88
Atlee's suture 538
Bandages, Barton's 515
crossed or knotted 474
Gibson's 517
the yard ^17
Bean's splint 520
Benign tumors 328
Bites of insects 589
Blood, composition of 172
Bonos, ethmoid 34
hyoid 43
(695)
696
INDEX.
Bones, lachrymal 42
malar 41
maxillary superior 21
■ " inferior 20
nasal 40
palate 20
sphenoid 3(j
turbinated 32
vomer 31
Brushes, improper use of 289
CALCTJLtrs, salivary 213
illustrative cases 210
Caries of maxilla 303
affinitj- for cellular tissue 305
constitutional treatment of... 107
general consideration of 103
local treatment of 187
of teeth 163
paper by Dr. Paul on predis-
posing causes of. IGG
peculiarities of. 306
scrofulous association of 304
treatment of 306
Carotid arteries 48
Character of oral hemorrhage.... 413
Chisels used in dentistrv 188
Chloroform ". 252
action of 253
at ditferent temperatures 254
in cerebral diseases 203
in heart diseases 261
in hysterics 200
in lung diseases 261
in pregnancy and menstrua-
tionX 261
in reference to age 259
objections to 255
strength and debility 200
tests of. 252
Classification of tumors 374
Cleft palate 633
Cobweb in hemorrhage 92
Comparison of nutritive elements 178
Compound cystic tumors 334
Congenital fissure of hard palate 635
Congenital hare-lip 634
Congenital hypertrophy of gums 205
Congenital union of gums 298
Congestion of nerve centers 108
Constitutional considerations of
neuralgia 438
Constitutional treatment of hem-
orrhage 92
Contraction of lips 548
Cow's milk.... 113
Crowded dental arch 289
Cutaneous hypersemia Ill
Cystic tumor of tongue 580
Cysts of antrum 349
Dental arch 289
Dental chisels 188
Dental necrosis 310
Dentifrices, improper use of 289
Dentigorous tumors 337
Dentition, associative lesions of.. 88
changes in deciduous teeth... . 86
diarrhoja from 102
irritative fever from 100
miliv teeth 79
new views of 82
observations of Goodsir,
Todd, and Bowman 80
periods of eruption of per-
manent teeth 86
skin eruptions from 110
spasms from .., 106
stomatitis from 90
Denudation of teeth 221
Depressor muscles 45
Dewar's compressor 539
Diagnosis of necrosis 506
Diai-rhcea 102
DietFenbach's rubber stud 053
operation upon lips 548
DiflTerential diagnosis of tumors.. 390
Dislocation asscjciated with frac-
ture of jaw...... 527
Dislocation of jaw 524
condition of parts in 525
diagnosis of 525
kinds of luxations 524
treatment of 527
Division of skin diseases 113
Double hare-lip 543
modification of 545
Duration of shock 477
Effusions into structure of the
tongue 588
Elevators for removing teeth 229
Epithelioma 395
illustrative cases 396
locations of. 395
views of Prof. H. H. Smith. 399
Epulic tumors 362
Erectile tumors of tongue 589
Eruptions on skin 110
from dental irritation 112
Erysipelas of tongue 588
Ether 243
effects of bad article 249
mode of exhibition 244
relations of atmosphere to... 250
quantity to be given 249
Ethmoid bone 34
Exanthematous necrosis 322
Excavators, hatchet 190
hoe 190
INDEX.
697
Eversion of lip 692
Excision of tongue 592
Face, arteries of 46
bones forming orbit 18
cellular fascia of 4o
lateral aspect of. 17
muscles of. 4o
nerves of 49
veins of .50
Favices, isthmus of 53
parts bounding 53
Febrifuge 209
Fergusson's view of bare-lip 532
Fever, irritative *. 100
Fissure of soft palate 638
Fistule, salivary 267
character of. 267
example of 267
treatment of. 268
Files < 189
Filling teeth 192
instruments used for 195
materials used for 192
Fissures of hard palate 633
Follicular inflammation 616
Food, animal 175
vegetable 175
Foot-spra}^ instrument 241
Foramen, infraorbital 19
mental 19
Forceps for extracting teeth, 225, 238
Foreign bodies in nose 508
Formation of mouth 52
Forms of aphthae 601
Fossfe, canine 19
incisive 20
of tongue 58
Fractures of maxillary bones 510
bandages used in 516
Barton's bandage 515
Bean's splint 520
Gibson's bandage 516
Gunning's dressings "577
gunshot 532
modes of dressing 516
of alveolar process 234
symptoms of. 550
the yard bandage 517
Functional expressions of tongue. 563
Ganglia, Gasserian 72
Meckel's 73
naso-palatine 74
ophthalmic 72
otic 74
submaxillary 75
Gangrene of tonsils 276
Gangrrena oris (519
Garangeot's obturator 677
Gibson's bandge 516
Glands, parotid ,59
sublingual 60
subrnaxillarj^ 59
tonsil 272
Glotti^^, oedema of ;. ' 278
Gold, leaf and crystal 192
Goodsir's observations on den-
tition 80
Gout 436
Gums, their diseases 280
accumulations of tartar 281
artificial teeth improperly
inserted 292
congenital union of 298
crowded dental arch 289
dead and loose teeth 289
lancing of 298
malignant impressions 90
mercurial impressions 282
periodontitis 282
scorbutic impressions 284
vulcanite impressions 294
Gunning's dressings 517
Gunshot fractures 532
Gutta-percha 194
Hare-lip 531
Bransby Cooper's views 532
condition of patient 531
Dupuytren's views 532
Dr. Houston's views 532
Dr. J. M. Warren's views... 533
general view of operation.... 531
mode of operating 531
Mr. Fergusson's views 532
Prof. Colles's views 633
" D. H. Agnew's views. 534
" Gross's views 534
" H. H. Smith's views... 534
<' Pancoast's views 534
time of life best suited for
operation 531
views of Skey 532
" Velpeau 532
Hemorrhage, arterial 473
after extracting teeth 235
capillary 473
treatment by acupressure.... 473
" by alum-water. ... 474
" by cold water 474
" by Monsel's solu-
tion 474
" by opium and
lead 474
" by pad and band-
'age 473
698
INDEX.
Hemorrhage, arterial, treatment
by tinct. Erigeron Cana-
dense 474
" by torsion 473
" of by ligation 473
venous 473
Hoe excavators I'JO
Hoey's clamp 635
Holes in palate 649
Hyoid bone 42
Hyperostosis 357
Hypertrophy of gum 395
Hypertrophy of tongue 591
Hysteria.....". 260
Illtjstkations in epithelioma... 896
Insanity in relation Avith ether... 264
Induction of insensibility by
anesthetics 257
Inversion of lip 692
Irritable aphthae 617
Isthmus of fauces 53
Lachrymal bones 42
canal 19
inflammation of 19
Lateral aspect of face 17
Lepidoid growths 415
Lips 531
eversion of 692
inversion of 692
hare 531
treatment for 536
Luxation of inferior maxilla 524
congenital 527
condition of parts in 525
diagnosis of 525
kinds of 524
treatment of 527
Malar bones 41
process of maxilla 23
Maxilla, superior 21
caries of 304
cases by Delamotte, Koberts,
and Heath 527
causes of 525
condition of parts in 525
congenital luxations 527
diagnosis of 525
difficulty of replacing when
of longstanding 526
discoloration associated with
fracture 527
dislocation of 524
fracture of 510
fractures of 512
Maxilla, gunshot injuries of 513
inferior 26
manner of reducing 528
subluxations 526
Stromej'er's forceps 528
treatment of 513
treatment of luxations 527
use of anuesthetics in 529
Maxillary fractures 510
Mechanical surgery 652
Meckel's ganglion 73
Melanoid carcinoma 388
Mental foramen 19
Mercurial impressions 282
necrosis 325
ulcers 503
Metastatic disease of tongue 590
Milk 173
cow's 173
mare's 186
woman's 170
Monsel's solution 237
Mouth, the 44
bones forming roof of 45
formation of 52
instrument for stretching.... 553
naucous membrane of. 58
Mutter's operation for en-
largement of 550
offices of 44
organs contained in 44
sectional expression of 58
soft parts of. 45
Myeloid tumors 876
microscopical appearance of. 877
Nasal bone 40
Necrosis 809
alveolar 312
dental 310
exanthematous 822
mercurial 825
phosphor 813
syphilitic 320
Nerves, fifth pair 63
facial 49
Neuralgia 435
a phenomenon and not a dis-
ease 436
character of pain , 435
constitutional character of... 438
difference between rheuma-
tism and neuralgia 435
illustrations 441 to 471
malarial relations 487
predisposing causes of 439
syphilitical relations 437
i Nitrous oxide gas 265
INDEX.
699
Nutrition 174
Nutritive elements 178
Obturators 652
construction of. 657
Dieffenbach's rubber stud.... 653
fixing of in mouth 638
illustrative cases 659
Kingsley's 678
principles of 652
Steam's 678
Odontalgia 201
continementof gas and pus in
pulp cavity 209
deposits of osteo-dentine in
pulp cavity 210
diseased state of periodon-
teum 208
for direct or indirectexposure
of pulp 202
for sensitive dentine 201
recession and absorption of
gums and alveolus 212
sympathy 212
treatment of 202 to 212
Odontocele 334
(Edema of glottis 278
Operations on lips and cheek 548
Osteo-carcinoma 386
derivation of term 386
diagnostic differences be-
tween carcinoma and sar-
coma 390
svnonyms of 389
treatment of 392
Osteo-plastic or tooth-bone 194
Osteo-sarcoma 371
derivation of term 371
its applicability as a noun of
multitude 371
Ozaena, causes of 497
associations of 508
constitutional treatment of... 507
diagnosis of 506
local treatment of 507
Palate bone 29
Palate, holes in 649
treatment of 649
Palatine defects, and their treat-
ment 633
Papilla of tongue 56
Parasite of aphtha' 616
Pare's obturator 677
Parotid fistule 259
gland 59
tumor 541
Periodontitis 202
Periods of eruption of permanent
teeth 86
Pharyngitis *.]." 301
Pharynx 53
Phosphor-necrosis 319
Plastic operations 556
Predisposing causes of neuralgia 439
Pressure in treatment of cleft
palate 635
Prognosis of shock 480
Ranula 621
character of 621
common illustrations of 627
curious case of 623
Recession of gums 212
Remarks on extracting teeth 234
fractures of alveolar process. 234
hemorrhage from 235
local anajsthetics used 238
luxation of jaw from 238
reduction of luxated jaw 528
Resection of maxillary bones 679
Deaderick's operations 689
Horner's operations 681
of both superior maxilla 685
of inferior maxilla 687
Rhigolene 241
Saliva, analysis of 213
Salivary calculus 213
Scirrhus carcinoma 386
of tongue 575
Screw for removing tooth-roots.. 231
Scurvy 284
treatment of 284
Sebaceous tumors 405
Secondary cyst of antrum 351
Sectional expression of mouth.... 52
Section of inferior maxillary
nerve 691
Sequestrum after measles 323
Shock, primary and secondary... 474
importance of diagnosis 475
views of Prof. H. H. Smith
on 475
Skin diseases, varieties of. 112
Skull, front and lateral regions of. 18
Spasms 106
for congestion of nerve cen-
ters 108
from dental irritation 107
Sphenoid bone 37
Spray of ether 239
Staphyloraphy. 038
anatomical study of part 039
literature of 042
preparation of patient for.... 638
700
INDEX.
Staphyloraphy, stages of opera-
tion G42
Steam's obturator 678
Stomatitis, sj^philitic D-1
Styptics 'Xl
Sublingual glands (JO
Submaxillary glands 59
Superior maxillary nerve 67
Swallowing of tongue 599
Symptoms of maxillary fracture. 50
Syphilitic diseases of gums 288
neuralgia 437
Tartar 210
Teeth 289
agents that destroy 290
anomalous or deformed 232
artificial 292
composition of. 165-170
diseases of. 140-201
first, or milk set
Thrush, treatment of CIS
Tin foil 193
Tongue 54
acute inflammation of 582
arteries of 57
character of 44
cystic tumors of 580
elfusions into 588
erectile, tumors of 589
erysipelas of 588
excision of 592
fatt_y tumors of 590
forms of 597
fossa and base of 58
functional expression of 562
furred condition of 565
hypertrophy of 591
insects, bites of 589
mercurial ulceration of. 573
metastatic tumors of. 590
operations for 599
organic diseases of 568
papilla of 56
scirrhus of 575
swallowing of 599
sympathetic diseases of 568
temperature of. 564
tongue-tie .. 597
uses of 44
view of 55
Tonsil glands 272
■ composition of 2:54
cystic growths of 276
gangrene of 276
hypertrophy of 274
relation of 254
ulceration of 276
Tumors of mouth 327
benign 328
comjiound cyst 334
cyst of antrum 349
degenerating sarcoma 383
epulides 362
fungus hajmatodes 387
meianoid 388
myeloid 376
osteo-carcinoma 386
osteo-dental 336
osteo-sarcoma 371
scirrhus carcinoma 386
secondary cyst of antrum.... 351
simple cystic 329
Tumors of parts associated with
the mouth 405
adenoid 409
arterial 411
cvstic 407
fatty 408
keloide 417
lepidoid 415
n.Tvi 411
sebaceous 405
venous 413
verrucous 416
Veins of face 51
Vomer bone 31
Vulcanite obturators GG9
WiLDMAN on facial defects 671
Wounds, of mouth and associate
parts 472
character of hemorrhage 473
hemorrhage of. 473
indications in treatment 472
injurious effects of Monsel's
salts in 479
removal of foreign particles. 472
treatment of 473
varieties of 472
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