urn ^H 1 1* ; ^ J m .rî;.. i oii'ii ■ « v-v* I J~ r . ^ A N *.<- ^ ** bo x o [American Lierary of Dental Science.] COMPLETE ELEMENTS SCIENCE AND ART THE DENTIST B Y M. DESIRABODE, SURGEON DENTIST TO THE KING, ASSISTED BY HIS SONS, DOCTORS OF MEDICINE FOLLOWED BY An Historical and Chronological Notice of the Works published on the Dental Art, from the time of Hippocrates. ADOPTED FOR THE SCHOOLS OF MEDICINE AND PHARMACY, BY MINISTERIAL ORDINANCE, RENDERED UPON THE REPORT OF THE ROYAL COUNCIL OF PUBLIC INSTRUC- TION J AND FOR THE HOSPITALS OF THE PORTS AND COLONIES OF FRANCE, BY MINISTERIAL ORDINANCE, UPON THE RE- PORT OF THE INSPECTOR GENERAL OF THE MARINE SERVICE OF HEALTH. SECOND EDITION. Translated from the French, for the American Library of Dental Science. BY * — A. — * BALTIMORE: PUBLISHED BY THE AMERICAN SOCIETY OF DENTAL SURGEONS, JOHN W. WOODS, PRINTER. 1847. v. ^ $ o y* "y transfer f rGto Pat. Office Lib. April lô l4< Entered, according to the Act of Congress, in the year 1847, in the Clerk's office of the District Court of Maryland. in INTRODUCTION. Whatever may be the science to the study of which we de- vote ourselves, we may promote our advancement and facilitate inquiry in two ways entirely different from each other. The one consists in patiently re-examining whatever of doubt- ful character certain points of the science in question may in- volve, in s omitting them to a new investigation, enlightened by the knowledge of the first causes; then to deduce from them general principles in harmony with the degree of advancement to which the other parts of our knowledge have attained, that have with them either simple analogies of origin or direct rela- tions of the end. The other consists in collecting all the facts that experience has positively and definitely determined, in binding the two together, and to establish upon their methodical resemblance and their reciprocal connections, principles immediately appli- cable to practice. The first of these two modes, more elevated, perhaps more worthy, constitutes that which we have concluded to call phi- losophical study, from whence flows Theory. The other, more modest, but not less useful, since it represents in the tree of science the branch which bears the fruit, constitutes the study of application, from which is derived art properly so called, or that which we term Practice. Medicine, whatever may be the fundamental homogenity of the parts of which it is composed, and the firmness of the prin- ciples which serve as a base for it, can no more than the other sciences withdraw itself from this double mode of study and this division in its exercise. Thus, although theory and practice, far from excluding each other, and progressing separately, ought, without doubt,more than any other thing, reciprocally to enlighten each other, and lend, IV INTRODUCTION. under all circumstances, a mutual aid ; it is no less true than strange, that among those who devote themselves to the allevia- tion of human suffering, there are many who, adopting their theo- ry, as it were, ready made, occupy themselves exclusively with its application. Still more, in this already circumscribed sphere, some confine themselves to a single branch, which they make the object of an exclusive preference and the subject of a par- ticular study. Such are dentists, oculists, lithotomists accoucheurs, her- nial surgeons, orthopedists ; all those, in a word, who devote themselves to that which we commonly name a speciality. Is this admission of the specialities in the practice of medi- cine of any advantage in the progress of the art, and, therefore, as profitable to mankind as the interested parties have generally pretended, and have endeavored to make others believe. Without wishing to examine thoroughly the value of these assertions by which each specialitist seeks to justify his excep- tionable position, and to make comparative advantages result from it, we think nevertheless that, if it is permissible to reply affirmatively to the question we have stated, it ought certainly to be so for dental medicine and surgery ; not certainly supe- rior by reason of the importance we would assign to the organs which form its domain, for all the parts of the economy are to our eyes important, since they are essentially necessary for the continuance of life and the preservation of health ; but be- cause, if it is demonstrated by daily experience that all the op- erations which belong to the other specialities are executed with an undoubted superiority by surgeons who occupy themselves with the general art, it is evident that dental surgery not only de- mands the various and complete studies which are indispensa- ble to the practice of the other branches of medicine, but it has still more, a very distinct and imperious necessity of a know- ledge of all the particulars of mechanism. Now, this knowledge acquired only by those studies which application in no other part of their practice find, would draw away by far too much those who destine themselves to general medicine, and even simply to surgery. Thus have there been, from time immemorial, some who oc- INTRODUCTION. cupied themselves exclusively with the diseases of the mouth, the treatment of which they specially require, and even the care very frequently necessary for the restoration of the dif- ferent parts which compose it, but particularly the teeth. The writings of Herodotus and Hippocrates, among the Greeks ; of Celsus, Pliny, Martial and Horace, among the Romans, have not left, as we shall more than once be able to prove, any doubt upon this subject. Unfortunately at this remote epoch, and even at a more re- cent period, dental surgery being included in that unjust dis- dain with which the most absurd of prejudices had stigmatised manual medicine, properly so called, was the prey of empirics, of charlatans, and even of jugglers, ignorant men, who, following the judicious remark of Theodore Z winger, had no reputation to risk, no merit to expose, and above all, he might have been able to add, no security to offer : who would have extracted with impu- nity a tooth and inflicted at the same time, upon the mouth, every possible mutilation. Besides, their ignorance found its excuse in the opinion so generally spread, and which their irrational manoeuvres constantly maintained, that the extraction of a tooth could not be effected without mangling the gums or at least breaking the alveolus ! It was reserved for the present age, besides being so fruitful in useful information and salutary institutions, to do away with an abuse so contrary to the dignity of the art, so little conforma- ble to the good of mankind, and against which there were in- effectually exerted, with all the strength of their genius and the influence of their position, the efforts of Ambrose Paré, Guy de Chauliac, Yigo, Dionis, who were at that time the fathers and glory of French surgery. The lawof the 5th of March, 1802, in refusing to any one the right of exercising the art of healing, without having obtained, by public examination, the grade of doctor of medicine or the title of officer of health, has implicitly recognised, in spite of the decree of the supreme court of the 23d of February, 1827, (a decree which constitutes an omission without establishing a principle,) this law we say, has declared, that the preservation of organs so valuable as the teeth ought not to be abandoned VI INTRODUCTION. to the stupid and brutal ignorance of empirics, whose destruc- tive vandalism might constantly be attended with the most so rious errors, and, consequently, the most deplorable accidents. "One of the most distinguished surgeons of our day, M. Mar- jolin,* whose word will always be authority when he speaks of that which relates to the good of the science and the dignity of the profession, truly says, the exercise of the art of the dentist constantly demands knowledge greatly extended and compli- cated. Hence it is important it should be practiced by those who have made it the exclusive object of their studies; for den- tistry does not consist in a knowledge of the most evident af- fections of a tooth, and the performance on it of the most simple operations and the most clumsy manipulations ; it is necessary to have the most accurate knowledge of the anatomy of the mouth, particularly that of the teeth, and to unite general notions of anatomy, physiology, medicine, hygiene, mechanism, and still more, the skill of the goldsmith." In publishing a new treatise upon the Art of Dentistry, an art which no word expresses directly in our language, but which we call odontology, or odontechny, when it is confined to the study of the teeth, and stomatono?ny, when it comprehends all the parts which compose the mouth, we have not the proud pretension either of rebuilding this branch of medical science upon a new basis, or of placing ourselves above our professional brethren. On the contrary, we are anxious to acknowledge to all, not only that this basis has been laid in a solid manner, by Fauch- ard, more than a century ago, whom we regard with reason as the restorer, or to speak more plainly, as the father of dental sur- gery,! but we recognise still more the developments that are given to the principles laid down by this celebrated practitioner, * Nouveau Dictionnaire de Medicine, article Dent. t It is by order of merit, and not of date, that we place Fauchard at the head of authors who have written upon dental medicine; it is true, the first edition of the work of this illustrious practitioner was not published until 1728, and as far back as 1582, it is said, nearly a hundred and fifty years before, Urbain Hemard had published at Lyons, an Essay upon the art of the dentist, in which some very judicious precepts were found united in the form of doctrine. INTRODUCTION. VU by the works of Lecluse,Bourdet, Jourdain, Gariot, and more re- cently those of M. M. Duval, Delabarre, Laforgue and even Le- maire, forming, by their combination, a theory which has permit- ted this art to march side by side with the other parts of our knowledge, whose study has for its means and end, the cure of the diseases of man. But our principle motive in writing, has been to unite in the same treatise all that which medical science, in its different branches possesses more immediately applicable to our speciali- ty, and to make subservient to the establishing of many practi- cal facts too lightly admitted, and even, it is necessary to say it, to the reforming of many errors, an experience acquired un- der circumstances the most favorable, an experience the extent of which we think no one can, at least without injustice, doubt, so far as the art properly so called is concerned. For, it is not necessary to conceal the fact, that we are evi- dently at an age, in which the progress of reason and light, urges the world to free itself from the great evils which induce disease of the teeth, and to conceal the ravages which acci- dent, in spite of every precaution, is liable, at every age, to inflict upon the mouth, forcing the dentist to make the operative and mechanical part of his art, if not his exclusive business, at least, his principal element. Undoubted truth, by which our professional brethren have daily profitted and regulated their conduct, though very few have had the courage, not to say the sincerity of avowing it pub- licly. As if our calling, when it may be reduced to the propor- tions of a mathematical art, even purely mechanical, could not now, by the great services which it renders in this isolated branch, be worthy of the most profound study, and throw some brilliancy upon the career of him, who devotes himself unre- servedly to it, without the fear of passing for a limited practitioner, and of being confounded with quacks. In reducing to its true state, all that which properly belongs to this work, we, doubtless, may omit reproducing by the publi- cation of a complete treatise upon the subject, opinions which have been before expressed, and which have become, for this very reason, the elements of our art. But as there are few Vlll INTRODUCTION. points, in practice especially, that our experience has not de- monstrated susceptible, if not of a total reformation, at least, a crit- ical examination, of which, the result may be a modification of the operator's procedure, we should have had difficulty in clas- sifying our remarks, which, being offered separately, would assuredly have lost their importance; which, on the contra- ry, being methodically interlaced in a complete work, form a compendium expressing exactly the true state of this part of the science, able to serve as a guide for such, to persons who wish to have a precise knowledge of it, and to make it a complete manual. There will no doubt be objections made to our work, because there exists already many didactic works upon our art, speaking only of those which have appeared in our day. It is true, and, we are far from being ignorant of the fact, as we shall prove sufficiently, and perhaps superabundantly for the good of some, in the course of our treatise ; but of these works, generally, only reproductions, commenting, more or less, upon each of those which have preceded them ; what then are those which can be called complete works ? Are they those of M. Duval? Without sharing, in any man- ner, the unjust disdain with which Laforgue treats the pro- ductions of this respected teacher, we cannot refrain from avow- ing that if these productions bear plainly the impress of the eru- dite, even of the great man, it is the truth, they do not always indicate the marks of a practitioner ; and that the most of the excellent precepts they contain are buried under a load of quota- tions, and figures little calculated to produce that for which they are essentially useful. Shall we search in the treatise of J. Lemaire on the teeth for that which we are not able to find in the productions of M. Du- val ? No, assuredly ; for that work, though correctly written, contains nothing that can guide the student destining him- self to practice, and wishing, consequently, to see in a trea- tise upon the teeth, something besides a display of rhetoric. It is by an opposite fault, the works of Laforgue err, which con- sist of only a dry assemblage of practical facts, which, although often detached from the result of critical observation, are not INTRODUCTION. IX bound together by any doctrine, and seem rather dictated by a desire to undervalue than to instruct. Let the works of M. Delabarre, and those of Maury, now oc- cupy our attention. But the first, although they declare the man instructed, and the practitioner as sincerely the friend of his art, as impressed with the dignity of his profession, form not by their union a complete treatise, since they treat of only cer- tain isolated points ; and, we say it with regret, and the love of truth demands from us this avowal, the most important of these works, that one which bears the marks of most originality, his mechanical dentistry, offers, to whoever would study it thorough- ly, the astonishing contrast of a brilliant theory, and of a prac- tice sometimes so irrational, that it would seem to have been dic- tated by the blindest empiricism. Thus, by the side of a truly elevated scientific appreciation of the reactors (commonly desig- nated by the name of resorts) we find a description given in the most serious tone of an operation, the object of which, is the at- tachment of a part of a set of teeth to the upper jaw, by means of what ? — of a band passing across the thickness of the max- illary bone, fyc. fyc. ! ! # As to the work of Maury, written under the influence of that prejudice, which seemed a long time since to confine the dentist within the narrow circle of the part essentially practical of his speciality, everything therein is reduced to the proportions which are rendered useful, only for an altogether summary study of the matter, or to serve as a memento to those who know it already. What we have said of the work of Maury, applies with still more reason, to M. Lefoulon's work, which is little more than a repetition, without the precision of certain practical details; it has still more a certain wordy air, which betrays its true desti- nation, and demonstrates that the instruction of dentists was not the chief aim of the author, as we shall often have occasion to prove, and as the practitioner himself proves, who thought him- * The term reactors applies more particularly to springs, such as are usu- ally employed for retaining in the mouth a double set of artificial teeth; upper dentures were also formerly confined in the mouth by this means. — Trans- lator. 2 X INTRODUCTION. self able to say in thirty-six lines, all that which concerns crotch- ets, are better and the most habitual means of maintaining per- manently in the mouth, the various parts of artificial teeth, and who devotes four pages to celebrating the virtues of the most in- nocent odontolgic paste, which has always been extolled. Being convinced that honesty is the first obligation, that those who write, contract with society, we shall bring in this exposi- tion, of that which is properly ours, nothing of that reserve and discretion which some of our confreres exhibit in order to make their discoveries, and operatory proceeding, mysterious. They are ignorant how much they render themselves culpable by it ; for, if these proceedings are perfect, they injure the propagation of them ; if they are only superior to those which are generally used, fortified by others, they might receive useful additions, and, in every instance, render the most eminent services to the public ; finally, if they are defective, they are liable, in refusing to allow them to be seen, to turn incessantly in a vicious circle, and often to fall from a position acquired by long and difficult labors. If the love of science and the desire of general good are not, to the eyes of our professional brethren improperly discreet, suf- ficient motives to render public the discoveries to which they have been conducted, sometimes by chance, sometimes by a par- ticular position, let them remember that their personal interest, for want of a more noble motive, demands it of them ; and if they are blinded by egotism to doubt this fact, let them medi- tate upon the following words of a master of the art, whose tes- timony and authority they often invoke. # "That one who publishes a discovery, ought not to fear that this publication will injure his interests; wealthy men always address themselves to the inventors of useful discoveries, be- cause they think justly that the author of a process is commonly the one who knows how to employ it best. Mystery on the other hand, in a useful thing, always restricts its use; it hin- ders it from being spread, accredited, and always causes more in- jury to the invention, than it procures advantages to him. I * Gariot: Treatise upon the Diseases of the Mouth. INTRODUCTION. XI think, then, that it h always by a false calculation, that one keeps a secret of this nature ; for, in admitting that the inventor of a discovery, experiences some injury in divulging it, this injury could not assuredly be put in the balance with the satisfaction that he ought to experience by its general use." To employ method in our work, and to bind all the parts which compose it in such a manner, that practical principles shall flow naturally from physiological facts ; that each object shall present itself in its turn, that is to say, following its rela- tive importance, that art, in a word, shall only be the summary of science, we have divided this work in two parts, forming two volumes, susceptible, nevertheless, of being united in one. The first contains four chapters, forming four principal divi- sions, the first is devoted to anatomy, the second to physiology, the third to hygiene and to orthopedia, the fourth to pathology and to therapeutics : this is science. The second part compre- hends, in two very distinct chapters, first, operative medicine; second, prosthesis, often so designated under the name of mechan- ical dentistry ; this is art, in its most absolute sense. This plan seems to leave little to be desired by us ; for, if by this simple, methodical, and in fine, logical division that it gives, noth- ing could have been omitted. In effect, if it is evident that the description of an organ, of whatever part of the body it ought to proceed as an indispensable base, all dissertation upon it, is as clear as its importance requires ; after the organ itself, are the laws of its development, the functions which belong to it, and the conditions upon which the integrity and entire accomplish- ment of those rest. Hence anatomy, physiology, hygiene and orthopedia. When the preservation of hygiene becomes impossible, disease manifests itself; hence, pathology, and necessarily therapeutics, in which we include all which belongs to causes, as well distant and predisposing as near and efficient to the particular character of the diseases of the teeth and even of their principal connec- tions, and to the treatment either medical, or surgical, which is appropriated to these affections, operative medicine places itself directly after pathology and therapeutics, of which it is one of the means ; for in dental medicine, it forms one of the most pow- XU INTRODUCTION. erful resources, one of the agents to which we are unfortunately most frequently compelled to have recourse. Finally, when art, often unable to preserve, is forced to destroy, and when nature has experienced the ravages of time, in the order it has imposed upon itself, or has not been able to struggle against the innume- rable causes of destruction which, at every age, menace inces- santly the teeth, prosthesis is able, by the innumerable and mar- vellous resources which it places within our reach, to furnish the means of supplying all the losses that they often experience, so as not only to deceive completely, but even of rendering detec- tion impossible by the most experienced eye — thus : fist. Anatomy; Part First, j 2d. Physiology ; Vol. 1. ] 3d. Hygiene and Orthopedia ; L4th. Pathology and Therapeutics. Part Second, C 1st. Operative Medicine ; Vol. 2. ( 2d. Prosthesis, or Mechanical Dentistry. In adopting this plan, we are then, as every one sees, almost sure, at least, of avoiding those two shoals, into which the most of our predecessors have fallen, of committing incessant repeti- tions, under the pretext of avoiding omissions, and of treating in the same chapter, of those things essentially different, as of opiates, powders, and even of teeth brushes, in the development of the materials of dental prosthesis, and of means sometimes very tri- fling, which insure the regularity of second dentition, through the instrumentality of manual medicine. Do not all these things belong more directly to hygiene? since they have no other end than to direct the execution of a function and prevent anything from disturbing it, and placing it in a natural condition. As to the secondary divisions established under the form of paragraphs, every one accustomed to judge a work, will perceive without difficulty, that in adopting those which we have follow- ed, we have constantly had in view, to speak rather to the mind, than memory, by our lectures ; in a word, to make true dentists simple mechanics. In studying in effect each object, we have considered it less following in the order in which it is employed, than in behalf of the principle which ought to serve as a guide for its completion or adjustment. INTRODUCTION". Xlll Thus, to quote an example taken from prosthesis the most of authors have made only a single article upon the pivoting meth- od of applying artificial teeth: prepared the tooth, furnished it with its pivot, prepared the root intended to receive it, and fixed the tooth to it. The result is, that after having indicated the man- ner of introducing and fixing the pivot in an artificial tooth, to be placed upon a root, they are obliged to come back that they may place it upon a metallic, osseous or mineral base. We have, on the contrary, divided this operation into two parts ; one which applies to the preparation of the tooth and fur- nishing it with its pivot, the other treats of the implantation of the pivot into the root. The first is described in the paragraph which relates to the mounting of teeth upon their supports or bases, the other in the paragraph specially appropriated to the description of the different ways of maintaining pieces of artifi- cial plate in the place which they ought to occupy in the mouth. Being convinced that the materials which ought to compose a complete treatise upon dental medicine and surgery, although regarded only in a practical point of view, are, by themselves, so extended, as to form the base of a voluminous and sufficiently im- portant work to fix the sole attention of those persons who would make it a thorough study; we will carefully avoid the descrip- tion of certain objects, which, as far as our art is concerned, be- long to it no more than other professions, as well as anatomical and pathological, which are the common property of medical sci- ence. Is it necessary to quote examples on this subject ? Of what use can it be in a work, addressed to dentists or to physicians who wish to initiate themselves in the particulars of our art, to make a minute description of convulsions, of pthyalism, and of opthalmy, which sometimes accompany the eruption of teeth, since these diseases are described with all detail and possible exactness in the different general treatises of pathology, which study should precede all special application. This description is even fastiduously repeated in all the works devoted to the disease of children. For the same reason, with what advantage has Maury, who is one of the last writers upon our art, thought to gain by following XIV INTRODUCTION. that part of his work, on operative medicine, by minute details on the description of forges, the malleability of metals, and the tempering of instruments which we shall use? These differ- ent things might, and even ought to be mentioned in their con- nection with our wares, but not minutely described, for they be- long no more to dental surgery, than to cutlery, or to the profes- sion of the jeweller. He might as well have described the la- bors of Montmartre, under the pretext that they furnished the plaster, which we employ to obtain the representation of mechan- ical pieces or of prosthesis, or that we are obliged to employ in some irregularities of conformation that we wish to correct. Be- sides, what could have appeared more inappropriate, to say noth- ing more, than to devote twenty pages to the natural history of platina and to washing of ashes, and an entire chapter, not only to the treating of certain physical and moral qualities which the dentist ought to possess, but still more to a minute description, pardon us for the expression, of the apartment that he ought to occupy, and of the furniture which should embellish it. Is it for the sake of erudition that the author whom we have quoted has adopted this course, filled with superfluities, in the midst of which, the end is necessarily sacrificed to the form, the indispensable to the accessory ? He would, according to our opinion, been able to have attained his end better by giving an exact account of the recent labors of Cuvier, of M. M. Geoffry Saint Hillary, Serres and Rousseau, and by putting that part of his work devoted to pathology and therapeutics more upon a level with the actual state of the science. To say, in effect, in anatomy, that "the teeth are the hardest bones in the human body," and in therapeutics, that, to calm the convulsions which accompany the age of dentition, "they should hold the child as much as possible in the open air, put salt in its mouth and apply cold water to his body," on the one hand, it is to content ourselves with propagating the most com- mon opinion, and on the other, it is, at least, to recommend the remedies of old women, if it is not to advocate irrational doc- trines of medicine. As to ourselves, we will seek no more to shine by a vain dis- play of erudition, a pleasure any one can procure now-a-days, as INTRODUCTION. XV every one knows, than to be remarked for a pretentious style. However multiplied may seem our quotations, we have, in the meantime, confined them to the degree necessary to prove that we have read all the important publications upon our art ; and when any one shall give himself the trouble of comparing them, he will easily perceive, that we are not content with read- ing, but that we have meditated upon each author. We shall think ourselves sufficiently erudite, if we shall first omit nothing useful; secondly, if we shall mention all the sources which we have consulted ; and we will suppose ourselves sufficiently elo- quent, if we are so clear as to be easily understood. Again, to render profitable and accessible to all the world the researches that we were compelled in obligation to make, we have added to our second part, under the form of an historical no- tice, a list of most of the authors who have written upon our art, either in a direct, or purely accessory manner. The alpha- betical order, employed by some authors in treating upon this subject, appears to us to be completely insignificant to the one who wishes, above all things, to form an opinion of the successive progress of the art, since he is liable to quote, at the same time, works separated by ages, and to place constantly the original work near that which is only a copy of it, we have substituted for it the chronological order. By this means, each work of any importance presents itself to us in the order of its publication, and we will have under our eyes a picture of the principal dif- ferent phases through which all the knowledge which has con- ducted to that which we know to-day has passed. We will divide this history into three periods : the ancient, which comprehends all that which has been published upon the teeth from the time of Hippocrates to the sixteenth century ; the middle includes all the writings of the sixteenth and seventeenth century; lastly the modern, which comprehends all those of any importance, which have been published principally in France, in the eighteenth, and all which have appeared in the nineteenth century. In the first of these three periods, we will add there- searches of M. Duval, and those which Blandin has more re- cently made, at the same time being careful to point out with precision the titles of these quoted works, and indicating accu- XVI INTRODUCTION. rately the period in which the authors which formed this remote period have lived. With regard to the two other periods, we are permitted to contribute the works of M. Dezeimeris, and the public notices contained in some of the medical dictionaries, to- gether with such as we have ourselves discovered, making in all at least one hundred and fifty works more than Maury, who has given the most complete notice.* Hence we will allow no op- portunity of escaping by which we can contribute to each epoch whatever it may be entitled to, and in the review which we are about making, in the course of which we will endeavor to an- alyse faithfully and to judge impartially, we will often be able to demonstrate, by facts, that the disdain which some modern authors show for the works of our predecessors is not always disinterested. But the desire of being just towards some who have preceded us in this undertaking, will never prevent us from declaring the merits of past times, or of forgetting the great progress of our art at the present day. On the other hand, our criticism will neither be severe or partial. Above all things we desire the good of the profession and the triumph of truth, we attack doctrines, not men, and when names are inscribed by our pen we do it not so much through the desire of elevating ourselves, at the expense of our professional brethren who have written, as it will be to place the reader in a position for judging between their views and our own. If some should occur oftener than others, it is that being placed within the first rank, they make themselves authority, and thereby liable to draw the student into their own errors. Finally, if we refer continually to dentists who have no art beyond the general principles of the science, we hesitate not to prove that more than one author, having written elementary trea- tises of surgery or of operative medicine, has committed errors in that part of his work devoted to our speciality, nor having that knowledge which long experience has been able to give for the * Some persons might perhaps think that this historical part should be placed here. Our reply to this is, the fear of turning the attention from the true motives we had in writing this treatise, prevented us from taking this course, which was the grand object of the introduction, we therefore prefer assigning to it a separate article at the end of the work. INTRODUCTION. XVII most part to us. Wishing them to respond to our title, which declares not only the art, but still more the science, we have followed, by a natural thread, the progress that each part of this art has made in arriving to our means ; and, in the description of these means, we are compelled as much to make known the pro- ceedings of our professional brethren as our own, reserving for demonstration the reason which have made us prefer ours to theirs. For the same reason, when we have established a principle, we have nearly always furnished as a support to it undoubted proofs, by facts found in our own experience and in that of au- thors the most worthy of credit, very different in that from the most of those who hitherto have written in our speciality, in personifying themselves, and in revolving in the sometimes too restricted circle of their knowledge. Can any one now reproach us with having neglected to treat, as they have done most of our predecessors, upon the different parts which compose the face, nay, even the whole head, prin- cipally the interior of the mouth, the pharynx, the velum of the palate, the tongue, for example, the nerves, the veins and arteries which nourish it ? We suppose not, for physicians and dentists know the force of this expression ; there is not one of the latter to whom daily experience has not proved that we are nearly always consulted relative to diseases of the teeth. Hence it is, that the study of these organs and the means of curing their diseases or of supplying their loss should princi- pally demand our attention ; and this is what we have endeav- ored effectually to accomplish. To discover the truth and to present it in the most clear terms has been our principal object? to be useful is our only wish ; should we have attained this, we shall be sufficiently recompensed for the mistakes that we may have committed in endeavoring to give proof of our zeal, that a mistaken rivalry might have taxed with rashness ; but do WHAT IS RIGHT, HAPPEN WHAT WILL. SCIENCE AND ART OF THE DENTIST. PART FIRST. ANATOMY, ORTHOPEDIA, PATHOLOGY AND THERAPEUTICS. CHAPTER I. ANATOMY OF THE TEETH. Nature has subjected all animals to the obligations of a gene- eral law : this is to seek in surrounding bodies for those ma- terials which are calculated to repair the injuries they sustain from the continual succession of the phenomena of life, and af- ter making a proper choice of these materials, to submit them to various preparations, of which the teeth generally speaking, con- stitute the principal agents. Hence the teeth, considered in this general point of view, be- come mechanical instruments, situated at the entrance of the ali- mentary canal, for the purpose of seizing and dividing the nutri- tive substances, and frequently to act at the same time as a means of attack and defence.* Some anatomists have given to the word tooth a much more extensive signification, and have applied it to horns, which occupy the same place in certain animals, f as the beak of a bird ; they have also made use of it to designate any calcareous or horny substance, that is seen either at the entrance of the diges- tive organs, or in the midst of these organs, the object of which is to keep a good hold of prey or to masticate food. * F. Cuvier : Des Dents des Mammifères, considérées comme carac- tère zooîogique. 1821. # Geoffry Saint Hillary : System Dentair des Mammifères et des oiseaux. Paris, 1824. 20 ANATOMY, ORTHOPEDIA, We do not deny the analogy — on the contrary : but as our object in the present work is to treat solely of human teeth, we have no desire to ascertain how far from truth authors have wandered in undertaking to give an almost unlimited sense to a term which moreover designates any organ having an edged character ; we will confine ourselves to the définition we have adopted with Cuvier, and which appears to express in a clear and general manner the organs we intend to treat of in the course of this work. f- Teeth have been long considered as real bones ; but anato- mists and dentists,* who have admitted this identity have de- pended upon simple appearances which a more critical exami- nation has demonstrated utterly incorrect. Already has Beclard and many other modern authors with him, raised doubts in re- gard to it, and endeavored to sustain their views by the different characters that exist between these two organs ; and which are now-a-day considered perfectly distinct. They differ thus : 1st. In respect to position : The teeth are naked and outward- ly visible, whereas bones, and this character is one of the most important, are enclosed in a periosteum. 2d. In an anatomical point of view : Teeth are formed by a bulb, or large papilla, surrounded by a calcareous case, composed of two substances, enamel and ivory. This calcareous case is not visibly penetrated by vessels, and presents no apparent ves- tige of cellular tissue.f In the long bones is found a medul- lary substance which bears some resemblance to the papilla of the teeth, but the flat bones are free from it. 3d. In respect to their development: In the teeth the forma- tion of the hard or bony substance takes place from the circum- ference to the centre ; whereas in the bones, this development is made inversely, that is to say, from within outwardy. J They afterwards present a renewal that constitutes a second dentition, * "The teeth are the most durable and compact bones of the body." Mau- ry; Maury d l'Art du Denteiste, page 17. t J. Cruvilhier : Analomie descreptive. 1834. % M. Flourens endeavors to establish that the bony particles are furnish- ed by the periosteum; but this opinion, which is but the reproduction of that of Duhamel, is far from being generally adopted ; it has moreover found strong opponents. PATHOLOGY AND THERAPEUTICS. 21 a phenomena unparalleled in the history of the development of bones. 4th. In a physiological point of view : Teeth are not as bones, levers to which the muscles are attached, the latter being the principal agents of our movements. 5th. In respect to chemical composition : Teeth possess a greater quantity of salt — and jelly does not penetrate the texture of the enamel, as we shall see hereafter, when giving detailed analyses of all the substances which enter into their composi- tion. Finally, the best evidence of the essential difference between the teeth and bones, a proof to which no physician or dentist has ever paid any attention, is, that the teeth never contract any real adhesion to the jaws : Now, it is well known how easily the organs of identical nature are united by the simplest pathologi- cal effort. Again, teeth known under the name of adherence, are nothing but teeth with diverging roots, upon which the alveo- lar partitions are engrafted in such a manner, that following out its various windings one would be inclined to believe that they were really soldered together. The most minute researches have never enabled us to prove this affinity, so often discovered amongst the teeth, particularly at their roots,* as we shall soon illustrate by example. From what has been said, it evidently follows that there is no analogy between the teeth and bone, except that they resemble each other in hardness and color. How then shall we rank them ? in what system of the economy? We do not hesitate to believe with Cruveiihier, whom we have just quoted, and who has followed the opinion of Aristotle,f adopted by Gallien, and afterwards reproduced by Urbain Hemard,J that they belong to the epidermic system. Here are the reasons upon which we found this opinion, so generally prevalent now-a-days. 1st. Examined in the scale of animals, they form an uninter- rupted series, from those that resemble the horns and nails, to those that present the most marked bony appearance. # Let any dentist separate this supposed adherent from the teeth, and he will be assured of the justice of this remark, t Aristotle : Book 2, chap. 9, etc. on the Parts of Animals. | Researches upon the Time Anatomy of the Teeth. 1 582. 22 ANATOMY, ORTHOPEDIA, 2d. Their texture is lamellated like that of the nails and hair. This texture is quite visible in certain animals ; amongst others it is not so, but only on account of the accumulation of the cal- careous salts. 3d. Their manner of development is similar to that of horns, nails and hair ; like them, they are deprived of apparent nutri- tive organs, are formed layer by layer, and are merely the pro- duct of secretion. Thus Geoffry Saint Hillary* as we have already said, considers the beak of a bird, which is evidently a horned production as connected with the dentary formation. Number and Position of the Teeth. The number of teeth in young persons at the period of first dentition is twenty, ten in the upper jaw, and as many in the lower. In the adult, this number is thirty-two, sixteen in each jaw. Man has, consequently, in the course of his life, fifty-two teeth : twenty temporary ones, and thirty-two that are permanent. The teeth, by their uninterrupted series, form two para- bolical curves corresponding to those presented by the alveo- lar arches which serve as their support. These two series or ranges constitute what is called the arches of the teeth. They are kept as if nailed together in the alveolar cavity, which are exactly moulded upon their roots. At the time when teeth were looked upon as real bones, this arrangement went under the de- nomination of gomphosis. This relation of contact of the teeth with the alveolar is, how- ever, only mediate. They have an immediate relation with the alveolar prolongation of the gum called likewise alveolo-dental periosteum, which envelopes the root, and with the dental pulp that fills their cavity in becoming an integral part of themselves. These are the two true means of union, by the assistance of which the teeth are mechanically fixed in their alveoli. The import- ance of this means of union will be fully appreciated by bearing in mind the loosening of teeth in persons afflicted with scurvy, and the facility with which they separate and fall in the skeleton. Each range of teeth, we have already stated, presents a re- gular and uninterrupted curve ; this arrangement is found # One of the most philosophical works that has been published upon the subject. PATHOLOGY AND THERAPEUTICS. 23 only in the human race. In animals, teeth have an unequal length, and the border of the arches of the teeth is frequently- irregular; besides their teeth are not continuous, and leave be- tween them considerable intervals. Hence it is, that in no animal do we find the teeth arranged with so much regularity and elegance as in man ; in children they form a semi-circle, which gives them quite a beautiful ap- pearance. In adults they form an ellipsis which increases the facial angle, and gives to the countenance a more stern and marked character. The arches of the teeth offer to our observation two fronts and two borders. Their anterior front is convex, their posterior front concave ; their adherent border or alveolus regularly fes- tooned; their border free, thin and sharp in front, increases gra- dually on the side where it is thick and with pimples. These arches are not equal amongst themselves : the above one repre- sents a more extensive curve than the one below, so that, placed upon the same line, they form an oval by themselves, the first being the large extremity, and the second the small one, and by approximating they meet each other exactly at the bottom of the mouth, whereas in front, the superior dental arch encases or sur- rounds the lower. Whoever will examine the arrangement of the teeth upon the skeleton during the coming together of the jaws, will find that the incisors below, slip behind those above, that the external tubercles of the lower grinders slip inside of the external tubercles of the upper ; it follows, hence, that the first correspond with the gutter that separates in the upper grinders the range of the external tubercles from that of the internal tuber cles, or in other words, all the upper teeth increase beyond the direction of their antagonists. The teeth of the upper jaw are in the geueral a little more volum- inous than those of the lower jaw. In a word, we would remark that no tooth corresponds exactly with that which bears the same name in the other jaw, we can always perceive a cir- cuit of more or less extent, whence results, not merely a simple contact, but an exact fit. Exterior Conformation of the Teeth. If we consider the configuration of the teeth, we shall not only find that they possess certain general characters which vary 24 from all the other parts of the organism, but that they have, moreover, particular characters, which distinguish them amongst themselves. Let us then turn our attention to the first, without making any apology for entering into minute details ; for if these details do not always find a direct application in pathology, they become at least of absolute necessity when we wish to reme- dy, by imitation, the parts which have been damaged or destroy- ed, which certainly constitutes one of the most important points of our art. Each tooth presents two very distinct parts : 1. One that is free, which is called body or crown. 2. The other which is implanted and concealed in the thick- ness of the jaw, and differs by its length and by its simple or multiplied condition, which is called root. That sort of con- traction which separates these two portions is called the neck. The crown has a different form, according to the species of tooth we consider. Its summit is entirely flat, only when it is worn by friction. In a perfectly sound tooth this summit is raised by one or many projections called cuspides. Its circum- ference is more round and projecting towards the exterior than towards the interior. Its entire surface presents a whitish tint, and brilliant giassy appearance. The root, it has already been said, is simple or complex; in many cases it only offers the traces of a longitudinal division which is not complex. Its form is that of an irregular cone, connected near the basis with the adherent portion of the crown. Its surface presents a yellowish hue, which contrasts with that of this last. In a fresh state it is connected in an intimate man- ner with the alveolar partition by means of the membrane of the follicle. The neck is formed in all the teeth, by the reunion of two curved lines, the convexity of which is turned towards the side of the root, and which meet each other by angles on the sides where the teeth correspond. The circumference of the basis of the alveolus does not correspond exactly to the neck, but with the root at a certain distance from the neck. It is this space that separates the neck from the alveolar border, which is occupied by the gum. The teeth have a vertical direction, or very near it ; we gene- rally sec, however, that the axis of the upper incisors is slightly PATHOLOGY AND THERAPEUTICS. 25 inclined, so as to present a divergence beyond the centre of the alveolar arches. When this obliquity is very marked, it gives to the physiognomy a disagreeable character which resembles the brute. The crowns of all the teeth present a length nearly equal, and we can easily conceive the advantage resulting from this disposition. If the teeth were separated far from each other, mastication could not be easily performed. It is on account of this that, in fractures of the jaw, the surgeon should use all possible care to prevent a harmful consolidation of the fragments, and the irregularity of the dental border which is the conse- quence of it. The teeth have, in general, the form of a hollow, irregular, and rather elongated cone, whose large extremity is free and projecting in the mouth, and constitutes the crown, and whose summit, simple or complex, is sunk into the alveolus, and constitutes the root. The conical arrangement of the root, and the exactitude with which the alveolus is moulded upon it, have this double advantage, that the effort of mastication is dis- seminated through all the points of the alveolus, and that the pressure is not felt at the extremity which receives the vessels and the nerves. According to form and custom, the teeth are divided into incisor, canine, small and large molars. The Incisors. The incisors (cunéiformes of Chaussier) are those whose crown have the form of a wedge, with the edge slightly fluted ; their office is, as their name indicates, to divide bodies that show but little resistance. They are eight in number, four in each jaw, two in the middle and two on each side ; they occupy the front and middle part of each dental arch. This class of teeth shows its peculiar powers most in vora- cious animals, such as the wolf and the beaver. General Character of the Incisors. Their crown is compressed in the form of a wedge, a little convex in front and concave behind, plain and triangular at the sides. Its basis is thick, continued from the root; its edge free, 4 26 ANATOMY, ORTHOPEDIA, a little larger than the basis, and cut obliquely at the expense of the posterior part for the upper incisors, and at the expense of the anterior for the lower incisors. When the incisor teeth have not been worn by friction, they present upon the edge three small unequal indentations, the mid- dle one being a little more elevated than the side ones.* As to their root, it is simple, flat on the side, of a conical shape, a little thicker in front than behind, and sometimes marked on the sides by a small longitudinal furrow ; we have even seen this furrow penetrate deeply enough to bifurcate the summit and even the whole of the root, which should be taken into consideration in placing pieces on a pivot. Difference in the Characters of Incisors. The upper incisors are nearly twice as large as the lower ones. The upper middle ones are much stronger than the side ones ; but a character that should be particularly pointed out, and which, however, the most critical anatomists, and even Cruveil- hier himself, (whom we have so far taken as our guide in our descriptions,) have omitted, is that the middle incisors have an edged border completely straight, whereas, upon the side ones, this border is cut obliquely from within outwardly; so that the four incisors, united together, form, by their free border, a straight line towards the centre, but slightly inclined towards the extremities. In the lower jaw, on the contrary, the lateral incisors excel the middle ones in magnitude, but this difference is scarcely perceptible. As to their edged border, it is straight in the middle, and rather crooked in the lateral teeth. Canine or Laniar Teeth. These teeth, conoides of Ç haussier, called canine, from the fact of their being so marked in dogs, and laniares, because they are so well calculated to tear in pieces — are four in number — * In the canine species this disposition is very manifest; it gives to the tooth the Jleur de lis, which is more prominent as the animal is younger, and as the tooth is less grown, as we shall see in speaking of the wearing away of the teeth. PATHOLOGY AND THERAPEUTICS. 27 two in each jaw. Situated outside of the incisors, they are con- sequently nearer the support and power which causes the lower jaw to move, and are thereby enabled to overcome greater re- sistance than the incisors, which are the extremity of the lever. Hunter has named these teeth cuspidati, on account of their pointed top. In carnivorous animals, their strength, however, is fully developed. It is by these teeth that the bear, and even the elephant defend themselves.* In certain fish, these teeth are bent back in the form of hooks, and serve not to tear, but to arrest swallowed up prey. General C/taracters of the Canine Teeth. These are the longest of all teeth, so that they hang over the incisors a little, which is principally noticed in the upper canines. Their crown is conoid, very convex in front, a little concave and unequal behind, and ending with a pointed top but most generally tuberculous, which very frequently over- hangs the level of the other teeth. Their root is simple, like those of the incisors, but much longer and much more voluminous; the alveolus that encloses it has quite a projection in front. Its extremity is sometimes separated in two, but generally characterised by a furrow which indicates two branches united in one, flattened on the sides. The neck of the canine teeth shows, in front and behind, two very marked curves. Difference in the Characters of the Canines. The upper canines are longer and thicker than the lower ones, but in the lower jaw the neck of the canine and the neighboring parts of its crown and of its root have a slight pro- jection from the parabolical curve of the dental arch ; which is the beginning of the relief we have already mentioned. * Such, however, was not the opinion of Aristotle and Pliny, who say that the elephant has two great teeth between those which are used for eat- ing, and who regard these two teeth as being of an altogether particular nature. Duval has vainly sought to give some credit to this opinion, in a notice inserted in the seventh volume of the Memoirs of the Royal Academy of Medicine. ; the opinion of Daubenton, corroborated by the researches of Cuvier, is more generally admitted. 2S ANATOMY, ORTHOPEUIA, The roots of the upper canines correspond to the ascending apo- physis of the submaxillary bone, and in some individuals become longer until they arrive at the basis of this apophysis. As these roots are directed towards the socket of the eyes, some have been ignorant enough to suppose that they were in some way connected therewith, and in consequence called them eye flaps. So evident is such an error that we scarcely deem it necessary to combat it ; we will simply observe that the length of their roots explains the difficulty frequently met with in their extrac- tion, and, moreover, the accidents which may result therefrom. The Molar Teeth. The molar teeth have a cuboide crown, the end of which is filled with tubercles, which are designed to grind like a mill. Hunter calls them multicuspides ; but the small ones having only two nipples, are likewise designated under the name of bicuspides. The molars are twenty in number, ten in each jaw. They occupy the five last alveoli of each half of the dental arch, and consequently are found nearer the point of articulation than all the teeth, which gives them, as we shall hereafter show, a very advantageous arrangement for having a powerful pressure upon the bodies which any one wishes to crush against them. Teeth of this class have, for general characters, in the first place a flattening of the top of the crown, and, consequently, a much greater extent of the triturating face than that of the two kinds already described. Their faces are parallel, that is to say, do not approximate to form a sharp or angular border. Their sur- face is unequal and projecting ; their crown is round and a little square, and rather short in a vertical sense. Their roots are numerous. General Characters of the Bicuspides. We already know they are eight in number, four in each jaw, two on each side, and occupying the space which is left be- tween the canine and the big molars, so that a line that would cut the orbit in two equal parts would fall into the interstice that separates the second small molar from the first of the three PATHOLOGY AND THERAPEUTICS. 29 large ones. Their crown is cylindrical, about as large as that of the canine, compressed according to the diameter which cor- responds with the parabolical curve of the dental arch; the anterior and posterior faces are even ; the two others, that is to say, the internal and the external, are convex. The smooth extremity of this crown presents two short conoid tubercles, one externally, a little larger, the other internally, sepa- rated by a furrow which follows the direction of the arch. As to the root, it is unique and bifid; but in the first case it is deeply furrowed in its length. Difference in Characters. The small lower molar teeth are not so strong as the upper ones, from which they moreover differ by the direction of the crown, which is slightly bent in by the wearing out of the ex- ternal tubercle. The first, a little smaller than the second, often presents but a single tubercle, which is the external, an arrange- ment which very often gives it some resemblance with the canine it touches. The tubercles of the small upper molar teeth are separated by a furrow more marked than that which divides the tubercles of the lower ones. In these they are sometimes reunited. The second from above presents, in the majority of cases, two roots, which makes it different from the others. To find, as a modern author* has done, the reason of this double root of the small upper molar teeth, in the fear that na- ture had that they might fall;, is truly a subtility which many persons will be astonished to meet in a work given as a serious labor. General Characters of the Large Molar Teeth. They are twelve in number, six in each jaw, three on each side, and occupy the remotest part of the alveolar arch. The last has received the name of wisdom tooth, on account of its late appearance. Their crown is much larger than that of the preceding ones ; its form is cylindrical, a little flattened on the two sides by which they correspond with each other, but round * Le foulon : New Treatise upon the Art of Dentistry, page 29. 30 ANATOMY, ORTHOPEDIA. and convex on the external and internal fronts. Their free and triturating surface is covered with four and sometimes five une- qual tubercles, cut into facets, separated by a crucial furrow, aud often by small dimples. Their root is always double or treble, and in this case one of the branches presents a longitu- dinal furrow, which indicates the union of two in one. Some- times it is quadruple or quintuple, but varies according to length and direction. These roots are sometimes diverging, sometimes parallel ; and frequently, after wandering off, they come together, and bend in the shape of a hook, which em- braces a greater or less portion of the maxillary bone. When the teeth present this disposition, which is not very rare, they are called barred teeth, they cannot be extracted without ex- tracting at the same time the bony portion which they embrace. All contrary pretension would involve an absurdity. Difference in Characters. The crown of the large lower grinders projects somewhat in- side ; that of the upper is entirely vertical. The large lower grinders are the only teeth that have a more bulky crown than those which correspond with them above. It is easy to dis- tinguish the upper from the lower by ascertaining the arrange- ment of their roots ; thus, in the lower ones, the roots are two in number, one in front, the other behind. These roots are very strong, large, flattened from behind in front, rather deeply furrowed according to their length, and bifurcated at the top. The upper teeth have generally three roots, two external, which are frequently united, and one internal, most commonly very diverging. The first large molar tooth is distinguished from the two others by its bulk, which is generally quite considerable. Its crown has generally four, and sometimes five tubercles, two within and three on the outside. The second, not quite so bulky as the first ; is attached to the lower jaw by four tu- bercles, separated by a crucial groove, which is less regular in the upper jaw, its body has a rhomboidal form. As to the third large molar, or wisdom tooth, it is distin- guished from the first and second by its bulk, which is some- PATHOLOGY AND THERAPEUTICS. 31 what less at its crown, which has generally but three tuber- cles, and at its axis, which considerably directed inwardly at its roots, which are sometimes completely united in one. But in this case we never fail to find in it all the characteristics of the molar teeth, that is to say, the vestiges of three roots, blended in one for the upper root, and in two for the lower one. Fur- thermore, the wisdom tooth is that which contains more varie- ties, and frequently, instead of taking a perpendicular direction, it takes an oblique course, both inside and out, and instead of presenting three or four tubercles, it only presents two or some- times but one ; whereas, in some instances, we have seen its crown divided into six, eight, and even ten tubercles ranged in two lines, and separated by a furrow, or sufficiently deep depression.* It is even sometimes found in individuals in whom it remained buried in the thickness of the maxillary tuberosity. Structure of the Teeth. But very few parts of the organization of man have en- grossed the attention of anatomists more closely than the struc- ture of the teeth. If we reduce to the most precise data, what has been written on the subject of the teeth, we shall find that they are essentially composed of two substances; one external, hard or cortical, which only offer slight marks of organization, that its resemblance with the general tissue of the bones gives them the name of osteoide, and divides itself into ivory and enamel; the other internal, soft or pulpous, deeply organized, called pulp or kernel of the tooth. Hence we see that the teeth are not full, but hollow near the neck, and as far as the centre of the crown. This cavity pre- sents nearly the form of the tooth upon which it is examined. It is generally the more considerable the less the individual is advanced in age. Frequently it is obliterated in the adult. Closed on the side of the crown, it prolongs in contracting more and more towards the summit of the root, and there opens, following the number of roots through one or many holes * Lemire gives, in his Treatise upon the Teeth, a very curious example of (his sort. We have many of them. 32 ANATOMY, ORTHOPEDIA, through which an artery, a vein, and a nerve pass. It con- tains the pulp or dental papilla. The hard, or cortical portion, is likewise composed of two substances, as Eustachius* has already demonstrated — one that lines the crown, and only the crownf, with a vitreus layer, of little thickness, and grows thinner as it approaches the neck : it has been called enamel on account of its resemblance with the glassy covering of the porcelain ; the other, which forms the entire root, and the deep portion of the crown, is the ivory which has also been improperly called dental bone. The enamel is a particular substance, unequalled in the econ- omy, semi-transparent, principally in the teeth of first den- tition, variable in color, not only in the same individual, but even in the same range of teeth, from the white of milky or bluish pearl, to the deep yellow, partaking even of the brown. Its texture is eminently fibrous, which is easily perceived when studied from the fragments of the crown, where it is quite evident that the enamel is composed of short fibres, which are a sort of crystalline needles, strongly pressed one against the other, and raising themselves, not exactly perpen- dicularly, but rather obliquely from the external surface of the ivory. Many modern authors seem to give this fibrous texture of the enamel as an anatomical fact, the discovery of which they claim. They are mistaken, for this texture has been long known : as a proof thereof, we will merely quote the following passage from Lahire, published about fifty years ago :J "The substance of the enamel is composed of an infinitude of small fillets which are attached to the internal part of the tooth by their roots, almost in the same way that the hair and nails are to the parts they are connected with. This composition is very easily seen on a bro- ken tooth, where we perceive that all these fillets are very much inclined towards this part and almost perpendicular upon the * Eustache : De Dentibus. Vide opuscul anatemi. 1574. ■f An anatomist, named Bertin, believes, however, that the enamel ex- tends in an extremely thin layer over the whole surface of the root ; but surely he has no authority for this assertion. J Memoirs of the Royal Academy of Sciences, 1699. PATHOLGY AND THERAPEUTICS. 33 basis of the tooth : by this means these fillets resist better the efforts they are obliged to make in this place." The enamel is extremely hard, and this quality is one of its most powerful elements of stability. As long as the teeth are covered with it, they resist the greater part of the causes of change that arises from the bodies with which they generally have re- lation ; but as soon as the ivory is exposed, they deteriorate* very easily. In old skeletons, when all the other parts of the tooth are reduced to dust, the enamel still preserves its consis- tency and solidity. This extreme hardness causes the enamel to be quite brittle ; and the sudden percussion of a hard body is able to crush it, or to deprive it of its brightness. The thickness of the enamel is very variable. In some per- sons it forms a great part of the crowns of the teeth, while in others it is found in very thin layers ; always thicker in an adult than in a child, in the large molars, than in the canines, and in the latter than in the incisors, it is more marked at the triturating extremity of the tooth, and is worn with time by the effect of friction, and almost disappears in old people. Although Mascagnif considers the enamel as entirely formed of absorbing vessels, it has nevertheless been hitherto utterly impossible to discover the least trace of vessels. Injections never penetrate it — the use of the madder never colors it with red ; subjected to fire, it separates from the ivory, blackens a little at first, tarnishes and becomes brittle after having resisted a longer time than the ivory of which we shall soon speak. By plunging the enamel into nitric acid, slightly tinged with water, it dissolves, and assumes a whitish color. Scraped with a sharp instrument, it is reduced to dust, which distinguishes it from the ivory which is divided into very thin plates, and forms a sort of chip similar to those obtained by planing wood with a straight fibre. The chemical analysis of the enamel has been frequently * This assertion, however, ought not to be received in an absolute sense, as we will show in the part devoted to pathology, when treating of cartes and the wearing away of teeth, etc. t History of the Lymphatic Vessels of the Human Body, etc, 5 34 ANATOMY, ORTHOPEDIA, made, but we consider the following of Berzelius as most satis- factory. According to him it contains, Phosphate of lime, 85.03 Carbonate of lime, 8.00 Phosphate of magnesia, 1.05 Animal matter and water, .20 94.28 The results obtained by Peppys, vary but slightly from these. This chemist merely pretends with Hatcheff, and, contrary to the analysis of Fourcroy and Vauquelin, that this substance does not contain any cellular or cartilaginous tissue. We are inclined to admit this last opinion, because it is founded on the entirely inorganic appearance of the enamel. The ivory constitutes, alone, almost the entire tooth of which it forms the root entirely, and the body in a great measure. It is neither as hard nor as brittle as the enamel. It is of a yel- lowish white color ; its texture extremely thick ; neither fibres nor cells are discernible in it, but it is easy to perceive a lamel- lous disposition, particularly in the crown which appears evi- dently to have been formed from concentric layers, of horns set in each other, and parallel with the exterior surface of the tooth. The root does not present, distinctly, this disposition. Its frac- ture has generally a silky and variable appearance. This part of the tooth is composed of calcareous and animal matter, as is demonstrated by the analysis we intend to give of it ; but the point that has caused most discussion, is to know whether it possesses vessels or not. Blake* and Fox, relying on the tumefaction and softness so remarkable near the root, to- gether with the soldering which they imagined they observed, with the alveoli, have come to the conclusion, that vessels should be admitted into it. There are, however, strong and numerous arguments for the adverse opinion. Thus it is evi- dent that the injection does not penetrate it. Once formed, it wears out by friction like an inorganic body without the least appearance of a nutritive motion. * Dissertation upon Dental Formation, etc. Edinburg, 1778. PATHOLOGY AND THERAPEUTICS. 35 Beclard, unwilling to admit a vascular communication be- tween the ivory of the crown and the dental pulp, thinks, ne- vertheless, that the ivory receives continually from the latter, a liquid by imbibition : that in consequence, it is in regard to the pulp, in the same condition that the hair, nails, horns in general, are in respect to the vascular part of the skin. As to the ivory of the roots, we think that its texture, organic action, and morbid alterations developed in them, with the further proof of the vessel's continuous w r ith those of the organism in general, authorise the belief that the question is solved in favor of their presence. Whatever may be the organization of ivory, air cannot easily penetrate it ; and. if subjected to the action of nitric acid, it acts like the tissue of bones, that is to say, its calcareous sub- stance is dissolved, and there remains in it a parenchyme, both tenacious and flexible, having neither a fibrous nor an alveolary appearance; when, on the contrary, it is submitted to fire, it burns in diffusing an odor that depends upon the presence of the gelatine, becomes black, and leaves a white, hard, and brittle substance. Berzelius found in the ivory substance in one hundred parts : Phosphate of lime, 61.95 Fluate of lime, '2.10 Phosphate of magnesia, 1.05 Carbonate of magnesia. . 5.30 Salt and chloride of sodium, 1.40 Animal matter and water, 2^.00 According to Peppys, the roots are formed of one hundred parts of Phosphate of lime, 58.0 Carbonate of lime, 4.0 Animal matter, 2S.0 Water and loss, 10.0 Desirous of procuring a more recent analysis of the part that constitutes the osseous tissue of the tooth, we have requested Doctor Fory, professor of medical chemistry, and at present principal apothecary in the Hospital of St. Louis, to have the kindness to make it. This honorable chemist obtained the following results : 36 ANATOMY, ORTIIOPEDIA, For the ivory matter of the crown, free from enamel : Phosphate'of lime, 61.93 Fluate of lime, 2.12 Phosphate of magnesia, 1.05 Carbonate of magnesia, 5.29 Salt and chloride of soda, 1.51 Animal matter and water, 28.00 For the root : Phosphate of lime, 58.00 Carbonate of lime, 4.00 Animal matter, 3.00 Water and loss, 11.00 Hence the ivory differs much from the enamel, for it contains a little animal matter similar to that of the bones, as is demon- strated by these analyses, and as can be easily seen in many preparations deposited amidst the collections of the faculty, whereas the enamel is almost entirely calcareous. This pre- sence of a cartilaginous matter in ivory, and its manner of acting in regard to the caloric, which acts upon it precisely as it does upon the bones, although insufficient to establish a similitude between the ivory and the bones, are nevertheless daily called in requisition, and will shortly be so for the purpose of explain- ing certain diseases of the teeth, which are, notwithstanding, all that can be said, the most striking resemblance with those of the osseous system. As to the union of the enamel with the ivory, Cuvier* pre- tends that there exists between these two substances, a line that terminates at the neck, and continues with the plate of the follicle, which adheres to the root of the tooth. This learned anatomist considers this line as indicative of the existence of a very fine membrane, which envelopes the papilla, when no part of the ivory is transuded. As this papilla gradually separates from the ivory, it draws inwardly, and also separates from the membrane, which always serves as a common tunic, both to the membrane and to the matter which it transudes underneath. The enamel on its part is deposited upon this tunic by the pro- * Studies and Researches upon Bony Tissues, PATHOLOGY AND THERAPEUTICS. 37 auctions of the internal plate of the capsule, and is in such a manner compressed by it, that it soon becomes imperceptible in the hard portion of the tooth, or at least appears on the cap of the tooth only as a fine greyish line that separates the enamel from the internal substance. M. Duval has latterly very strenuously insisted on the im- portance of this line, and M. Blandin* says positively, that he has found, and announced in his courses, the membrane that it represents. Blandin goes so far even as to compare the rela- tive disposition of the ivory and the enamel of the teeth to that of the osseous extremities and the cartilages of the articu- lations, and considers the membrane of which we speak, as per- forming the duties of the synovial which is placed between the bone and the cartilage. The soft portion or dental pulp, occupies the cavity which exists in the tooth, and exactly represents its form. It is, says Cloquet,t a sort of ganglion, of exquisite sensibilit, following the vasculary and nervous pédicule, which enters by the root, and of which it only appears to be a rudiment. Being of a greyish color, and a soft mucous substance, it is intimately connected to the vessels and dental nerves by means of a vas- cular and nervous pédicule which penetrates the root of the teeth by the aperture that perforates its summit. Blandin considers the pulp or dental kernel only a continua- tion of the dental follicles. He uses the following language in îeference to the subject : "The dental follicles are placed in the alveoli in the same number as the teeth. They are small sacs formed by depressions of the mucous membrane on a level with the neck of the tooth. Exteriorly they are intimately connect- ed with the alveolar periosteum, and sink into all the anfractu- osities of the alveoli ; interiorly, the follicle that comes out of the alveoli is filled by the root of the tooth to which it strong- ly adheres ; its buccal aperture embraces the neck and remains there ; its bottom gives birth to the papilla or pulpous kernel." We insist on this opinion, because it corroborates what we have already established, which is, that there is great analogy # Anatomy of the Dental System, in respect to Man and Animals. Paris, 1536. t Descriptive Anatomy, with plates. 38 ANATOMY, ORTHOPEDIA, between the dental follicle and that of the hair and of feathers, or to speak in more explicit terms, between the tissue of the teeth and that of the various epidermic productions. Both folli- cles are formed by a fold of the tegumentary membrane ; both, says Blandin, are principally connected to the neighboring parts by a nervous and vascular pédicule ; both have a contracted neck adhering to the organ which they produce, and surround- ed by a follicular circle ; both give birth to a papilla; in fine both enclose, the first the tooth, the latter the hair or the feather. The only very sensible difference, continues the same ana- tomist, which separates both follicles, consists in this, that the den- tal is mucous, whereas the hair and the feather follicles are almost always cutaneous, inasmuch as the first is sunk into the alveoli, whereas the other is sunk into the general cellular tissue, and finally, because the papilla of the dental follicle is pedicular, whereas that of the piliform follicle in particular is sessile and tubulous. This last difference explains the limited increase of the tooth, and the indefinite development of the hair, as we shall see when treating specially of the dental follicle in the chapter devoted to the physiological history of the teeth. To what has just been said let us add only that the swelling that forms the dental pulp is penetrated by a great number of bloody vessels and nervous fillets. The presence of the latter explains the excessive sensibility of this pulp, to the irritability of which a great many authors have attributed the various diseases of the teeth, and even all that has been written on the sensibili- ty and vitality of the teeth. Cuvier goes so far as to consider it almost as delicate as the gelatinous substance of the pit of the ear. In an excellent dissertation, published in 1817, M. Serres* whose researches on this subject have served as a guide for those who have since turned their attention to the apparel of the teeth, has described a series of small bodies which he calls glands of the teeth, and which are placed in a circle on the alveolar borders around the neck of the follicle.f These bodies * Essay upon the Anatomy and Physiology of the Teeth. t To be just, it is necessary to aver that Hippolytus Cloquet had written upon them before Serres ; see his Traites upon Descriptive Anatomy. PATHOLOGY AND THERAPEUTICS. , 39 are themselves small follicles that secrete a matter intended to lubricate the alveolar border before the teeth come out, and which, according to him, would afterwards form tartar. This last supposition unfortunately falls before the observa- tions of Em. Rousseau* who, acknowledging the existence of these glands, has, nevertheless, proved that they disappear after the eruption of the teeth. These bodies exist effectively, we are positive of it, but we think with Blandin, that these are absolutely unknown to tartar, as we shall have occasion to prove hereafter, and we believe they are more similar to the follicles that are found around the neck of the matrix of the hair. De- labarre acknowledges their existence ; but he thinks they be- long to the nervous and salivary apparel, and that they secret a part of the fluid intended to sustain the flaccidity and elasticity of the gums. Teeth of First Dentition. The anatomical characters which we have described belong exclusively to the teeth of adults, that is to say to those of the second dentition. But in an infant of the age of two or three, there are teeth of so different a character that we feel obliged to examine them separately. Upon the precise knowledge of the characters peculiar to them, practical facts of the highesUmport- ance are established. These teeth are called infantile or milk teeth, because they are peculiar to children, and make their appearance generally when the child is at the breast. They are likewise called tem- porary, in opposition to those we have described, and which are called permanent. The milk teeth are twenty in number, ten in each jaw. We will merely designate the characters by which they are distin- guished from the permanent. Their color, instead of being an ivory white or of a clear yel- low, is a bluish or azure white. The incisors and canine teeth are always distinguished from the permanent incisors by a less bulk and by the shortness of their roots, which frequently are entirely destroyed, as we shall show when treating hereafter of * Comparative Anatomy of the Dental System of Man and the principal An- imals. Paris: 1827, 8 vo., with thirty plates. 40 ANATOMY, ORTHOPEDIA. the physiological phenomena, by aid of which both species of teeth succeed each other. The two molars, that is the small ones, differ widely from the same teeth in the adult ; they approach very near to the large molar teeth, from which they are distinguished by the small height of their crown, which is cylindrical, and presents firm tubercles to the triturating face, three of which are outside and three in. The small molar of the adult have generally only two tuber- cles, and the large ones four, as already stated. Considered in regard to their bulk and general arrangement the infantile teeth present moreover the two following charac- ters : like the permanent they are stronger in the upper jaw than in the lower; but they do not form by their union, as the permanent parabolical ranges, but two arches which resemble the bows of a circle, and differ but little from each other. The comparative chemical analysis of the teeth of both den- titions also demonstrates that those of the first contain a little less phosphate of lime than those of the second. It is to this small quantity of salt we must attribute the transparency or milky appearance, and principally the great alterabiiity of the milk teeth ; they are also frequently affected with decay when falling out to leave room for others that succeed. Finally to complete the history of the human teeth, consider- ed indifferent ages, we annex an analysis made by Laissaigne 3 professor of chemistry in the veterinary school at Alfort. Animal matter Phosphate of Carbonate of Objects submitted to analysis. Teeth— Of a man 81 years of age, Of an adult, Of a child 6 years of age, Of a child 2 years of age, Of a child 1 day old, Of an Egyptian mummy, Cartilage of the gum Of a child 1 day old, 86.07 11.03 Dental pulp Of a child 1 day old, 77 23 Dental sac Of a child 1 day old, 57 37 in one hundred lime ; one hun- lime, one hun- parts. dree L parts. dred parts. 33 66 1 29 61 10 28.05 60 11.05 23 67 10 35 51 14 29 55.05 15 pathology and therapeutics. 41 Varieties and Anomalies of the Teeth. The teeth, perfectly identical in both sexes, present numerous varieties, and frequently very strange anomalies. Blandin* at- tributes these varieties to three circumstances : age, race and individuals; but as he is obliged to confess that races only im- press upon the teeth insignificant varieties, and as the researches to which we have a long time had recourse for the purpose of making our collection one of the most complete, have convinced us that the differences which sometimes exist in the teeth of certain people are less the positive consequence of natural char- acters than the result of certain habits, we will only admit two orders of varieties : those that depend on age, and those that re- late to individuals. Varieties of Teeth according to Ages. We have already traced some of the characters which the pro- gress of life impress upon the teeth : we have now to present the following considerations : The root of a tooth is always developed differently from the crown. In a very young child, the root, properly speaking, does not exist, but the crown, on the contrary, has already nearly ac- quired the size it should afterwards have. In a little more ad- vanced age, the root is far from having attained its entire length, still the crown begins to wear out at its extremity. In an adult, some teeth have already lost, by use, the small projections with which the top of their crowns are furnished, and their roots have ceased for a long time to increase. Finally, in old age, the crown is sometimes completely destroyed, while the root is still completely perfect ; so that their natural destruction takes place in the order of their development. The shedding of the teeth follow the same order as do their eruption. Thus, this prelude of destruction commences with the incisors. Is it because being first developed, they are shed before the others ? It is one reason without doubt ; but the thin- ness of the summit of their bodies, and the frequency with which they are used in man are likewise two perfectly admissible rea- sons ; the enamel furthermore is not so thick at their extremity as upon the other teeth. * Woik quoted. 6 12 ANATOMY, ORTHOPEDIA, At the expiration of a certain period, which varies according to a number of circumstances, but particularly according to the condition in which the teeth are after their formation, the small nipples with which the tops of their crowns are mounted have disappeared, and with them all the enamel that covers their sum- mit. It is this condition we allude to when speaking of a tooth that is rased. In this case, the centre of the triturating surface pre- sents a yellowish hue, and its circumference is surrounded by a line of a white color. In proportion as a person advances in age, the wearing of the teeth progresses. In old age, it frequently removes the entire crown, without, nevertheless, the dental cavity being opened ; this depends, as we shall soon hereafter see, on a new deposit of bony matter which presents itself like a stopple to protect the cavity. Hence, it necessarily follows from what precedes, that teeth, in the same degree as they are worn away, should furnish positive data for the determination of ages. This can be exactly ascer- tained in animals who have uniform food or a regular way of living ; but it would not be so in a man whose food is as va- rious as his tastes, and on whose teeth are impressed diseases which modify their composition and render their destruction more rapid. In considering these circumstances we are enabled to obtain results of much importance. We will soon return to this question. Varieties of Teeth according to Individuals. There is certainly no organ that offers so many varieties as the teeth. In order to conform with the general order, we will refer these varieties to five principal heads — to number, form, di- rection, position and structure. Varieties in number : These are either varieties by default or by excess. The first consist either in a total absence of teeth , as Fox, Borelli, Labatier and Baumes have quoted examples, or in the absence of a great many, as in a subject that we have known who only had in each jaw four incisors, and as Schmitt and Fauchard have observed ; or, in fine, the absence of one or two teeth only, a conformation which appears hereditary in some families, sometimes it is a canine, again an incisor, which has not appeared. PATHOLOGY AND THERAPEUTICS. 43 It is not un frequent to find individuals, particularly women, whose wisdom teeth never appear, especially in the lower jaw ; but generally in this case the tooth remains concealed in its alveoli, or in the thickness of the branch of the jaw, and finally comes out, for we think that a slow tooth is, if not the agent, at least the motive of an effort of expulsion which ceases only at its egress. We will remark that the anomaly in the development of teeth, which goes so far as to leave the jaws entirely naked, is extreme- ly rare; we have never seen it personally. As to the absence of one or more teeth, we frequently observe it in the large molars, and in some cases, we repeat it, their fault is only apparent, and depends only on the fact that they remain enclosed in their alveoli beyond the time when they generally appear. Doctor Devaut # furnishes an example of one of his fel- low students who died at the age of eighteen, in Paris, with five teeth less in the lower jaw, three molars on the right and two on the left; his gums were large and swollen, undoubtedly on ac- count of the germs they contained, and did not present the edged border which the gum of the newly born offers. He never re- members having had any teeth at this place, and never were any extracted from him. It is furthermore said that a magistrate of Frederickstadtf never had any but molars, and no canine or incisors. Fauchard has left us the curious observation, of a child five or six years old, in whom the greater part of the teeth had not ap- peared. Brouset, in his excellent Treatise on the Medical Edu- cation of Children^ likewise speaks of an individual of the age of twelve, who only had the half of his teeth, and whose alveolar border had acquired the consistency of the gums of an old person. Finally, there is no tooth whose absence has not been either separately or conjointly with others observed. The decrease of the number of teeth because two or more of them are uni- ted together, is a rare anomaly; but we think it less inju- # Essay upon the Nature and Formation of the Teeth: Inaugural Thesis. Paris, 1826. t See the Ephemcris of the ■ Nature of the Curious J Volume first. 44 ANATOMY, ORTHOPEDIA, rious than their absolute absence, for we have met with many examples ; we have, amongst others, two incisors on the same side united in such a way that in reality they form but one. What is hard to admit is the reunion of all the teeth in the same jaw : the examples of this sort related by Pliny, Plutarch, Bartholin, Melanthon and some other authors, historians or naturalists, are probably nothing else but facts badly ob- served. As to the union of two teeth in one, this is done either by the crown or by the root, or in fine by both. The first case is more common for the incisors, and the second for the molars ; and in carefully examining the examples of this last case, we are compelled to admit that there is not always direct adhesion, but connexion through means of the ossified dental alveolar periosteum ; that is to say, that it is a sort of ankylosis formed by the union of the roots of both teeth through the inter-alveo- lar partition, afterwards destroyed by the inflammation of the dental alveolar periosteum. The union of the crown, on the contrary, is a real fusion of the two teeth, in which the ivory substances are common to each other. It takes place when the teeth are still in an em- bryo state : two germs have been formed very near each other — the intermediary portion is not developed — they then remain in the same alveoli, their two papillae are confounded together and the calcareous layers, after being extended over this dou- ble papilla, separated for the purpose of forming the roots of the confounded teeth. If we form our judgment by the cases which we have observed ; the union of the canine with the lateral incisor, would be much more frequent. This is explain- ed by the strong pressure which the canine always exercises upon the lateral incisor from its formation. The excess of teeth always depends on the duration of those of first dentition. Likewise those teeth which are called super- numerary, whether they appear separately, or whether they form a complete series, almost always show themselves behind the others. There are, nevertheless, circumstances in which we are obliged to admit the existence of third germs in the jaws. Such undoubtedly was the case of the son of Columbus, the PATHOLOGY AND THERAPEUTICS. 15 anatomist, and^that related by Serres* of a servant of Geoffrory, physician in the Hotel Dieu, who had a double range of teeth, forty in all. We are frequently deceived in regard to .the ex- istence of the supernumerary teeth. We have frequently, by inspecting the mouth, proven to persons who imagined they were thirty years of age, that they were deceived by simple appearances. Finally, a variety of teeth' which comes under this class, is simply the internal existence of supernumerary teeth. We have many examples in our collection : in one, the tooth is stop- ped between the roots of a large molar : it is represented in plate 8, in the work of Maury, to whom we have entrusted it ; in the other case, it is developed in the cavity of another tooth, which it has split : in a third, we see a cell in the thick- ness of the upper maxillary, immediately beneath the nasal bone, on the very line of separation of the two maxillary bones. Variety in the Form of the Teeth. It is reasonable to consider the most part of the varieties ol form the teeth offer, as results of a morbid state, which has affected them at some period of their development. But we can likewise admit that a simple pain could have determined some of the various and capricious forms they offer in many cases. Sometimes there are teeth of immense size, or of extraordi- nary smallness ; sometimes we meet upper incisors, bent up wards in form of a hook, or having a double hook. Some likewise diverge from the crown and the root towards the neck, in form of the letter Z ; whereas, others bend in the form of C. We, moreover, find crowns surmounted with an unfinished tooth ; finally, crowns absolutely deprived of roots, and roots of crowns. But in enumerating all the varieties of form we have in our possession, we are compelled to admit that the extreme affinity, and the excessive divergence of the roots of the large molars are, if not the most remarkable, at least the most common ; for, in twenty teeth of this kind, we do not frequently meet with four * Memoir quoted, page 134. 46 ANATOMY, ORTHOPEDIA, that have the same form. We should observe that these varie ties of roots are seldom seen, if ever, in the milk teeth. Finally, a variety of form that is common enough, and which has not been remarked by any author, is the depression in form of a horn, from the posterior face of the anterior teeth, and of which the enamel has perfectly followed the contours. Varieties in the Direction of the Teeth. As these varieties are frequently accessible by the means of art, we will return to them by-and-by. In the mean time, let us here observe, that authors are much mistaken in saying, that thes^ anomalies of direction are sufficiently rare ; for, from the simple obliquity to a complete inversion, there is a number of bad directions, which it is useful to know, together with their causes, and which might possibly be corrected. Varieties of the Position of the Teeth. The annals of medicine exhibit very remarkable examples of the transposition of the teeth. It must certainly be interesting to the surgeon dentist to know something of it; for, this knowledge may be his guide in the appreciation of a tumor de- veloped in the vicinity of the dental arches. This variety consists in a simple deviation of the position which the tooth naturally occupies, but there is also sometimes a complete transposition — a real error in position. The first case is well explained by the improper directions which the teeth may assume ; those particularly of the upper jaw, which sometimes leave the alveolar border, either to be transferred to the side of the palate, or in any other direction, or to be placed entirely across the alveoli. But it is difficult to explain the cases of complete transpositions, or rather they cannot be ex- plained ; they may be observed and noticed. Here is a sum- mary detail of the anatomical pieees, the most remarkable of this sort is in our collection : 1. In an adult, a canine, on the right side, which is placed across the arch of the palate, adhering to the partitions of the PATHOLOGY AND THERAPEUTICS. 47 alveoli which contain the two incisors and the small canine, but without any communication with these alveoli.* A den- tist of the last century, found an almost similar case in an or- ganist of Payenne ; but the tooth, instead of being a canine, was a molar; and, instead of adhering to the alveolar partition, it occupied the very centre of the palatinal arch. 2. A canine on the right, and of the second dentition, which remains in its alveoli, but continues to increase towards the wings of the nose, and having, by the development of its crown, burst the alveolar partition, at the expense of which it was produced. 3. A canine that lies across the anterior part of the palatinal arch, adhering to the alveolar arch of which it destroys the entire plate to the extent of nearly three centimetres. 4. Two wisdom teeth, of which are entirely enclosed in the thickness of the branch of the maxillary bone, bursts the ex- ternal partition ; the other only showing a light part of the crown in the thickness of the base of the coronoid apophysis, but directing itself from behind in front, and not from above downwards. 5. A small molar having completely perforated the body of the lower jaw, above the mental foramen, having its crown perfectly formed, and its root equally perfect, but bent poste- riorly. Varieties in the Structure of the Teeth. Those varieties of which authors are merely pleased to an- nounce the possibility, without furnishing a single example, are sufficiently numerous, and depend, it is true, frequently on morbid causes. The most curious we possess of them is the incrustation of a root of an incisor by a layer of enamel, but the deposit, on different points of the roots of many molars, of small particles of enamel, which seem to escape from a brush intended to cover the crown with this greenish varnish; Doctor Devautf says that he has seen an example of this last case at * Colendre: see Essay upon the Most Frequent Diseases of the Teeth,and upon the Proper Means to Prevent and Cure them 1781. t Thesis quoted. 4S ANATOMY, ORTHOPEDIA, M. Dumon tier's of the Faculty of Paris. In this sort of varie- ties should be put not only this unequal distribution of enamel, which often presents lumps, hollows, holes, but, moreover, the exostoses which so often develope on the roots, the com- plete obliteration of the dental canal, the formation of the osselet which prevents the opening of this cavity, finally, the trans- formation of a tooth into a cartilaginous tissue, as we have many. THE MAXILLARY BONES AND THEIR ALVEOLAR BORDER. After the teeth, the parts of anatomical study most important to the surgeon dentist, and of which the conformation should always be present to his memory, are the maxillary bones, in which they are planted. These bones are three in number, two above and one below. The two first form, if not the whole, at least the greater portion of the upper jaw. The other, by itself, forms the lower jaw. Fixed immovably to the bones of the skull, the two upper jaws form, by their reunion, the middle part of the face. Con- sidered in all they possess of importance to the dentist, each of them offers two very distinct portions — a vertical one, called ascending apophysis, and by means of which they lean upon the frontal bones in forming the contour of the anterior aperture of the nasal bones — the other is horizontal, and forms the body of the bone ; let us enlarge upon this a little. The body of the upper jaw presents three faces, one external, one internal, and one above. The external face commences at the point of junction of the two bones upon the middle line, presents from the front behind, at first, a small cavity, in which the mystyform muscle is inserted, and which is directed out- wardly by the projection made by the alveolus of the canine tooth ; afterwards, another cavity, of greater depth, called the canine cavity, surmounted by the orifice of the suborbitary canal ; finally, further behind, a vertical top that separates the canine cavity from the maxillary tuberosity; this, evidently more projecting before than after the appearance of the wisdom tooth, is deepened by small conduits for the passage of the ves- sels and posterior and superior dental nerves. The anterior PATHOLOGY AND THERAPEUTICS. 49 part of this face corresponds directly in front to the upper lip, and at the sides to the soft parts which constitute the thickness of the cheeks. Of the other two faces of the upper jaw, the upper one, which is of less extent, forms almost the whole of the orbit ; the other, which is called naso-palatine, is itself divided in two unequal parts, one of which, situated above, larger behind than in front, forms a part of the platform of the nasal bones ; and the other, situated below, forms a part of the palatine arch, to which we will shortly advert. It is in this part of the internal face that is seen the orifice of the maxillary sinus, a large orifice upon an isolated bone, and which, upon an articulated bone, is straiten- ed by the prolongations belonging to the neighboring bones. This orifice leads to the interior of a cavity called maxillary sinus. This cavity, which makes the bone we are speaking of very light, considering its bulk, has the form of a pyramid, of which the basis corresponds inwardly, the summit outwardly, the up- per partition to the platform of the orbit, the anterior to the canine cavity, and the posterior to the maxillary tuberosity. If the extreme thinness of the upper wall explains to the surgeon dentist the influence of tumors developed in the sinus, on the condition of the organs contained in the orbitary cavity, the small thickness of the partition which separates below the bot- tom of the alveolus from its cavity, should also admonish the surgeon dentist that they can be easily penetrated by these alveoli, particularly by that of the canine, in perforating it to place a tooth on the pivot. Of the three borders of the upper jaw, the anterior, in unit- ing with its mate, forms the projecting line that is seen be- tween the two central incisors ; the posterior vertical is very thick, but less so than the inferior or alveolar, which is the firm- est part of the bone of which it forms in a measure the basis. With this difference from the upper jaw, the lower jaw is composed of a single bone. This bone which occupies the lower part of the face, has the form of a parabolical curve upon both extremities, which are called branches, form a right angle with the central part called body. This body represents a bent 7 50 ANATOMY, ORT110PEDIA, plate, convex in front, concave behind. Its anterior face oifers to the middle part a vertical line, called symphysis of the chin ; it is the mark of union of the two parts of which this bone is composed in young persons. This union is characterised in a man by the form of an arc instead of an angle ;* and again, by a vertical line instead of an oblique direction behind and almost horizontal ; thus, the chin is an exclusive attribute of the hu- man species. The symphysis terminates in front by a triangu- lar eminence, called mental, whence proceeds a line obliquely directed above to continue with the anterior border of the branch of the jaw. The posterior face of the lower maxillary is moulded in some way upon the tongue ; it presents like the anterior an oblique line which is directed equally behind and above, and becomes more projecting at the level of the last molar ; beneath this line is a large depression, but one that is rather superficial, which contains the submaxillary gland, and above a cavity that re- ceives the sublingual gland. The two oblique external glands, together with the oblique internal, divide the body of the max- illary bone in two parts, one superior or alveolar, the other infe- rior or basilary. The first constitutes, almost by itself, the body of the bone in the fœtus and in the child ; but it only forms the two-thirds of its height in an adult, whereas it disappears almost entirely in old age, when this body is, in a great measure, reduced to its basilary portion. The branches of the lower jaw are quadrilateral. Their ex- ternal face is covered by the masseter muscle, which is its prin- cipal mover; the internal connects with the pterygoid muscle, and presents the orifice widened by the lower dental canal. But what is of importance to us to know and appreciate is the union of these branches with the body of the bone. The angle * But it does not follow that this character will be exclusive to the human race, as many anatomists have said, for it belongs to many animals ; the ape, a large number of dogs, the cat, lion, and many others, have evidently the inferior jaw arched, in such a manner that if an anterior part of the lower jaw being found angular, one might affirm that it never belonged to man ; it would be imprudent to conclude the contrary, for the simple reason that the two parts which compose it unite and form an arch. PATHOLOGY AND THERAPEUTICS. 51 that results from this union, and which is called angle of the jaw, is extremely obtuse in a child ; it becomes completely straight in the adult, and reassumes in old persons the aperture it has in a child, not by the retrocession of the articular con- dyle, which, forming the centre of the movements of the jaw, remains invariably fixed in the cavity that is peculiar to it, but by the progress of the body of the bone. It is this progress which, joined to the alveoli, explains why it is that the chin of old persons is so projecting.* This variation of the body of the jaw and of its branches, de- termined by age, proceeds simply from the fact that at both ex- tremes of life the two jaws intending to touch each other, it was necessary that their branches and their bodies should be almost on the same line, whereas, in the adult, the branches should raise each other in order to remove the jaws from each other, and of leaving between them the interval necessary to the teeth. Hence arise, 1st, the repugnance adults have for eating, those who have no teeth I mean. 2d. The impossibility of placing a set of teeth in the mouth of a child, and the precautions we should use in placing one in the mouth of an old man, whose jaw has followed its natural evolution. Examined in their mutual relations, the two jaws present each, under the form of a parabolical curve, an alveolar border, in which are placed the teeth that seem to connect with it, and show themselves by exterior projections that give to this border a festooned appearance. The upper curve is greater than the corresponding alveolary curve of the lower maxillary bone, and we have already seen what the consequence has been for the mutual disposition of the teeth in both jaws. Each of these borders, less thick in front than behind, where it projects in- wardly, is surrounded by a series of holes, separated by their partitions. These are the alveoli, whose dimensions are propor- tioned to the roots they should contain, and which are sub- divided like roots into two, three or four secondary cavities. In the upper jaw, the bottom of these alveoli approximate the * Bichat has erred, as M. Serres very judiciously remarks, in saying thai the branch of the inferior jaw inclines as much more from the perpendicular a^ we observe in more advanced age. 52 ANATOMY, ORTHOPEDIA, maxillary sinus, from which they are separated only by a bony partition of extreme thinness, and in which they sometimes open : this is principally applicable to the canine teeth. On the upper alveolar border, principally in front, we can observe pro- jections that correspond to the alveolus, and depressions that correspond also to the interalveolar partitions. At the moment of birth, the upper maxillary bone, which then is not very high, is specially formed by the alveolar range that contains the germs of the teeth, and are almost contiguous to the platform of the orbit. As to the border of the lower jaw, it begins to exhibit itself at a period very near conception. The alveolar borders of each jaw subsist, in the course of life, on the important changes that arise from the eruption of the teeth of first and second dentition, and afterwards from the fall of teeth in old men ; a fall that causes quite a decrease in their height. Examined in the skeleton of an adult, the alveoli have, in general, a conical form, and are moulded exactly on the roots of the teeth for which they are destined. Their aperture is necessarily directed upwards, in the lower jaw, and below in the upper ; their bottom is pierced with holes that communicate with the dental conduit, and that serve to transmit to the folli- cle of the tooth, the nervous and vascular pedicle intended for it ; the thickness of their partitions differs according to the species of teeth which each one of them contains. Thus the incisors of the upper jaw have alveoli thinner than those of the other teeth ; those of the canines are stronger, thicker and deeper than those of the incisors, and even of the small molars ; the first large molar has alveoli stronger than those of the second and last, or wisdom teeth. In the incisors of the lower jaw, there is a similar disposition, and it is this that makes these teeth yield more easily to the blows they receive, and they also yield more easily to the efforts of the operator who extracts them. The alveolus of the first large molar, is not as strong as that of the second and third. The wisdom tooth, on the contrary, in the lower jaw, presents the strongest and thickest alveolus of all, because it is found deepened in the thickness of the coronoid apophysis. It is, moreover, useless to observe, that the alveoli are pre- PATHOLOGY AND THERAPEUTICS. 53 cisely in proportion as to capacity to the teeth for which they are intended, and that, consequently, small for the incisors, a little larger for the canine ; they acquire their summum of de- velopment in the region of the large molars. The partitions of the follicles of the teeth are confounded outwardly with the periosteum of the alveoli which forms the principal means of union of the teeth with the alveolar pro- cess in the normal state; union, whose intimacy causes the resistance and the principal strength of the teeth. It must not, however, be disowned, that this union is powerfully seconded by the perpendicular pressure which the teeth exercise towards each other, when the jaws are approximated : the proof of this action is acquired by the apparent elongation of each tooth, when the opposite one is missing, which very commonly oc- curs. There is, in this case, a simple eccentric motion of the tooth, but not a real increase in length. This last phenomenon is observed in certain animals, and not in man* It sometimes happens that the teeth are retained in their al- veoli much more solidly than we have just stated, from the fact of a particular arrangement of which we have spoken, in treating of the molar teeth. In effect, the summit of the cone of the roots may be bent in form of a hook, and fixed upon a projection from the bottom of the alveoli. The roots of the alveoli, as we well know, can likewise be strongly diverg- ing, and form, in this way, a sort of nipper, with bended points, and adhering to the line. Finally, by an entirely con- trary arrangement, the roots of the same molar teeth are occa- sionally convergent, and intercept, completely, a bony portion that seems to be connected with them. When a tooth has been withdrawn from the alveoli that con- tained it, this cavity soon sinks, so that it is no longer possible, after a certain period, to discover any vestige of it. And in ef- fecting the occlusion of this cavity, not only does the alveolar border sink, but also the bottom of the alveoli rises a little.f # See Memoir of M. Oudet, published in 1823, upon the Continued Growth and Reproduction of the Teeth of Rabbits. We shall soon have to refer again to this memoir, and to the phenomena to which it is devoted. fThis fact is rendered evident by the prompt extraction, in certain cases, of dead teeth placed in alveoli recently empty. 54 ANATOMY, ORTHOPEDIA, In the jaws of new born infants, the alveoli have not yet attained their development ; there are ten or twelve in each jaw; they are very small, not very deep; formed by partitions extremely thin, and presenting to the exterior as many platings. Each alveoli contains a dental germ. Hence it follows that the alveoli serve to fix the teeth, and furnish them with the requisite solidity to accomplish the action of mastication, and to resist exterior violence. Their method of union with the teeth, is unique in their organization : it is not an articulation, but a simple implantation. Summary Anatomy of the Gums. However solidly fixed the teeth may appear by the juxta po sition of the alveolus around their roots and their neck, nature has thought proper to increase the firmness by a fibro cellular tissue, sufficiently thick, that covers both faces of the alveolar borders, and even penetrates into the alveolus. To this tissue is given the name of gum. Anatomists ap- pear to see in it but a portion of the mucous membrane, which is distinguished by its intimate adherence to the periosteum by its thickness, and principally by a coriaceous density, almost cartilaginous, a density that enables it to resist the contact of hard bodies subjected to mastication. No doubt, then, that the gums have much analogy with the portion of the palatinal mem- brane which is near to them. They are arranged thus : They commence at about two or three millimetres — a line or a line and a half — from the basis of the alveoli, where their limits are marked by a relief of festooned appearance. Having reached the free border, or the basis of the alveoli, they continue their passage in the space of two millimetres, as far as the neck of the tooth. There they reflect upon themselves, and the pre- cise place where this reflection is effected is a free semilunar border, imitating the indented border represented by the bases of the alveoli. Those slight slopes correspond to the intervals of the teeth between which the portion of gum which the ante- rior face of the alveolus communicate with that which lines the posterior face PATHOLOGY AND THERAPEUTICS. 55 The reflected portion of the gum corresponds, without ad- hering to it, to the root of the tooth in all the parts of this root which grows over the alveolus, then sinks into it to constitute the dental alveolar periosteum, which we know is a powerful means of union between the root and the alveolus. The tissue of the gum, firm and elastic, presents a color of pale vermilion. It appears furnished with follicles, but which we persist in believing foreign to the formation of tartar. It va- ries much in color and density, according to individuals. One of its most marked characters consists in the special action exer- cised over it by scorbutus and mercury, under the influence of which it softens and become spongy and bloody. Another character of this tissue, but one that is entirely ana- tomical, consists in apertures very much developed, which are seen by a naked eye on a fine day. Almost insensible when divided by a sharp instrument, it nevertheless creates serious accidents when under the influence of the pressure exercised by the teeth. The tissue of the gum contains very little cellular tissue, pro- perly so called. It is, however, susceptible of being easily swal- lowed by delicate women, and also by lymphatic individuals, and ail persons who dwell in low, damp places; this indicates a great permeability. Furnished with capillary vessels sufficiently developed, which, by the pressure of the finger, causes it to ex- perience the discoloration of erysipelas in sanguine and vigorous individuals, and to preserve the clammy depression of the ode- ma in those who are weak and cachectic; this tissue forms at the neck of each tooth a small pad, whose thickness depends on the robust health of the individual. In subjecting the gums to a convenient maceration, we per- ceive in their tissue three layers or distinct membranes. The mucous membrane forms the first, at the same time that it con- tinues in the digestive apparel. Afterwards, a sort of pulpy substance is detached, which composes the second layer; and finally we perceive that the third is entirely distinct from the others, by its tissue, which appears of a fibrous nature. This last tissue is prolonged as far as the interior of the alveoli, and forms in it sacs or matrices of teeth which are found her- 56 metically closed by the pulpy substance, which is placed over them. It is then also accompanied by the mucous or first layer, which is introduced between it and the collar of the teeth and gives birth to the generating pulp of the teeth, as the skin forms that of the nails and hair. The fibrous tissue, of which we have been speaking, is very probably that indicated by Bichat, in saying that in the foetus, and before the eruption of the teeth, the double border is cover- ed with a particular tissue, very thick and very firm, that this tissue covers the alveoli and exactly obliterates them, as well as the dental germs which they enclose. It is undoubtedly this tis- sue that Serres and Meckel* have described by the name of den- tal cartilage, and whose destruction takes place at the first denti- tion. But how can we reconcile this opinion with what happens in the old man after the loss of his teeth. Does this pretended cartilage reappear then ? or do the gums return to the condition in which they were in early infancy ? This last opinion seems to us most admissible. Independent of all that has been written on the organization of the gums, it must be admitted that this part of anatomy has not been as fully investigated as it might be, and that the researches hitherto made on this subject have not been as clear and precise as might be desired. To complete the anatomical history of the dental apparel, con- sidered in a general way, it now remains for us to give a descrip- tion of the nerves, arteries and veins that lead to the three parts of this apparel. Nerves and Vessels of the Dental Apparel. Nerves. — The nerves that are distributed in the teeth and jaws are supplied by the fifth pair of the nerves of the skull, general- ly known by the name of trigemini. The upper teeth and the upper jaw receive theirs from the second branch of these nerves, or the middle branch of the upper maxillary. They are the pos- terior dental alveolar, and the anterior dental alveolar. * Manual of General and Descriptive Anatomy, translated 1823, by Bi- chat and Jourdain. PATHOLOGY AND THERAPEUTICS. 57 The first two, sometimes three in number, are detached from the upper maxillary, sometimes by a common trunk, sometimes alone, when about to connect with the suborbitary canal are forced in front and below, furnish fillets, which are distributed into the muscles of the face and the tissue of the cheeks and gums. They are afterwards received into canals made in the thickness of the maxillary tuberosity, and then present themselves under the appearance of small ribbons ; one of these branches, known by the name of superior posterior-dental, crosses the basis of the maxillary tuberosity and joins the level of the canine fosse by a fillet provided by the anterior dental ; it gives several fillets that pierce the substance of the bone to furnish the roots of the three or four last molars. The posterior inferior dental, stronger than the superior, crosses a crooked passage under the maxillary tu- berosity and joins at the level of the canine fosse, to the posterior superior dental. From their reunion arises a great number of fillets, which form a considerable quantity of networks; the fillets coming from these networks are included in the thickness of the bone, but nearer the internal surface of the sinus than the ex- ternal surface of the maxillary bone; they furnish filaments that are extremely thin, and which enter the small molars. The anterior dental alveolar arises very large, from the upper maxillary a little before it leaves the suborbitary canal. It after- wards enters a canal provided by the upper maxillary to be reflect- ed on the platform of the nasal bones. Having arrived at the level of this base, about a millimetre from the orifice, it spreads out in a great number of fillets, some of which go up, others descend. The latter reflect from below upwards in the thickness of the front nasal bone, where they disappear ; the first terminate in providing the incisors with dental nerves, also the canine and even the first small molar. Many fillets also disappear in the thickness of the bone. The lower teeth and lower jaw receive their nerves from the lower maxillary, the strongest and deepest portion of the three branches of the fifth pair. This nerve is forced outwardly and a little in front, leaves the cranium by the round hole which bears its zygomatic fosse, where it instantly divides in seven branches — of these branches, three are external : the temporal 8 58 ANATOMY, ORTHOPEDIA, profound, the masseterien, and the buccal, one is internal, which is the pterygoidian ; finally, two are inferior, the lingual and the dental inferior, which is the true termination of the lower maxil- lary. We will here treat of the lower dental. This nerve more voluminous than the lingual, is positively to the lower jaw what the portion of the maxillary nerve, known by the name of suborbitary nerve, is to the upper. It descends with the lingual between the internal pterygoidian and the branch of the lower jaw ; it afterwards connects with the dental canal, which it crosses with the dental nerve, and furnishes in this passage a filament to each root of the large and small molars. Having arrived at the level of the hole of the chin, it sepa- rates in two branches — one is called mental, the other incisor. The first being considered, on account of its bulk, as a contin- uation of the upper dental, leaves the hole of the chin and spreads out in diverging fillets, which act in respect to the lower lip like the suborbitary in relation to the upper. The second, extreme- ly thin, follows the first passage of the lower dental, and divides for the purpose of supplying the canine and the two incisors. As to the gums, independently of the nerves furnished them by the upper and lower dentals, they also receive them from the palatine, facial, and ganglion naso-palatine, discovered in 1815, by Hyppolite Cloquet. Vessels. — The arteries of the dental system go regularly with the nerves, and come from the internal maxillary. Those that repair to the teeth and upper jaw are the alveolar or dental, and the suborbitary which proceed with the buccal to the deep ante- rior temporal, at the level of the maxillary tuberosity. The first being forced very flexibly in front and below, is di- vided into many branches ; they are the gencival and periostic branches, which, having arrrived at the basis of the alveoli, re- flect around this basis to insinuate itself into their cavity and to be distributed in their periosteum ; then the posterior dental branches, which are connected with the small dental canals, pen- etrate into the alveoli of the molar, large or small, and divide into as many small branches as there are roots. The second, which sometimes proceeds from a common trunk with the alveo- lar, connects with the suborbitary canal, and leaves it for the pur- PATHOLOGY AND THERAPEUTICS. 59 pose of spreading out in a great number of branches, many of which penetrate into the gums, and thence into the alveoli of the canines and incisors. While advancing, it gives two branches, one of which is the orbitary, the other the dental. This last connects afterwards with the dental passage to furnish the ca- nines and the incisors into which they penetrate, by the sum- mit of the root. The arteries that are distributed to the teeth and lower jaw are as numerous as those that the internal maxillary furnishes to the level of the condyle : they spring from the lower dental. It is well known that at its birth this artery is forced downwards, then approximates to the upper orifice of the dental canal, crosses this canal, accompanied by the nerve of the same name, and having reached the small molar, divides into two branches, the one men- tal, which comes from the hole of the chin, the other inci- sor, that continues its passage and goes under the canine and in- cisor teeth to disappear in the bone. In advancing, the dental artery as well as its incisive divisions, furnishes the roots of the corresponding teeth with dental branches. These branches penetrate at first into the alveolus, and then into the tooth by the summit of the tooth. Finally, the veins of the teeth follow the direction of the arte- ries ; only the one that comes from the teeth and the lower jaw has its particular canal under that which protects the artery. As to the lymphatic vessels, their excessive thinness when they reach the jaw, prevents us from following them into the teeth, but there is no doubt that they penetrate the teeth, and join the nerves, arteries and veins to form the nervous vascular facia, which constitutes in the canal of the tooth the kernel of its cen- tral pulp. Such are the most prominent anatomical characters of the three principal organs of the dental apparel. Having only seen what bears upon our speciality, we have passed over many details of which the application to art by the dentist is not direct, we have even indicated certain bodies, such as follicles, and the dental pulp, of which a knowledge is considerably important. We have reserved them for the next chapter, because a description of them can only serve to explain the physiological phenomena to 60 ANATOMY, ORTHOPEDIA, which this chapter is devoted, and again, because this descrip- tion is remote from the purpose before us. Let us, however, observe, before entering upon the subject of the development of the ieeth, that if we were desirous of draw- ing from the anatomical characters we have assigned to the den- tal apparel, inductions calculated to designate the sort of food nature has intended for the constant use of man, we would feel constrained to admit that it is both vegetable and flesh. But is there an equal inclination to use the one as the other ? this is a question authors have differently answered. Some, as Grimaud,* deducing their opinion rather from the powers that cause the dental apparel to move, than from the condition itself of the apparel, compare the strength of the masticating muscles of man to that of other animals, and believe they are justifiable in con- cluding that man is fonder of flesh food than vegetable ; they, on the other side, leaving aside all anatomical appreciation, refer only to facts, and maintain that as many sects of philosophers, and many tribes of Indians have completely abstained from meat, that vegetable food is most proper for our organization. These opinions are both far from the truth. Broussonet, con- sidering that as man has in all thirty-two teeth, twelve of which are incisors and twelve canine, that belong principally to carniv- orous animals, whereas the remaining twenty are a more spe- cial attribute of the vegetable species ; and then estimating man's disposition for food, divides unequally this tendency for animal or vegetable food, accordingly, \\ to the inclination to ani- mal substances, and %% to that of the vegetable ; so that the question placed in equation gives for result that the want of vegetable food is to the desire of animal as 20 is to 12.f We adopt readily this simple, just and spiritual way of solving the question, at the same time making all allowance for the many modifications that climate, habit, and constitution causes the human system necessarily to undergo. * Complete Course of Physiology ; Montpellier, 1818. fSee the new edition of Elements of Physiology, by Richeraud,vol. 1. PATHOLOGY AND THERAPEUTICS. 61 CHAPTER II. PHYSIOLOGICAL HISTORY OF THE DENTAL APPARATUS. DEVELOP- MENT OF THE TEETH, OR DENTITION. The study of the development of the teeth is truly one of the most interesting parts of their history. It embraces the descrip- tion of the phenomena which precede, accompany and follow it: first, the cutting of the teeth of first dentition; secondly, that of second dentition. It supposes, necessarily, correct views, as well upon the development of the follicles and of the bony portion, as upon the growth and cutting of the teeth. These different points we shall successively treat of. Dental Follicles. We have already said that the teeth are the products of a true secretion, bearing the same relation to the mucous system as the various productions are to the skin upon the surface of which they are observed. Hence they are necessarily preceded by organs destined for their formation. These organs, equal- ing the teeth in number, and contained within the jaws, are the dental follicles. On examination of the jaws of a foetus of two or three months old, we discover that they contain long and deep gutters, divided into as many cells as there are germs of teeth. This groove is covered, on its superior surface, by the membrane of the gum, surmounted by a thin crest, of a fibrous nature, which is called, by some authors, dental cartilage, but only developed at the al- veolus ; the fibrous tissue of the gums sends into each alveolus a prolongation, (alveolo-dental periosteum,) which forms for each follicle a mucous sac, perforated at the bottom of the socket, through which pass dental vessels and nerves. It is in this membranous fold which the gum forms, that are lodged little bodies called follicles or dental germs, representing round sacs, attached to the gums superiorly, and inferiorly to a vascular and nervous pedicle, which runs along the bottom of the alveolar groove. This follicle is formed of one, and not two 62 ANATOMY, ORTHOPEDÏA, membranes, as some modern authors suppose, as Hunter, Blake,* Bichat, Cuvier and M. Delabarre, who have undoubtedly mis- taken the alveolo-dental periosteum, or the prolongation of the gummy membrane, for the external membrane of the follicle ; which makes an essential difference, as we shall soon see. This single membrane of the follicle represents a closed sac, and seems to bear the same resemblance to the different papilla?, as the serous membranes do in relation to the organs which they surround, that is to say, after having covered the gummy fibrous sac, which lines the alveoli, the follicular membrane is reflected upon the vessels and nerves which form the pedicle of the pulp, and appears to be a prolongation of the same. This membrane is free and smooth upon its internal surface, and adhering ex- ternally ; it is generally thin, transparent and very vascular; its vessels and nerves are supplied from the pedicle of the dental follicle and not from the trunks diffused in the mucous membrane. From the foregoing, we perceive that the dental vessels and nerves form two distinct systems ; one for the exterior of the follicle, the other for the part contained in the dental cavity. The first has its origin immediately from the vascular and ner- vous system of the buccal membrane, the other supplies special organs, (as the internal maxillary artery and the trifacial nerve.) The different pathological conditions of the teeth give daily proof of the distinction which we have just made, and upon which anatomists, according to our opinion, have not sufficiently enlarged. The true membrane of the follicle encloses a transparent and viscous liquid, like synovia, containing light flakes, which give it the consistence of mucilage. It diminishes, in respect to quantity, from the time of its first appearance until the eruption of the tooth, at which period it disappears. The office of the membrane proper is the secretion of the enamel ; it has only a temporary existence, which is no longer than the period necessary for the accomplishment of its func- tions. Blake has treated of it under the name of the caducous membrane. This function of the membrane proper has been defined espe- * Work quoted. PATHOLOGY AND THERAPEUTICS. 63 cially in the numerous researches of Hérissant. If we carefully detach, says this learned physiologist, this membrane above the crown, and examine its interior surface immediately with a magnifying glass of six or eight millimetres (three to four de- grees) of focus, we will instantly be struck with admiration at the appearance of an infinite number of small vesicles, which, by their transparency, resemble those by which the ice-plant is covered ; they are arranged in regular rows, one upon another, and which are, for the most part, parallel with the base of the tooth. These vesicles contain at a certain period a very clear and limpid liquid, which afterwards becomes thick and of a milky appearance. We cannot mistake the use of this liquid ; it is evident that when it is spread over the part for which it is des- tined, and when it has all the necessary consistency, the tooth will be clothed with a coat of enamel of great brilliancy. Its irregular productions produce anomalies, of which we have spoken, and of which we possess many specimens. Messrs. Rousseau, Desmoulins and Cruveilhier have confirmed by their own experience the opinion of Hérissant upon vesicular pro jections of the free face of the follicular membrane. The Pulp or Dental Papilla. We have already said that the membrane of the follicle con- tains only a transparent fluid, afterwards viscous and then slightly yellowish white. But near the third month (of fœtal existence) a little body makes its appearance, which, in the form of a papilla, rises from the bottom of the socket. This vascular and nervous papilla becomes gradually more firm, and of greater dimension. It is at first of a gelatinous consistency, and from its physical characteristics, bears some analogy to a nervous gan- glion. Its exterior surface is thin, membranous, and moistened by a liquid which it imbibes and transudes. From what we have said of the anatomy of the part, it is dirl- cult to ascertain precisely from what these little bodies derive their organization ; the only thing well defined in this respect, is, that they are formed by the termination and expansion of the 64 dental nerves and vessels, and that these two organic elements are here united in equal proportions. They are also the seat of very energetic, vital action, which creates in these germs the sen- sitive and living parts of the teeth. A very thin pedicle, formed by the dental vessels and nerves, is the means of union to that papilla which is there found suspended like the seed of a grape. The papilla is necessarily bathed for a time in the liquid which the sac contains and which diminishes in quantity as the papilla enlarges. In its more advanced stage the papilla acquires an increased consistency ; elongates, assumes its destined form, and gradually acquires the volume and form of the future tooth, of which it is an exact image, and to the secretion of which it ought to assist. The crown is the part first formed upon the pa- pilla, for we there find all the depressions and eminences which the tooth afterwards exhibits. Development of the Follicles. We have already shown that the follicular membranes were of the various rudimentary parts of the tooth, those which formed the first. We have seen from the beginning, that they are united in such a manner to the gums, that in exercising a slight pressure upon the latter that they rise with them, as also do their vessels and nerves. But, although the follicles of the apparatus of both dentitions exists at the same time in the jaws of the foetus, as M. Serres has correctly proved, these follicles are not formed at the same time and do not present the same characteristics. About the middle of the third month of fœtal life, we discover upon each half of the two jaws, four sacs, each of the two anterior and posterior pulps press against each other, leaving a sufficient space between the two pairs. The first follicles, which are the smallest, repre- sent the temporary incisors, the two latter are the temporary mo- lars. At the end of the third month, in the middle, but some- what anterior to the space of which we have spoken, there is seen a marked projection of the external plate of the alveolar ridge, which contains a fifth sac — it is the canine tooth. These constitute the complement of the follicles of first dentition. PATHOLOGY AND THERAPEUTICS. 65 The follicles or germs of second dentition correspond with the arrangement of teeth already formed, being separated from them by bony partitions. The following is the relation which we have discovered these pulps to bear to the follicles of the teeth of first dentition : first, the follicles of second dentition, that is the three last molars, are upon the same arch with those of the milk teeth, but occupying the lateral extremities of it; second, the follicles of the teeth of replacement, on the con- trary, are placed precisely in the rear of their corresponding de- ciduous teeth. These follicles are at first contained in the same alveoli that the temporary teeth are ; it is only after a certain lapse of time that they become gradually separated from them by a bony par- tition, which, at first fibrous, rises from the bottom of the alveolar groove, and finally ossifies. A long time, however, after the for- mation of this bony partition, the temporary and permanent alveoli communicate by an opening sufficiently large for the passage of a small cord which joins the two teeth. We shall now show the order in which the follicles of second dentition appear. About the end of the fourth month, we discover the sixth sac at the bottom of the groove of the jaws. This is the sac of the first permanent molar tooth ; it generally precedes the others sev- eral months. It is only until about the middle of the seventh month that we can discover the capsules of the permanent incisors. At a later period the capsules of the canine and second molar teeth are developed. With regard to the follicles of the wisdom teeth, although some authors have pretended to discover them in the form of ganglions at birth, they are not, however, to be seen at that period ; we can affirm that this is always the case; more- ever, in admitting with M. Serres, the existence of the follicles of the bicuspides or small permanent molars, in the fœtus, we must avow that we have never found them excepting in infants of eighteen or twenty months old. Thus far we have been treating upon the organs destined for the formation of the teeth ; now let us inquire what are the phenomena of their formation. 66 ANATOMY, ORTHOPEDIA, Development of Dental Bone. If physiologists generally at the present day admitted that, soon after the appearance of the follicle the tooth begins to de- velope itself in it, that is to say, such as are most precocious, about the third month of intra-uterine existence, they also agree that the formation of the teeth takes place in the interior of the follicle; but they are far from agreeing upon the precise pointât which the first deposite of the bone takes place. Cuvier con- tends that this takes place between the papilla and the proper membrane of the follicle which is reflected upon and entirely surrounds it; others contend, that this deposition of calca- reous matter takes place within the cavity of the membrane proper. Be this as it may, it is the crown of the tooth, particularly the cuspid part or summit which is first ossified. The pro- cess of ossification is preceded by a red circle which is situ- ated around the summit of the papilla; the production of ossifie matter now commences and is the result of a true secretion. Upon the prominent points which, at a later period, become the cuspides of the tooth, we observe very fine little scales forming, which encase the tubercles of the papilla ; these scales, at first yielding, become gradually stronger, and correspond in number to the prominences of the dental pulp. Hence these scales constitute as many points of dental forma- tion, agreeing with reason, with the number of points of ossifica- tion of the bone. Thus, for the incisors, there are three points, according to Hunter ; one, on the other hand, according to Albi- nus, Blake and Meckel, and the same for the canines ; but the molars have as many points of ossification as there are promi- nences upon the pulp. We have consulted numerous researches to determine this physiological subject, and we have constantly concluded that there is but one very small scale for the incisor teeth. This scale, occupying the free border of the dental papilla, is always more prominent in the middle than at the sides ; this fact leads us to beileve that this might have been the result of the union of PATHOLOGY AND THERAPEUTICS. 67 three solid points which were organized at the same time, This appears plausible to us as the free edge of the incisors of children presents these marked depressions. As to the canines, we never could discover but one solid scale. We have always discovered in the small molars, two points of ossification, each of which assumes the form of that which characterises the prominence of the crown, or in other words, it represents a small triangular and pointed pyramid. From this arrangement, and from the isolation which exists at a cer- tain period between the various points of ossification at the crown, we may regard the molars as a reunion of several ca- nines. Lastly, the large molars are always developed by as many points of ossification as there are tubercles. The small scales, of which we have spoken, gradually en- large — meet each other — unite, and embrace closely the extrem- ity of the pulp, upon which it forms a case, and represents ex- ternally its form, so that we cannot detach it without injury, although the internal surface is as smooth as the external. When all these little scales are united, we then see the grinding surface of the crown. The process of solidification takes place in the inferior jaw before we see any point of ossification in the superior. There is one question of importance yet to solve : it is the formation of the ivory and enamel of the tooth. There are two opinions upon these points. According to Jourdain* Auzebi,f and at a later period Rousseau, the enamel is secreted before the ivory ; in the meantime, we must acknow- ledge, that those who entertain the contrary opinion are the most numerous ; and, moreover, in opposition to these two opinions, Cuvier says that he has seen the bone and enamel appear nearly at the same time. Before declaring our manner of accounting for the formation of these two substances, let us examine, for a short time, hypotheses, more or less ingenious, which have been set forth relative to the production of this formation. # New Elements of Odontologia. Paris, 1736. t Principles of Odontologia, &c. Lyons, 1772. 68 Formation of Ivory. For a long time anatomists entertained the opinion that the papilla underwent an osseous transformation, and that the ivory- was formed from this by a progressive metamorphosis of its tissue. The diminution of the size of the papilla in proportion as the tooth acquires greater thickness, the gradual retraction of the dental cavity, and its entire obliteration in some old persons, gives a certain plausibility to that theory which, however, evap- orates at the moment of its investigation. Indeed, it is only necessary to examine the rudimentary tooth, to discover that it is simply placed above the papilla without adhering at all to its surface, which could not certainly be the case if the papilla became ossified. Cuvier, and others since his time, relying upon the analogy of the nail, and its matrix upon the one hand, and the feather and its papilla on the other hand, have proved, although after Hunter, that the ivory is secreted immediately by the dental papilla. When all the points of ossification, which we have seen sit- uated upon the surface of the papilla, are united in such a man- ner as to cover it completely, they present a bony horn, which gradually extends from the circumference of the vascular and nervous pedicle, to the point where this pedicle penetrates the alveolus. The exterior bone being formed, a second is formed within it, then a third is encased within this last ; thus, in turns, they are formed. This growth, which is limited to the period of the complete development of the roots, takes place, as we perceive, from without inwardly, or from the circumference to the centre. Once produced, the ivory is no longer subject to remarkable changes ; its durability depends more upon the ap- position of the layers upon one another, than upon the modifi- cation which is produced in its texture. Formation of Enamel. The history of the secretion of the enamel is more complicat- ed than that of the ivory. It is said that the enamel, like ivory, is the result of the secre- tion of the pulp, which product oozes through the different PATHOLOGY AND THERAPEUTICS. 69 layers of the ivory for the purpose of solidifying upon its surface. M. Delabarre especially entertains this opinion, which the fol- lowing phrase will refute. If the enamel is secreted by the pulp, the disc commencing the ossification which, successively, should form the crown, will be entirely composed of it ; or this substance does not exist there still, hence the enamel is not the production of the pulp. Other anatomists, as Bertin and Hunter, have contended, that the enamel is secreted by the membrane proper of the follicle, which remains in a state of dissolution in the liquid of this fol- licle until the formation of the crown, and then it forms crystals upon the internal surface of the crown. Hunter makes use of an ingenious comparison to demonstrate the crystallization of the enamel ; he says that it resembles the deposits of salt of urine deposited upon bodies found in the bladder. That opinion is not absolutely incontestable ; nevertheless, it seems generally admitted at the present day. Cuvier entertains this opinion, with this difference only, that the enamel instead of being deposited immediately upon the crown, forms upon the portion of the internal face of the follicle which covers the crown. In this manner he accounts for the greyish line which always exists, as we have stated in the anatomical part of this work, between the ivory and enamel, and which is nothing more than this seared leaf between these two substances. The enamel is soft and of a cartilaginous consistency at the time of its formation ; it is of a dull white and is distributed in drops, which are at first spread upon the first layers of the ivory, afterwards upon the succeeding layers. In the foetus we can separate it easily from the bony matter ; we then discover that it is thicker upon the prominences of the crown than in other parts, and it becomes extremely thin as it approaches the neck of the tooth. Hence, the deposition of enamel takes place in an opposite direction from the ivory, in other words it is deposi- ted from within outwardly. Its secretion is only temporary ; it is limited to the existence and to the functions of the membrane proper, and is necessary only to the production of the crown. In admitting the theories of which we have spoken in regard to the formation of the ivory and enamel, it still remains to be 70 ANATOMY, ORTHOPEDIA, explained why the crown is the only part which is covered with enamel. Hérissant is the only one, as we have already seen, who has suggested the means of solving this very difficult ques- tion, by stating that the part of the follicle corresponding to the crown, was furnished with glandules, whose functions were to secrete the enamel. We should in truth say, that wishing to convince ourselves of this fact, we have several times discovered upon the surface of the leaf of the membrane proper, as far as the top of the crown, a kind of pulp resembling little white molicular globules. These little bodies were very few in number, nearly impercepti- ble and atrophoid when the enamel had been developed and was visible, while their number and size may be perfectly dis- tinguished in those cases where the production of enamel had not yet commenced. We lay great stress upon this point, since it leads to the solution of this problem which has called forth so many theories, to wit : how does it happen that the enamel substance is deposited exclusively upon the crown. Indeed, when the crown of the tooth is once covered with a layer of enamel, the leaf of the membrane, or at a later period the little corpuscles are atrophoid. It is then evident that the root, the development of which is later than that of the crown, has nothing in it in common with the enamel. That opinion, which appears to us most reasonable, is still supported by the fact, that the teeth of animals which have not the follicular membrane are not covered with enamel ; while in those, on the other hand, in which this membrane exists after the eruption of the teeth, the secretion of enamel continues after this eruption, as that of ivory. The incisive teeth of the rabbit, beaver, rat and other gnawing animals, are in this latter case, as we shall soon see in speaking of the growth of teeth. In the meantime, we perceive from what we have already said upon the phenomena of the formation of the teeth before their eruption, that we can deduce the following consequences. Of the two constituent parts of the tooth, to wit : the cortical or hard portion, and the pulp or medullary portion, this last is first developed ; and of the two distinct elements of the hard portion, the ivory and enamel, the ivory is first formed. PATHOLOGY AND THERAPEUTICS. 71 The formation of the cortical substance of the tooth com- mences at the crown ; the roots are afterwards formed. The pulp or papilla rinding itself as it were enclosed in the midst of solid matter, in the formation of which it assists as much of itself as by its follicular membrane, and which gradu- ally contracts its cavity, diminishes continually in size and finally entirely disappears. In other respects we should frankly acknowledge that if mod- erns had prescribed facts upon which rests the theory of the development of the dental bone, they have found among the an- cients the basis of that theory perfectly established. There are abundant proofs of this assertion. We content ourselves with the following one, extracted and translated from a German anat- omist,* who wrote two hundred and fifty years ago, a period when anatomy was first brought to light : "The teeth are formed from a species of mucus, enclosed in the cavity of a follicle, they are developed like a rudimentary body, around which an incrustation is formed, differing in that respect (longe divcrsœ) from the formation of bone, which is effected through the medium of a cartilage (per intercessionem cartilaginum^) &c. &c." THE GROWTH AND ERUPTION OF TEETH IN GENERAL. The Growth. — When the bony covering is once formed around the pulp and envelopes it entirely, we may then soon see new layers under those first formed. These layers are at first more and more extended, in proportion as they are more distant from the period when the tooth first began to develope itself. At a later period they present an inverse tendency; they are en- cased in the preceding ones ; they gradually raise them and push them from the pulp, which they soon embrace from the circum- ference to the base. The crown is now completely formed ; the enamel is deposited upon it as has been already stated ; and the process of evolution, after having undergone a delay, according to some authors, the process is renewed. New layers of ivory, products of the pulp, embrace it inferiorly, forming successive caps which by degrees encase each other; they surround its pedicle, descend as far as its extremity and form the root, * Valcherus Coiten., cotemporain de Visale. 72 ANATOMY, ORTHOPEDIA, To depart from this epoch, says M. Blandin, the tooth has completed its growth in length ; the bony layers which succeed can then no longer increase its bulk, and as it is always by an interior juxta-position that this growth takes place, the dental cavity gradually contracts, the pulp diminishes, and the circu- lation being confined in its vessels, its secretion abates and soon entirely ceases. Here are limited the changes which the single rooted teeth undergo ; but, the mechanism of such as have several roots is more complicated. Their ossification commences, as we have already said, in several points, representing as many little caps as the tooth has prominences or tuberosities upon its summit, and as the pulp presents elongations ; for, in examining the in- ferior part of a germ, we perceive that the vessels which pene- trate it are divided into two, three or four bundles, according as it is destined to form two, three or four roots. Blake and Fox, # ignorant of this fact, describe upon the pulp, bony angles, which divide the base of the crown into as many segments as it ought to have roots. These caps are naturally convergent at their base ; each in- creases at its side, by the addition of successive layers increas- ing as they approach the base. They soon meet each other, and all at once unite, those that are without with those that are within; from this time they form upon the superior part of the papilla only one great cap, undulated upon its surface, and the growth of which continues the same as if it was primitively developed at the same point. Finally, when the ossiform stock of the tooth has reached the union of the papilla with its pedicles, the cal- careous matter is secreted at once around the body of the pa- pilla and its pedicles ; it encompasses each of them with a tubu- lous envelope, continues with this from the rest of the pa- pilla, and the growth progresses finally as in cases of one point, with this difference only, that the osseous layers, instead of pre- senting a series of simple cones, are subdivided into as many additional hollow cones as the tooth should have rrots. "Thus, (continues M. Blandin, from whose work we have quoted,) the teeth increase from the summit of the crown to the ■ Remarks upon Dentition ; Guy's Hospital, London. PATHOLOGY AND THERAPEUTICS. 73 end of the root, and from the exterior inwardly ; it is at once completed in length and thickness, by moulding itself upon the papilla, and embracing it accurately at every point." Here arises another very important question : why is the growth of teeth in general, and especially those of man, con- fined to narrow and very limited spaces ; or, in other words, what is it that impedes the growth of teeth ? For the solution of this question, it is only necessary to recollect that the forma- tion of ossiform substances being subordinate to the presence of the papilla, and that the growth of the ivory being effected in concentric layers, that is to say, from without inwardly, that the pulp, surrounded on all sides, and gradually constrained by them, it is necessarily more and more restricted, and in such a degree that its functions become arrested all at once, under the last long layers which it has removed. The growth of the tooth is now entirely completed. . That limited growth of the human teeth, whatever Fallopius may have said, and others since his time, who believed that they might have an indefinite increase, has been long since an incontestable fact noted by anatomists ; but no one that we know of has ever before given a satisfactory explanation of it, not JVL Oudet, as has been generally supposed, and as M. Blandin* has erroneously asserted ; but before Dr. Francis Lavagna, of the Imperial Academy of Genoa, who, in a work published in 1812, consequently eleven years anterior to the memoir of M. Oudet, has demonstrated that it is exclusively to the pediculated form of the dental papilla that the human teeth should embrace that part entirely, gradually press upon it, then to destroy it by its pressure, and hence to arrest of itself its growth in length, by the death of the principal agent of vitality which the teeth possess. Thus the incisors of the rongeurs , as the beaver, the hare, the rabbit, the rat, and so on, which possess the faculty of continu- ally growing, and even to be reproduced after being broken, as the following phrase, printed more than two hundred years, proves : " Quod si acutis forcipibus secantur, una tantium node renascuntur"^ Thus the incisors of the rongeurs present a pa- * Work previously quoted., page 101. t Mathiole^ Latin edition of 1674, page 299. 74 ANATOMY, ORTHOPEDIA, pilla, in conformation perfectly the reverse of that of the human teeth. That papilla is indeed unprovided with a pedicle; it is conical, and supported at the bottom of its follicle and the alveo- lus which encloses it, by the base of the cone which it repre- sents. In this way it can continually secrete calcareous layers, without ever being embraced by the osseous walls of the denta] canal, at the part whence it receives its vessels and nerves. As we do not wish you to think that, by depriving M. Oudet of all the merit of the new idea which is the subject of his me- moir upon the dentition of rongeurs, we cannot be deceived by the simple appearance of identity between his views and those of Dr. Lavagna, we will quote what this last writer says : # "The incisor teeth of rongeurs, at least those of the wolf, the hogs of India, and the mice that I have examined, are of the same thick- ness through their extent, and in this respect they are very dif- ferent from the teeth of man, which have pointed roots. The cavity of the teeth of rongeurs differs still more from ours; from the body of the tooth to the extremity of the root, this cavi- ty gradually enlarges in such a manner that the teeth, even in their roots, present a large cavity. m m * # This large cavity in the roots of the teeth must leave a free access to a great number of vessels, which, distributed through the substance of the tooth, must render it very compact and resisting. * m m # The teeth of man have, on the contrary, in their roots, so small a cavity, (unforame sipicciolo,) that blood-vessels, as it were in- visible, can scarcely penetrate it, etc. etc." Writers generally have been so much at a loss to explain the growth of the human teeth and those of the inferior animals which are analogous to these, and to account for the constant pro- longation and reproduction of the teeth of rongeurs, that they are content with the explanation of Lavagna, repeated by M. Oudet ', but, in our opinion, the following question should have been put : 1. How is it that the occlusion of the hole of the roots of the * His work is entitled, Esperienze e riflcssioni sopra la carie de* denti wnani coW aggimta di un nuovo saggiu su la riproduzione dei denti negli ani- malirosieanli. Th< ■ from pages 161 and 163. PATHOLOGY AND THERAPEUTICS. 75 human teeth should cease and leave an opening only just large enough for the passage of the nerves and vessels ? 2. How does it happen that in man, the teeth, after they have ceased to grow, their interior cavity does not only still exist, but that the hole at the extremity of their root does still exist ? 3. Finally, how does it happen that the cavity of a tooth which is exposed, be- comes closed by the deposition of osseous matter, which would appear impossible if the functions of the pulp had entirely ceased? The foregoing remarks do not, assuredly, prevent us from adopting the explanation which we have already given — in the impossibility of which, we will substitute in the place of it another more reasonable. Thus, what we know of the manner by which the growth of the calcareous portion of the teeth is effected, we are obliged to admit that it takes place by a simple juxta-position, and not by intus-susception, as is the case with other bones. The experi- ments of Hunter upon the nutrition of young animals with madder, establish these facts, since the teeth become red on the part that is forming during the time the animal is fed with this article.* Various pathological facts also prove this mode of growth, as we shall see when treating of the diseases of the dental follicles. We very often observe, indeed, upon the crowns of the teeth of certain individuals, prominent undula- ting transverse lines ; sometimes we observe rough grooves or deep pits, which are nothing more than the effects of disease under which such individuals were laboring when children. They affect the whole bony structure of the tooth, as well as the enamel.f We shall now bring our remarks upon the development and increase of the teeth to a close, by treating of the order which they follow in their solidification. * This fact, however, has been recently contested by M. Flourens, secre- tary of the Academy of Sciences, who has shown that it is not only the part of the tooth whose formation is going on becomes colored when fed upon madder, but also such parts as had been previously formed. This necessa- rily presupposes a more complicated or more vital process than that of sim- ple juxta-position. fThis is sometimes, but not always, the case, for it often happens that the enamel is the on)y part which sustains a direct or immediate injury. — Trans. 76 ANATOMY, ORTIIOPEDIA, This process proceeds in the same manner as do the develop- ment of the follicles. The appearance of the first points is seen in the fœtus, between the fourth and fifth months, beginning with the central incisors, and those in the lower sooner than those in the upper jaw; the lateral incisors, and then the ante- rior molars are the next. At a later period these points appear upon the canines, and then upon the second small molars. The solidification of the permanent teeth commences during the last month of gestation, in a small point upon the anterior and external tubercle of the first large molar. Sometimes, before the term of foetal existence, there are three or four isolated points in place of the one just mentioned, which unite at the close of the first year. After the first large molar, the central incisor becomes ossified during the month after birth. Two months after this, the follicle of the lateral incisor is covered with a small scale ; then, about the sixth or seventh month, the canine is discovered to be ossifying. It is not until about the third or fourth year that the formation of the bicuspides commences : these are followed by the second large molars. As to the third molar, or wisdom tooth, we have rarely seen it formed before between the ninth and tenth years. The following is the man- ner in which the teeth are cut. The Eruption of the Teeth in General. At birth, the temporary teeth, enclosed in the socket, present the following appearance : The crown of the middle inferior incisor is nearly completed ; the superior is a little more tardy. The lateral incisor is later, especially that of the superior jaw. After these, the small anterior molars, the various isolated parts of the crown of these are now united ; this gives them a large size, though they have not at this time acquired their full height. As for the canine and small posterior molars, the first of these present only the extremity of its crown, the second has the most of its parts separated from each other, and connected only by a very thin pedicle. During the development of the teeth, changes are going on in the jaws ; the partitions which separate the follicles arecom- PATHOLOGY AND THERAPEUTICS. 77 pleted ; the alveoli form and accurately mould themselves to the teeth ; finally, the maxillary bones acquire volume in every part. The inferior jaw offers this exception, instead of having only one canal, it is traversed by two, which sometimes have each of their openings partially bifurcated ; at other times only one ; each of these canals contains an artery, one belonging to the teeth of first, the other to those of second dentition. The superior, if perceivable at the time of birth, gradually diminishes, and soon leaves only the vestige of its first existence ; the infe- rior continues through life. Be that as it may, it is no less true that if, at the time of birth, the teeth are very much developed, they still remain closed in the alveoli, and covered by the gums. Pliny, Columbus, Van- swieten, Donatus, Haller, # Soemmering and Bandelocquef of later date, quote many examples of children who have been born with teeth, (all the world know that such was the case with Louis XIV and Mirabeau ;) but these are only exceptions, and it is well known that it is very rare for one or two teeth to be cut at birth. The presence of teeth is perfectly useless to a child while it derives its nourishment from its mother, still the jaws need a certain firmness to support the efforts of sucking ; nature, like- wise, attentive to all the necessities which has nothing super- fluous, has furnished both the alveolar borders, which are after- wards to be occupied with teeth, with a cartilaginous substance which we know has been called by many authors dental carti- lage, and which diminishes as the eruption of the teeth ap- proaches, and entirely disappears after they have come through. But the child, a few months after its birth, not finding in milk, nourishment proportioned to its wants, and consequently being compelled to have recourse to more solid and more abundant food, it becomes indispensably necessary that at this time its maxillary apparel should be fortified with proper instruments for separating and chewing its aliment. This results from the ap- * This learned physiologist mentions, in his Elements of Physiology, nine- teen cases of children born with teeth, t Traite d'Accouchements. 78 ANATOMY, ORTHOPEDIA, pearance of the teeth externally, which were before contained in the alveoli. While these organs are developing and their roots increasing in length, the crown, yielding to a vital motion which forces the tooth outwardly, progresses in its alveolar cavity, removes from its bony partition, and reaching shortly the gum, appears through its tissue. But what is the cause of this singular phenomena, true action of locomotion, in virtue of which the teeth advance in their alveoli, and removing the obstacles which oppose their egress, terminate by removing the enclosure in which they were en- veloped? In a word, how and why do the teeth daily penetrate through the gum? A question assuredly simple, but the solu- tion of which, however, has long since become an arena, upon which the makers of hypotheses have exercised a show, against which the sagacity of the most profound physiologists have fallen. Some have thought that the eruption of the teeth could be ex- plained by the pulsation of the arteries, others have believed that they could account for it by a struggling which exists be- tween the vital force of the teeth and that of the gums, a strug- gling which would result to the advantage of the first ; others again attribute this phenomena to the contraction of the alveoli. As neither of these three hypotheses can stand the test of a crit- ical examination, we have sought for a better explanation; it has also been said, that if the teeth pierce the gums, it is because their roots, in proportion as they elongate, press upon the bot- tom of the alveoli, which presents to them a firm resistance, forces the tooth through the gum, which, more yielding than the base of the socket, gives way to the^ efforts which the crown ex- erts against its interior parts, spreads itself, finally ruptures and permits the tooth to escape. This explanation has, at least, the merit of extreme simplicity ; it has also deceived many phy- siologists ; but we, who know that the membrane which lines the base of the alveoli is by far more sensitive, and consequently by far more irritable than the tissue of the gums, and moreover, incapable of offering the support necessary to the progression of the tooth, we are forced wholly to reject. PATHOLOGY AND THERAPEUTICS. 79 This assertion has something in it similar to that of those who admit that the eruption of the teeth is effected by the ap- proximation of the alveolar walls and the elevation of the floor of the alveoli ; but this opinion is inadmissible, for the reason that the alveoli, on the one hand, narrow themselves transversely, and that on the other, they become deeper, as the teeth develope themselves. M. Delabarre, moved without doubt by the desire, assuredly a praiseworthy one, of explaining the eruption of these organs by the laws which govern the other functions, has, so to speak, as- similated this phenomena to that of parturition, in declaring that the tooth forces itself out by the contraction of the internal mem- brane attached to its neck, as we know, a neck which is drawn towards the surface of the gum, and which, arriving there, can go no farther, because the contractile force of the membrane is exhausted. This theory is assuredly very ingenious, but difficult to sus- tain, in truth, how can we suppose this excessively delicate membrane, which lines the follicle, is sufficiently powerful to force out a body like that of a tooth ? Little satisfied with the explanation of M. Delabarre, Lemaire, who in all things aims at originality, pretends that when the body of the tooth is formed, the vessels which penetrate its cavi- ty, being no longer charged with furnishing it with calcareous matter, take a new action and greater energy, whilst those which belong to the gum, carrying life to the capsule, become useless and obliterated; then the body of the tooth, by the energy of its vessels and nerves, elevates itself in its alveolus, whose orifice distends to give it a free passage ; the roots form progressively ; the crown finds itself in immediate contact with the gum ; this latter permits itself to be penetrated, absorbed, and then passes through it without any other aid than the extensibility of the one and the contractility of the other. There are two objections to the theory of Lemaire ; first, it will be committing an anatomical error to suppose that the bor- ders of the alveoli enlarge of themselves for the purpose of open- ing a passage to the teeth : another objection is that the alveoli always show openings sufficiently large for the escape of the 80 ANATOMY, ORTHOPEDIA, teeth ; second, nothing proves that the vessels and nerves of the teeth at the time of their eruption have acquired an energy dif- ferent from that which corresponds to the general progress of the whole economy. Whatever this energy may be, it explains only with difficulty the movement of the ascension of the infe- rior and the descension of the superior teeth. Finally, M. Serres, fearing, doubtless, to add an hypothesis to those of his predecessors, contents himself with explaining the fact, by the fact itself, and he considers it as the result of a pri- mordial law, analogous to that, in virtue of which the testicle passes, in the required time, from the abdominal region in the scrotum, or to that to which the fœtus obeys, when it breaks the envelopes which holds it to the uterus. As prudent as M. Serres, perhaps more fortunate than him- self, we content ourselves by saying that the opinion which ap- pears to us the most plausible, and which is altogether con- firmed by observation, is that which explains the cause of the passage of the teeth from their alveoli in the progress of their growth ; in other words, that the teeth depart from the alveoli because these last can no longer contain them, and if they reach the level of the socket sooner than its base, it is that they are drawn thither even by the tendency of the internal membrane of their sacs which envelope them, and which, from the gummy membrane, connects itself to the neck of the tooth, to which it strongly adheres. That cause is not assuredly unique, it exists at other parts of the gum, which is far from being foreign to that organic action ; in such a manner that at the same time that the tooth is forced to escape from the alveolus, it is effecting, in the interior of the gum, a process by which a way is prepared for its passage. In the actual state of the science, it is not easy to say if that outlet exists before the eruption of the teeth, or if it is formed at the time of their eruption. Physiologists do not agree upon this point. Some, among whom are Blandin, otherwise inclined, as also M. J. Cloquet, has made a concession to an opposite opin- ion, viz. "the young tissue being raised, the mucous tissue swells, reddens, inflames and becomes painful ; it very soon becomes white, one or more openings appear upon its surface, PATHOLOGY AND THERAPEUTICS. 81 according as the crown is furnished with one or more tubercles, and these last appear outwardly, in the first case, after having simply dilated the simple opening which is prepared for it; in the second, after having ruptured the different parts which sepa- rate all these special openings, converting them into one.* That opinion, as can be plainly seen, gives us sufficient latitude to ex- plain the diseases generally attributed to dentition. Other physiologists, on the contrary, at the head of whom is M. Delabarre, contend that the opening through which the tooth passes is not the result of an ulceration of the gum, but of the neck itself, dilated from its follicle, in such a manner that the opening, once effected, need not be enlarged. This opinion, repeated by M. Hérissant, who says, the permanent gums are neither tarn nor pierced by the teeth which pass through them, as has been supposed ; this opinion, we say, which leads to the conclusion of an iter dentis, has nothing which offends, when we think how great, under all circumstances, is the foresight of nature, as it is also generally admitted ; besides, it is another proof to those who believe that the diseases which often attack infancy, during the eruption of teeth, are altogecher strangers to it. Eruption of the Teeth of First Dentition. The period at which the teeth of first dentition appear is va- riable. There are examples, as we have before said, of children having one or more teeth at birth ; there are other examples, also, in which they have not cut any of their teeth for one, two, three or more years, and still be in perfect health, as Alphonso Leory has stated.f Vanswieten reports a case of a child, very vigorous and healthy, who had not cut a tooth until she was nineteen months old. J Charles Raiger has made mention of a child, whose four canine teeth did not appear until the thirteenth year.|| We also find, in Maury's work, a similar case of a young girl, seven years of age, who had not cut the two central inferior # See the Memoirs of M. Blandin, page 110. t Traite de Medicine Maternelle. J Comment, in Aphor.,, torn. 4. || Collection Académique, partie étranger, torn. 1. Il 82 ANATOMY, ORTHOPEDIA, incisors. We ourselves have met with several cases of tardy dentition. We may, however, generally say, that the temporary teeth ap- pear from the sixth to the eighth year after birth, rarely sooner but sometimes later. The order in which they appear through the gums is the same that follow in their development, and are liable to like variations. Thus, from the sixth to the eighth month, the inferior central incisors appear; the superior follow these ; one or two months later the lateral incisors follow the same order. At the twelfth or fourteenth month the small mo- lars appear ; sometimes, however, the canines appear at this time ; finally, the second small molars complete, about the age of two years, or two and a half, first dentition. We again repeat that the eruption of the teeth does not always follow the order which we described, and whoever will observe this process of nature, (a phenomenon as important as it is complicated with the organism,) upon a certain number of infants, will be aston- ished at the diversity he will meet with. Below we give a table of the usual periods at which the teeth appear. From 6 to 8 months, the 4 central incisors. " 7 " 10 do. " 4 lateral incisors. " 12 " 15 do. " 4 small anterior molars. " 15 " 20 do. " 4 canines. " 20 " 30 do. " 4 small posterior molars. Total, 20 temporary teeth. We have adopted, as will be seen, the opinion of M. Serres, who admits, in opposition to the order established by Sabatier, Bichat, Boyer, and the most distinguished anatomists who have preceded him, that the canines do not appear until a few months after the eruption of the small anterior molars. We adopt it as a common consequence of a law of the organization, which we have always been forced to acknowledge, that at all stages the canine are not developed so soon as the first small molar. In justice to the celebrated Scotch dentist, Blake, it is necessary to state that M. Serres has only copied the opinions of this distin- guished writer, whose views we have frequently quoted, and who, twenty years previously to the publication of the work of PATHOLOGY AND THERAPEUTICS. 83 the latter, said, "On examination of the teeth of a number of children at birth, I discover in both jaws that the crowns of the central incisors are perfect ; that those of the lateral and the an- terior molars are far advanced, and that the canines and poste- rior molars were but slightly developed." Blake and Serres content themselves by stating this fact ; perhaps, if they had explained it by saying that the office of the canine teeth was to tear, and that it required the assistance of the hands, nature had not seen fit to develope these teeth before the hands were capable of assisting them. When the crown has entirely passed through the orifice of the alveolus, the gum which is united by its fibrous portion to the external roots, under the name of alveolo-dental periosteum, adheres around the neck of the tooth, which it closely embraces. The maxillary bones at the same time undergo great changes ; their alveoli, which had been distended by the crowns of the teeth which they contained, afterwards contract and adapt them- selves accurately to the roots ; this brings about an entire change in the physiognomy of the child. The milk teeth then continue to increase ; their roots, at first hollow and short, become filled up, elongated, and there is a time during which they are shed and replaced by others. But before speaking of these phenomena, let us examine the organs which, in the jaws, are opposed to them, and which nature has prepared for replacing them. We have said above, and anatomical researches have suffi- ciently demonstrated, at the term of gestation we distinctly dis- cover follicles of the incisors, and even of the secondary canine teeth. They are placed in as many alveoli, in the rear (but very deep) of the capsules of the corresponding temporary teeth, from which they are separated by a fibrous partition, the exis- tence of which has been denied by Meckel, on account of its great thinness. But, in proportion as the milk teeth grow, and especially when they have passed through the orifice of the gum, carrying, in its progressive movement, the alveolar pro- cesses, it gradually becomes more distant from the follicles which then appear to sink themselves; the extremity of the capsules, which is immediately connected to the gum, lengthens 84 ANATOMY, ORTHOPEDIA. out, and forms as many little prolongations, which afterwards being enveloped by the progress of ossification, is found con- tained each in a little canal. These are the prolongations already described by Fallopius and Eustachius, and verified by Albinus, Blake and Meckel, to to which M. Serres has given the name of gubernaculum dentis, wishing thus to express the use to which they were intended. But we will observe, that if they had this office, the teeth of second dentition would always have pierced the place where these canals terminate ; but this is far from being the case in the incisors, it is rarely seen in the canines, and never in the molars. Some authors look upon these appendices simply as a kind of elongation of lines of continuity which unite the folli- cles of the second teeth to the gums ; and as to the osseous ca- nals in which they are lodged, as in cases they would be, ac- cording to these authors, the necessary result of the ossification of the parts which they traverse. In other respects, these pro- longations, an attentive examination of which permits us to prove the existence of the cavity, are in number equal to those of the follicles of the secondary teeth, which alone are pro- vided with them. When the child has arrived at the age of six or seven years, the permanent teeth are nearly completely developed. The central and also the lateral incisors have already grown slightly near the roots ; the crown of the small molars, and those of the canines, are nearly complete. Each jaw contains, at this time, twenty-six teeth, ten temporary, ten of replacement, and six per- manent,which are the six large molars, the eruption of which, for the four first, generally takes' place about the seventh year, and always precedes the loss and replacement of the milk teeth. All these teeth are lodged in a certain number of alveoli, divided in three apartments, the anterior or smaller of these be- longs to the teeth of double dentition, and the posterior to the permanent, which are succeeded by no others. The partition marks the limits of these apartments, which separates, on each side, the first large molar from the posterior deciduous molar. Things are then so arranged that the permanent teeth, that is to say, the large molars, are placed upon a line of the arch occu- PATHOLOGY AND THERAPEUTICS. 85 pied by the temporary teeth, which assists in the continuation of the curve posteriorly. As to the teeth of replacement, they present the following arrangement: the incisors and canines are placed in the rear of the roots of the corresponding tempora- ry teeth ; the bicuspides below the deciduous molars in the infe- rior, and above them in the superior jaw. By this arrangement, the first and second large molars, which solely occupy all the external apartment, are very slightly lodged here ; thus there is reserved for the bicuspides a part of the interior of the jaws oc- cupied by the deciduous milk teeth. The incisors and the canines have been, under the relation of replacement, not as conveniently situated as the molars ; they are at first considerably larger than their corresponding temporary teeth ; afterwards, they occupy posteriorly a smaller circle in the arch ; this causes them to be pressed against each other, so that the alveoli of the four incisors of replacement oc- cupy as much space as do those of the deciduous canine and incisor teeth. It also occurs, from this arrangement, that the canine teeth of replacement, not having sufficient space by the side of the incisors, are deeply imbedded exteriorly in the infe- rior jaw, and in front of the lateral incisors, whilst the superior incisors occupy, far from the alveolar border, a narrow space which is reserved for them at the base of the apophysis of the superior maxillary. Finally, when the teeth of replacement have acquired their full size, which happens about the seventh year, it only waits for a suitable time to break the barrier which the gum offers to them, and to rise from the socket. But before this eruption can take place, the milk teeth should give way for them. It is this process which we shall now treat of. Shedding of the Milk or Temporary Teeth. We shall now treat of that which generally takes place about the seventh year of age, as the teeth of first dentition are shed, and those of the second commence to appear. The order in which the milk teeth appear is always such as is observed in their shedding. Unhappily, in this circumstance, as in many 86 ANATOMY, ORTHOPEDIA, others, nature wishes to conceal from us the laws by which she controls her operations. Let us, in the meantime, endeavor to penetrate these views, by explaining, if it is possible, the phe- nomena which accompany this shedding. Thus, as we know, each jaw presents, in infancy, two series of parallel alveoli. The anterior series is destined to receive the milk teeth, the posterior encloses those of replacement, so that if the first teeth are not shed before the eruption of the teeth of second dentition, each jaw would be furnished with two rows of teeth : a circumstance very rare, but which, however, has happened. The first effect of the movement of progression of the second teeth is the pushing or forcibly removing the obstacles which they meet in their course, and which at first consists in the alveolar partitions separating the two classes of teeth. But this obstacle being removed, the roots of the milk teeth experience the pressure; this pressure, gradually increasing, contracts the vessels and nerves of these teeth, and finally cuts off their vi- tality. The fluids of which the milk teeth are thus deprived, are carried in abundance to the matrices of second dentition, and augment the eruptive force of the teeth of that class. This method of explaining the shedding of the milk teeth by the mechanical destruction of their alveolar partitions, the com- pression of their nutrient vessels, and the destruction of their roots, is far from being above all doubt, at first, because it can- not be applied to the very frequent cases in which the teeth are shed without having been in contact with those that are to re- place them ; in the second place, because they do not show why these teeth, which have ceased to exist before their shedding, are not shed before having lost a part, sometimes even the whole of their roots. It is, then, necessary to add another cause of the change of these teeth to those of which we have spoken, and that cause, w.hich we have believed resided in a particular work of absorption, whose existence we have admitted with M. Dela- barre,* who, however, found concerning it some very clear ideas expressed by Soemmering, and developed by Bichat himself. * Treatise upon Second Dentition. PATHOLOGY AND THERAPEUTICS. 87 Thus, whether the milk teeth, becoming foreign bodies, cause irritation, or whether the development of the permanent teeth contributes to a more active inflammatory action, it is cer- tain that the vitality of these parts and consequently the energy of their absorbent functions, are always considerably increased. This results from the destruction or rather absorption of the phosphate and carbonate of lime which enter into the composi- tion of the roots of the milk teeth. This kind of wasting away ordinarily commences at the extremity of the roots, which be- come unequal, rough, and gradually disappear; it is not effect- ed, as some other organs subject to like destruction, at the ex- pense of all the exterior or deep molecules of which they are composed ; all this commences at the surface, and proceeds from the circumference to the centre; but the enamel always resists, except towards the internal part of the crown, where it has been observed to be sometimes eroded. This mechanism is the same for all milk teeth ; but the de- struction of the alveolar ridges takes place differently around dif- ferent teeth. Around the incisors and canines the ridge is de- stroyed perpendicularly, but around the molars the process is more difficult, for the reason that their roots diverge to the right and left in the jaw, more especially in the superior. This work of destruction commences here on a level with the alveolar bor- der, from thence it goes on ; the ridge of porous tissue between the roots is the last destroyed, upon the phenomena of which we shall soon treat. Such is the mechanism of the shedding of the temporary teeth ; the explanation which we have given of it is simple, and in conformity to the laws of our organization. This loss of the temporary precedes the eruption of the permauent teeth, of which we shall presently treat. These two phenomena are so connected, the one with the other, that children who lose their first teeth prematurely, are those whose second teeth are the most precocious. Eruption of the Teeth of Second Dentition. ; We shall now see how the shedding of the teeth of first den- tition is effected, and treat of their immediate replacement by 88 ANATOMY, ORTHOPEDIA, other organs. This process is subject to great variations ; for, indeed, we often find that the destruction of the roots of the milk teeth progresses so slowly that these organs maintain their posi- tions and impede the progress of the temporary teeth ; on the other hand, from some unknown cause, the replacement of the teeth does not occur until a very long time after the moulting of the milk teeth. We find, in the General Archives of Medicine^ the example of a woman, aged forty-three years, who had her four incisor teeth posterior to the four deciduous incisors. A year later, the four molars, which until this period were wanting, showed themselves. Her parents said that she yet had milk teeth. We know of several similar cases. After the seventh year, at which period there are twenty teeth situated in the whole extent of the alveolar arches, between the maxillary tuberosities above, and the coronoid apophyses below, these arches ought to receive successively the second teeth which replace an equal number of temporary, and posterior to these are added three new organs in each side of both jaws. But how do the maxillary bones adapt themselves to the arrange- ment of all these productions? How do the teeth arrange themselves in a line upon the alveolar borders, without impeding each other in their course, without turning each other from their route, without usurping the place of each other? Let us en- deavor to unravel this intricate question, whose solution is far from being unimportant. At first the development of the maxillary bones does not go on simultaneously and in a continued manner upon every part of their extent, as we observe in the other parts of the osseous system. The cause of this difference is that these bones pre- sent in their composition two substances essentially distinct, as much by the manner in which each one developes itself, as by the ulterior metamorphosis that they undergo. Concerning these two substances, the one belonging to the general osseous system, forms and regulates itself according to the laws which regulate the other bones ; it comprises nearly the whole of the * June number, 1840. PATHOLOGY AND THERAPEUTICS. 89 jaws, or rather it forms, truly and properly speaking, the maxil- lary bones ; the other constitutes the border or alveolar process. Although this last may be equally osseous and lasting as the first, it forms not an essential part of it, and is, as it has been plainly said, only a phenomenon of dentition ; it appears in the same time with the organs which produce the teeth, it is developed with these last, moulds itself upon their external forms, follows their direction, undergoes all the changes to which they are subject, and disappears with them. If we examine the interior of the jaws soon after conception, [six or seven weeks,] we will be convinced of the truth of what we are about to relate. In fact, the interior of the jaws is, at this period, filled with a spongy tissue, whose pulps contain the rudiments of dental follicles. These follicles soon give birth to [the rudiments of] teeth ; these necessarily expand, and by the great volume that they acquire, the cellules of spongy tissue, in the midst of which they are plunged, press on all sides against the neighboring cellules, and cause the ridges that separate them to disappear, transforming them into thin layers of compact sub- stance, whose reunion constitutes the solid walls of as many cavi- ties or distinct alveoli as there are crowns of new teeth. And when these, continuing to increase in height, have pierced the gums, the roots which follow them, being much smaller, the remaining space is filled by the closing up of the alveoli. During the eruption of the milk teeth, the alveolar arch as- sumes the best arrangement for the accommodation of these organs, the jaws, as we have already seen, taking the most am- ple dimensions, sensibly elongate, their angles become more distinct, the substance of the bones themselves deepen, while the alveolar borders diminish in thickness after the completion of dentition. The temporary teeth having all appeared, is the maxillary arch always of the same size? Blake and many other anato- mists, among whom are Soemmering, Sabatier, Boyer, Bichat and Beclard, his worthy commentator, finally, of a later day, M. Serres, have thought these arches elongate during the whole period between first and second dentition. Hunter con- tends, on thecontrarv, that from the age of fifteen or eighteen 12 90 ANATOMY, ORTHOPEDIA, • months, the anterior part of the jaws do not grow, and his opinion is maintained by Fox # and M. Duval. M. Oudet, hold- ing this opinion, to the triumph of which M. Mielf has written a memoir, dedicated to the Medical Society of Emulation, has taken from twenty children, selected promiscuously, at the age of three years, plaster models of their teeth ; and after having repeated upon them, even to the age of six years and a half the same experiments, at intervals more or less near to each other, he pretends to have always found, during this period, the arch to be uniformly of the same size, and that the relation between it and the teeth to have undergone no change. These two extreme and opposite opinions are, according to our belief, both equally destitute of foundation. In fact, in admitting the progressive increase and continued growth of the alveolar arch, Blake has confounded the maxillary bones with those of their border, in which the teeth are implanted ; for if the growth of this last was continued uniformly, as those of other bones, it would exactly follow the laws which govern os- sification generally, and from whence follows two conclusions : first, that the temporary teeth, from the moment they appear are always inclined to separate, and leave a space between them ; second, that the alveoli, in dilating, abandon, without support, the teeth they contain. Now, observation proves, although Beclard and M. Serres assert the contrary, these two facts never existed. Then the alveolar arch does not sensibly increase be- tween the two dentitions. It is this immobility in the alveolar processes, in opposition to the progressive growth of the jaws, that makes, at six years, the mental and suborbital foramina still more distant from the first temporary molar. This immobility, however, applies only to that portion of the arch which receives the temporary teeth, for, posteriorly, they are elongated for the reception of the second adult molars. But then, if the opinion of Blake is false, is not that of Hunter, strongly defended by M. Duval, Miel, etc., necessarily conforma- * Natural History and Diseases of the Teeth, translated by Lamaire. t Some Ideas upon the Two Dentitions. PATHOLOGY AND THERAPEUTICS. 91 ble to truth ? No; for the reason, that if the alveolar arch did not grow between the two dentitions, it is conclusive, against the most absolute evidence, that this arch is of the same size in the infant that it is in the adult. This growth commences at the moment of the eruption of each tooth of replacement; it is a necessary consequence of the intimate dependence in which the teeth hold the alveoli, which belong to them much more than to the jaws, and yield to their effort as an elastic barrier, which permits itself to be extended. Thus it is, that each tooth aug- ments this arch only in the degree necessary for its own accom- modation. Nevertheless, let us remark, that this growth is less than one would naturally suppose ; for observation demonstrates that if the incisors and canines of replacement are larger than those of the deciduous set, the temporary molars are larger than the bicuspides which succeed them, so that what the jaws lose in space anteriorly, they gain posteriorly. But the same changes do not take place in the two jaws ; in the superior, the relation between the gain and loss of space is less as the growth of the arch which confines this species of fixture, which the superior maxillary receives with the bones with which it articulates. And are irregularities of dentition more common in the supe- rior than inferior jaw? In order to reduce this question to all possible precision, and to avoid details that would be more appropriate to a special me- moir than to an elementary treatise, we may say, the ten teeth of replacement of the inferior jaw require, in order to arrange themselves, a space necessary to twenty ; they only find a space equal to seventeen ; of the three-twentieths wanting, they gain two of them by the increase they themselves occasion in the alveolar arch, and one by the small space that the two small de- ciduous molars allow to the two teeth of smaller size which re- place them. In the superior jaw on the other hand, the three- twentieths that are wanting after the fall of the first milk teeth, are obtained, one by the increase of the alveolar arch, the second as in the inferior jaw, by the difference in volume between the two classes of teeth ; and finally, the third by the direction of the incisors, which make room for them by diverging a little. It is from this slight divergency, so perfect in the adult, that we ( J2 ANATOMY, ORTHOPEDIA, think the encasing of the two anterior tiers of the inferior jaw by the superior is occasioned. We repeat, if the eruption of all the second teeth were to take place at the same time, their arrangement, doubtless, would be irregular, since, in the superior jaw particularly, as we have seen, they would find an insufficient space. But this is not the case, the fall and replacement of the teeth do not happen at the same time. These organs have to pass through a series of con- secutive phenomena, which embraces an interval between the sixth and seventh years ; thus each, proceeding separately, has time to advance regularly, and to assume its proper position. If the anterior arch of the jaws increases gradually, in proportion to each new tooth, all would place themselve in the semicircular line that they should occupy ; but if this arch experiences ever so small a variation, it is generally the canines that cause the irregularity, because, commonly appearing behind, they are then obliged to deviate themselves, or cause other teeth to do so, in order to pass through the gums. This places beyond doubt the possibility that the teeth possess the ability of causing the alveo- lar arch to yield ; this happens in cases of supernumerary teeth, examples of which Camper and Soemmering have given ; we have also seen them. This arch in front allows all necessary space for the accommodation of supernumerary teeth. Let us examine the intermediate points through which nature passes to accomplish her desired end, which is to furnish the jaws of the child with teeth that are most capable of performing the necessary functions at that period. The renewing of the teeth according to the progress of their eruption, commences always with the incisors. The central inferior incisor appears first; a short time before the shedding of the temporary tooth, it gradually elevates itself in the interior of the alveolus of this latter organ; it pushes it from below up, so that the temporary tooth is merely retained at the orifice of the alveolar cavity. It is at this period that the tooth of replace- ment effects a slight enlargement of that small portion of the dental arch to which it corresponds; the enlargement is visible a short time before the shedding of the milk tooth, which is sensibly removed from its neighbors. PATHOLOGY AND THERAPEUTICS. 93 When, by some cause, the milk tooth is shed at a proper time, we observe the permanent tooth coming through behind the dental arch in an oblique position, which causes it to appear in front of one of its lateral borders ; we at first believe, from its enormous size, that it is too large to be received into the place to which it is destined ; it, however, gradually redresses itself during its progress upwards, assumes a direct position, elongates and enters into the space that it should occupy ; it then presents no irregularity of position. What we have just said is applica- ble to all the incisors, which are subject to like phenomena upon the dental arch that they occupy. All the permanent incisors are well arranged during the course of the ninth year. There the work of replacement stops some time, and it is only towards the end of the tenth year that we perceive the first small molar or anterior bicuspid, in whose ar- rangement we do not perceive the least difficulty, since it has a volume much less than the molar milk tooth that it ought to replace. Soon after, the second small molar appears ; then, at about the eleventh year, the canine, which does not at first oc- cupy its position upon the line of the arch, but delays to do so some time. Very nearly at the same time that the two canines are cut, we perceive the second large molar ; finally, the last, which is the wisdom tooth, appears from eighteen to twenty-five years. The time of the cutting of this last is variable. Hippocrates has fixed its appearance between the thirteenth and fourteenth septenary. It is principally among women that this tooth remains sometimes forever enclosed in the interior of the jaw; the result of this generally is a less spacious maxillary bone, without that their teeth would have less volume. Of all, the wisdom teeth are most subject to anomalies of form, volume and position. The following table presents the ordinary phases of second dentition : From 6 to 7 years, the 4 first large molars ; 7 " 8 ce I( 2 inferior central incisors ; 7 " 9 CI (( 2 superior central incisors; 8 " 10 11 (( 4 lateral incisors ; 9 " 11 cc il 4 first small molars ; 10 " 12 (( (C 4 canines; 94 ANATOMY, ORTHOPEDIA, From 11 to 13 years, the 4 last small molars; " 12 " 14 " " 4 second large molars ; 11 18 " 25 " " 4 third large molars, or wisdom teeth. Total, 32 permanent teeth. During the replacement of the teeth, some changes that we should mention are taking place in the jaws. Their bodies become more extended in height, the suborbitary holes and mental foramen elongate from the alveolar process and from the symphysis, and correspond, at about twenty years, to the root of the second small molar. The crookedness that the base of the inferior jaw presents, at a young age, disappears gradually, and becomes angular. The superior alveolar floor contracts trans- versely at the seventh year, finally enlarges itself very sensibly in this respect, in proportion as the growth of the horizontal por- tion of the maxillary bones progresses. The inferior arch does not dilate sensibly, as we have said, and preserves, crosswise, nearly the same separation before and after the renewing of the teeth. But the most important modifications are those which take place in that portion of the maxillary bones which corresponds to the posterior extremity of the arches. That portion of the dental arch contains, principally, only the first large molars, is considerably enlarged, in order to receive the wisdom tooth, which ranges itself behind them ; it is that elongation of the arches posteriorly which developes the face, and consequently distinguishes the adult from the infant. In the inferior jaw, it causes the gradual redressment of its branches, in such a manner as to make them describe, with the remainder of the bone, an angle less and less obtuse, whilst to the upper jaw it causes posteriorly pterygoid apophyses ; that the maxillo-palatine suture, which, in the young child, was situated opposite the space contained between the posterior temporary and first permanent molars, corresponds at a later period to the second, and finally, when the work of den- tition is completed, it finds itself a little posterior to the wisdom tooth. The elongation of the posterior part of the superior arch coincides with the growth of the maxillary sinus, a double effect which has for its object the development of the large molars, to the volume of which it is always proportioned. PATHOLOGY AND THERAPEUTICS. 95 Phenomena subsequent to the Arrangement of the Teeth. When the teeth have cut the gums, their crowns have acquired their full size; but this is not the same case with their roots, which still continue to increase in bulk and length. As the roots grow in length, their canals diminish in size, and the cavity in their crown gradually disappears. The crowns of the teeth, submitted to the action of foreign agents, become affected by them; the denticulated edges of the incisors gradually wear away, the summit of the canines becomes at first smooth, and then obliterated, and the tubercles of the molars diminish in size, and finally disappear. While these changes are going on, the pulp forms new layers of bone, and the cavity which it occupies gradually diminishes ; these vascular and nervous communications, and sometimes even the production of its secretion, becomes altered. When the teeth arrive at that stage that the blood no longer penetrates their cavities, and that their nerves no longer communicate their in- fluence to them, they change in color, become truly foreign bodies, loosen, and rise from their gums, and finally drop out. The alveolar processes do not undergo remarkable changes as long as they are occupied by the teeth ; but so soon as these organs are lost by disease or accident, the vacuum that their loss occasions diminishes, fills up, and after a few years disappears. When once the jaws are deprived of their organs, their bodies diminish very much in size ; from this loss of their alveolar border, they assume the circular form that is had during infancy ; the suborbital and submental foramina are then near the edge of the jaws ; the maxillary sinus and tuberosity return upon them- selves : the branches of the inferior jaw are thrown back, and assume almost the same direction which they had during child- hood. Finally, deep wrinkles, prematurely marking the face, show a loss in the vertical diameter of the face, which consti- tuted its principal and most handsome feature. All of this process occurs according to design of nature, which has caused that the two dentitions, of the divers phases of which we have spoken, should suffice, in each individual, through life. There are, however, well authenticated cases of 96 ANATOMY, ORTHOPEDIA, nature having deviated from her usual course, and that a third, and even a fourth dentition have occurred. These new teeth, a freak of nature, as if to show the effort and resources of the economy, may appear at any period of life after the time destined for the eruption of the last molar teeth. Their eruption has been viewed by physiologists and authors who write upon dentition, only as a curiosity or an unusual occur- rence; but they merit a more serious recognition, since they may produce injurious effects to the regular dentition, under the impression that these new organs have to pass through the gum nearly of a cartilaginous consistency. Sennertus* relates a case of a lady who, during her sixty and some odd years of age, cut twenty new teeth, the eruption of which occasioned diseases analogous to those which children experience during first or second dentition Joubert speaks of of a similar case, of a woman seventy years old ; and a German author, Ungebauer,t states, that twelve teeth of a child of ten years of age, were three times shed. If examples of the almost complete renewing of the teeth pre- sent themselves so seldom that some authors have thought proper to deny them, this cannot be urged against the partial renewal of some. This last phenomenon often occurs, and has been noticed by men of undoubted veracity, or at such recent periods that it cannot be doubted. Eustachius, whose anatomiical works exhibit so much sagacity and precision, has seen the incisors of a youth, twenty years of age, after having been drawn, to be replaced by others during the same year. Dufay, physician for the port of Lorient, has, in that town, seen a man fifty-four years of age, to whom nature, at that age, had endowed with two incisors and two canines. Gehler, who has written a work upon third dentition, relates a case of a canine tooth, which had been three times extracted, and had been three times replaced by a similar organ. Haller states that he has seen this phenomenon, which Cardan and Diemerbroeck had witnessed in themselves, the former at fifty-three, and the latter at fifty-six years of age. # Dissertatio de Dentium Dolore. t De Dentitione Secunda Juniorum. PATHOLOGY AND THERAPEUTICS. 97 The most remarkable examples of this nature have been re- ported by M. Serres, who witnessed them in the charity hospital. One was a man, aged thirty-five ; his two inferior central inci- sors dropped out accidentally, and were replaced, within a few months, by two others. The other case was an individual, seventy-six years of age, who, when recovering from an attack of bilious fever, experienced, in the inferior jaw, lancinating pains, accompanied with tumefaction of the gum and cheek, which terminated in a multicuspid, situated upon the surface of the part that the second large molar of the left side had occupied. The alveolar border of this old man had not been absorbed, the symphysis of the chin did not project forward, and the angle of the jaw recede, as it should have done ; hence M. Serres infer- red that there were other germs of teeth enclosed in the jaws, and that new teeth would, after a time, show themselves. The foregoing case of M. Serres may give rise to the following question : are there in the jaws several germs, or do the germs contain organs capable of forming and producing new teeth ? The first of these questions appears to us to be the most plausi- ble one; for it is more simple, as the learned author whom we have just quoted says, to admit that certain individuals may be born with supernumerary germs of teeth, as we see them come into the world with supernumerary fingers, kidneys and ovaries, than to attribute to the teeth the faculty of reproduction. We have in our possession several pieces of pathological anatomy, which would lead us to that conclusion, and which the recent observations of Lemaire and Blandin would confirm. The first of these gentlemen extracted a canine, from which he readily detached four distinct teeth ; the second found, in an adult jaw, a new tooth, the crown of which was partly formed. It is cer- tainly from such germs that we should attribute the dentition of old persons. Functional Importance or Uses of the Dental Apparatus. The part that the dental apparatus takes in the execution of the inherent functions of the human organism, is as varied as it is important ; but of all the attributes which are attributed to it, 13 98 ANATOMY, ORTHOPEDIA, the most prominent, those to which it is most adapted, from the nature of its formation, are prehension and mastication. We will examine these two functions, which, reduced to the physi- cal properties, according as they are accomplished, resume them in action : the first, as a pair of pincers to tear and cut ; the second, as a vice to bruise, and as a mill to grind. Prehension and Mastication. — All of the teeth may be em- ployed, says M. Blandin, in the prehension of solid substances; but the incisors are better adapted to this office. Pressing in a direction opposite to the materials to be divided, they are well arranged to accomplish this function, for they have cutting edges, and cross so as to act like the blades of scissors ; but, on the other hand, placed at the extremities of the jaws, which there form a lever of the third species, the masseter muscles of «which are the power, the tempero-maxillary articulation, the point of support, and the body to be divided, the resistance ; they are so arranged as to exercise great force, especially upon large bodies, which, requiring the jaws to be opened wide, and put the elevator muscles of the inferior jaws in the position to act very obliquely upon the arm of the lever of resistance. § Hence, as all physiologists have remarked, when we wish to break a hard substance, we instinctively place it far back in the mouth ; and by shortening the arm of the lever very much, by which the resistance acts, we correct the lever of the third species, which, although employed oftener in animal mechanism, is, moreover, the most useful of all. The canine teeth, on the other hand, from their pointed shape and great power, are more adapted to tear than to cut. These two offices occasion the teeth to be employed both in the pre- hension of the hand on the one part, and the extensor muscles of the head on the other. They then act like pincers, with which we would hold the body that we wish to tear ; the point of support which they afford in such case is sure, by the length of their roots, in proportion as they firmly set in the jaws. As to the molars, their form and position in the posterior part of the mouth, render them altogether unsuitable for prehension, except in preliminary circumstances, when the assistance of the teeth is required for bruising a body, or for holding it, while it PATHOLOGY AND TTIERAPRUTTCS. 99 is being torn ; they afford, in this latter case, much better the power of retaining objects, as they are placed near the muscles charged with the office of closing the jaws. But this is not so in mastication ; they combine the most proper conditions in that process, which has for its object the faculty of bruising and reducing food into very fine particles. By the great volume of the crowns, furnished with asperities, which alternate from one jaw to the other, they can retain for along time substances upon their surface, as if placed between two mills, the office of which is to triturate them. We should notice that it is not solely in the arrangement of the teeth that nature has taken such happy precautions for the execution of the process which now engrosses our attention ; she has likewise established the most perfect concord between the functions exercised by the superior and inferior jaws, and in such a manner that the former acts like a hammer upon an an- vil. The superior incisors also, which never have to undergo forcible offices, are situated below the nasal cavities ; while the canines find, in the external orbital apophysis of the frontal bone, a support which enables them to resist the force which is often required of them, and which, posteriorly, they are com- pelled to remain strictly tight during mastication, which almost entirely devolves upon them ; "nature has doubly protected the superior alveolar border against the base of the cranium, by placing between them the zygomato-jugale and pterygoiden columns." It is not merely the conical form of the roots which concur mainly to the transmission of forces, by causing the efforts that they have to sustain to be lost upon the alveolar borders, which closely embrace them. The number of the roots, are they not also in proportion to the violence that each class of teeth have to sustain? Because each tooth generally has distinct functions, we should conclude, however, that their action is separate, and that the labor of some ceases when that of others commences. When food is once reduced to a proper size, by the teeth, it is succes- sively carried from one tooth to another, by the combined mo- tions of the tongue, the lips, and the cheeks, and committed, by turns, to a vertical pressure and a horizontal grinding. 100 ANATOMY, ORTHOPEDIA, This process is well performed, when the teeth of both jaws are arranged in the following manner: the superior central inci- sors close before the inferior central and half of the lateral inci- sors ; the superior lateral incisors correspond to the remaining half of the inferior lateral and half of the canine teeth ; the supe- rior canines pass before the remaining half of the inferiors and half of the first small molars ; the first small molars of the superior jaw cover the first and second inferior molars ; the second large superior molars cover the second and third inferiors; finally, the superior dentés sapientiae correspond to the inferiors which pass them, to a greater or less extent. The great precaution, as can be readily seen, which nature has taken to render the action of the teeth upon alimentary sub- stances, are numerous and wonderfully combined, and never- theless they cannot appear to be exaggerated, except to those persons who are so blind as to forget the influence of mastication upon digestion. "When great numbers of the teeth are missing, so that mastication cannot be continued for a sufficiently long time, chymification is with difficulty performed ; the stomach, irritated by refractory aliment, because it is not sufficiently mas- ticated, becomes inflamed, and other injurious consequences arise from it. Old men, who have lost their teeth, are obliged to adopt a suitable regimen, under the pain of suffering injurious consequences ;" if they would not prefer to have recourse to dental prothesis, which offers to them the sure means of pre- venting these injurious results, as daily experience testifies, and which we shall very soon attempt to prove. Articulation of Sounds. If there is a fact that it suffices to express, in order that it may be immediately understood by every one, it is the influence of the teeth upon the pure and clear articulation of sounds ; for if the voice is the product of the vibrations that the air exhaling experiences in crossing the larynx, the word, as Magendie* justly says, results frem the modification of the voice by means of the * Elementary Treatise on Physiology. PATHOLOGY AND THERAPEUTICS. 101 tongue, whose most movable portion strikes at one time the palate, at another the teeth. But all the teeth are not equally important as it regards this : the incisors should be placed first ; we readily see their want of thickness and the width of their faces make them true sonorous bodies, as well as their position at the confluence of the column of air which escapes from the mouth; the canines come next; then the small molars; the last have little or scarcely any influence upon the pronunciation. The better to appreciate the importance of the teeth in arti- culating sounds, it is only necessary to observe those who are deprived of them altogether or in part. Let us notice, in regard to this, some details, whose recollection will serve at least in the completion and combination of the different pieces of dental prothesis. The loss of teeth is partial or complete, and each of these circumstances has, in a word, inconveniences which belong to them, and which vary according as the loss affects the superior or inferior jaw. For example, persons who have lost the central superior incisors, cannot pronounce agreeably dental syllables, which take the labial accent, and their conversation is often but a continued hissing. If, on the contrary, these same teeth are wanting in the inferior jaw, the guttural consonants, such as G, take a sound which is midway between that which belongs to it and that of Gh and Ch, and which often prevents them from being understood. When the inferior jaw has lost all of its teeth, the sound of the voice is not changed, the pronunciation only is altered ; but it is not so with the superior; as soon as it is deprived of its teeth, the alveolar border sinks, and, the palate having lost the con- cavity that it acquires by the development of the permanent teeth, the sound of the voice becomes harsh and guttural; for it is a fact worthy of observation, in every point conforming to that which establishes theory, that the more the palatine vault becomes flattened, the less brilliant and forcible the voice, even among persons furnished with all their teeth ; that which con- firms this opinion is, that the palate is a vocal pipe like that which is the parillier to the instrument called horn. Then, the loss of the teeth has as much more influence upon 102 ANATOMY, ORTHOPEDIA, the diminution of volume and force of the voice, as it is more complete, and as the alveolar border is more depressed. When they have totally disappeared in both jaws, the voice loses not only its force, but its harmony ; it becomes, as Delabarre remarks, sharp and suppressed, the pronunciation can be accomplished but very imperfectly, and only by a new mechanism, which de- mands, in every case, a long exercise, often even a painful habit. Secondary Functional Importance, The assistance the teeth offer to man is first, in his life, by nutrition, by the work of preliminary disintegrating that which is necessary for nourishment ; secondly, in his life by relation, by the active part that they take in the articulation of the voice, constituting, as we have said, their principal functions, but these are not the limits of their physiological acts. Being placed at the superior extremity of the digestive tube, they assist in forming a barrier which retains in the interior of the mouth the saliva destined to facilitate the actions of the different mova- ble parts of that cavity, and to augment the digestibility of the alimentary bolus ; approaching the superior members, they are able to be of assistance to the hands, as a support, to conquer resistances, and to become even in some cases a means of de- fence and attack. . Finally, if they exert an action upon the organs, they are also in their turn influenced by them. Although it seems effectively paradoxical at first to sustain, by example, that the lips, the cheeks and the tongue assist, not in giving to the teeth the proper direction, but in maintaining them in this direction, still nothing is truer. When the lips are destroyed, the teeth direct themselves without, whilst they incline inwardly when the tongue is cut off or diminished in volume. We have had re- cently occasion of proving this last result, upon a subject who had long since lost the anterior part of his tongue. We can then assert certainly, with Blandin, that the teeth are naturally placed between two forces, which affect them in opposite directions, the one from without to within, the other from within to without, and that from this equilibrium results a great part of the sensible vertical direction that they have amongst us. PATHOLOGY AND THERAPEUTICS. 103 If, in order to complete the examination of the list that acts in the economy of organs which we are now treating of, we wish to study the character that they imprint upon the physiog- nomy, we should only notice the influence of their loss in this respect. Now, that influence varies according as the loss is total or partial, and according as they have a place in the upper or lower jaw. For example, the loss of eight or still more of the ten anterior teeth of the inferior jaw only thickens the lower lip, and renders the chin pointed, by the retreat upon itself of the alveolar border, which contains the teeth. If to this loss we add a parallel one in the superior jaw, the middle part of the face becomes square, and the physiognomy wears a sad and monotonous aspect. If it has only a place in the superior jaw, the change is still more apparent ; for the upper lip, wanting support, sinks in and leaves the lower one projecting out; at the same time the nose seems to be forced in. The molar teeth only, on the contrary, being wanting, the jaws flatten, become flabby and hanging, and the form seems elongated. As to the loss of the teeth of both jaws, the result inevitably is to diminish the vertical diameter of the head, and consequently to shorten its form. SUMMARY AND CONSEQUENCES OP THE PRECEDING PHYSIOLO- GICAL FACTS. As we have been obliged, in the description of the physiolo- gical phenomena which belong to the dental apparel, we have given some discussions and even sometimes made some repeti- tions, which might be able to cast some uncertainty upon the mind in regard to the principal points of these phenomena, we shall briefly recapitulate. Now, we have seen that all the teeth, as well of the first as of second dentition, exist in the jaws of the fœtus; their develop- ment takes place in the following order : 1st. After the third month of intra-uterine life, the germs of the milk teeth are apparent, under the form of a small stony pulp or papilla, which seems to be but a mixture of vessels and dental nerves, enclosing, in a sac, a kind of capsule called follicle. 104 ANATOMY, ORTHOPEDIA, This folliculous membrane, which we believe to be of a serous nature, is composed of two leaves, an external one, which is confounded with the alveolo-dental periosteum, and an internal one, whose exterior surface is moistened with a sero-mucous fluid. These follicles, appended to the gummy membrane, as a fruit to a horizontal branch, are not developed at the same time, nor do they offer the same disposition. Towards the middle of the third month, we distinguish, upon each half of the two jaws, four sacs, two before, two behind, inclining by pairs, which leave between them an interval. The first, smaller, belong to the temporary incisors ; the second to the molars. A fifth sac, at a later period, fills the interval, for the canine, which forms the total number of the follicles of the first teeth. The follicles or germs of the teeth of the second dentition, ac- cording to Serres, appear after the end of the fourth month ; those which belong to the two large first molars first, and upon the same line as the germs of the milk teeth ; afterwards, but only towards the end of the seventh month, do we see the folli- cles of the secondary incisors placed precisely behind those of the primitive teeth to which they correspond. 2d. A little after the appearance of the follicle, the tooth com- mences to develope itself interiorly ; the top of the crown appears first. The formation of bone is announced by a reddish circle around the more prominent parts of the papilla. Afterwards, the production of the calcareous bony matter, which is effected by a true secretion, deposited under the form of very fine scales, encasing the tubercles of the papilla, of which they are equal in number. We admit, generally, that of the two substances, the ivory and enamel, which form the hard portion of the tooth, the ivory is secreted first. It forms itself upon the surface of the papilla in circular lines representing horn, which is enclosed from with- out inwardly, as rolled wafers, and has for the time of its forma- tion only the development of its roots. The enamel, on the contrary, is secreted by the external face of the interior leaf of the membrane of the follicle, and seems to be deposited in crys- tals upon the crown; but no person, to our knowledge, has PATHOLOGY AND THERAPEUTICS. 105 explained in an unclouded manner why the crown is the only part of the tooth which is covered with enamel. 3d. When the first bony cap is formed around the papilla and envelopes it on all sides, new layers form themselves in the inte- rior, and are embraced in the last in the whole of its circumfe- rence, even to its base. Then the crown is formed ; but soon new layers of ivory envelope inferiorly this papilla, surrounding its pedicle, descending even to its extremity, and forming the root. Finally, when the papilla becomes closely covered in all parts, it cannot extend its functions of secretion, the growth of the tooth is entirely accomplished, and can never go beyond, as we remark among rongeurs, who have the central canal of their incisors extremely extended at its entrance. It is only towards the end of the last month of gestation that the solidification of permanent teeth commences, which com- mences by a speck, which we perceive upon the first large mo- lar. In the eight first months after birth, the central and lateral incisors and canines solidify successively. The formation of small molars rarely takes place before the fourth year ; afterwards the second large molars ; but the wisdom teeth do not ossify ordinarily until the eighth, ninth and tenth year. 4th. The milk teeth, to the number of twenty, appear ordina- rily from the sixth to the twenty-eighth month afterbirth, rarely sooner, but sometimes later ; their cutting depends upon the time of their development and solidification ; ordinarily, the inferior median incisors appear first. All are generally cut at the thir- tieth month. Their escape from the alveoli, which cannot contain them, is owing to the progress of their growth, and to nothing else ; and if they gain their opening sooner than their base, it is because they are drawn there by the same disposition of the internal leaf of the capsule, which separates the neck of the tooth from the gum, to which it strongly adheres. As to the shedding of the milk teeth, it takes place simulta- neously with the cutting of the teeth of replacement. This double phenomena ordinarily commences at the seventh year, always with the inferior central incisors, and terminates ordina- rily towards the twelfth year, with the second small molars ; but it is preceded for some months only by the first large molars, 14 106 ANATOMY, ORTHOPEDIA, which are permanent, and immediately followed by the second large molars, which appear five, ten, and sometimes fifteen years before the wisdom teeth. As soon as the teeth have come through the gums, they have acquired the volume they will have during the whole of their duration. During the interval which separates the cutting from the shedding of the milk teeth, the bodies of the maxillary bone increase necessarily, as all the other parts of the skeleton, but the alveolar arch, properly said, experiences no change in length ; as the teeth remain always in juxtaposition, that which might not have room in the case or space enlarges itself; they might leave between them some space. But, at the cutting of each tooth of replacement, the arch dilates with inexpériences a growth proportioned to the volume of the new tooth, which it is ready to receive, and which is undoubtedly larger than those of the milk teeth. 5th. The duration of the teeth is very variable, and depends upon the use made of them, the care that they have had, and the diseases to which they have been subject. In the meantime we can say that in general they carry, from an early period, the marks of wearing away, which blunts at first the cutting edges of the incisors, and at a later period wears off the tubercles which form the summit of the crown of the molars. At their shedding, the alveoli that were empty diminish, sink down, and after some years disappear entirely. The jaws once unfurnish- ed, their bodies diminish in volume, and return again to the circular form that they had at a young age ; at the same time the face loses a part of its vertical diameter. Such is the summing up of the different phases through which the teeth pass successively, from the moment of their formation to their shedding, which happens, unfortunately, nearly always before their assistance had ceased to be useful to us ; such are the principal physiological facts which should serve as a guide in the methodical study of their diseases. But what consequence shall we deduce in order to establish the proper degree of vitality which belongs to them ? Is it neces- sary, in a word, to place them in the range with organic living tissues, or regulate them in the class of inorganic productions ? PATHOLOGY AND THERAPEUTICS. 107 Let us examine this question without prejudice, and perhaps we can resolve it simply, in separating from each of the two pre- vailing opinions all that which is exaggerated, and substitute a less term in the consequences to which each of them has been conducted, as rules in pathology and therapeutics; rules which do not surely accord always with physiological facts which serve as a basis. It is natural that the teeth, placed at the entrance of the diges- tive canal, destined to the laborious functions of crushing the food, exposed to the attacks of foreign bodies, to the contact of the air, and to the sometimes rough and violent movements that the two jaws exercise upon them, should be the most hard and compact of all bodies that enter into our organization. At no very distant period, in which they were counted amongst the pieces of the skeleton, they were considered to possess a vitality equal to the bones. But from the time that it was discovered that those of their parts upon which devolved their functions, their crowns were covered with a calcareous matter of a stony hardness, which, in its formation, passed through none of the intermediate points through which the osseous tissue did, and in which could be discovered neither pores nor cellules, this opinion was believed to need some modification, and there arose from it this opinion, that negative characters belong to the tooth entirely, which belonged only to the superficial envelope of its crown; that is to say, the teeth were regarded as inorganic bodies. It is in vain that the advocates of the doctrine of the vitality of the teeth, at the head of whom are placed Mascagni, Blake, Fox, and whose number is augmented by Duval, Delabarre and Toirec, allege, as a demonstration of the fact, the presence of vessels and nerves in their bony parts : 1st. That the teeth bleed, that their wounds are painful when penetrated to a certain depth, and that the acids cause a particu- lar sensibility in them, as also certain caries and some superficial wounds. 2d. That they become discolored when an animal is nourish- ed upon madder, and that in certain diseases they take a tint, red in the cholera and some cases of asphyxia, yellow in the jaun- 108 ANATOMY, ORTHOPEDIA. dice, blackish in adynamic fevers, whitish in diseases attributed to lymph. 3d. That their fractures or solutions of continuity perfectly cicatrise, and that they will become impaired as promptly as artificial teeth, if they contain not the elements of organization. The advocates of the contrary opinion, supported in their researches by Eustachius, Duveney and Hunter, to whom the illustrious Cuvier has lent the aid of his name, have replied : 1st. That if deep wounds furnish blood and cause sharp pain, these result from the papilla being affected ; that the phenome- non of teeth set on edge can be explained by the imbibation of the ossiform part or of the calcareous layers, and by the direct action of an acid upon the papilla, and that the wounds and superficial caries develope only the pain, by producing the de- struction of the tooth, and by rendering their external envelope less fitted to preserve the papilla against exterior agents. 2d. That the coloring of the teeth by madder deposes much more against than for the vascularity of the teeth; for if the ex- perience of Hunter establishes that, in these cases, the coloring matter is deposited in the parts of the teeth which form during the time that experience contends, they have proved, also, that the parts first developed preserve their primitive color; that which happens to the true bone, which, under the influence of madder, colors it in every instance red ; as to the color that they take in certain diseases, they owe it to a simple imbibation, whose materials are conveyed into the dental cavity by the nourishing vessels of the papilla. 3d. "That if fractures cicatrise, it is always the result of a new ossiform production, secreted within by the papilla ; and if the natural tissue of the teeth is not impaired as artificial animal teeth, it is by an analogous reason to that which causes the nails not to dry so much as to remain adherent to their matrix, because they are surrounded by parts which keep them mois- tened with a substance which they imbibe, and which maintains them in their normal state." As we see, if some of the objections made to the vitality of the teeth seem established, others also seem more specious than solid; for example, in taking in the following order, in which PATHOLOGY AND THERAPEUTICS. 109 they were stated, we are forced to avow that the phenomena of teeth set on edge is sometimes too quick, and depends in some instances upon causes too light to be explained by the imbi- bation of the ossiform part or of the two calcareous layers of the teeth, which, at an advanced time of life, form nearly all the thickness of the crown. To maintain, in the second place, that the coloring of teeth in certain diseases, is owing to imbibation, is to avow that their ossiform tissue is so permeable that it permits itself to be pene- trated by every colored liquid with which they come in contact, that which is not positively certain, and which does not explain how they take their normal color at the recovery from the dis- ease ; or it is to admit that the vessels of the papilla continue in the ossiform part. As to the inductions which are believed to be drawn from the manner in which, according to Hunter, the teeth are colored under the influence of madder taken as nour- ishment, we have already said that Flourens has proven that they rest upon facts badly observed. Finally, to explain the cicatrization of fractures of teeth by the secretion of a new ossiform substance, is, on the one hand, to forget that we have recognised in principle that the secretory functions of the papilla cease entirely when, by the complete formation of ivory, it is reduced to a nervo- vascular cord which forms its centre ; and it is, on the other hand, to assimilate the teeth to bones, whose fractures con- solidate as by a new calcareous cellular production. As to the insensibility of the teeth in their healthy state, we know nothing to allege against their vitality, for we acknowledge in man diverse white tissues, which only have the property of feel- ing when in a pathological state. Besides, this insensibility of the teeth is not as absolute as one generally believes ; for all, in recognising that the very dis- tinct perception of the sound of a watch placed between the teeth is the result only of the sonorous vibrations communicated by the teeth to the jaws, by these to the skull, to the labyrinth, and from thence to the brain ; one cannot deny, however, that they are susceptible of receiving certain impressions, and of transmitting them to the common sensorium ; cold and heat, 110 ANATOMY, ORTHOPEDIA, carried to a certain degree, affect them disagreeably ; finally, we are able, by them, to know the qualities of certain bodies, which are accidentally placed in contact with them, that which we would be unable to do by artificial teeth, of whatever nature they might be. We well know, although, to explain the impressions of heat and cold, and the sensations resulting from mechanical action received by means of the teeth, it is said that they first act upon the nerves and vessels of the dental pulp, to which they are transmitted across the thickness of the crown, and that the second are communicated by the membrane which envelopes all the length and each division of the root. But this explana- tion, satisfactory at first, ceases to be valuable when we reflect upon the tenuity of the dental pulp, especially at an advanced age, and upon the thickness of the two calcareous layers of the crown. Thus Beclard, # in these days, seeing the insufficiency of this explanation, said that, "the crown of the tooth is formed of an organic animal matter, which one could not believe vascu- lar" It were nearly as well, as every one perceives, to admit that it is sensible. Still later, Blandin, acknowledging that the dental osteoide possesses, in its superficial layers, a peculiar sensibility, accom- panying certain caries,t commencing between the enamel and ivory, &c. &c, has thought that it might be possible that this sensibility was inherent in the greyish line, intermediate be- tween the ivory and enamel, that Cuvier believes it formed by a prolongation of the internal lining of the follicle, and in which some one of the nerves remains, that this lining possessed before having been taken between the two substances of the tooth, even at the moment of their formation. Certainly, if it was thus through it, the instantaneousness of the phenomona of teeth set on edge would be understood more * Dictionary of Medicine, vol 6, article Teeth. jThis fact presents itself so often to the observation, that we cannot con- ceive how Lemaire could have declared that, in diseases of the teeth, the pain manifests itself with violence, when a part of the substance of the crown being destroyed, as far as the cavity, the pulp was discovered. PATHOLOGY AND THERAPEUTICS. Ill easily, since, in this manner of viewing it, the acid which pro- duces it would have need only of imbibing the enamel, a sub- stance little thicker, and thus it might act nearly at the point of contact. But this explanation is a pure hypothesis, for there is little logic in inferring from the sensibility the existence of a membrane which has long since ceased to be, and whose former existence is affirmed only from a linear mark ; this might cast in the shade the inherent properties of the body which produced it; in a word, realise a pure chimera. Is it not, then, more reasonable, and more conformable to that which daily observation demonstrates, to admit, that of all parts of the teeth, the enamel alone is deprived of life, and conse- quently insensible ; that the ivory, essential production of the papilla, is united to it by relations foreign, and contact too intimate not to receive, under some form, even inaccessible to our senses, a part of the agents of its excessive vitality ? Ail the question relative to the presence or to the absence of vessels and nerves of the ossiform part of the teeth are summed up in these : the teeth have three distinct parts in them ; the central organ or the. pulp, which is essentially the nervo-vascular part, and consequently the most vital ; the ivory, which protects this pulp, and which, although less sensible, is sufficiently so to avert the presence of hurtful agents; finally, the enamel, abso- lutely inert, which is there only to protect the other two sub- stances from all attacks of strange bodies. There are, as for the rest, from our own experience, numerous facts, which appear to us most conclusive in demonstrating not only that the ivory is not insensible, but that it possesses a sen- sibility sufficiently marked, and which it exerts even promptly. Let any one introduce into the cavity of a tooth, newly extract- ed, entire and provided with a central canal still very marked, a little stem of wood or of iron, colored with blue turnsole, and let the crown of that tooth be touched with a pencil impregnated with some acid ; if the instantaneous setting on edge which follows the application depends, as it is commonly said, and as all the world has formerly believed, upon the action upon the dental pulp by that acid, which suddenly imbibes all the ossiform part, that action will be perceived by the blue color which has filled 112 ANATOMY, ORTHOPEDIA, the canal and turned it red. Well, this does not suffice, for it is a long time, before this color is affected by the acid. We have even held the crowns of teeth, whose canal we had filled with a purple fluid, plunged in vinegar, (acetic acid weakened with water,) many minutes, with this liquid becoming reddened. Then the setting on edge has its seat primitively in a part situ- ated less deep than the pulp, and which could only be the ivory. Our opinion, as is perceived, has the double advantage of rendering as satisfactory account of the physiological phenome- na of which the teeth are the seat, and of avoiding the whimsi- cal contradiction into which the most of authors have fallen, which, after having strenuously denied all traces of the organi- zation of the dental osteoide, they please, nevertheless, to de- scribe the diseases by which it is so frequently affected, and of which development no one could logically explain, except by the laws of general vitality. CHAPTER III. DENTAL HYGIENE AND ORTHOPEDIA. We have hitherto been occupied with the anatomical and physiological facts which constitute the science of the surgeon dentist. But here commences his real art ; for we are about to describe, under the name of dental hygiene, a methodical expo- sition of all the cares and precautions which are intended to facilitate the development of either dentition, or to preserve the teeth in a constant state of health and cleanliness. We will append to this chapter, under the name of orthopedia, and in accordance with the true acceptation of the word, now much used and well understood, a series of means which, although requiring the application of the hand, cannot, nevertheless, be properly considered as operative surgery, inasmuch as they ad- dress themselves to conditions which, properly speaking, are not diseases. Such are the straightening, shortening and separating of the teeth : matters with regard to all of which we are about to announce precepts which are rational and of easy application. PATHOLOGY AND THERAPEUTICS. 113 Sec. 1. — Of the Means of Directing the Eruption of the Teeth, a} id Facilitating their Arrangement First Dentition. — If we must believe the most of the authors who have written upon the diseases of children, during the las century or early part of this, or even of the dentists who, in our day, have published special treatises under the influence of the opinions of these authors, the eruption of the teeth, (particularly of the first dentition,) although performed in the order we have described in the preceding chapter, is an epoch so fearful that few children can pass through it without being assailed by dangers, capable at any moment of destroying their life. But when we take the trouble to study nature without preju- dice, and, above all, to judge by the facts, we easily escape from the exaggerated opinion which makes us see a continual cause of death in the execution of a natural function; and, in a great number of cases, we find one of two things : either that the eruption is entirely unconnected with the diseases which attack children at this period, or that it often is but a secondary cause of their existence, by putting in action morbific causes, to which the organs, the seat of these diseases, are predisposed; which would equally have been effected by any other stimulant. This exaggeration once perceived, we must not fall into the contrary extreme, by refusing to admit that the escape of the teeth from the alveoli is one of those processes which nature rarely undertakes without effort ; an effort accompanied, almost always, by pain, and which may also, under some circumstances, be the direct cause or simply the index of accidents sufficiently serious to claim serious attention. The trouble resulting from it may even cause itself to be felt in every part of the economy, or at least throughout the whole extent of the two organic sys- tems which predominate in infancy, those which preside over nutrition and sensibility. But why is the cutting of the first teeth often a laborious function? Is it due to the piercing the gum, or the dilatation of the gubemaculum dentis, as we adopt the old or new theory of the mechanism of the eruption 9 Though, while replying to this question in the affirmative, we cannot render an exact ac- 15 114 ANATOMY, ORTHOPEDIA, count of all the morbid phenomena which may happen at this time, we are, nevertheless, compelled to adhere to the opinion, for it promises to explain, to a certain extent, the most prominent of these phenomena. We know, indeed, that the local inflam- mation arising from a laceration or a simple dilatation, might be sufficiently great to irradiate itself upon the mucous membrane of the digestive and respiratory passages, and their appendages, and give rise to discharges aphthae, ophthalmia, and even otitis, which often appear, and it will suffice to bring to mind the nervous disorders which laceration of tissues excites, to explain the convulsive movements which may accompany laborious den- tition. As the description of these different accidents, and the treatment appropriate to them, belongs necessarily to the province of general pathology, we will not consider them here : the dental surgeon is rarely called upon on such occasions, or if he is, it is only required of him to attend to the local conditions of the ap- pearing tooth. Instead of uselessly swelling this work, by copy- ing what belongs to treatises on general pathology, it will suffice us to remark that the particular constitution of each child has much to do with the occurrence of these accidents ; that they oc- cur most commonly during the eruption of the eight small molar teeth, that is to say from the second to the third year ; that they are more common to feeble, delicate, badly nourished children, or those born of nervous parents, than to others ; finally, that the most efficacious means of prevention are to accustom them from birth to the changes of atmosphere, to subject them to insolation, frictions, and all other means likely to counteract the nervous constitution so common to children born in large cities. From the fact that the morbid phenomena just described cease, often instantaneously, in the midst of the greatest intensity, from the moment that the teeth penetrate the gums, which re- tained them, and compressed their pulp at the bottom of the alveo- lus, has arisen the precept to divide that barrier when it opposes too much resistance. This little operation, which is effected with the point of a thin bistoury, the blade of which is guarded with linen for the space of four millimetres from its extremity, will often succeed so immediately as to cause regret that it had been so long postponed. In some cases, unhappily, premature PATHOLOGY AND THERAPEUTICS. 115 and ill timed incisions close again without any advantage to the child, as M. Guersant,a physician who has, in our time, devoted himself very successfully to the diseases of children, has fre- quently observed; a fact which seems to justify the supposition that the tooth thus denuded is propelled less rapidly than others. It has also been remarked, that the incision of the gum has favored caries, either because the teeth had been scratched by the point of the instrument guided by an inexperienced hand, or because they had been exposed before the enamel had be- come perfectly matured, if we may be allowed the expression. We must conclude, then, from all we have said, that while the incision may be a means approved by reason, and, in many cases, sanctioned by experience, we must not have recourse inconsiderately to a practice which the children always resist, and which frightens the parents. Before proceeding to it, we must be very sure of the imminence of the eruption, and the necessity of accelerating it ; which may be ascertained when the tooth projects under the gum, and seems ready to break through it. In other cases, we may content ourselves with making the child chew some body of moderate resistance, or a hard body so polished as to lessen the danger of violent pressure. A crumb of bread, a piece of liquorice root, or of mallow, an- swer, if there be tumefaction of the gums : corals, or pieces of ivory or crystal may be better, if the eruption be yet distant and the gum not swollen. Finally, general means should not be neglected, especially such as tend to lessen the excitability of the sanguineous and nervous systems. But, we repeat it, it is especially in the wise application of hygienic principles that we must seek the means to prevent the storms which threaten first dentition, and reduce that function to that state of harmlessness which it ought naturally to present. Certainly, as a modern author rationally remarks, by the aid of these precepts, we will be more likely to reach the desired end, than by amber necklaces, serpents' teeth, and the crowd of amulets which ignorance and credulity confide in, and which some dentists, careless of the dignity of their art, have yet the wickedness to advise, or the weakness to authorize. UG ANATOMY, ORTHOPEDIA, Second Dentition — Indirect Means to Prevent Eirors. The cutting of the second teeth, called teeth of replacement, permanent, or secondary, is surely always less painful than that of the primitive or temporary ones. But, although the remarks we have made with regard to the exaggeration of the dangers of the first dentition apply still more forcibly to the case of the second, it is not the less true, whatever may otherwise be the constitution of the child, that the part of the gum surrounding the tooth to be replaced is almost always slightly inflamed. This inflammation, which rarely proceeds without pain, and sometimes terminates by little local abscesses, does not confine itself to the mouth, for it sometimes, upon slight provocation, extends to the surrounding parts. We even encounter, at this time, inflammatory and nervous accidents which attest a shock communicated to the whole economy, and accompanied always by indigestion, to which, moreover, the obstacle which the loosening of the milk teeth presents to regular mastication, is a further inducement. It is principally when the small molars, or molars of replace- ment appear, which happens at the tenth or twelfth year, that children experience a feeling of malaise, and general indisposi- tion, which can only be properly attributed to the efforts of nature, occupied with the replacement of the temporary teeth. In the second period, or what may be called the third dentition, that is to say, at the appearance of the second and third great molars, though effected at an age when the system is in a better state to resist, we sometimes encounter very serious morbid conditions, as we ourselves have frequently observed. As in these last cases, there is more reason to attribute the accidents to the resistance of the gums, than those which occur during first dentition ; it is prudent to proceed, as promptly as possible, to incise the tumefied gums, and even useful to scarify the surrounding parts with the point of a lancet. But we must not forget that these means will prove altogether inefficient, if the accidents which accompany the eruption of the teeth depend either upon the too close pressure of the teeth upon one another, or upon the want of space between the coronoid apophysis and PATHOLOGY AND THERAPEUTICS. 117 the second large molar, impeding the wisdom tooth. Their ex- traction is then indispensable, unless the difficulty of getting hold of them shall determine the operator rather to remove one anterior to them, so that they may occupy its place. This is generally the plan adopted, as the following case, given in the clinique of Prof. Velpeau, and belonging to the particular practice of M. Toirec, will show. Mad. R. experienced, two or three months after her marriage, a dull pain at the angle of the lower jaw of the left side ; the pain soon extended to the median line. Some months having passed in this condition, and the pains becoming daily more acute, a rheumatism was suspected, and different curative mea- sures were employed. After a consultation of physicians, Mad. R. was sent to the springs. After her return, still suffering great anguish, she came to consult me. The face was pale and contracted, the emaciation of the body extreme, the appetite gone. The calm of the night seemed to augment her despair. The teeth, examined with care, were sound, white and well arranged ; the gums in their whole extent were of a pale rose hue; nothing gave evidence of the cutting of a wisdom tooth. Nevertheless, I directed my researches to that point. I made a deep incision upon the gum, behind the second great molar. A small sound introduced, discovered a hard, shining body, around which I could pass the instrument, except in front, where it was arrested. I did not hesitate to believe that there was a tooth, directed obliquely from behind forward, the crown of which, resting upon the neighboring molar, was arrested by the latter; nor did I delay to extract the second large molar, to favor the escape of the wisdom tooth. Gradually the suffering disappear- ed, and five or six days after the operation, she ceased to feel the slightest pain." M. Blandin also has been called to remove one of these teeth, which, locked up in its alveolus, as it were ri vetted by bone, had occasioned fistulous openings, against which all the re- sources of art had been exhausted. Finally, one of the most striking examples of the tardy, slow and difficult escape of a wisdom tooth happened to one of us, who, being at Moscow in 1804, extracted from Dr. Saint-Marie, US ANATOMY, ORTHOPEDIA, then sixty-four years old, one of this kind of teeth, which he had but lately cut, and by which he had been incommoded, at different times, for more than thirty-five years. Direct Means to Prevent Errors of Second Dentition. We again see that there are pathological phenomena which signalize the replacement of the teeth, as well as those which appear at the epoch of their first eruption ; to prevent these acci- dents, and apply to them suitable treatment under all circum- stances, belong properly to general medicine. But the sym- metrical arrangement of the teeth is especially the work of the dentist. What, then, are the means proper to favor this ar- rangement? Is it necessary, as some ancient authors, and many modern ones, have pretended, to take out early the primi- tive teeth, or rather to seek to preserve them until they naturally fallout? It is difficult to establish, in this respect, a precept rigorously applicable to all cases. We may, nevertheless, say, in general terms, that unless it is evident that the primitive tooth is an obstacle to the appearance of that which should replace it, the extraction is, to say the least, useless. It is to extend the sphere of our operations, but not to respect physiological function. But in the case, on the contrary, where the tooth is a mechanical cause, hindering the permanent one from developing itself properly, or to place itself in its proper position, there is a further indication, an absolute necessity, to remove it; for by delay we expose the child to irregularity of denture, a deformity easier prevented than cured. This operation has for a long time been opposed by the fear of removing, with the milk tooth, the germ of that of replace- ment ; but this fear can now have no influence, except for practitioners who do not know that from the age of four and a half or five years, this germ is entirely ossified, and no longer touches the primitive tooth, whose root begins to disappear. This disposition, however, is subject to variation : hence we often see the crowns of permanent teeth push so exactly from below those to be replaced, that they are, so to speak, dove- PATHOLOGY AND THERAPEUTICS. 119 tailed into each other. We perceive how, in such a case, the evulsion of the milk tooth might be prejudicial, for it would almost infallibly cause the loss of the secondary one. But, we repeat it, as much as it will be improper to temporize when there is indication, there will be equal impropriety in too much haste ; for when many teeth are extracted before they are loosened, the temporary ones do not arrange themselves so pro- perly, or level themselves so equally as they ought. Take away the four incisors ; they are replaced ; but those that appear, be- ing larger than those which are lost, necessarily force the canines out of place, and dispose them to loosen too quickly. The small molars are taken away; those which should replace them, no longer finding the lateral resistance which the canine, as a guide, should offer, advance freely forward, and occupy its place; in such a way, that when the canine of the secondary set appears, finding no place for itself, it falls within, or more commonly without, the dental circle. Another reason for objecting to the premature evulsion of the milk teeth, is that their presence may aid the enlargement of the alveolar circle, which, at that age, is yet much under its complete development. We nevertheless frankly confess, that in sound physiology we cannot attach to the presence of these teeth as much importance as has commonly been attributed to them, and for two reasons : first, because the milk tooth, arrived at the natural term of its fall, has no or almost no root implanted in the alveolar border, and is not firmly enough fixed to furnish the slightest point of support : the second, that already, as we have said, the germ of the secondary tooth is completely ossified, and occupies, in the thickness of the alveolar ridge, a space which the fall of the primitive tooth cannot diminish. Hence, Fox properly observed, "The advantage of extracting these teeth will depend entirely upon whether it is done at the precise moment when nature proves backward in effecting the absorption of the roots of the temporary teeth. To avoid operating unadvisedly, we must thoroughly understand the progress of second dentition, and observe exactly the appearance of the gums, which swell when a tooth is upon the point of piercing them. 120 ANATOMY, ORTHOPEDIA, We further quote from this skilful practitioner, who, without doubt, has discussed this question most ably : "To aid the permanent teeth in ranging themselves in suita- ble order, it does not suffice to extract those which obstruct, for considerable time will always be required to enable the irregular tooth to resume its natural position; often, indeed, it fails to abate its irregularity altogether. We ought, therefore, to ex- amine the mouth of a child frequently, so as to be able to make the extraction opportunely. The absorption of the roots of the temporary teeth is sometimes performed so slowly that they do not loosen until the permanent ones have pierced the gum be- hind them ; in such a case, if the permanent molars have ap- peared some time before, and if there be engorgement of the gums behind the two permanent central incisors, we ought to extract the two temporary central incisors, which correspond to them, even though they be not loose. When the absorption of the roots of these incisors has been prompt, which often occurs, these teeth shake, and the child can easily remove them himself, a little before the appearance of the new ones. But often, though they be loose, they do not fall of themselves before the perma- nent ones appear ; in such cases it is useful to extract them, in order to give to those which ought to succeed them, the facility, of taking their proper place. If, as we might soon detect, the new teeth have not sufficient room to develope themselves, it will be necessary to extract the two temporary lateral incisors. "Two or three months afterwards, or even later, it will be time to give attention to the central incisors of the upper jaw. If we find them loosened, it will be proper to extract them ; if they are yet firm, and the gums be engorged, they should also be extracted ; for if they be left in place, the permanent ones, which are ready to appear, will take an irregular direction, ugly and hard to correct. It will also be proper to extract the lateral incisors, to procure to the permanent central ones the space needed for their development, but this should not be done until it is time for the latter to pierce the gums. Afterwards, the lower jaw should be attended to, when the incisors should ap- pear at the end of three or four months. If we perceive any swelling of the gums through which they must pass, we should PATHOLOGY AND THERAPEUTICS. 121 extract the temporary cuspidati ; three months afterwards, at the furthest, we must examine the upper jaw, and if we perceive that the permanent lateral incisors give signs of near appearance, we should also extract the temporary cuspidati. "After this, the jaws will often require no further attention until the end of a year, when the incisors are entirely developed. After this, the cuspidati and bicuspides are ready to appear; then we must be on our guard, to prevent the first taking an irregular position. We must examine the gums, and if they are promi- nent, we should extract the first temporary molars; these often are loosened, (Fox might have said most generally,) before the appearance of the cuspidati, which follows hard upon their ex- traction. Some circumstances should exercise much influence over the manner of treating these latter teeth. If, when one or the other of the cuspidati is ready to appear, we perceive that there is only a small space between the lateral incisor and the first bicuspid, already in its place, we must be careful to extract the second temporary molar. The bicuspid will then fall back, and give the cuspidatus a sufficient space. "After this last operation, there remains no further obstacle to second dentition. The second bicuspides come naturally into their proper place, and the molars, encountering no opposition, successively occupy their proper position." Sec. 2. — Of the Different Means of Preserving the Teeth. When the teeth naturally occupy their assigned places, or have been artfully conducted to them in the mode which we shall soon describe, it is necessary to watch their condition and preserve their health. So many causes are continually acting to alter them, that it is not surprising that it has always been felt necessary to preserve their health by care. Hence we find, in all the works on medicine, ancient or modern, judicious advice for their preservation, and if we consult general history, we will find that many people have attached so much importance to their preservation, that they have made it a part of legal require- ment, a religious precept. Some savage tribes, in that depravity of taste which accompanies ignorance and barbarism, have sub- 16 122 jected their teeth to horrible mutilations, outraging nature in their efforts to adorn it ; but all civilized people, with whom the cultivation of the arts has proven that the beautiful is allied to the good, have all agreed as to the importance of a healthy and regular mouth to an agreeable appearance ; and the kind of care necessary to the different organs it contains. The preservation of the teeth, as of all parts which compose the body, depends evidently upon two kinds of care. The first is general, that is, does not regard the teeth except as they are affected by laws regulating the entire economy ; the others are special and particular, that is to say, exclusively applicable to them. Let us first examine the former, confining ourselves to what is particularly connected with our subject. General Cares. The choice of food is certainly the first of the precautions which any person who values his health, and consequently his teeth, should observe. But it is impossible, in a work such as this, to trace precise rules for this selection. For the constitu- tion of each individual being the first thing which he should consult, it is evident that the best aliments for him will be such as tend to moderate the tendencies of his temperament to disease. We may, nevertheless, say, in general terms, that animal food is less favorable to the preservation of teeth than vege- table diet; and this for two reasons, first because animal food conveys to every part of the system exciting principles^ which no organ, the teeth no more than others, can well sustain in excess ; secondly, because it is difficult to remove from between the teeth the residue of meats, the presence and decomposition of which is a cause of local alteration. The abuse of green fruits and other acid substances is hurtful to the teeth ; alcoholic liquors also do harm, if not through their chemical action, yet because they inevitably keep the gums and mucous lining of the digestive organs in a state of excitement, which the teeth will assuredly suffer from. It is a matter of observation, that all food which contains sugar is injurious to the teeth. To explain this, we may observe, PATHOLOGY AND THERAPEUTICS. 123 that when alone and under a solid form it acts as all powders of a gritty kind ; and when in syrup or otherwise dissolved, it runs under the teeth, subjects them continually to the action of air, and makes them the seat of a morbid susceptibility, which may be the prelude to caries. The sensation (setting on edge) which it produces with many, seems to be explained upon this hy- pothesis, and indicate the necessity of moderation in the use of this article. Every body knows that the use of well-water rapidly injures the teeth, and what the chemical analysis of these waters would lead us to suspect, experience demonstrates. Indeed there are few persons, who reside in places where river water is inacces- sible, who have not lost the greater part of their teeth before they were forty ; this is especially the case with women. For the same reason, persons resorting to mineral springs usually return with their teeth in bad condition. Waters containing carbonic acids, free or combined, are those which produce the most remarkable effects. The composition of aliments is not the only thing to be re- garded as influencing the teeth ; we must also attend to their temperature. Pains should also be taken to avoid the habit of cracking nuts, bones, etc., with the teeth, or of drawing corks with them, especially if they be badly planted and have long crowns, this longitude being in inverse proportion to that of the roots. As to the precaution relative to the temperature of ali- ments, it consists in not only shunning the two extremes, but passing rapidly from one to the other. Hence it is a bad habit to drink cold drink directly after soup. We may readily sup- pose that the rapid transition from a state of high excitation to the contrary, may dispose the pulp to inflammation. "Next to aliment and air, clothing should most claim the attention of persons anxious to preserve their teeth. The most important precaution, so far as the air is concerned, is to avoid extremes of heat or cold, and especially the rapid transition from one to the other. Under the influence of the latter cause, the teeth may be altered in two different ways, directly or secon- darily: directly, by the lively stimulation that the cold imparts to the vessels and nerves shut up in the dental canal; seconda- 124 ANATOMY, ORTHOPEDIA, rily, by the rapid suppression of the transpiration, which is thrown back upon the mucous membrane of the mouth, and from it upon the teeth, causing those inflammatory swellings of all the walls of the mouth, generally called "fluxions." It is prin- cipally in this way that we may explain the destruction of the teeth of smokers; for, as we have long remarked, it is not the pipe which hurts the teeth, as is generally supposed, for it only acts mechanically, but rather the cold air, which, penetrating the mouth, whose walls are moist, sometimes creates an inflam- mation of the dental pulp, whence may arise a caries, which commonly developes itself upon those which, from structure and position, are already inclined to that disease. The expe- rience of M. Don ni confirms our own observation as to the harmlessness of the fumes of tobacco as a chemical agent. In his excellent treatise upon the properties of saliva, he says, «'It is true that tobacco communicates to the saliva a certain very sharp acridity, very unpleasant to those unaccustamed to it, but it does not render it at all acid, as I have fully convinced my- self; hence we cannot say that smoking alters the saliva, since it still preserves its alkaline quality, and may still neutralize gastric acids," &c. Women are indebted to their extreme impressibility, and to the fatally imperious yoke which our habits and prejudices im- pose upon them, for the sorrowful lot to be more exposed than we are to the sad action which the causes under consideration effect. They should never, if they would preserve their teeth, quit suddenly warm clothing for that which is thinner ; never wash the head with cold lotions ; never walk on cold ground with thin shoes, &c. Among the toilet articles which may hurt the teeth, we may mention the several kinds of paints, waters and pomades intend- ed to remove freckles, &c, from the face, or to color the hair. These cosmetics, almost all of them, contain astringent and even caustic substances, as antimony, bismuth, the hydro- chlorates of mercury and lead ; substances which act directly upon the teeth, to which they are carried by the lymphatic vessels, which, proceeding from the skin, ramify upon the buc- cal mucous membrane, enveloping the neck of the teeth, and PATHOLOGY AND THERAPEUTICS. 125 entering the alveolar cavity. Those who, from their position, are compelled to use these substance, ought, as far as possible, to confine themselves to such as are purely vegetable ; if these are not harmless, they are at least less injurious to the teeth. It has always been remarked, that persons living in low, wet places, near to lakes or marshes, as inhabitants of valleys, and those who reside in ports where the temperature changes fre- quently during the day, generally have bad teeth. As to work- men, constantly employed in factories where the air is continu- ally charged with metallic particles or acid vapors, capable of combining with the constituent parts of the teeth, it is possible, if not to protect them completely against these pernicious ema- nations, at least to lessen the danger of them, by properly ven- tilating the rooms, and by inducing the workmen to wear masks, as Dr. Loude advises, furnished at the part corresponding to the mouth, with a number of little pieces of sponge, upon which the mineral or acid emanations may condense without entering the mouth. Special Cares. By pursuing the general precepts which we have just laid down, undoubtedly a great number of the diseases of the teeth may be prevented. But these will hardly avail, if we neglect the particular precautions, which are none other than the cares of neatness, which form the daily " toilette" of the mouth. These are simple, and hardly require to be named. But as people sometimes with the best intention suffer themselves to be led by a blind routine, we ought to omit no details which may lead to a proper appreciation of these daily cares. As the milk teeth, for the most part, require no care, we may say that we need not accustom children to the toilet of the mouth until the eighth or tenth year ; but after that time they should be taught to regard this as an imperative necessity, caus- ing them to use, every morning, water, moderately warm in winter, and of natural temperature in summer. The use of the brush is, to say the least, useless at first, for it would only dif- fuse over the gums and teeth the mucosites collected during the night. 12G ANATOMY, ORTHOPEDIA, Pure water will suffice, ordinarily, until the fifteenth or eigh- teenth year; but after that, (and sooner, if any local affection or derangement of digestive or respiratory organs should taint the breath,) the water should be qualified with a few drops of some aromatic spirituous liquor, such as Cologne water. After- wards, we should use some kind of dentifrice, with which we should rub, in every direction, not only the teeth but the gums. Should this dentifrice be applied, simply by using a piece of cloth or a corner of a towel rolled round the finger, as is the habit of some who wish to simplify their wants ? Certainly not; for the pressure of the linen must certainly amass and harden the tartar in the places where it is disposed to accumulate ; that is to say, between the teeth and about their necks. Experience has positively established this fact, and pronounced in favor of the brush, which, if mounted properly, can be directed against the sides of the most distant teeth, can penetrate into the inter- vals which separate them, and rub them in all directions ; espe- cially since brushes are made in so many forms as at present. The other means advised to fulfil the duties of the brush are entirely and properly abandoned; the sponge, not only because it produces, in many persons, a sensation so unpleasant as to be absolutely painful, especially when the teeth have lost some of their enamel, but because it soon gets hard in flattening upon the staff which supports it. The several roots, such as liquorice, and mallow, because, however prepared they may be, they either harden or soften, as they are exposed or not to moisture. To avoid the inconveniences sometimes attributed to brushes, they ought to be of a force proportioned to the sensibility of the gums, and to the thickness and hardness of the enamel. It is also necessary that they be kept in a state of perfect neatness, and that they be renewed as soon as they begin to wear out, because they necessarily become harder as the hairs of which they are formed become shorter. As to the manner of using them, it consists in rubbing the teeth, before and behind, and to make the brush pass lightly from top to bottom, so as to cleanse the interstices as much as possible. This little operation finished, the mouth must be rinsed again, to take away the buccal slime which the brush must have de- PATHOLOGY AND THERAPEUTICS. 127 tached,or the residue of the dentifrice if one has been employed. Simple water, cold or warm, as the season may require, will suffice for this purpose, but if aromatised liquids be required, as we have before said, a few drops of Cologne water or some elixir will answer. Finally, we should always remember that after eating we must use a tooth-pick, to take away the particles of food which may remain between the teeth. In France, quills are generally used for this purpose; but in other countries, as in America, England, Italy and Spain, they use tooth-picks of flexible, tough wood. These have the advantage that, as their points are not very sharp, they are not so likely to wound the gum. They are also made of whalebone, tortoise shell, ivory and bone ; but we should never use needles, pins, or other metallic bodies. After using the tooth-pick, which should be done carefully, the mouth should be immediately rinsed. This is a precaution becoming common in France, and which we cannot but approve. Whether this should be done at table or elsewhere, is a question of good manners which we are not empowered to decide. Elixirs, Powders and Soft Dentifrices. As the cleansing of the mouth with water, qualified by a few drops of aromatic spirituous water, generally answers every purpose, we have limited ourselves, in the preceding chapter, to recommending the use of the simplest preparations. But many- persons, in whom caries has already produced ravages, or who smoke, or whose breath is impure, either from bad constitution or disease, require more powerful means. This necessity has led to the exercise of industry, which, unhappily, has too often resulted in injury to the public health. Therefore, though the composition of these dentifrices is rather a matter of materia medica or pharmacy, we may with propriety adopt the common usage, and give some recipes ; indeed, custom has hitherto per- mitted dentists to keep an assortment of them, and furnish them to their patrons. We may only remark, with Gariot, that all the recipes containing a crowd of drugs, of analogous, and some- times incompatible qualities, form fantastic mixtures, which are 128 ANATOMY, ORTHOPEDIA, not as useful as those obtained by mixing two or three sub- stances of well known character. Elixir proper for Morning Use, to Rinse the Mouth. R Brandy of Guiacum, six ounces, Vulnerary spirituous water, do. Essential oil of mint, rose or violet, four drops. Two or three drops will suffice to aromatise a glass of water. It suits persons whose mouths are perfectly healthy ; but such as have bleeding gums or strong breath may substitute the fol- lowing preparation, to be used in the same way. R Brandy of Guiac. (prepared,) six ounces, Camphorated brandy, four grammes, Essence of mint, six drops, Essence of cochlearia, six drops, Essence of rosemary, six drops. Another Tonic Elixir. R Ratany root, four ounces, Spirituous vulnerary water, two litres, Essential oil of mint, four grammes, Essential oil of orange peel, six grammes. Bruise the ratany root, infuse it for eight days in the vulne- rary water, filter the tincture, and add the essences, previously dissolved in twenty-four grammes of alcohol. Elixir known as Botet Water. R Alcohol, at 33° two litres, Crushed cloves, ") , ^ . A veach, thirty-two grammes, Green anise, ") Cochineal powder >each, sixteen grammes. Essence of peppermint, j Dentifrice Powders, (AliberVs.) R Magnesia, six ounces, Red shell, one ounce, Florence Tris, five ounces, Supertartratc of potass, two ounces. PATHOLOGY AND THERAPEUTICS. 129 Maury's. R English magnesia. 1 „ . >each, one livre, Cremor tartar, 3 ' Sul. quinine, twenty grammes, Cochineal, forty-eight grammes, Essential oil of mint, sixteen grammes, Essential oil of cinnamon, twelve grammes, Essential oil of orange, eight grammes, Muscated and roseated spirit of amber, four grammes. Messrs. Milne Edwards and Varasseur. sixteen grammes, R Peruvian bark, 1 , >-eacn, Magnesia, _) Cinnamon, four grammes, Essential oil of cloves, one drop. This preparation we consider better than the two preceding. It is particularly good for persons who have spongy relaxed gums. Mr. LefoulorCs. R Equal parts of— Cochlearia, Mint, Horse radish, Pellitory, Guiacum, Aromatic calamus, Quinine, Ratany. It is evident that, in composing his powder, by uniting all the substances commonly regarded as odontalgic, M. Lefoulon has rather aimed to satisfy public opinion, than to accomplish any positive indication. None of these substances can cleanse the teeth, and the powder is much better qualified to inflame the mouth than preserve the enamel. The English, according to a note inserted in the Journal of Pharmacy and Chemistry, August, 1842, often use the following preparation : White chalk, well dried, three grammes, Camphor, powdered extremely fine, one gramme. This is intimately mixed and triturated, and preserved in a flask hermetically sealed. 17 130 ANATOMY, ORTHOPEDIA, We cannot but think that camphor, however small the quan- tity, must give the mouth a very unpleasant taste. / There is another powder, which not only whitens the teeth •' perfectly, but gives to the lips and gums a fine rose color, which lasts part of the day. We give it, assured that it no more de- grades our art to descend to such details, than it does to describe the manner of making false gums, or to point out the unpleasant results to the physiognomy of losing one or two teeth. R Red coral, four ounces, Sandragon, one ounce, Fine carmine, five grains, Lemon peel, twenty grains, White sugar, sixteen grammes. The advantages latterly derived from chlorine, as a disinfect- ing and discoloring agent, have led some dentists to introduce it into dentifrices. In however small quantity it may be, it acts upon the teeth ; hence it should never be used more than two or three times, to take away the deep yellow color which the teeth of some persons present. M. Taveau has made it an in- gredient of pastilles, which he recommends to smokers. Here is the composition of those which Magendie prescribes for the same purpose : R Chloride of lime, 8 grammes, Sugar, 280 grammes, Starch, 32 grammes, Gum adraganth, 4 grammes, Carmine, 15 centigrammes. Make pastilles of three or four grains ; two to four to be taken within two hours. Mr. Magendie advises, besides, for restoring to yellow teeth their natural whiteness, to rub them with a brush slightly mois- tened and sprinkled with the following preparation : R Dry chloride of lime, four grains, Red coral, eight grammes. Opiates and Mixtures. These preparations only differ from the powders, in that they are blended in a sufficient quantity of syrup or rectified honey PATHOLOGY AND THERAPEUTICS. 131 to make them soft and pasty. They have no advantage over the powders, except that they are less liable to be scattered over the toilet, and are more easily carried about; but they rapidly deteriorate. Maury's Formula. R Best honey, two livres, Calcined alum, two ounces, Extract of Peruvian bark, one ounce, Essential oil of peppermint, sixteen grammes, Essential oil of cinnamon, sixteen grammes, Muscated and roseated spirit of amber, eight grammes. Boil the honey to the loss of a third, color with a little alca- net, mix the extract of bark, and pass through a fine cloth. When almost cold, add the alum, and, when quite cold, the essences. Upon the plan of these dentifrices is composed the water which bears our name, (Desirabode water,) and which a minis- terial circular, dated Nov. 13, 1838, places particularly among the preparations permitted to be sold, as innoxious. We may here observe, that the employment of elixirs charged with resinous and balsamic matters, is preferable to powders and electuaries. These latter being composed of pulverized matters are rarely so thoroughly incorporated as to prevent the inconvenience resulting from their interposition and continuance between the teeth and the gums. As most powders which enter into the preparation of denti- frices, are composed of acid salts, which may rapidly affect the teeth, a distinguished chemist has suggested to substitute alka- line salts for them. He has, therefore, under the somewhat far- fetched name of odontine, presented to the public an electuary, or rather a soap, composed very simply of the sub. carb. of mag- nesia and cocoa butter. The academy has been a little too fast, it seems to us, in patronising this preparation, for the action of alkalies ought to affect the enamel, if alkaline waters have the power ascribed to them of dissolving urinary calculi, and if drinks of the same kind hasten the solution of gouty concretions. We will also say, that the idea of composing dentifrices with 132 ANATOMY, ORTHOPEDIA, alkaline salts did not originate with Pelletier nor M. Oudet, who claims the suggestion, for, before 1S36, Dr. Donni had pointed out Mr. Blondeau, pharmaceutist, as having tried such prepa- rations. Whatever be the elements of these preparations, the greatest pains should be taken to powder well all the hard substances which compose it, to reduce them to an impalpable powder ; they should be thoroughly commingled, for if this precaution be not taken, they will not only be disagreeable, but may injure the teeth by their physical qualities. Many persons endeavor to accomplish the end for which these preparations are intended, by cleansing the teeth by many sim- ple substances which are commonly at hand, as carbon, soot, salt and snuff. The antiseptic property of charcoal has occasioned it, for a long time, to be regarded as among the best dentifrices ; its em- ployment is yet popular, but by no means deserves the prefe- rence given it ; for, if it be only partially powdered, it always wears the teeth more or less, and, if it be very finely levigated, it insinuates itself between the external wall of the alveoli and the gums, to which it lends a violet transparence. We have sometimes been obliged to detach the gums in order to favor a hasmorrhage, which might wash out the particles. We do not deny that charcoal has some antiseptic quality, which may ren- der it useful to certain persons, especially to such as have soft and bleeding gums. Table salt cannot be used with perfect safety, because it acts like other powders ; besides, it is composed of soda and hydro- chloric acid, whose action cannot be nugatory in the whitening of the teeth. Its employment also occasions abundant saliva- tion, which, though useful enough in some circumstances, is foreign to the end we have in view at present. As to soot, its employment as dentifrice depends only on the fact that some persons, misled by the apparent whiteness of the teeth of sweeps, have supposed that they could obtain similar results by the use of this substance. But, besides being very uncleanly, and imparting a very unpleasant taste to the mouth, it communicates a very yellow or brown tint, which it is almost PATHOLOGY AND THERAPEUTICS. 133 impossible to remove, and which is not perceived in sweeps, owing to the habitual blackness of their faces. The following is a formula of which soot is the basis, and which is lauded by Dr. E. Kemmerer. R Powdered wood soot, one ounce, Powder of strawberry plant, five drachms, Cologne water, several drops. What we have said of the inconveniences of soot, also applies to snuff, whose usefulness is too doubtful to compensate for its filthiness ; and to Peruvian bark, the tannin of which must, in the long run, tarnish the teeth. Nevertheless, as the powder of cinchona enjoys an evident tonic quality, we may sometimes combine it with other substances, for the purpose of forming a dentifrice, useful under certain circumstances. For example, R Powdered charcoal, two ounces, Peruvian bark, one ounce, White sugar, two ounces, Oil of mint, one drachm, Oil of cinnamon, thirty grains, Muscated and roseated ess. of amber, nine grains. Sec. 3. — Of Tartar, and the Means of Removing it. In subjecting the mouth, early, to the rules of cleanliness, and to different hygienic precautions, which we have described with a minuteness that will not appear excessive, except to dentists who have never considered the importance of it. We assuredly place the teeth in the condition most favorable to their preserva- tion ; but to obtain their full efficacy, these precautions should be regular and continued. If discontinued a short time, the teeth lose their lustre, and be- come encrusted with a calcareous yellowish matter, called tartar, a hard coating, which, if left to itself, does not fail to loosen them, by detaching the gums, introducing itself even to the alveo- li. It sometimes forms considerable masses, completely encasing the teeth, and causing them to appear as entirely blended. Hence we may remark that some have been too rash to con- clude that the examples reported by the ancients of the teeth 134 ANATOMY, ORTHOPEDIA, being apparently soldered together, were not correct. This premature opinion is like many others which modern presump- tion leads us to entertain with regard to the experience of our predecessors. Recent facts confirm the account of these appa- rently conglomerated teeth. The physiological history and chemical composition of tartar have long occupied the attention of authors, who have written upon our art, or upon some of the sciences upon which it is based. Until lately it has been regarded as a deposit of earthy salts, precipitated from the saliva by chemical affinities, and de- posited gradually upon the teeth, where it is attached by the mucus of the mouth. But M. Serres thinks that it is secreted by glands contained in the gums, and M. Delabarre regards it as a noxious exhalation from the mucous membrane which covers the gums : two opinions originating in love of innova- tion, rather than assurance of truth. For, if we may overthrow the one, by remarking that no such glands exist, or if they do, only in children, who are little subject to tartar, we may re- ply to the other, with equal force, that the teeth of healthy people are as subject to it as those of invalids. We must, there- fore, adhere to the old explanation, although it does not explain why some are more subject to it than others, although exposed to the same circumstances. The chemical analysis of tartar sustains this opinion : being made Dec. 31, 1825, by the celebrated Vauquelin, aided by M. Langier, it has shown tartar to be composed 1. Of animal matter, different from that of the bones. 2. Of organic matter. 3. Of phosphate and carbonate of lime. 4. Of a brown matter, resembling oxyd of iron, and formed of iron and phosphate of magnesia, viz. Phosphate of lime, - -66 parts, Carb of lime, 9 Phos. of mag. and oxyd of iron, 3 Mucus, 14 Water, .-.,.. - 7 99 PATHOLOGY AND TEÎERAPEUTICS. 135 We know that the mucus of the saliva (the only part which can furnish tartar) when burned, will yield much calcareous phosphate, and a little phosphate of magnesia. Berzelius, some time before, had found it to contain as follows : Earthy phosphates, 79 parts. Undecomposed mucus, - 12.5 Peculiar salivary matter, 1 Animal matter, soluble in hydrochloric acid, 7.5 100.0 But the most important question for us is neither its origin nor chemical qualities ; we are more concerned about the harm it does to the teeth, and the gum corresponding to them. We may first observe that it collects principally upon the six ante- rior teeth, more on the inferior than superior ; it sometimes ap- pears only as abundant slime, but ordinarily it forms a hard, greyish-black body, or a thick yellow crust, which gives the teeth the appearance of petrified bodies. It is more abundant upon the side of the mouth which, from any cause, is least used in mastication, and in the case of persons compelled to live upon soft food. Smokers are also very liable to it. We have, in our possession, masses of it of extraordinary size and shape. The inevitable effect of the tartar is to prevent the action of the air upon the teeth, and in certain cases to soften the enamel, and favor its disappearance. When it thus finds itself in con- tact with the bony structurent irritates and inflames it, and pro- duces a caries, the ravages of which are rapid in proportion to the denuding of the ivory. Insinuating itself soon between the neck of the tooth and the gum, it destroys the attachment, loosens the tooth, and so diseases the gum as to cause it to se- crete fetid matter. Tartar, once formed, never disappears spontaneously. In most cases, it can only be removed by instruments, against which there is great prejudice. Simple and easy as the operation may be, it nevertheless demands address and certain precautions, which are soon learned by practice, which may, however, be reduced to rule, as we will do as briefly as possible. The first care the dentist should take, which, indeed, applies 136 ANATOMY, ORTHOPEDIA, to all his operations, is not to begin until he has disposed at hand all his instruments and accessories, such as brushes, towels, warm and cold water, and a flask of elixir. The necessary- instruments are scalers, gravers and crotchets. They ought to be very clean, made of fine steel, very highly polished, sharp and firmly fixed on their handles, so as not to be dismounted during the operation, which would cause the loss of time, and fatigue the subject of the operation. The operating chair should be so heavy as to prevent its tilt- ing, of such a base as renders it firm, and of a form convenient for resting the arms, and for affording the head a soft reclining plane, slightly leaning backwards. It should face the light. About to begin, the dentist should, as in all similar cases, wash his hands, so as to remove any disgust which placing his fingers in the mouth might create. This being done so rapidly as not to give it the importance of a serious matter, he should place upon the back of the chair a napkin to cleanse his instruments. Occupying the right of the patient, but behind her, he passes the arm around her head, and taking a scaler, proceeds to operate upon the lower incisors. The lower lip, being abased by the thumb of the left hand, and forming a fulcrum to the ring fin- ger of the right hand, he makes the cutting edge of his instru- ment to pass below the tartar, breaking it in pieces, working from below upwards, so as to avoid wounding the gum. The anterior surface being thus cleansed, he uses a thin, flexible blade, dull at the extremity and passes it between the teeth like a tooth-pick. He pushes out the accumulated tartar, which, by its presence, acted as a wedge. The operator then proceeds to the internal surface, and for this he causes the patient to lean forward, the lower lip still pushed down by the thumb of the left hand, but the ring finger of the right being applied to the crowns of the incisors and canines. Then he removes the tar- tar, always working from below upwards, either with crotchets or scalers, ended with thin facets, acute-angled, and with cutting edges. We may remark that, as it is very difficult to see the tartar in this position, it is often necessary to use a small oval mirror, the case of which is well guarded, and which serves both to exhibit the parts and push back the tongue. PATHOLOGY AND THERAPEUTICS. 137 To operate on the teeth of the upper jaw, the dentist, always keeping his left arm around the patient's head, with the index finger of the left hand lifts the upper lip, the thumb of the right applying itself to the cutting edge of the tooth next to that to be cleansed, and the thumb and index holding a sharp scraper, cutting near the extremity, he raises, breaks and detaches the tartar from the teeth, causing it to follow the contour of the gum. The scraper answers for the eight or ten anterior teeth, but for the large molars the lancet and scaler are preferable. As to the internal face of the upper teeth, it should be examined, but it is rarely covered by tartar. The continual movements of the tongue ordinarily detaches it as soon as formed. If it existed, the round ended scraper or the crotchet would be the proper instrument for removing it. When cavities are filled with tar- tar, unless we prefer to plug them, we should permit it to re- main, especially if it be in sufficient quantity and is solid enough to fill the cavity. It is hardly necessary to observe that during the operation we should repeatedly cause the patient to rinse her mouth, not only to facilitate the expulsion of detached tartar, but also to afford an opportunity to relieve a fatiguing position. We would not mention the utility of a brush in cleansing the teeth, were it not necessary to observe that a dentist should have brushes of various forms ; straight for cleansing the teeth without ; curved to act upon their inner surface. When the teeth are abundantly charged with tartar, it is sometimes proper not to cleanse them completely at a single sitting, and this especially in cold weather, for the teeth, suddenly deprived of this kind of calca- reous envelope, acquire a sensibility which, in nervous subjects, may be very painful. When there is no urgency, the time of operation should be fixed when there is little to fear from atmos- pheric variation. By not taking this precaution, and many others which good sense indicates, but the details of which would be tiresome, we may authorize persons whose mouths have been cleansed to accuse our instruments of causing pains of which they were altogether innocent. Finally, to conclude what belongs to the daily care of the mouth, and the cleansing of the teeth, we may observe, that in 18 13S ANATOMY, ORTHOPEDIA, spite of all these precautions, they will sometimes acquire a yel- low hue, which may be natural to them. We would act very im- prudently if, in such cases, we should endeavor, by instruments or any other agency , to procure whiteness and brilliancy for them ; because, in many cases, we would not succeed, and if we should, it would be at the expense of the enamel. Let us observe, also, that this yellow hue is sometimes the proper product of age, against which all remedies are vain. Sec. 4.— Of the Means of Remedying Irregularities of Denti- tion — Vices of Conformation dependent upon the Teeth. In describing, with all necessary minuteness, the cares neces- sary for the preservation of the teeth, we have admitted that they were regularly arranged ; but, whatever care we take to favor this arrangement, it happens but too frequently that they persist in taking a wrong direction. Our art is not helpless un- der such circumstances ; it is only necessary to be well per- suaded that the success of our means will depend much upon the circumstances under which they are employed. As to the nature of these means, they are far from being, as some recent writings would inculcate, modern discoveries. There is not a dentist who has practiced for thirty years, who has not employed, every day, the very means now in use; and if some practiciens seem to make this a subject of particular attention, this is rather the result of enlightened public opinion, which better appre- ciates these things, than of anything they have added to former knowledge. The irregularity of the teeth depends either upon their devia- tion, their formation or implantation. Each of these vices may be carried to the extent of true deformity. Let us first examine vices of deviation. These irregularities are commonly known as obliquities. The obliquity may be forward, backward, laterally, or by rotation, according as the teeth which constitute it are directed outward or inward, mount upon the faces of their neighbors, or have undergone such a movement that one of their sides presents forward, and another posteriorly. PATHOLOGY AND THERAPEUTICS. 139 The primitive or temporary teeth rarely exhibit these devia- tions, and when they exist, they are generally so little impor- tant as to be unworthy of attention. As to the secondary teeth, the incisors and canines are most frequently thrown out of their proper place, which is readily enough explained by the fact that their roots being single, and occupying less space in the alveo- lar border than their crown does beyond it, they are more ex- posed to forces which may be brought to bear upon them. It must not be supposed that any great force is necessary for this purpose. It only requires a slight default of antagonism between two powers in the midst of which the teeth are placed, that is to say, between the lips in front and the tongue behind. Do we not perceive that, in almost all cases of hare-lip, the teeth corresponding to the fissure, throw themselves forward ; and that the operation which cures this deformity also replaces the teeth ? This is an important fact, which goes far to enlighten us upon the choice of means proper for replacement. If we study the causes which produce these deviations, we find it sometimes in an organic malady of the alveolar border ; but the more common cause, as we have already said, is the defect of relation between the size of the teeth and the space they ought to occupy ; the tardy shedding of some primitive tooth ; the presence of a tooth trespassing upon the space pro- per to another ; finally, the existence of a supernumerary tooth, which we have called a surplus tooth. Art has two kinds of means of remedying obliquity : the first act slowly, continuously, and are incapable of occasioning the least accident, or even the slightest pain : the others, on the contrary, act promptly but painfully, whence they would be abandoned, even if there were not other peculiar inconveniences attending them. The first of these expedients consists in bringing back the distorted tooth into its proper place, by the aid of traction exer- cised upon it by ligatures, which have their point d'appui upon the neighboring teeth ; but two conditions are necessary : there must be sufficient space to receive the tooth, and the tooth which forms the basis of support to the traction must be more firmly fixed than the one to be moved. 140 ANATOMY, ORTHOPEDIA, As many persons doubt the success of this proceeding, it is proper to observe, that the tooth to be removed does not repre- sent an inert force to be overcome, but an active force, the direc- tion of which should be changed. Let us reflect upon the fa- cility with which the most firmly resisting of our tissues yield to the action of slight forces when long continued ; and we will perceive that there are few cases in which a simple lever, skil- fully used and firmly fixed, will not suffice, especially in young subjects, to replace a tooth, however distorted it may be. Every thing depends, in these cases, upon the address and judgment of the operator. But should we have threads alone, reckoning upon their own elasticity, or only use them as means of attachment? We be- lieve that threads have rarely the power supposed, and expe- rience shows that they are fraught with great inconvenience. In the first place, they loosen the teeth around which they are thrown for support ; and again, they strip these as well as those to be moved, and act too near the neck. We know that, to obviate the loosening of the supporting teeth, those are chosen which have stronger roots than the irregular teeth ; and that to prevent the ligature from gliding under the gums, use is made of a small hook, one of the curves of which fits upon the cutting edge of the tooth, while the other holds back the ligature. But, on the one hand, the form of the roots is too variable to permit us always to calculate upon their respective forces; and if, on the other hand, the hooks applied upon the teeth prevent the thread from slipping, they are means which always impede the action of these last, and hinder it from being direct. Thus, then, if we would act with certainty, we ought rarely to confine ourselves simply to ligatures. There being a certain resistance to overcome, as must be the case in patients somewhat advanced in age, we may augment the power of the ligatures by combining their action with those of different apparatus, commonly described under the name of plates or bands. These are a kind of metallic springs, narrow and thin, adapted to the contour of the alveolar border, and applied in front or behind this border, according as the irregular tooth has deviated forward PATHOLOGY AND THERAPEUTICS. 141 or backward ; but better still, a double band, which gives to the thread a surer support, by hindering it from gliding upon the crown of the tooth, especially towards the neck. In order to explain their action and the mode of applying them, we will cite an example : Let us suppose an incisor thrown forward and having space enough to permit it to be reduced into line. We take the mould of the defective dental arch, as it will be described in the "prothesis" » Then, upon the posterior and anterior faces of the teeth, we adapt a bandelette of gold, some- what less wide than the height of the teeth, but touching them all in the direction of the alveolar border, terminating at each of its extremities by a kind of bracelet, or better still by a true cap, which envelopes the two last molars, upon which we wish to take a firm support. Before applying this little appara- tus, we pierce each bandelette with two holes in the same hori- zontal direction, and precisely at the point corresponding to the irregular or oblique tooth. Finally, when it is applied, we pass through the holes a thread of raw silk waxed, or of platina, and twist them round the tooth to be replaced, v This apparatus, which is the only one we employ, as it is much more sure than the simple thread, has this advantage, that its action is constant. This continuousness results from the incessant action of the spring reacting upon the thread. The power may be increased by so arranging the spring that it shall not touch the teeth which form the sides of the vacant space to be filled by the tooth to be retained. We have cited the sim- plest case in which the band is applied ; but it is easy to per- ceive that it might be used upon several teeth as easily as upon one. It is only necessary, in complicated cases, to pierce the bandeau with as many holes, and pass through as many liga- tures as there are irregular teeth. Whatever modern authors may say of the means we have described, claiming it as their own invention, and supposing, upon the ground of some modifications, that they have "resolved a problem never before thought of," it is nevertheless true, that it was known to the ancients. A detailed description of it may be found in Fauchard, and if our predecessors have not derived as much benefit from it as ourselves, it was because they did 142 ANATOMY, ORTHOPEDÏA, not avail themselves of firm points d'appui, a first condition in all apparatus of replacement. When one has become' familiar with the mode of applying bandeaux, formerly called plates, and which are nothing more than springs, he will perceive that they are only applicable to anterior and posterior displacements ; but generally simple liga- tures are used to correct lateral and rotated obliquities. In the first case, the thread is firmly fixed upon the last or even the two last molars of the side opposed to the deviated tooth, and we tie it upon the latter, causing it to pass in front of the neigh- boring teeth, when the tooth presents inwardly, and vice versa. This direction of the ligature exercises less traction between the two lines which the tooth must traverse in order to reach its place, for it is evident that if, in a case of inward lateral obliquity, of an incisor for instance, the thread departed from the inward face of the molars, it would only draw backwards, but not into the vacant space to be occupied. As to rotary deviations, they are generally corrected by sur- rounding the tooth with a strong silken thread, one of the ends of which is carried inwards, the other outwards, to be fixed upon the last molars. As these teeth, especially if they are incisors, leave sufficient scope, by the very fact of their movement, to the means to be employed for their restoration, we surround them with a little ring, which embraces them exactly, and bears in front and behind a small hook, into which the thread is received to go to fix itself upon the molars of each side, either directly or by the intervention of a little cap placed upon these latter, or a small ring upon which the thread may be tied. Generally, by these and similar means, we may succeed, in less than a month, in restoring a tooth to its natural place. In the course of treatment, the ligature must be changed and re- adjusted every three or four days. When the desired end has been obtained, we sustain the tooth for one or two months, or more, by means of a smaller ligature or a gold thread, until the alveolar border shall have acquired sufficient firmness to main- tain the tooth in the direction given to it; but what is yet bet- ter is to cause the patient to wear at night a kind of metallic cap- sule, fitting exactly upon the teeth, and enclosing not only the restored tooth, but those surrounding it. Pathology and therapeutics. 143 We may perceive the importance of this, if we remember the intensity with which the jaws are sometimes clenched at night. We have seen this so strong as to displace artificial pieces, when inconveniently arranged. It is well to take another mould of the mouth after the success of an operation of this kind, as, by the comparison of this with the previous mould, we may the better judge of the result in all its extent. We have remarked that besides ligatures there was another way to restore a deviated tooth to its natural direction. This means is incomplete luxation. As it is not without danger, it should never be tried except when the inefficiency of ligatures is well established, as in the case of an individual twenty or thirty years old, in whose case one or two teeth should project within the alveolar border. If the operator concludes that the space des- tined for the distorted tooth is not large enough to receive it, he will file away the adjacent teeth and the displaced tooth, until the necessary size is obtained, when he will luxate the latter, and restore it to its proper position. Pincers will ordinarily suffice for this purpose ; but, in order to success, it should be done with all possible care, and all effort should cease as soon as it is brought to the level of the others. It is then prudent to preserve it in its new place by ligatures. Some weeks will suffice, it is said, for the alveolar border to adapt itself intimately and render it as firm as before. But, we repeat it, this manœuvre, which properly belongs to surgery, is not only of doubtful efficacy, but may be attended with disastrous consequences. It is indispensable, indeed, that in practising it, even with all possible care, we may not only break and tear the gums, tear the alveolo-dental periosteum, fracture the alveoli, but even break the tooth. Therefore, we have never undertaken it, and we advise all young practitioners to avoid it, or never attempt it until they have well balanced the chances. We have all along supposed either that the space proper to the tooth remained unoccupied, or that room could be made by extracting a tooth. When, however, there is nearly sufficient space, it is not necessary to make such a sacrifice. The end can be obtained by filing slightly the sides of the displaced tooth or of those between which it is placed, as we have already said. 144 ANATOMY, ORTHOPEDIA, CHAPTER IV. PATHOLOGY AND THERAPEUTICS. Of authors who have written on specialities on our art, some, as Maury, holding no account of the relations of organization and of the end which unites the dental bone and its central ganglion, content themselves with dividing the diseases of the teeth into those which relate to their hard parts and those which effect their soft parts ; whilst others, as Lefoulon, having no very- just idea of that which they ought to understand as diseases, have added to the number of those of their teeth, simple anoma- lies of form and of arrangement. More logical in this respect than those, we have arranged the changes of the organs, which we shall now treat of into three distinct classes. The first includes the vital or pathological changes properly so called, which are, injuries of the follicles; erosion or atrophy of the teeth ; discoloration and decomposition of the enamel ; consumption of the roots ; caries and its different varieties ; exos- tosis and the spinal ventosis ; softening ; inflammation ; fun- gosity ; ossification even of the dental pulp, and finally the differ- ent nervous affections of the teeth. The second comprehends, on the contrary, injuries purely physical, as the wearing away, cracking and fracture of the teeth ; their loosening, fluxation and denudation. Finally we have arranged in the third class the diseases of the auxiliaries of the teeth, either the diseases of the gums of an in- flammatory nature, or the diseases of the alveoli. VITAL OR PATHOLOGICAL CHANGES. Diseases of the Follicles. For every attentive practitioner to return to the first origin of diseases, it is manifest that a sufficient number which effect the teeth can be referred to other causes than the disorders to which their follicles have been exposed. This circumstance has ne- cessarily been overlooked a long time ; for, to place it beyond doubt, two things are necessary which are rarely presented; PATHOLOGY AND THERAPEUTICS. 145 either that the alveoli were open when they contained only the follicles, or that later, when it is possible to penetrate the scalpel with the hand into the interior of the gums, we will find there the follicles which precisely at this period have disappeared. Oudet is believed to be one of the dentists who were first oc- cupied with this important subject; for, in a treatise relating to this question, he relates as something new that, in many cases where the crown of the tooth still remained in its follicle, it offer- ed signs of atrophy, he has found also many points of the in- ternal membrane much redder than in its normal state. We have proven this fact in later years and in many instances ; from thence we desire this opinion, that we publish as a funda- mental maxim, that a great number of changes to which the teeth are subjected are dependent upon an inflammation which at an earlier period has affected the internal membrane of the follicle. A circumstance which goes still more to strengthen this opin- ion is, that we have many times met follicles whose cavities con- tained a purulent, yellow and thick matter, which could only have been the result of an inflammatory work, whose effects have inevitably made us sensible of a germ within, whatever may be the theory that we adopt to explain the formation of this germ. It is even possible, in analyzing with care the writings of many ancient authors, Jourdain* and Bourdet,f for example, to find some traces, if not of the express opinion that certain changes of the teeth had primitively taken place in the follicles, at least of an opinion nearly analogous ; for they admit that many changes of the enamel depend upon the vicious qualities of the fluid exhaled by the internal membrane. Jourdain quotes to this effect, many observations made upon individuals who have been attacked, either by putrid fevers, or varioloidal and scorbutical affections, and among whom he has discovered remarkable changes in the fluid of the follicles. As one perceives, these observations are not altogether unim- * Treatise upon the Diseases and Surgical Operations of the Mouth. 2 vols, in 8, 1756. t Researches and Observations upon every part of the Art of Dentistry. 2 vols, in 12, 1756. 19 146 ANATOMY, ORTHOPEDIA, portant, yet one must not be too positive, still they are no less important, when one considers, in effect, the manifest correla- tiveness which exists between many changes of the teeth and the different diseases which have exerted a troublesome influ- ence upon the development of the follicles, we cannot refuse to believe that the different secretions which have a place in the interior of them, and which preside at the formation of the teeth, exert a powerful influence upon the manner of which these den- tal bones will be organized. The same dépendance in which we find the other fluids of the organization bear to these secretory organs, we find between the tooth and its follicle ; in such a manner that the least cause which troubles the functions of the latter must necessarily be reproduced under the configuration of the first. This is a general law to which the teeth have never made a single exception. Let us add to that, that the teeth once formed, and deprived in part if not altogether, of the vasculary elements, would them- selves only become the seat of a weak nutritive process, and con- sequently pathological ; we hence perceive the great importance of these organs which have immediately contributed or only pre- sided over their formation, and which constitute the natural bonds by which they were held dependent upon the organiza- tion of which they have received all of their injurious influences. Also, the ill health of parents, the diseases which attacked the mother during pregnancy or lactation, all diseases to the fœtus or child is subjected during the first or second dentition, do they effect the teeth only in acting upon their follicles. As all these diseases might have a different degree of strength and intensity, as they might attack separately or at the same time the two secretory organs which enter into the composition of the follicle, the morbid effects which result ought consequently to vary. Thus, often, without presenting any sensible change, the texture of the teeth will become extremely delicate and weak, a disposition which is the principal cause of a premature destruction. At another time, we discover more or less injuries upon the surface of the enamel, injuries which are perceived at the time of the formation of the teeth, and showing that the in- ternal membrane of the follicles had been diseased in several PATHOLOGY AND THERAPEUTICS. 147 parts of its extent; finally, in some instances, the ivory will be the seat of many changes which depend very evidently upon diseases to which the functions of the pulp have been exposed. This truth once well established as a fundamental indication, let us examine successively the different diseases of the teeth, following for their description the eminently methodical order that we have heretofore adopted. Congenital Defects of the Enamel. Erosion or Atrophy. — If we were always obliged in order to form an exact idea of things, to search for the literal sense of words employed by us to designate them, we ought surely to understand by erosion only a change of the teeth caused by the action of an erosive agent, as an ulcer, and acid, and large file, and by that of atrophy, their defect of development, as we have before said; but dentists, for the most part such bad et^-~ virologists, have commonly described under these two names, a change of teeth which depends upon a defect in the secretion of enamel. This affection is always congenital, that is to say, that it ex- periences no change after the formation of the crown, but is the constant result of a defective secretion of the internal membrane of the follicle, a little before birth. It then seems that nature has not sufficient force to form a sufficient secretion of enamel, and that it has been arrested in this work by causes difficult to be understood. The forms under which this change presents itself are very variable ; we are able, however, to reduce them to three principal ones. The first variety of atrophy of the enamel affects only the sur- face of this cortical envelope. It consists in spots of a milk white or of a yellow more or less deep, sometimes black. The spots, often irregular, do not injure the brightness of the enamel ; they remain stationary, but nothing can make them disappear. The second variety, the most common, consists in small irre- gular indentations, like pricks scattered irregularly here and there, variable in number, upon the different parts of the free surface of the teeth. Ordinarily very small, superficial, these 148 ANATOMY, ORTHOPEDIA, indentations form a rough surface which is a true erosion. They have often considerable extent and present facets ; sometimes these furrows or depressions are circular in the form of gutters, which traverse the contour of the crown ; or finally these trans- verse sinuosities are united or separated by projecting lines. As to the third variety of atrophy, it differs entirely from the preceding, in this respect, it affects all the dental substance, but especially the enamel. In rigorous language, it merits only the name of atrophy; for it is a kind of modification, a sort of wasting. In this variety, there is a loss of substance more or less great which occupies most commonly the centre of the external face of the crown of the exterior teeth or the triturating surface of the large molars. Often, then, the free extremity of the teeth is almost entirely deprived of enamel to a certain height, as if it had been plunged in a corrosive liquid. The incisors offer deep and irregular dentings, the canines are very long. The diseas- ed tooth remains ail entire by a decree of development ; some- times it is completely deprived of one of its constituent parts ; so much so that its crown is reduced to two-thirds of its volume, so much so that it offers a circular depression, and even a true cavity. We have also remarked, that the roots of teeth thus disfigured offer similar sinuosities, projecting and circular lines, and that they were knotty and very short. Atrophy is idiopathic or symptomatic. We meet the first among subjects of excellent health who have never been sick. It evidently depends upon local causes which have troubled the functions of the follicular membrane. The second is common among individuals who are in bad health, of a lymphatic and scrofulous constitution. The varioloid, scarlet fever, measles and different gastro-intestinal inflammations appear to have a powerful influence upon its development. Thus, whilst idiopa- thic atrophy affects only a small number of teeth and appears only in few parts, symptomatic attack ordinarily most of the teeth and causes great disorders. As the different changes of which we are speaking might have a very variable intensity and duration, the depth, extent and number of lines traced by atrophy ought also to vary. More- over they do not occupy, when many teeth are affected the same PATHOLOGY AND THERAPEUTICS. 149 place upon the crown ; they might occupy the cutting edge of the second incisors and the triturating t surface of the first mo- lars ; and thus in order. These differences evidently answer to the order of succession that agrees with the formation of the teeth, and might even seem to establish, in a manner sufficiently precise, the time at which the subject had been attacked with some serious disease. If, for example, the incisors are only af- fected, we are authorized to presume that the person had been diseased towards the first or second year ; if they are, on the contrary, the small or the two permanent molars, the disease might have existed at the fourth or fifth year, a period at which the fourth and even often the six anterior permanent teeth have already their crowns entirely enamelled. It has long since been observed that the milk teeth are much less liable to be affected with atrophy than the permanent ; but they are affected by it, they are a sufficient number whose de- velopment is prevented by it. As to the permanent teeth, those which carry most commonly traces of this change, are the inci- sors and the first large permanent molars ; the second large mo- lars and the small of the same name, or bicuspides, next come under this relation. We have until the present spoken only of erosion in the sense that most authors give to this change, they attribute it nearly always to a defective secretion of enamel. But erosion exists not less as a disease affecting this body consecutive to its forma- tion, or, to be better understood, we say that independently of congenital defects of the enamel of the teeth, they might still, long after their eruption, find themselves at one instant deprived in many parts of their crown, of their vitrous en- velope. This kind of erosion, that we shall name consecutive, in opposition to the first, is very common among young subjects exposed to affections of the digestive organs. Do the mucous fluids, in the midst of which the teeth bathe in these diseases ac- quire corrosive qualities sufficiently marked to explain its de- velopment ? It is this that we are ignorant of, but the return of minds to the study so long neglected, will permit us to see the solution of this question. Let us remark, nevertheless, that we have often met consecutive erosion upon subjects attacked by 150 ANATOMY, ORTHOPEDIA, diseases occasioned by the presence of intestinal worms ; we had observed, some time since, an example of it upon a young girl attacked with epileptiform hysteria, and whose teeth had been perfectly healthy until the time of this affection. When the depressions which we have remarked upon the enamel are light and very numerous, and this presents its natu- ral color, they present really no deepness. But when they penetrate so deeply as to impair or deprive the tooth of a part of its enamelled covering, or where one part of the crown is de- stroyed, they constitute a grievous state, because they are the forerunners of decay. As it is so difficult to make the different changes resulting from dental atrophy disappear, it is principally their causes that we should attack and combat with, either to prevent them or stop their progress. This indication, as we perceive, cannot be remedied, excepting by the observance of the rules of hygiene, of those whose end is to prepare a perfect set of teeth. If the change depends upon a general affection, we should direct all the efforts of therapeutics to the treatment of this last. In some circumstances, nevertheless, the aid of surgery would undoubt- edly be advantageous. Thus, where the depressions occupy the free extremity of the crowns of the anterior teeth, they can be made to disappear by use of the file, being always careful not to wear away too deeply the tissue of ivory. If the crown is excavated in such a manner as to present a cavity of a certain extent, like that which generally happens to the large molars, the caries can be prevented by filling it with gold or silver leaf, or other substances, after having first cauterised the base. Decomposition of Enamel. The enamel can yet present changes of another nature, whose origin relates equally to follicular injuries. Amongst these changes, there is one very common — one which merits our attention, and which we have named, with Maury, decomposi- tion of enamel. It manifests itself by brown or black spots, which develope themselves upon the anterior face or sides of the crown. These spots often extend to the internal face of the PATHOLOGY AND THERAPEUTICS. 151 enamel, which, however, in most cases, preserves its lustre. Although in general it takes its origin in the rudimentary tis- sues, yet this alteration may depend upon too great pressure, or upon the great nearness of dental caries ; but, in this case, the tooth is not painful, and its alteration ceases mostly with the destruction of the mechanical cause which produced it. In another kind of decomposition of enamel, we observe the spots to be of an unpolished white, circumscribed, situated ordinarily on the anterior face of the incisors, and very often near the external part of the neck of the inferior molars. Their color becomes yellow by degrees, and disappears with the lustre of the enamel. This possesses a delicate and brittle texture, which causes it to break into small particles, even to its com- plete destruction, with the least effort. In this case, the teeth are sensible to cold, to heat, and even to the contact with all strange bodies, and become easily encrusted with buccal acid and tartar. As a habitual prelude of caries, this variety of de- composition affects, in preference, persons of a bilious tempera- ment, convalescing from long diseases, in the course of which they have been frequently salivated. If the affection is light, it heals itself often, by the re-establishment of health, assisted, by all means, with habitual cleanliness. Discoloration of Enamel. The teeth offer, under the relation of color, certain differences, which constantly coincide with certain general dispositions of individuals, and often, in this respect, furnish important indica- tions. In general, those of first dentition are of a brilliant milk- white \ but among adults the shading of color is very variable ; we can, however, reduce them to three principal ones. The unpolished white, approaching to yellow, is found principally among subjects enjoying excellent health ; they are ordinarily short, in regard to the stature and strength of the individual. Grey- white denotes, on the contrary, a quality less advantageous. But, of all the colors of the teeth, the least to be desired is blue-white. They are most ordinarily found among young subjects, (especially young girls,) who are affected with diseases 152 ANATOMY, ORTHOPEDIA, of the chest, principally those that characterise a development of tubercles upon the lungs; subjects that are vulgarly desig- nated by the name of consumptive, and who very rarely possess the advantage of preserving their teeth perfect until the end of their lives. This observation has already been made by Blu- menbach and Camper; it follows that the azure tint of the teeth will be the manifest symptom of an alteration existing in the ivory of the teeth. Thus it is, in a great number of chlorotics, the teeth take, after the first period of the disease, the color of brick-yellow, which we always regard as the sign of a fatal termination.* One perceives, then, how all the relative details to the diver- sity of the tint of the teeth, and to the appreciation of causes after diseases which might have occasioned it, ought to be of importance to the attentive physician, since their simple inspec- tion affords not only a knowledge of their length, but of the constitution of the individual, and of the different diseases he might either have been affected with, or more particularly ex- posed to. How, can it be asked, do these differences of color and quality belong to the teeth? This question has not, certainly, until now, obtained the attention that it merits. All that which is believed to be known, and which contents us, is that these differences belong to the chemical composition of their organic substance. Thus, those whose tissue is of deep yellow, and scarcely impressible, might have a superabundance of calcareous salts ; those, on the contrary, which are distinguished by their whiteness and sensibility, and which are tender and delicate, might owe these quatities to a predominance of animal matter. These two fundamental differences, whose existence is little contested, are met in two kinds of constitution and temperament, altogether opposite, and evidently belong to the general dispo- sitions of the economy. * Begin has also reported to the Academy of Medicine, that, in this case, the teeth present sometimes a bluish color, which not only occupies their surface, but even penetrates into the interior of the dental tissue; this color- ing became so deep that the boys of the amphitheatre complained of not being able to sell them. PATHOLOGY AND THERAPEUTICS. 153 From thence it is perceived how it is difficult in admitting that the discoloration of the teeth, in a great number of cases, may be the result of a pathological state, to trace to its relative exact therapeutic rules. This discoloration, being ordinarily effected under the influence of a general change in the organism, our course should be always subordinate to the treatment of this change. Thus, when in the course of a disease, the teeth have taken an unusual color, we see them take their natural color when the affection ceases, especially when it is of short duration. But in the mean time, this change or return of color seldom takes place where the disease is long, or after the age of forty, or even of thirty-five years, a period when the vitality of the teeth has necessarily lost a great part of its reactionary force, All attempt, in this case, will be, as we have already said it, chance with an imprudent or inexperienced dentist. We except, by all means, from this anormal coloration, which belongs to a general state of economy, certain greyish or yellow- ish spots, which form often near the neck of the teeth, without having anything in common with tartar. These spots have no thickness upon the enamel, and ought to be observed. Consumption of the Roots. This affection is rarely idiopathic ; for it is nearly always oc- casioned by an alteration of the envelopes of the roots, as of the periosteum, of the alveolar membrane, or surrounding soft parts, which, by their inflammation, and consequent suppuration, cease to adhere to the teeth, which they reduce to the state of a foreign body, whose destruction becomes inevitable. This disease is developed in various conditions of age and health ; sometimes among subjects from the age of forty to fifty years ; among those, principally, who, at that age, experience a sud- den change of constitution ; sometimes, on the contrary, among young men; but now and then among females newly brought to bed. This disease, which is not confined to a single tooth, but extends sometimes to many, and even to the alveolar border of both jaws, although local in its origin, can, as we perceive, 20 154 ANATOMY, ORTHOPED1A, acquire a troublesome importance. It is natural to think that the use of topical tonics, even a few astringents, in modi- fying the vitality of diseased tissues, ought, after the inflam- matory period, oppose the loosening of the tooth and prevent its consumption, or at least the atrophy of its root. Expe- rience unfortunately does not always accord with this indica- tion of the theory. We are sometimes obliged to abate a disease, by applying a button of caustic upon the principal seat of the disease ; and if this means does not succeed, it is necessary to extract the tooth around which there is the most inflammation. This sacrifice ought even to extend to many, if the disease has reached the whole of one jaw or different points of both ; and this had better be done too soon than too late ; the conse- quences, however, must be weighed well first. Dental Caries and its Varieties. We designate under the name of caries, that change so com- mon to the teeth, which consists in a gradual destruction of a part or of the whole of their substance. Is this change of nature absolutely identical with that which affects the bones in general? It was believed so a long time, and this opinion was inferred by the analogy which seems to exist between the osseous tissue and that of the teeth. But the opinion at the present time is, as we have already advanced and demonstrated at the commencement of this work, that the teeth constitute in the economy a kind of substance, a part of whose intimate composition is certainly far from being exactly that of bone ; for the enamel which forms, as every one knows, the most exterior layer, contains neither fibrine nor albumen : water alone is found there, in combination with phosphate and carbo- nate of chalk; and if some animal parts enter into the tissue of the subjacent layers, they are so mingled with these two salts that they do not absolutely perform any contractility, and are endowed only with a feeble irritability. The absence of nerves and visible vessels in the ivory, the kind independent of the teeth, although they partake directly of life, do not permit us to establish between them and the bones PATHOLOGY AND THERAPEUTICS. 155 any exact relation, it is natural to suppose that there might be between the morbid affection which is the object of this article, and the caries of the bones, as much difference as exists between the tissue of these two parts.* This supposition admitted, it is no less just to avow that these two changes have, for a common characteristic a softening and decomposing of the earthy parts which enter into the substance of the organs that they affect. There are few diseases which, since the time of Hippocrates, may become the object of more researches, and the subject of more writings, than dental caries ; and, however, in spite of these enterprising works, mostly made by celebrated physi- cians, able observers, it is still difficult to form an exact idea of the pathological phenomena which constitutes it. This difficulty happens principally from this, that authors have confounded, under the common name of caries, diseases that are important to be distinguished, because there exists between them remarka- ble shades, under the relation of causes, of the progress, of the final results, and, consequently, under that of the treatment, which forms here the essential point. Of these diseases, designated under the general name of caries, some are entirely produced by local agents, and consist in the chemical destruction of the dental substance; destruction which is made from without inwardly, and of which we will speak hereafter; others are caused by a disease of the pulp, or a primi- tive defect of the ivory, and develope themselves spontaneously from within outwardly. This last kind we designate more par- ticularly under the name of caries. * At the same time when we give the passage for print, we take notice of the memoir that Nasmyth, member of the College of Surgeons at London, has submitted to the institute, and in which he says that the teeth offer not ajibrous disposition, as it has been believed until the present, but porous and cellular. This fact, which appears very important at first, destroys com- pletely the difference which exists between the bones and the teeth. It shows only that they have a common character besides to add to those which reside in the presence of calcareous salts as a base for one another. But the identity of their mode of development does not seem sufficient to establish the fact that they are upon the same line in that respect. (See the exact account of the meeting of the Institute of December 5th, 1842.) 156 ANATOMY, ORTHOPEDIA. Whatever may be the import of the denomination, the dis- ease is so common, that few persons, even in the best of health, are exempt from it. It attacks indiscriminately children, young men, adults, and even spares not old men. It is natu- ral to suppose that organs which, during the time of their formation, have been submitted to the influence of general causes, which have acted upon the whole constitution of the individual, ought necessarily to undergo, at a later time, the effects of them. That consequence, that we have already treated of, in speaking of the diseases of the follicles, and to which the most simple observation conducts, we explain, because we daily see it in individuals born full of vigor, whose health has never been im- paired, and who, in the mean time, have had, from their youth, very bad teeth, whilst others, of a weak and languid constitu- tion, have very beautiful and strong ones. It would be, then, as irrational to endeavor to trace all the causes of caries to the time of the formation of the teeth, as to disavow all the influence that the diseases of the first age might exert upon the develop- ment of caries with which the teeth are attacked even at an advanced period of life. Caries being the most frequent disease of the teeth, a disease whose treatment and results form the most important part of our calling, we should study it with great care. In order to omit nothing useful, let us examine it successively, under the relation of its causes, of its symptoms and its course, of its seat, its diagnosis, its prognosis, and its treatment. First, Causes. — Amongst authors who have studied caries, in explaining the causes of this singular and often exclusive dis- ease in its course, some have admitted only internal ones ; others, on the contrary, but external ones. But the greatest number, at the present time, believe they result from both, and most generally from simultaneous action. Hunter* thinks that it is hereditary, and regards it as a kind of mortification or ne- crosis of the dental substance. When we reflect, in effect, upon * Natural History of the Teeth and their Diseases. London, 1771. Trans- lated in Latin, 1773 ; German, 1780. PATHOLOGY AND THERAPEUTICS. 157 the frequency of caries in the members of the same family, we are not far from admitting this disposition. Fox* believes it always is a defect in the primitive formation of the teeth. This opinion is corroborated by this fact, that we have already estab- lished, knowing that the disorders of caries are confined often to teeth which formed during the course of a certain period of den- tition. It is to this kind of alteration that it is necessary to refer constitutional caries that we meet so often among members of certain families, that have either caused primitive and original disposition, or that they depend upon local or accidental in- fluences. Caries, we have said, does not escape any age ; but habitual observation declares that women and young men are more ex- posed to them than middle aged and old men. They seem en- demic incertain countries, particularly in humid and marshy dis- tricts, or neighborhoods bordering on the sea. Holland offers a remarkable example of this.f It is, then, in the influence of gene- ral agents, which modify all the organism, that it is necessary to seek for the first causes of caries. It is thus that the teeth, whose texture is weak and soft, which are of a milk-white, of a dull blue, and consequently defective, carry in themselves the sources of their premature destruction. There is in them a number of organic or accidental diseases, as scrofulous affections, tetters, lymphatic gout, severe or chronic inflammations, ner- vous diseases, too rapid growth, which are as many general causes, under the influence of which caries developes itself. Although many of the causes that we have shown as capable alone, by their powerful influence, of affecting the composition of the ivory, to involve the teeth, as soon as they are formed, in inevitable ruin, it cannot be denied that, in a great number of * TJie History and Treatment of the Diseases of the Teeth, Gums, $*e. London, 1806. t"We have two very striking examples of this in France; the inhabi- tants of the countries of Caux, and those of the environs of Bauvais, in Picardy, have, for the most part, the two central incisors of the superior maxillary decayed; after these the laterals are affected ; and thus, in turn, in such a manner, that at the age of thirty years they have lost the greatest part of their teeth." (Rosseau : work quoted.) 158 ANATOMY, ORTHOPEDIA, cases, they exist only as prédisposants, and have effect only by the train of local circumstances, or, to speak plainer, actual ones. Is it not observed, in truth, every day, that caries destroys with promptitude teeth which have scarcely appeared through their alveoli, whilst among other subjects, as unfavorably placed, it commences a long time before manifesting itself, or appears only to occasion accidental influences, perfectly characterised. Amongst the local causes which produce caries, it is necessary to place those bodies which, being placed in contact with the teeth, are capable of exercising upon them an unfavorable effect, by their temperature or chemical action. The influence of heat upon them is most evident, as we have already observed, in the chapter devoted to hygiene. Likewise, the use of warm drinks, among certain nations, seems to us eminently pernicious, as those in England, Holland, and as we have even observed frequently in Russia, where wealthy and opulent men lose their teeth in early years, whilst their domestics preserve theirs per- fect to an advanced age. Many authors also have thought cold to be one very powerful cause of dental caries. If this assertion is not completely false, it is at least much exaggerated ; for the people who occupy the regions of the extreme north, as we say, have the most beautiful teeth. It is not, then, very probable that cold by itself exerts an unfavorable influence, but only the sudden passage from a warm temperature to a great cold, which, destroying the equilibrium in the cohesion of the molecules which compose the teeth, causes in them hasty movements of dilation and obstruction, the more common result of which is caries. As to the preference which caries has for the two superior inci- sors instead of the lower ones, all things besides being equal, it is explained, according to our opinion, very naturally, by the posi- tion of the first, which renders them more exposed to the action of external bodies. Finally, in the action of prehension of liquids, or, to speak plainer, in the action of drinking, they receive nearly always the impression of the fluids, which the inferior are prevented from, even by the vessels we use. A great number of bodies cause caries by their chemical ac- tion. It is thus that acids act, although it may not be as easy PATHOLOGY AND THERAPEUTICS. 159 as it might be thought to explain why this chemical action en- genders caries sooner than a simple decomposition of enamel ; which, according to our opinion, is another thing. An able dentist of our day, Regnard, # it is true, considers ca- ries only as "a destruction of the teeth by decomposition" and this decomposition finds only a cause in an acid developing it- self, either in the humors of the mouth, or in the alimentary substances which remain around the teeth. "He gives as a sup- port to this assertion three proofs, thus : "1st. Artificial teeth were fastened by threads of silk. These threads, which surrounded the neighboring teeth, became im- pregnated with saliva, and covered with alimentary particles, and soon corrupted them ; they became then a cause of caries to the teeth. This is so true, that the limits of the caries proceeding from this cause are traced by the thread itself. "2d. For sustaining the artificial teeth, metallic caps were made to envelope one or more of the teeth. These constantly served to remove the pain produced by the rapid wearing away of the teeth. These caps were not made with so much preci- sion, that there did not exist any space between them. The fluids of the mouth, the alimentary particles, soon lodged in these spaces ; and if persons who wore these caps were not very careful, these fluids of the mouth, these alimentary particles, de- composed, and became then an active cause of caries to the teeth. I have seen molars whose crowns were entirely destroy- ed by the action of this cause in the space of six, five and even four months. "3d. Human teeth and the teeth of the hippopotamus were used for artificial teeth. These teeth being of an organic nature are capable of decomposing in the mouth. Then, if by a badly arranged economy, the persons who wore them preserved them still when they are in a state of decomposition, they decayed the neighboring teeth, which are immediately in contact with them." Regnard strengthens these different proofs by the following considerations : "If, now, I devote my attention to the parts of the teeth in * Of Dental Canes. Brochure in 8, Paris, 1838. 160 ANATOMY, ORTHOPEDIA, which decay commences, I see that they are precisely those where the aliments and fluids of the mouth stop and remain sufficiently long to decompose themselves. It is in the necks of the teeth, in the interstices of these organs, in the anfractu- osities of the large molars, in these pointed holes, that we ob- serve sometimes upon the external face of the first and second large inferior molars or upon atrophoid teeth. If we reflect pre- cisely upon the mode of action of caries, we see that they act in the same manner as an acid, that they deprive the tooth of its phosphate of lime, and upon the point where it exerts itself it reduces it to a cartilaginous substance. Let us see if we can find, in the decompositien of the alimentary particles, or buccal hu- mors, an explanation of this phenomena. Now, chemistry teaches us that all vegetable or animal substances, in a state of decomposition, give birth to acidiferous products ; to nitric acid, acetic acid, sulphuric acid, etc. all acids which produce the same effect as caries upon the teeth." To take the action of acids upon the teeth as cause of decay, in as absolute a sense as Regnard, is, according to our opinion, an error, a great error. In adopting it, to the exclusion of all other causes, this practitioner commits the same fault that a sur- geon did who, in order to demonstrate that a fall upon the wrist would disjoint the arm, would minutely describe how it acted in the production of luxation, and who, for the correlativeness ex- isting between the cause and effect, would conclude that the arm did not disjoint only in a fall upon the hand. If we were not prevented by the fear of being too extended upon a pathological point which, all important as it is, is not however the only thing to study, we might make innumerable objections to the theory of Regnard ; but we will confine our- selves to the five following, that we shall expose in the order of their importance : 1st. A great number of caries commence in the ivory which is often deeply affected whilst the enamel is entire ; a circum- stance which has entirely escaped the notice of Doctor Serrurier, who, however, has made a very judicious refutation of the trea- tise of Regnard.* * See the Gazette of the Hospitals of the 20th and 25th of September, and 1 Uh of December, 1838. PATHOLOGY AND THERAPEUTICS. 161 2d. Many teeth, principally the last large molars, come from their alveoli deeply decayed, without having consequently been submitted to the action of any kind of acid. 3d. If it was always and solely an acid which affected the teeth, this action would be general ; it would not have but one point of decay ; the whole of the dental system would be certain- ly decayed. 4th. It is against the evidence of facts that Regnard declares that the use of cider, among persons who inhabit Normandy and Picardy, accounts for the frequency of caries ; for, Rosseau re- marks justly, that the inhabitants of these two provinces who oc- cupy healthy places, "have most generally the most beautiful and healthy teeth," # contrary to that which befals those who oc- cupy low places, that is to say humid ones. 5th. Finally the saliva and buccal humors are notas frequent- ly acid as Regnard thought ; we have often found alkalies among many persons who had their teeth deeply decayed. Our researches, in this respect, accord perfectly with the opinion of Doctor Uonni, who expresses himself thus : t u The alkalinity of the saliva has been avowed long since ; but it has been proven only in these latter years, particularly by the experiments of Tiedman and Gmelin." Donni is not satisfied even with proving the alkalinity of the saliva, he endeavors also to explain it in these terms ; ancient and modern authors have said nothing of the part that relates to the alkaline principle of the saliva. Beyond the usages that is generally attributed to it, it seems, according to my researches, to neutralize the excess of the acid of the gastric juice. This is supported, by most experimenters ; 1st, upon the neutral state of the gastric fluid ; 2d, upon the impossibility that this effect can- not produce the salts and saliva found in contact with the acid of the gastric fluid; 3d, upon the nature of the salts, contained in the gastric fluid, a great part of whose basis is salts." Whatever may be the opinion of Regnard, we do not at least acknowledge that the presence of the acidity of the saliva, upon a point of the enamelled substance, might be a cause of decay; * Work quoted, page 225. t Work quoted. 21 162 ANATOMY, ORTHOPEDIA, but then we admit that the person is under the influence of some derangement of the digestive organs, as the author that we have precedingly named establishes so clearly in this re- mark : "This acidity of the saliva coincides the most frequently with a primitive or secondary state of irritation or inflammation of the stomach, andean serve to establish the differential diagno- sis of some gastric affections." To prove this acidity it is only necessary to place upon the tongue a piece of blue turnsole paper : if the paper becomes red, we can predict that the subject is un- der the influence of some disease. We have also remarked that this acidity coincides often with a thready, thick or glutinous state of the saliva. The use of certain medicaments, as of mercury, gold, mineral waters, acting equally upon the teeth of their chemical proper- ties, can also be, not only the predisposing, but direct cause of caries. Blows, falls, commotions, and counter blows cause vi- cious conformation and too great nearness of the teeth, &c. We might add to this series, a crowd of other causes that au- thors have mentioned, but they would be too long and super- fluous to enumerate here. And how could we explain, in this multiplication of causes of decay, the diversity of effects which produce this kind of dissolution of the teeth, and the variety of aspects under which it presents itself when we consider it, either under the relation of the color and form of the spot which an- nounces its existence, or under that of the place that it occupies, or, finally under that of the rapidity or slowness with which it proceeds in its course? 2d. Symptoms and Course. — Caries, according to our know- ledge, as we have already said, proceeds frequently from the in- terior to the exterior. Smote in its vitality, either by an act of nature that cannot be explained, and to which the pulp is not always a stranger, or because the delicateness of its tissue was not able to resist the agents with which the teeth are constantly brought in contact, the ivory becomes the seat of a change which affects at the same time its color and the force of cohe- sion which unites its particles. A yellow or brown spot mani- fests itself near the enamel, which it invades by degrees until it extends upon the surface of the crown. This envelope loses in PATHOLOGY AND THERAPEUTICS. 163 this respect its transparence, a natural consequence of the sepa- ration of the elements which constitute it. Whilst the internal layer of ivory which unites the enamel with the suhjacent lay- ers is not destroyed, the spot preserves the color and even shin- ing aspect which belongs to the teeth ; but it loses this brillian- cy as soon as the connection is severed which binds the ivory and enamel together. As there are a great number of external agents which have the power of destroying the cohesion of the elements of the ena- mel in its most superficial layers, without effecting its deepest layers, often the tooth loses its transparence upon the point at- tacked, without losing any of its whiteness. The evil does not extend ; the decay is arrested there ; often it gives no other sign of its existence than a slight depression resulting from the dis- engregating of the elements of this envelope, an effect which mastication produces sooner or later; it is this that authors have called dry or stationary decay. It is rare, however, that this de- pression is not succeeded by a yellow spot ; for nearly always the salivary fluids deposit a sediment there which alters the color of its subjacent layer. Besides the contact of the air suf- fices to change the whiteness of the crown deprived of its enamel. Gradually the tissue of the tooth softens in the place where the yellow spot manifests itself. It forms there a cavity which, increasing in consequence of the progress of its destruction, re- duces the enamel to the most superficial of its external layers, so that this substance, being deprived of support, breaks and dis- closes decay. This cavity thus formed, increases gradually in the interior, representing a cone whose base is at the surface, and whose diameter diminishes in proportion as its depth dimin- ishes. The course of this first period of the decay is ordinarily slow, and often the person who is affected is warned only by vague sensations, by obscure pains and the bluish tint of the tooth, which, to a practised eye, is a certain sign of the existence of decay. The opening once formed in the enamel, continues gra- dually to enlarge. If, however, it does not increase, it is be- cause the force of the destructive agent has ceased to act upon the opening, and is confined entirely to the internal layers of the 164 ANATOMY, ORTHOPEDÏA, ivory. It forms there, with the assistance of atmospheric air and other destructive agents, a large and deep cavern which presents exteriorly but a small opening ; the enamel may be easily broken, and we discover as in another case, the extent of the ravages in the interior of the tooth. Authors have called this humid caries. The progress of decay is, in general, more rapid among young subjects and among lymphatic individuals ; pregnancy appears also to have a great influence upon its course. But it is princi- pally afterwards that it appears externally, that its progress is sen- sible, as we will now show. Its cavity is entirely filled with a soft, brown, yellow or black matter, of a fetid odor, that the in- strument can easily divide and detach in successive layers, which become denser as the healthy parts are approached. This matter, which, according to Regnard, acts as an acid, assists powerfully by itself to extend the evil ; it constitutes one of the most active causes for propagating the decay. When the caries has penetrated to the interior of the dental cavity, the pulp finds itself in contact with external influences and becomes sensible to heat and cold and the impressions of hard bodies. The tooth is then the seat of obstinate pains which sometimes are spontaneously disclosed, sometimes pro- voked by the slightest exterior causes. These pains manifest themselves generally by access, and are accompanied by all the symptoms of a local congestion, and to which is added many times different nervous complaints. Throbbings are felt in the tooth and often in the temporal arteries, and an abun- dant salivation afterwards follows. This paroxysm, which is more or less long, is repeated at different intervals, and are often only the prelude of inflammation and suppuration of the pulp ; from thence is produced more or less serious inflamma- tory fluxions and different disorders. If, in this state, one removes the tooth, its cavity is found fill- ed with a greenish and very fetid matter. Its vessels trace across the ivory of the root a black color ; the dental cord is very large and filled with blood. Thus deprived of the organ of its vitality, the ivory continues to be destroyed ; the enamel alone remains, becoming broken off by fragments, and finally the root PATHOLOGY AND THERAPEUTICS. 165 alone remains, which ceases generally to be painful until extrac- tion, displaying itself in being extracted. All these ravages have place in the interior of the tooth, without they are called by some other symptom, but we do not observe their exist- ence before the rupture of the layer of the enamel, if, as the principle of evil, it is not accompanied by a pain at first obtuse and like a dullness, but finally becomes very acute. Caries of this kind, although less common, are nevertheless met with very often. Caries presents, in its course and in its symptoms, a number of modifications, which it will be difficult to describe ; which, however, some authors have attempted to reduce to species. Among others, Uuval admits seven, that he calls calcareous, decorticating, perforated, carbonated, disruptive, stationary and erosive decay. Maury has punctually followed this division. We do not follow it for two reasons : the first is, the characters which serve as a base for them are very variable, and altogether arbitrary, and that many do not really belong to caries, but to defects altogether different, with which Duval has confused them. The second motive is, that in multiplying divisions and subdivisions, in the study of specialities, it seems as if we wish to withdraw from the organs upon which they exercise the general laws of common life, which, ordinarily, ought to suffice to explain all. The adoption of the division of Duval causes us to regard caries as the type of all the diseases of the teeth, and of their changes that we have already described, under the names of discoloration and decomposition, and of erosion, and which we shall soon examine under those of the wearing away and even of fracture. This will approach least to error. If it is necessary to adopt a division, to facilitate the study of the disease which we are now treating of, we do not hesitate to receive that which we have formerly proposed, according to which there are two fundamental distinctions, under the names of dry or stationary caries and humid or progressive. If it limits too much the shades of caries, it has at least this advantage, that, in a practical point of view, it unites the most important charac- ters of the disease, that which, consequently, renders it more just, and better founded than the most of the numerous distinc- 10G ANATOMY, ORTHOPEDIA, tions that the desire of novelty and singularity has sought, in our day, to establish. 3d. Seat. — It can be said, in general, that there is no tooth the seat of decay, for all are subject to it ; some, however, more so than others ; the molars are principally affected. The inci- sors and canines of the upper jaw are more frequently affected with it than those of the lower jaw ; it shows itself nearly always upon the sides of the anterior teeth ; less frequently upon their external face ; more rarely still upon their lingual or inter- nal face, and scarcely ever upon their cutting edge. The large molars are frequently decayed upon their sides which touch each other, but more commonly it appears in the midst of the depressions of their triturating faces. If the teeth of this class are more subject to decay, it is because they pre- sent the most extended surface, and because the layer of enamel which covers their triturating surface is often weak and badly crystallized between the tubercles and sinuosities of the crown. It is necessary to add to these reasons the power of the mechani- cal forces which have the greatest resistance to overcome in the act of mastication, and the particles of food which remain in their depressions. The lateral sides of the small molars are at least as subject to decay as their triturating borders. Those of the lower jaw, but one point clearly marked, the same is the case with the incisors and canines. Finally, the teeth do not always commence to decay upon one point. We often find caries between all the eminences of the molars, upon the two sides of the anterior teeth, and some- times even upon different parts of the same side. All the parts above the gum, being more exposed to the action of exterior causes, can consequently be affected by it. The first signs of decay manifest themselves sometimes at the place where the enamel terminates, that is to say, the neck of the tooth ; but its progress is generally terminated here, and leaves the root untouched. There are, nevertheless, examples of the root being affected ; it is, however, very rare that the dis- ease penetrates to their extremity ; they are changed only in some parts of their extent ; still it is necessary to avoid consider- ing the different affections of the root as belonging to caries, for PATHOLOGY AND THERAPEUTICS. 167 very often, as we have already said, they are the results of morbid effects of the periosteum, which cause disorders more or less serious. • There is no practitioner who has not remarked that the cor- responding teeth in the same jaw are very often attacked with caries at the same time, or at very near intervals. This co-rela- tiveness is so evident to every one, that authors have sought to explain it. Some confine themselves merely to saying, that the corresponding teeth in the same jaw, being of an identical texture, become decayed at the same time ; others, that the dis- tribution of nerves being the same in them, they necessarily are equally susceptible, and yield at the same time to the active causes capable of producing unfavorable effects upon the dental system. Neither the one or the other of these two explanations, given for the purpose of contenting superficial minds, are admissible. In effect, the texture of all the teeth, except in regard to their quantity of matter, being identical, nothing, in this respect, can explain why the corresponding teeth in the same jaw are de- cayed at the same time. The distribution of the nerves can explain this phenomenon, if each dental nerve comes directly from the sensitive system to the tooth that it is required to give life to ; but, as we know, each of these diverse fibres comes from a common trunk, which communicates to all an identical sensibility, we can deduce nothing from this. The following, according to our opinion, is the only explana- tion which seems rational : the teeth which correspond in each jaw, being generally submitted to the same phenomena of forma- tion, development and appearance, ought, then, to possess an equal degree of vitality and sensibility, and consequently are compelled to yield at the same time to the action of agents which might put in play the predisposing diseases with which they are affected. This opinion confirms, besides, two asser- tions that we have already put forth and developed ; to wit, that a great number of the diseases of the teeth date their forma- tion from the follicles, and that caries is very often the result of interior causes. Finally, the wisdom teeth are sometime decayed when they 168 ANATOMY, ORTHOPEDIA, are cut, especially when their eruption is retarded ; this fact will also assist to prove that which we formerly endeavored to do, namely ,«that the acids that the aliments contain, or which form accidentally in the mouth, are not the principal causes of caries. The milk teeth are very often affected, generally the molars, and particularly the inferiors, whose roots destroy themselves gradually, even to the crown. These are often forced to be ex- tracted without the teeth of replacement, which are ordinarily separated from them by a partition, undergoing any change. But that which is still more remarkable, and which, to our great astonishment, we do not find described in any w T ork, is, that the caries of the milk teeth cause very rarely those sharp pains which accompany so frequently that of second dentition. For do we not see small children carried to a dentist, on ac- count of true dental pain? When we reflect, we see that it might necessarily be thus, because these teeth, condemned to fall, are separated, at an early period, from the centres in the midst of which they derive the materials necessary to their life and sensibility. The practical consequence which flows from this fact is this, when a child is brought to us for the purpose of preventing pain coming from the milk teeth, instead of treating the decay, we should examine if some fragments of roots do not tumefy the gums, or even perforate the alveoli, &c; and we will be assured that that pain is produced by some tooth ready to be cut, or by another cause. 4th. Diagnostic. — It is not always easy to discover caries, when it has not manifested itself by any external sign. The sensibility and pain, which often causes us to suspect them, do not always exist ; we have even seen persons lose a part or all of their teeth, without experiencing the least pain. Sometimes caries manifests itself by sympathetic pains, as chronic opthal- mies, otites, stubborn coryzas, etc., which cease, as by enchant- ment, after the extraction of certain diseased teeth. Then the pain and sensibility experienced by heat and cold, and by the contact of hard bodies, are not certain signs of caries, since they could be completely in fault. The inspection of the teeth remains to prove it, which, in general conducts to a more certain diagnostic ; we say, in general, for in some cases PATHOLOGY AND THERAPEUTICS. 169 we are obliged to resort to another mode of examination, which consists in percurating, successively, the teeth, one after another, by means of some hard body, until, by the pain or sensibility, we can determine the right one. 5th. Prognosis. — The prognosis of caries varies according to the extent, the seat, the progress and nature of the affection, and often according to the constitution, the age of the subject, and the diseases to which he has been exposed. Decay which attacks lymphatic individuals, whose parents had lost their teeth in early years, those which attack at the same time a great number of teeth, are in general a sad omen; for they are always followed by a total destruction of the dental system. That which is of a yellow color, ordinarily progresses more rapidly than that which is black. When its seat is at the neck, it is always more dangerous, because the destruction is very near the dental cavity, and necessarily reaches the pulp sooner. Again, this kind of caries is sometimes concealed, and we are not consulted in relation to it, until it has made great progress. Finally, experience attests that caries which affects persons who have a compact denture is always more dangerous. If we wish to enlarge this volume, and to deprive it of the practical character that we had intended giving to it, we might seek why the too great nearness of the teeth is harmful, and becomes, in a great number of cases, a cause of caries and a means of increasing the disease. But it suffices us here to prove the fact, and to re- mark that a modern author* has perceived himself able to explain it, in saying that caries proceeding from the obstacle that the near- ness of the teeth offered to the free course of the fluids which circulate in the enamel ; but this is a hypothesis too gratuitous, and which has not the appearance of reasonableness. By what means, then, can we remedy the inconveniences of a too com- pact denture ? By separating, with a file, the edges which touch. Now, a loss of substance might oppose still more the free course of the fluids of the enamel. We will return again to this subject. 6th. Treatment. — If, from pathological considerations which # Delabarre : work quoted. 22 170 ANATOMY, ORTHOPEDIA, precede, we pass to the therapeutical question, we must acknow- ledge that, in the treatment of caries, we ought to have in view but three distinct objects : to preserve the teeth healthy and from all disease ; to seek to remedy their disorders by endeav- oring to arrest their progress; to destroy or alleviate their pains. To accomplish the first, we must remove all the causes, that, directly or indirectly, cause or develope caries ; and we can ar- rive at this result only by following, with punctuality and per- severance, the hygienic precaution and cleanly habits, to the development and explanation of which we have devoted a chap- ter. If the tooth is badly decayed, it is necessary to extract it, or if it is possible to plug it, or if the disease is light, to isolate the affected part by the use of the file ; for it is an incontestable fact, that caries can be propagated by simple contact, whatever may be the explanation of the means we have sought to give of this propagation. The natural deduction, from what we have previously said, is to separate, at an early period, the decayed teeth that touch, and for a still stronger reason those which thus change rest one upon the other, generally, when this vicious disposition is carried too far, others multiply. Many practitioners, struck, without doubt, with the insufficiency of the explanation given of the propaga- tion of caries from one tooth to another, have denied the utility of this operation, because some persons have preserved their teeth free from decay, notwithstanding their close proximity. This reason is specious, for it rests upon exceptions, which proves nothing in the presence of the plurality of cases which attest this law of communication. Let us, then, conclude, that when the decay has made but little progress, and affects their lateral surfaces, it is necessary to hasten to remove, by means of the file the decayed portion. But when it has been carried so far that it occupies the external or internal side of the crown, when it will be difficult to use the file, it is necessary to plug the tooth, or, to speak more concisely, to fill it with leaves of gold, silver or platina, or some other sub- stance capable of exactly filling the cavity, in such a manner as to completely exclude all foreign substances. PATHOLOGY AND THERAPEUTICS. 171 This operation succeeds in a great number of cases, especially if the dental pulp has not been exposed. But if it has been, it is necessary to proceed with prudence to those operations, the results of which might be injurious; for it is easy to perceive that if the tooth be the seat of a sharp pain or acute inflamma- tion, the presence of foreign bodies employed to fill the diseased cavity, would only augment the one and favor the other. Some practitioners abstain from plugging teeth in pregnant women, under the pretext that they have seen accidents follow the most simple operations, especially among women who have a dispo- sition to dental fluxions ; they prefer, when pregnancy is much advanced, to wait until after the birth of the child. We do not approve of this plan ; for, during pregnancy, the caries has at the same time destroyed the tooth altogether, and causes us to regret a temporization that, according to us, nothing will justify. According to our opinion, even in the exceptionable condi- tions that we have mentioned, it is necessary to remove the caries promptly from the action of the air, and the contact of ali- mentary particles ; for among these persons it progresses with fearful rapidity, and communicates easily ; to temporize it would be an imprudence which has the double inconvenience of favor- ing the progress of the decay, and of rendering it difficult or impossible to keep the mouth clean. Some dentists, struck with the inconveniences of plugging teeth affected with humid caries, have proposed different sub- stances to dry these caries, and to render the tooth in a fit state for natural remedies, by the hardness that these substances have appeared susceptible of acquiring. These pastes are composed of different salts and of some sharp narcotic powders, to which they have given the name of obliteric cement, or something analogous to it. As these pastes, notwithstanding the hardness that they can acquire, do not dispense with plugging, we believe them to have been advised rather by the desire of attracting public attention, eager for novelty, than by the wish to disclose a therapeutical indication rationally established. We will speak more of it in future. Dental caries, we have said, is ordinarily accompanied by pain, which constitutes a particular indication for treating this 172 ANATOMY, ORTHOPEDÏA, disease. When these pains have acquired an extreme intensity, and have become permanent, without doubt the tooth should be extracted, which is the seat of the disease, as this will relieve the pain. But, in many cases, the pain is slight, and manifests itself at distant intervals, and only as the result of accidental circum- stances, whence it is easy to recognize the cause, and to destroy or moderate the effects. It would then, at least, be imprudent to sacrifice an organ scarcely affected, which might in a moment have its pain removed, and still render important services. As decay is the cause of the extraction of a great number of teeth, perhaps it is this more than any thing else which in- duces us to blame the readiness with which a number of per- sons, for a slight pain, wish a tooth extracted, and the cold in- difference with which certain dentists accept their proposition. Let any one reflect an instant, either upon the mutual relation which exists between the teeth and the bony cavities which re- ceive them, or the reciprocal support that they furnish one another, and he will be fully convinced that their great solidity depends in part upon the preservation of them all. In extracting a tooth, we shall see, in the description of operative mechanism, what precautions one should take in per- forming this operation, for he is liable to fracture more or less the bony partition which forms the cavity destined to receive it. This fracture causes a weak point in the maxillary arch ; the necessary consequence is then, by the collision of the jaws in the act of mastication, that all the teeth, pressing towards this point where it finds a defective resistance, are liable to lose that firmness which they enjoy in their natural state. Without doubt we see every day persons who have very solid teeth, althoi gh one or more teeth may be wanting ; but these excep- tions do not destroy the physiological reason by which we could prove that the teeth themselves furnish reciprocal aid. Being convinced of this fact, the dentist ought then, in nu- merous instances, to seek to calm the pain before resorting to the extremity of extracting. And certainly, if the possibility of arriving at this result be proportioned to the multiplicity of the means proposed to this effect, the destruction of the pain will be the simplest and easiest thing in the world ; for there is no point PATHOLOGY AND THERAPEUTICS. 173 in medicine, however fruitful, upon which the genius of thera- peutics, might not be exercised. Many persons, guided unfor- tunately more by the desire of gain than by the love of science and good of mankind, make sport of deceiving the credulity of the public and their taste for the marvellous, by giving, as certain specifics, either efficacious means, but which, reduced to their just worth, have but a circumstantial action, or other means ab- solutely useless, but whose imaginary action, depends upon cer- tain imposing or mysterious demonstrations which accompanies their employ. Truly, as a modern author remarks, these are the fallacious promises which have sharpened against us the arms of the sa- tirist, whose darts are not only too just in numerous instances, but which prejudice many persons unfavorably with regard to our art, thereby preventing them from counselling us, which, had they have done in time, might have preserved their teeth but slightly altered, and prevented them from sustaining so many painful operations to which improvidence reduces but too often to our calling. "It is in vain that experience has proven a thousand times the inefficacy of most of the sovereign remedies to cure the pain dental caries occasion, still they are sought with eagerness, and received with an admiration which, without legitimacy, shows perfectly at least the net drawn on all sides for the credulous public. Happily the vogue of this remedy is as ephemeral as it is great; but so great is the fear of pain, that persons are mis- taken, and a number belonging to the enlightened classes of so- ciety have recourse to their use. These remedies, which have appeared with so much brilliancy at different epochs, have fin- ished their career by being unmasked." To the eyes of every enlightened person, the means employ- ed for calming pain, caused by caries, ought to differ as much as this disease varies in its intensity, its cause and its nature. Whatever may be these means, their mode of action is reduced ; first, to calm the inflammation of which the dental pulp or the auxiliaries of the decayed tooth might be momentarily the seat ; secondly, to excite another part more or less distant from the diseased tooth, and to absorb thus the pain in this last ; thirdly, 174 ANATOMY, ÔRTHOPEUIA, to suppress locally or generally or even to destroy the sensibili- ty of the tooth ; fourthly, to withdraw the cavity of the caries from the action of the air, of alimentary particles and from all matter more or less irritating, with which it may come in con- tact. There is no substance having any efficacy, whatever may be the prestige or secret of its use, even emuletes on and reme- dies of commerce, which does not belong to one of the four classes of which we shall now speak. We will pass them successively in review, and reduce them all to their just worth. The means which belong to the first are the antiphlogistic. These are employed, although their name indicates this, when the pain is developed with inflammatory characters, as for ex- ample, when it appears under the influence of a sudden change of temperature ; when the gum surrounding the decayed tooth is rough and tumefied; when the neighboring parts, which seem to occupy all the side of the jaw from the diseased tooth, are swollen, and when the vital reaction is made known by an elevation of the pulse, a redness of the face and a beating of the temporal arteries. The most efficacious of these means are sanguine evacua- tions, general or local. The first is obtained by opening a vein in the arm or foot ; the second, by applying some leeches behind the ears or below the angle of the jaw, and even upon the tume- fied gums. This last means, although it remedies the disease, is more simple and less difficult to employ than is commonly believed ; it consists in enclosing a leech in a glass tube, and presenting its buccal extremity to the gum that it may deprive it of its superfluous blood ; this can be accomplished still better by scarifying it first with a small lancet. These sanguine evac- uations are commonly followed by diet, drinks, softening gar- gles, fumigations, cataplasms, and applying upon the gum a warm fig, etc. In the second class are arranged, under the name of deriva- tives or revulsives, all the means capable of producing reactions, pediluvia and sinapisms, applications of cold water to the head and upper part of the neck, and of blisters and cups behind the ear. Finally, sudden moral feelings, strong impressions, which PATHOLOGY AND THERAPEUTICS. 175 sometimes instantly calm the most acute dental pains, among nervous persons, are only derivatives which, affecting the brain immediately, convey the painful sensation from the cavity of the tooth. We can then attribute to fear the cessation of pain which so often takes place, as by enchantment, even when the patient arrives at the door of the dentist, or, in other cases, at the sight alone of the instruments which are employed in the extraction of a tooth. Sometimes an energetical purgative has produced the same result. In the third class are placed the innumerable odontalgics, or means which are employed for the purpose of calming or even of immediately destroying dental pain. They act in three ways : narcotics, which moderate active sensibility; they com- prise all preparations in which opium, camphor, henbane and belladonna enter ; tinctures and natural oils, which excite the the membrane which lines the dental cavity ; finally, concen- trating acids and cauteries, which cauterize either the dental nerve, or the decayed part. Opium is ordinarily employed in the state of an extract, and in doses of one half a grain, which is dropped upon cotton, and then placed in the cavity of the tooth ; the tinctures are fre- quently of myrrh and spoonwort; and the essential oils those of mint, cloves, cinnamon and cajeput; we might add a number of other preparations, as, for example, a plant known under the vulgar name of catsherb, (nepeta cataria de Linne,) whose use Dr. Guastamacchia recommends, and which have nearly the same chance of success. Their mode of employment is similar to that of the acids, with this difference, the moist cotton should be covered with a piece that is dry, in order to preserve the neighboring parts from the irritating action of these substances, which is either hydro-chloric acid or tincture of cantharides and creosote, Ex. belladonna, .... gr. 10, Camphor, gr. 10, 01. cajeput, § i, Tr. cantharidei, • . . . § i. Misce. This opiate and similar ones seem convenient, as Maury with reason remarks, when the odontalgy caused by the caries has its seat in the superior jaw, because we can apply them in an immediate manner ; which might not be as easy if we employed medicinal liquids. We can make for the same pur- pose a paste consisting of a concentrated decoction of roots of sweet fennel, ginger, frankincense, heads of cloves and of cin- namon, reduced to the necessary consistence. We notice that this means has in view an irritation sufficiently great to inflame the dental pulp, and under this influence it ceases to be sensitive, by the destruction of its vitality. Finally, in order to complete the list of means prescribed to arrest caries, or the evils attendant upon them, we should men- tion camphor, which a learned chemist has recently prescribed PATHOLOGY AND THERAPEUTICS. 177 as an infallible remedy.* The therapeutical indications upon which this is founded, is the destruction of the worm which, ac- cording to some, accompanies the disease. This opinion is not new, as we perceive ; for it is the basis of all the boastings of the charlatans, who seek to deceive the blind credulity of the people. We should, then, refuse to give credence to this, although, by means of microscopic examinations, made without prejudice, we have sought to enlighten ourselves ; and we see, in the cam- phor, only a substance which adds to its anti-spasmodic quali- ties the odontalgic action which it exercises sometimes. Concerning all of these means, and an infinite number of others, which ignorance and cupidity daily divulge to the marvel- lous, if they succeed sometimes, they fail oftener, and frequently the patient is relieved of his sufferings only by fluxions, which cause the suppuration and destruction of the dental pulp. When the caries has made extensive progress, the extraction of the tooth can only free the patient from the lacerating pains that habitually accompanies it. Before adopting this final operation, many authors have proposed other means. One of the most specious is the excision and extraction of the dental ganglion; for this operation a small drill is used, which is placed in the cavity of the fang, and, giving the drill a few rotary motions, it is withdrawn with the dental pulp attached. Delmond has described, with care and much detail, this ope- ration.f If we have not at hand the proper instrument for this operation, a substitute might be made of iron or platina wire, resembling a single fades, and which can be readily introduced into the canal of the tooth. By giving the wire a shape resem- bling a cork-screw, we can with it readily withdraw the dental pulp. When this method, which cannot be employed excepting for the six anterior teeth, on account of a number of difficulties which we might mention, and when the crown is not suffi - * M. Raspail, Letters on ihe Medical Virtues of Camphor, in the Hospi- tal Gazette, November and December numbers, 1838. f A Treatise upon a New Method of Destroying the Dental Pulp. Paris, 1824. 23 178 ANATOMY, ORTHOPED1A, ciently injured for us to decide to sacrifice the tooth, some prac- titioners prefer to trepan it in the direction of the root, with a small burr drill. The dental cavity being thus exposed, they destroy the nerve, and plug it, after having kept it filled with cotton several days, if the cavity continues healthy. In speaking of Oudet, as a practitioner who frequently adopts this method, we do not pretend to say that he was the originator of it; for we find, in the Medical Review, a detailed description, given by Fattori. "This method," say the compilers of the article, "is entirely based upon this principle, that, whatever may be the cause of the pain, it ceases when we extract the nerve, or in any other way destroy it. It is necessary, then, in order to remove the pain, to find a mode by which we can cut off the dental nerve at the point where it enters the tooth. It is this to which Fattori has arrived. By means of suitable needles, which he adapts to a trepan, he cuts off the nerve, after having promptly perforated the painful tooth, which becomes, by this operation, ever after insensible." This operation, unfortunately, is as far from being certain in its results, as it is ingenious and rational. From the knowledge which we have of the anatomy of the teeth, is it always certain that we can strike the nerve in perforating the tooth ; and if, as it might ordinarily happen, the operation has to be repeated, what one will be sufficiently patient to endure the pain of a secoud operation, and honest enough to avow that it is not equal to the loss of the organ? This operation, to say the least of it, is rarely successful ; and not much can be gained in per- forming it upon teeth which have but one root. M. Malgaigne thinks that, in executing the operation of Fat- tori, it is necessary, at least for the posterior teeth, to make a large incision in the gum, and finds that some advantage is ob- tained by extracting the tooth posterior to the origin of the pain, in order to permit the proper instrument to be introduced to di- vide or crush the nerve, to the depth of its alveolus. We will first remark, that if Fattori had ever dreamed of making an inci- sion in the gum, for facilitating the operation he recommends, the remedy truly is worse than the disease. We remark, sec- ondly, that, since Malgaigne recommends the extraction of a PATHOLOGY AND THERAPEUTICS. 179 tooth, it would be better to extract that which is diseased ; there are one hundred probabilities to one, that the pain of the opera- tion would be greater than the patient could endure. The manner in which the nerves of the dental apparel are distributed strengthens this belief; it is certain that the destruction of the nerve of one tooth, a nerve which has nothing in common with the one preceding it, is a means incapable of destroying the one which adjoins it, much less could the destructive instrument reach the common trunk of the nerve, that which would be of great inconvenience, excepting in cases of very intense general dental neuralgias, as we shall soon see, in speaking of nervous diseases of the teeth. Ambrose Paré and Urbain Hémard have also advised, in case of caries, to excise the crown of the tooth. They call this operation decapitation of the tooth, doubtless in opposition to the chaplet that the teeth form over the nerve, by the union of their bony structure ; this operation is followed by cauterization of the nerve. But it is not always exempt from danger; the shock communicated to organs which are already the seat of an exquisite sensibility, and other accidents that often follow it, have caused it to be neglected by modern practitioners. We perform it constantly only for the six anterior teeth, when we wish to preserve the roots, in order to adapt artificial crowns to them. In order to practice this excision, which is generally very painful, we should, as we shall see hereafter, grasp the crown with excising forceps, or remove the crown by the file. Some other operations more or less injurious have been pro- posed for quieting the pain of the teeth and for preserving them. Such as their luxation, extraction and replacement and excision of their nerves ; but we hesitate not to say, that it is more in accordance with the speculative spirit of the age than with a healthful practice that these ideas have been advocated, we do not think that the above should be adopted as general rules of practice. Exostosis and Spina- Ventosa. Under the name of exostosis we designate hard immovable ISO ANATOMY, ORTHOPEDIA, tumors, which develope themselves upon the surface of bones, and which it is believed are formed by a swelling, and consist of a true hypertrophied condition of their tissue. The teeth are subject to this affection, but the great degree of analogy which exist between the bones in general, and the roots of the teeth, explains why these last are most ordinarily affected. We say the most ordinarily because there exists examples of exostosis even upon the crowns ; we have seen a large incisor upon the anterior face of the crown of which there is a sort of node raised upon the enamel ; the person to whom this tooth belongs has observed the gradual development of this deformity, and used efforts to arrest the pains which if occasioned by the enlarge- ment of the alveolus, upon the circle of which the enlargement in its progress toward the root has encroached. The cause of this swelling of the teeth, when it affects the roots, is very obscure and difficult to perceive before extraction. It exists sometimes only upon the side of the tooth, which pre- sents a rounded or angular form, and, in some cases, it occupies the whole circle and height of the root ; in other cases it accom- panies the consumption of the root. This disease, of which we possess a great number of examples in our pathological col- lection, is nearly always the result of engorgement and the ossification of the dental periosteum. It may exist when the crowns are healthy, but it more frequently manifests itself upon subjects whose teeth have become painful, either from indolent inflammation, caused by the decay of the body of the tooth, and which extends even to the roots, or is the result of a gouty or rheumatic diathesis. It is difficult to prove, in an exact manner, the existence of exostosis of the roots, for it never causes suppuration, and the gum nearly always continues in a healthy state. It may be in- ferred from the severe pain which accompanies it, pain whose intensity is not always the same, and which, in every case, an- nounces itself after it has acquired considerable size; then the alveolus becomes enlarged by the pressure of the diseased root upon its walls, and this either becomes movable or is forced out by the alveoli, and passes beyond the level of the neighboring tooth, at which point it is altogether opposed to mastication. PATHOLOGY AND THERAPEUTICS. 181 Some persons, says Fox, with reason, attribute this kind of deformation to congenital vice of conformation of the root, but as it differs very much from all the defects that the different or badly formed roots of the teeth that are not diseased present, one is compelled to believe that the cause is not a morbid action which occasions an osseous deposit, as in all the other cases of exostosis. All that art can do in this disease, is to seek, when the pain exists, to combat it by the three odontalgic remedies which we have described in the course of this chapter, local bleeding and topical emolients, narcotic medicines and révulsants. But if the pain continues, so that the tooth becomes loosened, or by its swelling occasions a perceivable deformity, it is necessary to ex- tract it. The example given by Fox,* proves that to delay this operation is prejudicial to those who are affected with this dis- ease. But in doing this we should be careful not to confound it with rheumatic affections of the jaws, and especially with the alveolar arches, of which they are, however, often the seat, and about which we shall soon speak. As to spina-ventosa, it attacks principally the roots of the teeth, but it differs from exostosis, as the swelling is not so compact, but spongy and sometimes lamellar. The cavity of the diseased root is enlarged, its opening is larger than in its normal state, its thin wall seems to have been distended by inflation. This dis- ease is very rare ; we do not possess a single example of it. It is accompanied by the same symptoms as exostosis, and has the same therapeutic indications. Softening of the Teeth. Although authors have made no mention of this disease, it does, nevertheless, exist as an essential affection. The teeth af- fected with it presents a cartilaginous consistence, denoting that, under the influence of a cause whose nature it is difficult to de- termine, are deprived of the earthy salts which enter into their *This author relates the case of a lady, all of whose teeth he was obliged to extract, one after another, because their roots were exostosed. 182 ANATOMY, ORTHOPEDÏA, composition and are reduced to a parenchynea into themesches of which they are deposited. Those teeth resemble bone which have been in a concentrated acid ; a circumstance which might confirm the opinion of those who assimilate teeth to bone. We have met with many cases of this extraordinary disease ; one of the most curious was a young subject whose two small molars, one on the right, the other on the left, were reduced to the consistence of wax. Pressure exerted upon the crown by the finger, was sufficient to make them undergo a very evident change. We preserved them carefully as the only well authenticated example of this affection, until we had occa- sion, last year to speak of it to Dr. Sander, the ancient teacher of cliniques at Rotterdam ; this honorable confrere assured us he had met with a lady who had lost all her teeth from a soft- ening of their tissue. We requested him to give the most pre- cise particulars of this case. His reply, dated 10th of April, 1 842, we here quote : "Having arrived at Rotterdam, I spoke with the surgeon, A. Nortier, who with me visited the lady, Madame D ; I was confirmed that her teeth was in a complete softened condition ; we could by taking the teeth between the thumb and finger change their shape. Their consistence was similar to the ma- terial which the glazier uses for fixing in glass. This lady, aged more than sixty, was very scorbutic, her gums were swollen and a fetid odor escaped from her mouth. She lost all her soft teeth to the alveoli, and these were filled with soft matter, which be- fore constituted their roots." As this disease, habitually declared under a deterioration of the general constitution, it is towards this last state that all our therapeutic efforts should be directed ; the office of the dentist in this case should be wholly confined to the extraction of the teeth, as they are rendered by this transformation altogether use- less, and very annoying. Diseases of the Dental Pulp. In the pathological view which we have presented of caries, we have seen that the severe pain which sometimes accompa PATHOLOGY AND THERAPEUTICS. 183 nies this affection, is in general the result of its invasion of the dental pulp. This pulp can, nevertheless, in some cases, be af- fected without any traces of caries ; and this affection is either an inflammation, a fungus, an ossification, or finally a pure neu- ralgia. 1st. The inflammation of the pulp, in nosological language, is called odontitis. It more frequently affects the teeth of adults than those of children, and is generally more common in the com- mencement of the caries or wearing away, than in advanced stages of this disease, this inflammation is characterised by a sharp pain which is increased by a blow upon the crown of the tooth, and which does not extend at first to the gum or the jaw, but toward the second or third day the inflammation and pain reaches their structures, if however it does not progressively di- minish; then all the nerves of the face participates in this pain and are pulsative. But the pulsations of the arteries of the pain- ful side are much more accelerated and the beats stronger, whilst in purely neuralgic pains they are only much stronger ; sometimes, however, without taking this characteristic, the in- flammation ceases altogether, and the disease only leaves its traces by a species of bastard paralysis, which accompanies the swelling of the gum. The pain is such that we are obliged to extract the tooth. We perceive the dental pulp, at the extremi- ty of the fang inflamed, tumefied and even sometimes suppu- rated and gangrenous. This is not expressing a baneful opinion, when we say that the causes of this inflammation are sometimes the impressions of cold and heat — sudden changes of temperature — violent shocks upon healthy teeth or light blows upon those decayed, or the retention of alimentary particles in the decayed portion of the tooth, or finally a metastasis of disease from other parts. This last cause wants especial attention; for it is to this we can bring to bear a great number of very intense odontalgics, which are completely rebellious to the means which might not be appropriated to their special use. It is thus that we have seen a young man a prey to the most agonizing pain of the teeth, and who submitted to have four, successively, extracted without relief, and which yielded only to a nasal haemorrhage, to which he was accustom- 184 ANATOMY, ORTHOPEDIA, ed, which was effected by powders inhaled for the purpose of irritating the mucous membrane of the nares. As to the treatment of odontitis, it ought to be in conformity with the rules for caries, either anti-phlogistic or anti-spasmodic, or over-exciting, or, finally, escharotic. We will confine our- selves to noticing this inflammation in its most ordinary forms, under its least dangerous character ; it often happens, as we shall see in speaking of dental neuralgia, properly so called, that the inflammation of the pulp increases the size of the nerve be longing to the tooth, and even affects the brain at the point where this nerve arises, and occasions sympathetic affections in the parts to which the fifth pair of nerves are distributed, or cerebral accidents of a serious nature, against which the extrac- tion of the tooth, which was the primitive point of pain, in most cases, is altogether useless. 2d. When the dental canal has been dilated by disease, or finds itself accidentally opened, the soft parts which it enclosed may be the seat of a fungus. If the canal has been dilated towards the extremity of the root of the tooth, the tumefied pulp becomes consistent, reddens, and forms a cord larger than when in a natural state of health, and in this condition remains, with a thickened alveolar membrane. When the canal is opened by caries or fracture, there appears exteriorly, on the pulp, a small red tumor, bounded by the edges of the cavity of the tooth, and very sensible to the contact of for- eign bodies. This sensibility is sometimes such, that mastica- tion is not only impossible on the diseased side, but the patient dares not even close the mouth, for fear that the corresponding tooth, from above or below, should strike upon the fungus. It happens often that this tumor becomes hardened, falls, and of itself disappears. In cases where this advantageous result does not take place, art should not fail to effect it. It can be effected by excising the fungus, or cauterising it; or, when these means have been used without success, it should be ex- tracted. The dental pulp may be, as we have said, independent of the inflammation and the fungus, the seat of a true ossification, which is caused by two means : either when the tooth is worn PATHOLOGY AND THERAPEUTICS. 185 off, then the pulp is ossified at its contact with the table which closes the dental canal ; or, when the tooth is decayed, the ex- tremity of the pulp terminates by a bony fibre, which remains suspended to this pulp; for, assuming a pathological state, this ossification, according to the judicious remarks of Mayelin, is the result of a beneficent foresight of nature ; for, in the case of wearing away of the bony plate of the tooth, it becomes adherent to it, and augments its thickness ; in the case of caries, it closes the cavity, and prevents the denudation of the parts contained in the dental canal. But it often happens that this bony fibre prolongs itself in the interior of the canal, compresses the pulp, and occasions the pains, the cause of which it is difficult to determine at first. It is that which we have observed many times, as Rousseau expresses in these words:* "A young man, of about thirty years of age, being tormented with very violent pains in his teeth, presented himself to me, in order to have the tooth extracted, which he believed was the cause of his sufferings. This tooth was not affected by caries, and, in the mean time, 1 endeavored to con- vince myself that this was the principal seat of the pain. I ex- tracted it; not having been able to discover any change in it, I broke it in order to examine the interior, and I found, in the dental cavity, a bony fibre of considerable size. I perceived, then, that this fibre, by its continued growth, irritated the ner- vous pulp, and pressed it against the walls of the cavity, had caused an inflammation, and was the evident cause of the pains which this young man was a prey to for so long a time." This case appears much more frequently than it is believed, even at the present day. We find a remarkable one in an Italian collection.! It is thus stated : "An Italian lady expe- rienced a continual glowing or tingling in her left ear, which appeared to increase daily, and which she compared to the noise of a bell. This obstinate sensation having resisted every reme- dy, this lady became very sad and hysterical. She had recourse, finally, to Dr. Buzzi, dentist to the court of Tuscany. This * Work quoted, page 257. t Medic. Observ. Naples, 1st December, 1833, 24 186 ANATOMY, ORTHOPEDIA. physician examined, with the greatest attention, the external auditory passage, the Eustachian tube, and the buccal cavity, and discovered no derangement there. He perceived no caries upon the teeth, which he examined very carefully ; nevertheless, he pierced each, and when he came to the left canine of the upper jaw, the lady perceived the tingling sensation. Regard- ing, then, this tooth as the seat of the disease, Dr. Buzzi ex- tracted it, and immediately the lady was freed of a disease which had, for a iong time, tormented her without ceasing. He cut the tooth in two, lengthwise, and found, in its interior cavity, a small bony fibre, suspended to the nutritive artery, and similar to the clapper of a bell." Nervous or Dental Neuralgia. Independent of the different kinds of pain which determine, in the dental system, the different diseases that we have treated of, and which have their primitive seat in the diseased tooth, that is to say, which proceed from the periphery to the centre, the teeth present others, which have no very apparent cause, proceeding from the centre to the periphery, which is dependent upon a direct lesion, either of the nerves distributed to these organs, or from that part of the brain from whence these nerves originate. The first are generally of an inflammatory nature; the second, on the contrary, are nervous, and consequently auxiliary, and, in strict medical language, we should give them the name of odontalgics. Thus, while some are of an inflammatory nature, which discloses their usual progress, their throbbing sensation, and the rate of the individual they affect, which are ordinarily men, adults, robust and sanguine subjects ; the others are fol- lowed, on the other hand, by a brisk and unexpected action, are not usually accompanied by arterial beatings, often take an intermittent form, and principally affect susceptible individuals, who have suffered from long disease, hysterical women, finally, persons tormented with rheumatic affections and transcurrent nervous diseases, which have a strange analogy to rheumatism, and which we commonly designate rheumatic pains. PATHOLOGY AND THERAPEUTICS. 187 In the odontalgia which we have already spoken of, by the percussion of the teeth upon the place where the pain is felt, we at once ascertain which is the diseased organ ; in those in which there is doubt, this method of examination is sufficient only to prove that all the dental range on one side is affected at once. There, all the phenomena are concentrated upon a single point; here, sharp sympathies are put in action ; these are otites, tic- douloureux of the face, in a word, phenomena which prove that different divisions of nerves, of the fifth pair, are affected. Thus, as a consequence of this fact, and of those that we have given, whilst the extraction of the diseased teeth, in the case of inflammatory odontalgy, causes the pain to cease, in nervous odontalgia this extraction is a useless operation. Some dentists, being ignorant of this distinction, daily com- mit horrible mutilations, and compromise an art, which, properly attended to, would conduct to the best results. Nevertheless, we acknowledge that elementary works, written at the present day, upon this art, are far from having established this distinc- tion, since some of them have not even suspected it; but, in reading with more attention the general treatises of surgery, dentists might have avoided this error. There, in place of seek- ing to calm all dental pains by local means which we have de- scribed, they would seek, at early periods, to employ means more appropriate to the nature of the disease, as revulsives, and applying sinapisms to the legs, or very cold pediluvia, applying cups to the nape of the neck, or even upon the cheek, bark or sulphate of quinine in large doses, narcotics, such as opii y bella- donna, ether, &c. Benjamin Bell, an English surgeon, a member of the college of surgeons of Ireland and Edinburg, has confessed the distinc- tion that we have made; he expresses himself thus:* "Under certain circumstances, we perceive that the pain from the tooth depends upon an affection of another part and no remedy will succeed, unless directed towards the primitive disease. Rheu- matism is sometimes the source of the disease, or arthritic * A Complete Course of Theoretical and Practical Surgery, translated by Ed. Bosquillon, 1796, wol. A, page 181. 188 ANATOMY, ORTHOPEDIA, diathesis ; it is often the symptom of hysteric affections which pregnant women are subject to ; it frequently depends upon a disordered stale of the stomach. Among the sympathetic affections which determine dental neuralgia, there are none which are more frequent than those which have their seat in the organ of hearing. These changes sometimes have a most fatal result, as the following proves, which has been related to us by Dr. Meleg, formerly of the school of Strasburg. "A young boy, of a good constitution, presented himself at the venereal hospital of Strasburg, affected with a blennoragia and itching. The treatment of these two affections were prompt- ly conducted, but with much prudence. At the end of a few days, a very severe odontalgia manifested itself; fever, headache, beating of the temporal arteries, &c. followed. He was bled copiously, but this had but little effect ; we then extracted the decayed and painful tooth. Then pains in the ear appeared, which we endeavored to appease by applying leeches to the mastoid apophysis ; but the toothache continued, and the pain extended to the whole of the lower jaw, accompanied by loss of rest, incubus, frightful dreams, and sharp cries. The violent pains of the ear continued, and assumed the character of a noise like that produced by the blows of a hammer upon an anvil. Six days elapsed, but he still suffered the most agonizing pain. He was now seized by so furious a delirium, that no one could approach him. Although the auditory canal was healthy, all the teguments of the ear and temples were so tender, that the most light contact with them produced the most agonizing pains. The delirium and fever continued, accompanied by spasmodic motions of this lines, great dilation of the pupils of the eye, continued weeping, rattling in the throat, a lethargic state, and, finally, the death of the patient, after eight days of the most excruciating sufferings. "On opening the subject, the brain was found penetrated by a general vascular injection ; in some places its substance was similar to sand ; the dura mater, corresponding to rock, pre- sented a remarkable redness, and was lightly raised in reference to the superior semi-circular canal. The incision of the mem- PATHOLOGY AND THERAPEUTICS. 189 brane caused a small quantity of reddish and clotted pus to flow. After having washed the surface, we perceived that the walls of the canal were decayed, and that they had evidently communication with the labyrinthial cavities in which the pus had formed which flowed from the dura mater. Moreover, the pus had the same consistence that the morbid products which are found in the interior of the ear, whose membranes were red, thick, and seemed softened. The middle ear appeared un- touched ; on examining the mouth, we found many of the teeth decayed only at their roots." It might be asked, what was the primitive cause of all these disorders? We do not hesitate to admit that odontalgia was. The pain which accompanies it increases, and is propagated to the brain, and is limited by causing, in this last organ, a primitive sympathetic disturbance, but which, under the incessant action of the odontalgia, locates itself in the cerebral centre, and ra- diates towards the internal ear, where it locates itself with an energy as much greater, as the organ affected is more delicate, and as the patient finds, in the noise of the great hospital, a cause of excitement sufficient to aggravate his disease ; for every one knows how prejudicial noise is to persons affected with otitis. That sympathy so intimate which unites the dental apparel to the organs of the ear has, however, been noticed long since ; thus Hard, Deleau,and most physicians which are occupied in a particular manner with diseases of the ear have often sought to prove the original cause of nervous surdities, which date their first existence from a primitive and concurrent injury of the dental apparel. No author, however, has given a satisfactory explanation. Jobert says, in reference to this subject ; # "we should, nevertheless, seek an explanation of this fact from the anatomical arrangement of the different parts. Examine, then, the relation between the chorda tympani and the dental and lingual nerves, as the termination of this same chorda tympani as in the facial nerve, of which it appears to be only a branch ; notice, then, the anastomosis of this last nerve with the acoustic ♦Studies upon the Nervous System. 190 ANATOMY, ORTHOPEDIA, nerve in the internal auditory channel, and you will probably be in the right track. I believe, in effect, that is the result of the nervous distribution that we can attribute the surdity which accompanies the phenomena of dentition." This explanation, says Mueg, # seems to lack exactness. It is established daily, that the anastomosis are only of juxta posi- tions ; that the nervous fibres, after the reunion of the two roots never unite together; they proceed separately, and independent of each other ; and that, consequently, there can never be the least conflict between them, excepting in the case of nervous sympathy. (We have already made this observation on page 257, in speaking of the proposition that Malgaigne makes in order to destroy the nerve which belongs to one tooth in order to calm the pain which is felt in the preceding one.) We draw two conclusions from thence ; first, that the pain neither irritates it, pathologically, or mechanically, nor can it transmit itself to the different organs by the anastomosis of their nerves ; second- ly, that each time that a pain co-exists sympathetically in a part with the pain of another region more or less distant, it manifests itself by a reaction of the nervous centres. We can thus ex- plain perfectly the auricular sufferings which so often accom- pany odontalgia, and vice versa ; hence these always result from the phenomena of reflection." We may now definitely conclude that all the pains which are felt about the teeth are only the result of a physical alteration of their substance ; that, whatever may be the cause from whence they proceed, they may radiate towards the brain and produce serious effects; finally, that the dentist who employs no other means but extraction, will sometimes be exposed. In every case, when a dental pain is evidently of a nervous nature, two kinds of means present themselves for our consider- ation ; the one is under the jurisdiction of the medical matter, the other belongs to the operative physician. The first are placed in the numerous class of anti-spasmodics, as opium, which is principally administered under the form of salts (acetate or * Of Electricity applied for the cure of Surdity, Review of Specialities, Sep- tember, 1842. PATHOLOGY AND THERAPEUTICS. 191 hydro- chlorate of morphia) by the endermic method, that is, by the deprivation of the skin of its epidermis, in doses of from the fifth of a grain to a grain; henbane, datura stramonium, bel- ladona, that Deleau pretends to have employed, with the great- est success, under the form of cataplasms, in all neuralgic affec- tions of the face; afterwards the asafoetida, cherry leaves; finally, he employed cups, blisters, by the epidermic method, that is to say, after having deprived the skin of its epidermis, to ad- minister doses of from the fifth of a grain to a grain ; Deleau pretends to have employed with the greatest success under the form of cataplasms, in all facial neuralgics, as guiacum, datura stramonium and belladona ; afterwards, asafœtida, cherry leaves ; finally, blisters, cups, moxas, etc. If, as is sometimes the case, the pain takes an intermittent form, we should not hesitate to administer sulphate of quinine. Another means which belong to operative medicine, and which should never be employed unless the first have failed, consists in separating the dental nerve from the common trunks which are the superior and inferior maxillary nerves. The first we attack at the point it leaves the sub-orbitary foramen by cut- ting it in the interior of the mouth, or, to speak clearer, towards the internal face of the lips or cheeks by a simple puncture or by an incision as recommended by the elder Berad ; and the second according to the directions of Warren, Yelpeau, the elder Berad, Malgaigne, to the works of which we refer, persuading dentists at the same time not to take upon themselves the re- sponsibility of similar operations. PHYSICAL CHANGES OF THE TEETH. The Wearing Away of the Teeth. The wearing away of the teeth, considered in itself, properly called is not a disease ; it constitues rather physiological pheno- mena, which is the inevitable consequence of the exercise of these organs. It is not only when the wearing shows itself among young subjects, and when it progresses with rapidity, or when the destruction of the teeth amongst more aged persons, is 192 ANATOMY, ORTHOPEDIA, sufficiently great as to give place to accidents, that it should merit the attention of the pathologist. In wearing away, the teeth diminish in height in proportion as they are employed. This diminution, show amongst all in- dividuals whose dental apparel is complete, regular and well situated, is much more rapid among those who wear a greater or less number of their teeth (those which being well arranged are submitted to more frequent use) or among those who have them badly arranged. Numerous circumstances contribute to cause the wearing away of the teeth ; such are, as predisposing and occasional causes, then friction during mastication, their delicate texture, the chemical influence that certain aliments exert upon them, the employment of certain dentifrices which are not well ground, that of acids, the use of earthen pipes, which should always be furnished with fine wires, the habit of chewing upon one side, the action of breaking hard bodies in the mouth, the grinding of the teeth resulting from a convulsive action of the muscles of the jaw, that we observe principally among persons during sleep, &c. Wearing attacks particularly the parts which touch in the meeting of the alveolar arches. Thus, we observe it principal- ly upon the triturating surfaces of the molars, upon the anterior parts of the superior incisors and upon the posterior of the infe- rior incisors ; when the first generally, as we have often remark- ed, have deviated inwardly from the line representing the curve of the alveolar arch. In order to be convinced, the touching of the teeth is the principal cause of their wearing away, it is only necessary to examine the state, even at a very advanced age, of the incisors of that species of bull dogs, whose inferior jaw makes a large projection outwardly to the superior. These teeth preserve at all times the form of a Jieu de lis. Now, we know that, in the canine species this conformation of the incisors is regarded as an indication of youth, and its disparity as a more equivocal sign of the contrary position. This form undoubted- ly disappears because the continual contact of the teeth, either between themselves or between them and other hard bodies, has worn only the tubercle or projection the union of which three forms the flue de lib. PATHOLOGY AND THERAPEUTICS. 193 Besides, particular circumstances often vary the manner by which the teeth are worn away ; we have observed, that the incisors are worn away more rapidly when the molars are wanting ; and the same is often the case, cœteris paribus, with the latter. As abrasion of the teeth is common to all, and as it increases with years, it would seem probable that inductions hence might be drawn, with regard to the age of individuals ; but this is not the case, because it is caused either by irregu- larity of the teeth, as in the case of which we are about to speak, or by the difference of food ; it exists among persons who have suffered the loss of a considerable portion of the substance of their teeth at an early age, whilst among others this loss is scarcely manifest, even at an advanced age.* Although the wearing away of the teeth is not rendered very evident until advanced age, it is no less true that it no more spares infancy than old age. In effect, if we examine the teeth of a young subject, whose first permanent molar has appeared, and if we compare it with the neighboring milk molar, which should be immediately replaced, we see that the tubercles of the first are elevated much above the deep sinuosities which separate them, whilst those of the other have entirely disap- peared, or are nearly level with the rest of the surface, and only present between them imperceptible sinuosities. These sinu- osities have a yellow and dull color, whilst the parts which surround them are of a brilliant white; this is of the greatest importance to be known, in order to prevent mistakes in ex- traction. Whilst the enamel is not destroyed, the triturating surfaces of the teeth remain white ; but when the ivory can be perceived, we observe, at first, in the centre of each tubercle of the crown, a yellow spot, which gradually enlarges, until the layers of enamel disappear; the tooth then presents nothing more than a flat surface, more or less unequal, of a yellow color, * In veterinary medicine, this wearing away is the index most con- stantly consulted, principally in the horse species, for determining age. But horses being accustomed, generally, to the same kind of food and care, the wearing away of their teeth ought to he the same among them. This opinion, however, has often caused serious errors to be committed. 25 194 ANATOMY, ORTHOPED1A, its circumference bordered with enamel, and leaving, in the direction of the dental canal, a spot of a deep yellow or blackish color. The first indications of the wearing away of the teeth are, a great sensibility, a setting on edge easily by acid or sweet sub- stances, and by impressions of heat and cold. In proportion as it increases, the sensibility becomes more intense, and some- times replaced by incessant pains. If the individual has very delicate teeth, if the painful impressions are renewed too fre- quently and with too great intensity, the dental pulp participates with this morbid state; it inflames and suppurates ; from thence follow very acute pains, and an inflammatory swelling of the neighboring parts, which the meeting of the jaws increases, and which yield only to extraction. These are more common than one might believe. Most commonly, it is limited by exciting the functions of the pulp, which, stimulated then, assumes a greater vitality, and preludes a kind of bony cicatrization, consisting of a deposit, in the inte- rior of the dental cavity, of an earthy substance, which strength- ens the ivory by a new interior layer. This new substance, of which we have already spoken of in the ossification of the pulp, which forms and increases principally upon the side of the worn part, and which Rousseau names the osselet, was already known to Hunter and described by others. It absolutely resembles the other parts of the teeth ; some- times more yellow, yet it is always as transparent and as brittle; it assumes no regular structure, detaches itself from the dental cavity, and isolates itself altogether from it, and the sides which correspond to this cavity are much more dense than its interior sur- face. The portions of worn teeth are then reproduced ; but this addition of osseous substance is a cause, often, of their destruc- tion without pain. It is in consequence of this addition, which insensibly takes the place of the stony pulp, and which, in fill- ing the cavity, destroys the sensibility of the teeth, that old men are less subject than young to dental pains, or have these pains infinitely less intense, because, amongst them, the central canal is not penetrated by the air, nor by other strange bodies. We say, that the parts of teeth that are worn away are not PATHOLOGY AND THERAPEUTICS. 195 reproduced; consequently, for the treatment of this, it is not only necessary to remedy the loss, but to suspend and destroy the cause which occasions it. Thus, when a tooth is worn away by the friction against the opposite one, we can diminish this last by the file ; this is applied principally to the incisors or canines. The different forms which abrasion gives to the teeth produce irregularities which injure the neighboring parts; it is necessary to remove them by the same means. We advise, that as such dentifrices as may be too rough, and such drinks as may be too acid in their nature, and which may be the cause of the wearing away of the teeth, that they should not be employed. But if the tooth becomes too much worn, or too painful, we might perforate the dental cavity, and afterwards plug it ; and if this operation is impossible, we might cauterize the crown of the tooth, which would remain then insensible. As to per- sons subject to grinding their teeth during sleep, they affirm that if they place a piece of linen, cork or any other hard sub- stance between their jaws, in the night, that they can avoid the consequences. Cracks and Fractures of the Teeth. Cracks in the teeth, which are, to speak plainly, but a small fracture, causes no morbid change, for it is superficial. A num- ber of causes produce it; they are, perhaps, occasioned by the grinding of the teeth, by convulsions,* by the contact with hard bodies during mastication ; sometimes, by the effort exerted by the jaws to break hard substances; sometimes by blows and by falls. The pain, at the moment that the crack takes place, is more or less severe, according as the loss of substance is more or less great ; afterwards, for some time, it is more or less sensi- ble of impressions of cold, heat, acids, or by the contact of hard bodies. We can limit, as in certain cases of the wearing away of the teeth, the fractures of the teeth, by filing their angles, in # We have seen, in a house of health, a young lady of fourteen years, affected with general convulsions, which were so violent and tumultuous to the jaws, that after some days the whole cutting edge of the anterior teeth had successively disappeared by fractures. 196 ANATOMY, ORTHOPEDIA, order to prevent them from cutting the soft parts of the mouth, and also in order to give the teeth a more regular appearance. Whatever resistance the texture of the teeth may offer, they are, nevertheless, susceptible of being completely broken by fractures, not only in consequence of exterior violence, as a blow, a fall upon the face, and an improper attachment of artificial teeth ; but still by the simple closing of the mouth, by the compression of the jaws, etc. Most ordinarily, it is true, they possess a predisposing cause to this accident, in constitutional disease, as the scurvy, rickets, scrofula, syphilis, or any other affection capable of breaking them, or in a local affection, as caries, atrophy. Sometimes we see healthy teeth fractured crosswise, without any apparent cause. Laveran gives an example of a small molar. Duval has also observed, upon a man of sixty years of age, the two bicuspides of the superior jaw fractured lengthwise, without a blow or without pain : we ourselves have met with similar instances. As for the rest, a tooth may be fractured at its crown, at its neck, or at its root; the fracture may be complete or incomplete ; take a longitudinal, transversal or oblique direction ; finally, it may be simple or complicated, that is to say, exempt from or accompanied by the contusion of the neighboring bony or soft parts. Some ancient authors thought that a fractured tooth cannot be ossified. They say, the teeth are exposed to the action of the air, and of the surrounding cold air, an obstacle in the formation of osseous matter. They add, no^rgguliiiative fluid can flow from the teeth, on account of the dry?iess of their substance ; or, if it floios from them, it is very much diluted, and has not the necessary qualities for consolidating the parts, on account of their small quantity of heat. This explanation proves they were far from entertaining an exact view of the manner by which the two fragments of a broken bone may be consolidated ; besides, it applies only to the crown of the tooth, the only part which may be affected by, and exposed to the cold of the surrounding air ; finally, it rests upon a fact which the researches of Behu, Jourdain, and, more H- ^ PATHOLOGY AND THERAPEUTICS. 197 recently, those of Duval, etc., have proved erroneous; they have demonstrated, in an incontestable manner, by experiments upon living animals, that the fractures of the crowns can, as well as of the roots, be consolidated. The procedure which nature employs to effect this end, differs, nevertheless, from what we observe in the union of fractured bones ; that which exists in the difference of organization between the teeth and other osseous structures ; the adhesion of the fragments of teeth is not effected between their extremities, but results, universal- ly, from the formation of new layers of ivory, furnished by the pulp, which layers extend themselves between the parts, in order that they may unite themselves, as it were, mechanically to- gether. The result of these observations is, that in order that adhesion may take place, it is indispensable that the fractured parts re- main in contact with the pulp, and that this tissue does not suffer too great a change. It is not, then, affected by a cicatrix of dental bone; this is so true, that when a space exists be- tween the fractured extremities, the union is effected no less by it, although the primitive separation exists. Fractured teeth are more susceptible to the action of external agents than those which have been simply cracked. This sus- ceptibility, sometimes so great as to be attended by pain, exists to an indefinite period after the fracture has taken place, and even extends upon the layers of ivory furnished to the interior of the tooth, by the pulp, have been completely developed. As to the rest, teeth which have experienced the action which we have described, lose their brilliancy, and become yellow or black : it is, nevertheless, to be remarked, that they seldom decay, unless a cavity is formed by the fracture. The superior incisors are the most subject to fractures, be- cause their position exposes them most frequently to mechanical injuries from without. When the fracture is small, consisting of a simple crack, the greatest inconvenience resulting from it is, that it causes asperities capable of irritating the neighboring parts ; it is always easy to remove them, by using the file. If the loss of the enamel injures the form of the crown, and ren- ders it necessarily less fitted to perform its functions, it, how- 198 ANATOMY, ORTHOPEDIA, ever, does not draw, as we know, the loss from the tooth, although it can lessen much of its hardness, and become broken by a premature age. It is not necessary to believe, as some authors, that the loss of the substance of the teeth always has an injurious effect. Fox principally considers the enamel as not being absolutely indispensable to their preservation. To strengthen this opinion, he quotes examples from many savages of India and the interior of Africa, who are in tbe habit of giving to their incisors a strange form, and that of individuals, who, after having filed their teeth, have preserved them to old age. These examples prove nothing, if only superficial changes of the enamel are not always injurious, although, in the part we have devoted to caries, we have proven the necessity of sepa- rating teeth with a file, for the removal of caries. But it, at the same time, establishes the principle that, in all cases where great portions of the crown of a tooth have been fractured, it constitutes a serious injury, which, sooner or later, results in the destruction of the injured organ. We can even, in order to prove that we do not exaggerate more the innocence than the danger of the loss of the enamel, quote examples given by Fox, of caries which affect the teeth of the Malay Indians, after having had horizontal grooves cut across the anterior surfaces of their crowns. It is principally where the ivory is exposed to the action of external agents, that fractures, when of considerable extent, be- come dangerous. As to the means which art has to oppose their effects, they vary according to the nature and extent of the fracture. If the fracture is confined to the crown, without extending to the pulp, the tooth can be preserved ; it is, how- ever, necessary to guard against inflammation, which may de- velope itself, for if this occurs, the tooth may become the seat of excessive sensibility, which it is necessary to remove imme- diately, by cauterizing the fractured surface. The deformity which might result from it may be corrected, by slightly dimin- ishing with a file the height of the adjoining teeth, if that can be done without danger. When the pulp is almost entirely ex- posed, cauterization is still more necessary ; afterwards the tooth should be plugged. PATHOLOGY AND THERAPEUTICS. 199 When the fracture extends to the neck of the tooth, which is always a serious accident, and always causes great local disor- der, independent of the most acute pain, the procedure of the dentist should vary according to the age of the patient. If an adult, after having subdued the inflammation, it should be cau- terized with a red iron ; then, after some days, the root should be filed to a level with the gum, and either plugged or a tooth engrafted on it. But if the subject is young, this procedure, in most cases, would be a feeble resource, for the teeth at this time possess a vitality which renders them very susceptible to the action of foreign bodies ; besides, their roots are not completely develop- ed ; they may then become the seat of different affections which hasten their loss ; it would, then, be very hazardous to attempt to preserve them at a later period, by inserting artificial teeth. This is an important branch of practice ; we recommend it to the attention of our professional brethren ; experience will prove that the most rational course among young subjects, is to extract the tooth. The space caused by it will gradually disap- pear by the approximation of the adjoining teeth, but if it should remain, it will be but a slight inconvenience compared with that which would result from the presence of a foreign body, as a plug or false tooth, introduced into a root possessing great vitality. With regard to fractures which extend lengthwise to the root, we should not hesitate for a moment to extract the loose pieces. If we delay too long their removal, their presence in the alveolar cavity will be the occasion of violent pain, inflammation, of ab- scesses, and of other serious accidents, which will not subside until the total extraction of the fractured tooth. If the crack does not extend to the root, we can seek to unite the two divided parts by a ligature, which will maintain them joined lengthwise, we can then avoid the inflammation of the pulp and fistulous ab- scesses. Finally, in order to conclude this article, we say, furthermore, that the fractures of roots are not always easy to be perceived ; but they constitute, in every case, a serious accident, not by the solution of continuity in itself, but by the injuries of the pulp and of other parts contained in the alveoli, by which they are 200 ANATOMY, ORTHOPEDIA, most ordinarily accompanied. Thus, the best course to take as regards this, is to extract the tooth. Notwithstanding the advice of some authors, who, as we have already said, have pretended that these fractures can be consolidated, and the ob- servations upon which they support them, we still advise, in these cases, the rules which we have given to be followed, and which, being applicable, if not universally, at least in most cases, will always provide against grave errors. Concerning Accidental Luxation of the Teeth. The causes which occasion the fracture of the teeth can, with- out doubt, act in a less degree than those which cause a solu- tion of continuity. Then, in place of breaking, the tooth expe- riences but a simple displacement, that is to say, changed in- wardly or outwardly, and departs more or less from its alveolus. This displacement may be simple, or complicated by contusions, by wounds of the gums, by fractures of the alveolar borders, and even of the jaws. The incisors and canines are more ex- posed to luxation than the others. There are two reasons to account for this: the first is, that, though firmly implanted, having but one root, they yield easily to the influence of exterior violence; the second is, owing to their situation, they are less protected than the others. These luxations may be complete or incomplete. In the first instance, all the treatment, as good sense merely shows, is to replace the tooth in its primitive position, and to secure it there by a ligature, being careful, at the same time, not to attach it to the adjoining teeth, which might soon become so unsteady that they would be placed in an inflammatory centre, but either to the second or third. If we have reason to believe that, in the various movements of the jaw, this luxated tooth will come in contact with the op- posite one, it will be necessary to remedy this by applying a light plate of platina, of gold, or any other substance upon the neighboring teeth, to prevent the meeting of the jaws. During the first week liquid aliments should be used, and during the second, aliments easy to be masticated ; this will assist in the PATHOLOGY AND THERAPEUTICS. 201 consolidation of the teeth, which is not sometimes accomplished for a fortnight. We have treated merely of simple luxation, but the case may be more serious, and extend even to the raising of the tooth, with the complete destruction of the natural adhérences which retain it in its alveolus; that which occurs, for example, when a dentist extracts one tooth for another. His conduct here should be the same as in the preceding case ; it is necessary, after hav- ing examined the mouth with care, to replace the tooth, and to wait, not that he may take nourishment, as is customary, how- ever, among some practitioners,* but that the surrounding parts may be adapted to it, in order that it may solidify, as in the natural state. That which convinces us that a tooth implanted has ceased to live, is, that it takes a yellow or dull grey tint very soon ; for the pain that it seems to feel when we pierce it, is the effect that the shock determines in the neighboring parts, but not the result, if we may speak thus, of a sensible vitality. We shall treat again of this subject, in speaking of dental trans- plantation. It is nearly useless to observe that the consolidation of luxated teeth is subordinate to two conditions : the age of the subject and the state of the surrounding parts. To this effect, we know that at twelve or fifteen years the orifice at the extremity of the root allows the nerves and blood-vessels to penetrate it with a facility which permits a free action upon the tissue of the tooth ; we conceive, then, that if the luxation was the result of a frac- ture of the alveoli, or of a violent contusion of the gums, the inflammatory work which results from it will be more unfavora- ble than propitious to the reunion of the separated parts. This is the case with individuals of a bad constitution, whose gums * Fox says he has seen a replaced tooih perfectly firm in its alveolus six hours afier having been extracted. Bell, who we have already quoted, in treating of the different characters of dental pain, even believes the possibility of the intimate union of a transplanted tooth; he expresses him- self thus on this subject: "This operation is suitable only for young men and adults, for it succeeds only, as it appears, when the tooth contracts a direct union with the contiguous parts, by means of the blood-vessels which communicate between them,'* 26 202 ANATOMY, ORTHOPEDIA, are constantly bleeding or choked up, the replacement of the luxated teeth, and, with a greater reason, those that have been extracted, never has a favorable result; the first should be ex- tracted, and the latter operation prudence would require us to omit. Of the Loosening of the Teeth. Instead of being fractured or luxated, the teeth may simply become unsteady or loosened in their sockets. The causes which determine this accident are exterior or physical, interior or constitutional. Exterior causes are, as one would suppose, violences which have not been sufficiently great to cause a fracture or luxation ; to those causes it is necessary to add acts belonging to our art, as a ligature or a brace improperly applied, a support badly taken, and, finally, the incrustation of a tooth by tartar, which has ex- tended even to the root, by introducing itself between its neck and the gum. The interior or constitutional causes are the different changes which the softened and spongy gums experience by the effect of a scorbutic or scrofulous diathesis, by a rheumatic or gouty affection, by a severe disease, by the use of mercury, by inhabit- ing places where the vapors exert an unfavorable chemical ac- tion upon the teeth, and, finally, from many diseases of the alveoli ; the critical age, among certain females, is sometimes, also, the cause of it. But, of all, the most frequent is old age. This difference in the causes of the vacillation of the teeth draws from it one, necessarily, in the choice of the means to be employed to remedy it. Is it the result only of accidental causes, we confine ourselves to treating of local phenomena, to prescribe the use of aliments easy of mastication, to warn the patient of the danger he might experience in testing improperly the solidity of his tooth by touching it with his finger or tongue ; and we advise him to use, in the course of the day, many gar- gles with water sharpened by a tonic sipatous liquor. If the accident is occasioned by ligatures, bands or resorts, it is very plain that their solidification is subordinate to their removing; it is the same case with tartar, that it is necessary to destroy, PATHOLOGY AND THERAPEUTICS. 203 and of the excessive length of a corresponding tooth to that which vacillates, which must, of necessity, be shortened. Unfortunately, the process passed through is not as simple when the teeth are loosened by an interior or constitutional cause. This is the cause that must, before all, be opposed ; the teeth become tightened of themselves, by the treatment which belongs to them. It is, nevertheless, nearly always proper to second the efforts of nature by emollient lotions, tonics or astringents, according as the parts which envelope the tooth offer the appearance of a tumefaction, sponginess, or of an œde- matous swelling; for we regard this assertion ofManryasan error, or at least as a great exaggeration : that "the loosening of the teeth may be considered as an affection which is dependent rather upon the state of their tissue than upon that of the parts with which they are in connection." DISEASES OP THE DENTAL APPENDAGES. Diseases of the Gums. The gums are composed, as we know, of a very vascular sub- stance, eminently susceptible of swelling, by the least irritation, and which adheres to the necks of the teeth, which it surrounds on all parts, as also the alveoli, whose exterior walls it en- velopes. When healthy, the gums are strongly attached to the teeth, immediately above the alveoli, and their edges rest upon the enamel. Firm and of a rose-white color in their natural state, smooth and united in infancy, irregular and scolloped in the adult; hard, resisting, semi-cartilaginous in old age, they not only participate in the affections of the teeth, to which they are united by intimate relations, but they are themselves subject to many changes, of which the nature of their tissue and their position explains the frequency, and in the course of which they inflame, tumefy, ulcerate or produce excrescences. Sometimes, as we know, the gums become the seat either of more or less acute inflammations, which often terminate by sup- purations, and give place to abscesses, or of apthas, pains, exco- 204 ANATOMY, ORTHOPEDIA. nations, fistulas and of ulcerations ; sometimes they diminish in volume, so as to scarcely cover the alveolar borders, or they enlarge and swell, so as to give birth to fleshy excrescences, that are often difficult to make disappear ; changes that, in order for us to conform to the order generally adopted, we shall divide in three sections : firstly, inflammations and swellings ; sec- ondly, ulcerations ; thirdly, tumors, excrescences and fungi. The first includes, therefore, inflammation, followed by the perforation of the gums at the time of dentition, apthae, ab- scesses called purules, suppurations, dental fistulas, to which we have added abscesses of the maxillary sinus ; finally, the adher- ence of the gums with the cheeks and lips. In the second, we find scurvy of the gums, gangrene, different changes considered as results of scrofula, of syphilitic virus, and of the use of mercury. Finally, the third section comprises a description of excres- cences, designated under the name of epules, and of some other tumors of the same nature. Inflammatory Diseases of the Gums. Of Inflammation of the Gums, resulting from the Cutting of the Teeth. — In treating of the physiological phenomena of den- tition, we have already designated the inflammation of the gums as one of the ordinary accompaniments ; and, in the chapter devoted to dental hygiene, we have described some of the prin- cipal means for preventing it. But, whatever precaution we may take, however good the constitution of the child, it is rare that it does not experience some ill effects from it ; and we re- peat it here, that no doubt may be left of our opinion regarding it, although the frequence or at least the dangers of this inflam- mation has been many times exaggerated, it is no less demon- strated by experience, that it can, in some instances, be carried to a degree capable of giving serious injuries. We shall not return again here to the determining cause of this phlegmasia. We are compelled, for many reasons, to regard it as a consequence of the action of the teeth, which, being ele- vated above their alveoli, advance and push towards the interior PATHOLOGY AND THERAPEUTICS. 205 of the mouth through the gums, which are too little disposed to yield to this influence. We even believe this explanation as ap- plicable to the cutting of the second as of the first teeth ; for if, in this latter case, it resists so much as to prevent the eruption of the teeth, in the first, being altogether more dense and hard, it is less easily distended, particularly if the premature cutting of the gum has cicatrized, which the permanent tooth, of necessity, has to break through. At one period or the other, the inflammation of the gums may be so violent as to extend even to the face, and determines, principally, either that which is commonly named fluxion, or a similar state, upon the mucous membrane which lines the eye, the internal ear, the nasal fossae, or a swelling of the sub-maxil- lary glands, and of the lymphatic ganglions which surround the neck. Accidents may be much more serious yet, especially at the time of the cutting of the large molars of the inferior jaw, a cutting which may cause extensive abscesses, which are, unfor- tunately, liable to open exteriorly, and sometimes to invade the maxillary bones. We also conceive that if this occurrence fol- lows the eruption of the temporary teeth, it may cause the de- struction of the germs of the permanent ones, and, by the ab- sence of these last, change, as we have already said, the features of the face. In considering this inflammation only as the result of a me- chanical cause, we necessarily simplify the treatment ; to soften the swollen gum, or to open a passage for the tooth in the right place, are, in first dentition, the two indications to be fulfilled. It is principally with the milk of the mother, as all authors say, that this softening is effected. We find, from this, the means of appeasing the thirst with which the infant is always torment- ed, and of assuaging the local pain. If it is already weaned, we must have recourse to the mucilage of flaxseed, gum arabic, althee, to which we add a little honey, and when the gums are harder, with a small brush, or with a piece of the root of althse, or with the finger. If these means, employed a certain length of time, do not suc- ceed, a passage must necessarily be opened for the tooth ; but this operation, in order to meet with that success it should, is 200 ANATOMY, ORTHOPEDIA, subjected to certain conditions of opportunity and execution, which certain young practitioners are generally too disposed to despise. We then repeat here, that the section of the gums is indicated when they are very firm and hard ; it can be discover- ed by touching it, and when we perceive, at the place of contact of the tooth with the gum, a white spot, which is circumscribed by the general redness of these latter. The incision will be, on the contrary, contra-indicated, if the gums are very much swollen, and if the inflammation is very acute ; for besides, the pain, cœteris paribus, is much more in- tense, the vessels being filled with blood, it may happen that a section of them may occasion a hemorrhage, which, though in general not very considerable, is sometimes embarrassing, either by the difficulty of suppressing it, or by the trouble which is ex- perienced from the blood flowing into the mouth or passing into the stomach. As to the manner of incising the gums, this is of some mo- ment. Some authors, after having acknowledged the necessity of the operation, pretend that a simple scratch, made with the nail, is sufficient, and abandon it to the nurse. This is a gross error, which common sense would at once refute. A simple separation of the gums will not assuage the symptoms, or ac- complish all that may be obtained from the resources of our art ; it is even more capable of giving rise to evils than of remedying those for the relief of which it is employed ; for experience demonstrates that the unequal tearing of the soft parts, even of those not inflamed, may occasion the most serious nervous dis- orders. These lacerations are even true wounds, which do not prevent accidents from having their course, nor does it re- move them, because the tension of the periosteum will be often an obstacle to the free cutting of the tooth. All observing prac- titioners agree upon this point, that a simple incision is not always sufficient to subdue the effects which result from the tension that the gums experience from that part of the tooth that seeks to make its way through it. John Hunter relates that, being called upon to visit a child affected with convulsions, caused by a difficult dentition, and which had resisted all the anti-spasmodics, and most of the other means known ; he caused PATHOLOGY AND THERAPEUTICS. 207 this alarming state to subside in less than a half hour, by scari- fying the gums as far as the teeth. But as he did not extend his incision sufficiently far, the gums cicatrised from the imme- diate contact of the edges of these small wounds ; the teeth continued to grow, and to increase beyond the space which the scarifications had procured for them, the convulsions returned, and he was obliged to renew his operation, which caused them to subside as promptly as the first time. At the present time, similar instances have been presented to us. It is, then, important that the incision of the gum, inflamed by the action of the tooth, should be well executed, that is to say, completed. We believe that which is made by a crucial incision is preferable to any other, because it better prevents a reunion of the lips of the wound, and more easily permits the excision of the shreds, which is often necessary to be practised, in order to expose the tooth. We may, although some authors say that they can determine what teeth this should be practised upon, give the crucial form to this incision, provided we take all the necessary precautions which the case requires. This remark appears to us useful, in order to prevent practitioners who are too timid, in equal cases, from submitting the child to the difficulty for the cure of which he had practised the exci- sion. We shall return again to the selection of the instruments and the proper procedure of the operator. Aphthœ. — The ancients give this name to nearly all the su- perficial inflammatory diseases of the mouth. We find, in effect, under this denomination, in their writings, simple erythema psuedo-membranous affections, exudations of a soft and cheesy substance, true ulcerations and gangrenous eschar ; some have still more augmented this confusion, by adding the gangrene to this order of diseases. But the actual state of pathological anatomy does not permit us to confound, under a generic name, entirely different morbid changes ; we have restricted the history of aphthœ to all the light phlegmasia of the mouth, of which we shall treat, and which name we will reserve for eruptions of vesicle or round forms. Thus, then, we mean by aphthœ a kind of eruption of superficial or profound whitish tubercles, which develope them- 20S ANATOMY, ORTHOPtiDIA, selves particularly upon the mucous membrane lining the inter- nal surface of the mouth, and which reaches, sometimes, the vale of the palate, the tongue, the pharynx, and even the intes- tinal canal, or air tubes. This eruption commences by a small, transparent, white or pearly vesicle. At the first, or as late as the second day of its appearance, a grey or white swelling, hard at its base, developes itself above and around the vesicle, and gives it the appearance of a small pustule. This pustulous character developes itself the second or third day, because the vesicle bursts and allows the transparent liquid which it contains to escape, and is re- placed by a more or less painful ulcer. This second period of aphthae, which we might call the period of ulceration or suppuration, is prolonged, ordinarily, many days, and sometimes even one or two septennaries. During its con- tinuance, the swelling it presses down by degrees into the level of the surrounding parts ; the ulceration enlarges, and is limited by a small red circle, which announces, ordinarily, the tendency to cicatrization. This third period, viz. that of cicatrization, proceeds very rapidly until the small ulceration is cleansed, and often it is over that day or the one following, without leaving any other trace upon the mucous membrane than a small red spot, which soon disappears. Such are the general characters of aphthae, which sometimes is distinct and proceeds more or less rapidly ; again, on the con- trary, it is confluent , and proceeds slowly, that is, it is stationary. Distinct aphthce attacks, as if by preference, children who do not suck, and adults. The pustules are then always isolated, less numerous, and occupy only the mouth ; the eruption pro- ceeds, in most cases, without fever; however, it is sometimes accompanied by febrile action, with gastric and intestinal dis- turbance ; we regard it, ordinarily, in this case, as symptoms of fever. This very mild disease is observed in all countries and in all seasons. It is, however, much less frequent in France than the stomatic, characterized by small psuedo-membranous plates, which is daily taken for aphthae. Distinct aphthae pro- ceeds through all its phases in the space of a septennary, and, although it may be sometimes accompanied by a kind of severe local pain, it does not give place to serious affections. PATHOLOGY AND TH ERAPEUTICS. 209 Confluent aphthce, has a slow course, in opposition to distinct aphthae, which has often lasted four or five days. It is rarely- confined to the mouth, for it extends, nearly always, to the pharynx, and even to the intestinal canal. It attacks particu- larly adults, but principally women in childbed, and it can as- sume a very serious character. It commences, nearly always, by chills, headaches, fever and vomitings. These symptoms calm, in most cases, after the eruption, the fever diminishes continually, and it is even accompanied, sometimes, by parox- ysms more or less decided. The fever appears again, not only after the eruption, but is one of its symptoms ; whilst, on the contrary, in ephemeral aphthce, fever, when it exists, is either accessary or simply concomitant, but is dependent upon another cause than eruption. In this second variety, the inflammation of the mouth is much more intense and extended ; this cavity is hot, and cannot bear the impression of the most mild liquid, as the pain is acute. The disease takes often, in certain cases, a still more serious character. Then there is difficulty of swallowing, on account of the number of pustules, varying in size, which we observe upon the veil of the palate, and in the back part of the mouth. Often respiration is constrained, there is heat about the breast, hoarse- ness of the voice, extreme dryness of the buccal mucous mem- brane, upon which we see a number of small pustules, very simi- lar to those which appear after the varioloid eruption ; in this latter case, it is very common for it to occupy the interior of the mouth. When the eruption extends to all these parts, and is very confluent, as we have had occasion of observing, the patient is tormented by pain in the precordial, by anguish, by nausea, and even by vomitings. If the eruption extends to the intesti- nal canal, abdominal pain, diarrhoea, and often even of typhoid symptoms, accompanied by other phenomena which we have noticed, and then the disease may sometimes be prolonged to the third week. When the disease is intense, the pustules soon form a crust, similar to thickened and coagulated milk. The volume of these crusts increases rapidly, and their color be- comes yellowish or brown. Finally, it soon forms a scab, after removing which, we perceive an ulcer of a reddish brown, from 27 210 ANATOMY, ORTHOPEDIa. whence flows a fetid matter, and which, when it is extensive, may cause gangrene, and, in a great number of cases, death. Notwithstanding the numerous dissertations upon aphtha?, it has been difficult, even at the present time, to determine its true causes. Authors have uttered, as it regards this, very simple probabilities. We believe, however, to have observed that it appears, most ordinarily, under the influence of a humid tempe- rature, and that it was most common in cold and marshy places ; also, we have observed it more frequently in autumn than in any other season, and most commonly in Denmark, in Holland and in Zealand. But that which appears to be most certain is, that it attacks, by preference, children and old men, individuals of a lymphatic and debilitated constitution, those which are subject to catarrhal affections ; finally, persons whose teeth are decayed or incrusted with tartar. It is worthy of observation, that the infraction of the laws of hygiene, as habitual slovenliness, the use of bad aliments, such as cheeses, salted meats, improper nourishment and care of children, the use of badly prepared mercurial preparations, of too hard aliments, unlooked for blows on the mouth, the result of which is decayed or broken teeth, are as many causes capable of giving rise to aphthae, or at least of favoring its development. We have even seen this disease rage in an epidemic manner, principally in hospitals destined for infants, and to attack, as if by preference, those whose constitution was the most feeble or most diseased. As the dentist is so often consulted concerning the disease, the history of which we are tracing, although, in many cases, it extends to the organs which form his special domain, he ought to know that the treatment which belongs to it is deduced prin- cipally from the knowledge of the causes which produce it. Thus, in discreet aphtha?, it is necessary to withdraw the patient from the morbid influence in the midst of which the eruption is developed, in order that it may disappear of itself; softening gargles, a little acidulated, emollient drinks are the only reme- dies employed for adults ; the milk of a good nurse and clean- liness are the best remedies for infants. If, on the contrary, aphthae is confluent, it will be advisable PATHOLOGY AND THERAPEUTICS. 211 to touch the diseased part with a small lancet, steeped in a fluid sharpened by sulphuric or hydro-chloric acid. On the neck of the patient we should apply warm cataplasms; we should give him for drink, at first acidulated barley, afterwards a decoction of quinquina. We should then seek to diminish the progress of the disease by revulsives, as a blister on the neck or arms, foot baths, sinapisms. If the swelling of the throat was such that, as at the beginning, the respiration was constrained and the swallowing difficult, it would be prudent to apply, about the neck, but particularly beneath the mastoid apophysis, leeches, the number of which should be proportioned to the age of the person, or the intensity of the disease. We should insist, in the second period, upon gargles made with common water, the honey of roses, and a few drops of sul- phuric acid. We should seek to calm the pain, by edulcorating the drinks with the syrup of white poppy, or any other opiate; we should follow the applications by tonic washes and gelatinous baths. But it is sometimes prudent, in these cases, to lighten his responsibility by seeking the advice of a physician, after being well assured that the disease is not occasioned by caries, or by the presence of any asperities that might be found neces- sary to remove. Phlegmasia or Abscess of the Gu?ns, ( Parulis.) — When the inflammation of the gums has been carried to a certain point, it is not rare that it terminates by suppuration. There is then formed, in the tissue of the abscess, true phlegmasia, which we designate under the name of parulis, and which, in certain cir- cumstances, assume a very serious character. These inflammatory tumors may be occasioned by decay of the tooth or maxillary bones, by phlegmasia of the alveolar peri- ostea, by irritation of the dental nerve, by contusions, compres- sions, accumulation of tartar upon the gums, the presence of an artificial piece in the mouth, and a bad plug; finally, they result sometimes from that which we call a constitutional affection, from rheumatism or from metastasis ; we meet with them, some- times, without being able to assign any positive cause to them. These abscesses, in general small and confined to the gum itself, appear, by preference, in the neighborhood of decayed 212 ANATOMY, ORTHOPEDTA, teeth, more commonly near the anterior and small molars than the large ones, and oftener in the superior than in the inferior jaw. Sometimes they constitute a pustule, and are developed in twenty-four hours, and even in less time ; sometimes, on the contrary, they form vast deposits, which affect the whole jaw on the diseased side, and progress so slowly that they do not suppu- rate at the expiration of a month, or six weeks, and even longer. In the commencement of the gummy phlegmasia, the patient experiences burning and a painful tension in the diseased part, which, from a vermilion red, becomes livid in proportion as the tumor increases in size ; soon there appears in the centre a small white point, which opens of itself, if it is not opened, and from whence flows a greater or less quantity of pus; as soon as this liquid has escaped, the small opening closes, and the in- flammation which affected a portion of the gum disappeared. It often happens that this small abscess forms for itself an issue, not very far distant from the suppuration, and it is necessary to expel the pus. This kind of tumor seldom terminates by reso- lution. When a great portion of the gum is inflamed, the correspond- ing jaw participates in the swelling; the heat is burning; and extreme sensibility is now developed, which increases by touch- ing it, or by the least movement of the jaw. Sometimes it in- creases continually, the phlegmasia increases in violence, and affects the whole economy ; from thence follows a general fever, headaches, chills, inability to sleep, ptyalism, difficulty of open- ing the mouth, and of talking; together with symptoms which increase by degrees until the abscess opens ; this generally takes place in the interior of the mouth, and is effected in eight or ten days. When the disease is not very intense, we confine our reme- dies to topical emollients, small revulsive blood-lettings, or even to applying one or two leeches upon the gum ; but we should not forget that leeches increase sometimes congestion, by the irritation of their pricks, and by favoring suppuration instead of preventing it ; furthermore, we should only apply them around the inflamed tissue. We add to these different means, softening gargles, and, in some cases, fomentations, with water slightly PATHOLOGY AND THER APKUTfCS. 213 adulterated with spirituous liquor. We are sometimes so happy, by these means, to obtain a complete resolution before the pus has formed. But suppuration cannot be avoided ; it would be irrational to confine ourselves to local remedies, for the treat- ment of which, it is necessary, in following the directions of Delamotte, to open the abscess, and make it too soon rather than too late; by temporizing, we risk the suppuration extending to neighboring parts, principally to the jaws ; and we are com- pelled to believe that the pus opens for itself a route from with- out, and causes a denudation of the bones, or of fistulas which can with difficulty bs cured. If the abscess appears to follow this course, it is necessary to open it largely, in the cavity of the mouth ; in other cases, a simple incision would suffice. But, whatever may be the manner of opening which we think proper to employ, the surgeon should always incline the head of the patient forward, without which he will swallow the pus, which is very disagreeable, and also very injurious. As to the best means for preventing the formation and return of the abscesses of the gums, which depend upon the caries of the teeth, it is necessary to extract the diseased tooth ; when they depend upon the presence of the pivot of an artificial tooth, it is prevented by its extraction, and principally by that of the root which supports it; sometimes, from an abscess which is opened into the mouth, a fistula remains in the gums, main- tained as by the dental caries ; the extraction is nearly always the only means of remedying it. Suppuration of the Gums, ( Interalveolo-dcntal Pyorrhoea.) — After having treated of the different phlegmasia of the gums, and of their abscesses, it might appear scarcely physiological to treat of their suppuration in another article. But when we have defined that which we understand by suppuration of the gums, the necessity of this arrangement will be perceived ; we do not pretend, in effect, to speak here of this suppuration, which is one of the results so common from inflammation having affected the tissue of the gums : we now shall treat of phlegmasia. The affection that we shall describe consists in a purulent dropping, which results from a morbid secretion of the gummy alveolous membrane. 214 ANATOMY, ORTHOPEDIA, This disease has, for a long time, been confounded by authors with scorbutical diseases of the gums ; it is only in latter times that its nature has been known and properly described. It affects all periods of life, but particularly persons from thirty- five to fifty years. It is common upon individuals who are large and plethoric, who eat much ; it attacks both sexes, although it appears to us to give the preference to women, espe- cially at the time when their menses cease to appear. Among the causes which may occasion this purulent flowing of the gums, it is necessary to reckon habitual uncleanliness of the mouth, the accumulation of tartar around the teeth, inhabit- ing of unhealthy humid places, bad air, and, finally, all the causes of general debilitation. In the next place, the mercurial treatment, the suppression of artificial ulcers, haemorrhoidal fluxes, the repercussion of certain diseases of the skin, scrofu- lous affections, syphilis, etc. The suppuration of the gum is effected only by degrees. Confined, at first, to certain teeth, it is not until after the expi- ration of a certain length of time that it affects, one after the other, all the rest. The incisor and the canines of the inferior jaw are ordinarily the first attacked. Afterwards, it affects the corresponding ones, and finally the molars. This affection often presents, in its beginning, no appreciable symptom which might reveal its existence. We could discover nothing by the simple inspection of the gums, the patient did not even experi- ence any pain. Only by pressing this membrane towards the free edge, we may perceive, between it and the teeth, a certain quantity of whitish matter, slightly glutinous. If the disease is hereditary, or if it manifests itself in young subjects, it announces by causing an indolent swelling of the gums, which are soft, livid, fungous, and causes a dull sensa- tion and a pain scarcely sensible ; afterwards, though the sup- puration manifests itself, the teeth loosen and become painful to the touch. Nevertheless, the teeth preserve their solidity whilst the inflammation does not extend to any depth in their alveoli, and the gums do not lose until late their normal color. The patients complain only of a troublesome local feeling, and of a dryness to which they give little attention. Then, as we have pathology and therapeutics. 215 said, if, at this time, we press the superior gum from above downwards, and the inferior ones from below upwards, we per- ceive a white matter runs out, which is inodorous, not thick, and which is soon reproduced. One remarkable particularity is, that this fluid accumulates at first only upon the external face of the gums ; it is only at a more advanced stage of the disease that it has place equally upon all points of this tissue which surrounds the necks of the teeth. In the meantime, the disease making progress, those teeth which until then had no cause of pain, acquire sensibility, mobility and lengthen a little ; they become soft, to use the ex- pression which the patient employs to express the sensation that he experiences, when the opposite teeth come in contact. The purulent matter becomes more and more abundant; the mouth exhales a fetid odor ; the gums, if they have not already undergone any apparent change, tumefy around the neck of the tooth, principally upon the external face, and are of a violet red. Whilst these symptoms manifest themselves upon the gums, phenomena no less remarkable are taking place upon the roots. Their external membrane furnishes, incessantly, a purulent fluid, which escapes between them and the walls of their alveoli. By degrees, this latter, yielding to this morbid influence, wears away, and finally disappears, in proportion as the inflammatory phenomena of the external membrane become more intense. But, for the same reason that we have seen that the labial por- tion of the gums is the first aflec ted, for the same also the ex- ternal layer of the alveolus is the first absorbed. A contraction of the gums results, the gums coming in contact with the roots and abandoning the necks of the teeth. At times, the disease arrives at this crisis, the teeth are late falling, and when this happens, if we examine the surface of the roots, we will find there something of a milkish white, and scattered with purulent strice. Such is the course of this disease. We do not know pre- cisely its duration ; for it extends, in certain instances, to the entire loss of the teeth, that it takes six, ten, and even fifteen years to destroy. It has, nevertheless, a rapid progress, and it 216 ANATOMY, ORTHOPEDIA, is not rare that it suddenly ceases to progress, and even that the purulent dropping, which takes place under the gums, ceases without any aid of art ; the teeth continue to be movable and elongated ; but this is often only many years after the disease commences. As most of the local affections that we have spoken of disap- pear after the extraction of the tooth around which the dropping takes place, we naturally regard the teeth as the first cause of all these disorders. Fauchard and Jourdain have at least estab- lished the conclusion, that the disease may be regarded as purely local : according to them, all the affections that we have described are only the inevitable result of the development of the efforts that nature makes in order to cause the expulsion of organs that it has affected even in their vitality. If this reasoning is sometimes conformed to the truth, yet we cannot deny that, in the greatest number of cases at least, this disease affects not the general constitution of the subject, but principally the changes which follow in the exercise of different functions at certain ages of life. According to some authors, the dropping of the purulent matter ought principally to be re- garded as a salutary secretion, capable of preventing the devel- opment or suspending the course of serious affections ; this seems to be the most probable opinion. Bourdet, who considers this affection as purely local, pro- poses, in order to remove it, to destroy the ulceration, at a point beyond the suppuration, with a flat and small cautery, strongly heated, that he places as far as possible between the gum and root, even to the depth of the space resulting from the destruc- tion of the alveolar ridge, having care to burn, two or three times, the whole internal face of the gum. If, eight or ten days after, we press the edge of the gums, and there still flows a little matter from it, we cauterize, according to him, a second or third time. Finally, when, in spite of these cauterizations, the flow- ing continues, he advises to destroy, with the scissors, by two incisions, which unite to the right angle of the side of the point of the root, all the part of the gum deprived of its alveolus. Toyrac, who doubtless had never read Bourdet, proposes exactly the same means as he gives, as the result of his own experience. PATHOLOGY AND THERAPEUTICS. 217 Cauterization is, unfortunately, far from being as constantly followed by success as Bourdet believes. Jourdain, who has had occasion of seeing equally as many persons affected with this disease, asserts that he has never cured a single person by the use of this means. Let us admit, then, although it will not be a fact altogether demonstrated, that this purulent state of the gums is the result of dental caries, or a change of the alveolar partitions, we might be liable to see all local treatment fail, at least if the disease is recent, and the subject does not enjoy good health. To change the general constitution the efforts of art should aim ; it possesses, in this respect, means whose general thera- peutical action might produce advantageous results. Let us take notice, at the same time, that if the suppuration is abun- dant, and when it exists many years, it is always advantageous, in the course of general treatment, to establish an artificial ulcer, and to prescribe the use of purgatives, at intervals suffi- ciently near to avoid the brisk succession of the flowing of the purulent matter. Dental Fistules. — As we have already seen that decayed teeth decay often at their roots. A suppuration results from it, in the alveolus, always accompanied by a painful swelling in the gums. Here, as Fox justly remarks, the laws which determine the flowing of pus are the same as those which we observe in ab- scesses in general. The suppuration is established in some part of the surface of the root, and forms an opening in the place most favorable to its flowing. The periosteum which covers the root where the deposit is formed, tumefies, and sometimes at- taches itself. The pus collects, then, as in a sack, which, in swelling, produces a considerable pressure upon the walls of the alveolus, whose anterior edges are partly absorbed before those which are found within the mouth. The progress of ulceration continues until the gum itself becomes pierced through that part which corresponds to the extremity of the root, and the flowing of pus made by this opening, whose edges generally swell, has the appearance of a small red fungus. Sometimes, after the discharge of pus, the inflammation ceases ; but the ulcer rarely closes, and a small crooked opening remains, which constitutes what we call a dental fistule. 28 218 ANATOMY, ORTHOPEDIA, Some authors confound this affection with the fistulous ul- cers of the gums. Maury places himself amongst these, by say- ing, that it often happens that, after the opening of the abscesses of the gums, not having been brought under the influence of the remedy, in spite of the general means employed, forms the general fistules of moderns. In that, both commit an error ; for fistulous ulcers of the gums differ from dental fistules in this, that the first are only openings of the abscesses belonging to the gums, whatever may be the cause that prevents it from closing, whilst the second have their first cause in the alveolus, and affect but passively that part of the gum by which they are surrounded. The dental fistules are then generally occasioned by the de- cay of a tooth or maxillary bone, or even by the parts of a tooth or alveolus, which, not having been affected by the suppuration are situated under the gums or engaged in their tissue. Some- times, the ulcer presents only a small orifice, often obstructed by the presence of a watery ichor, which flows from it, and dries when it comes in contact with the eye. Sometimes we perceive two or three of these openings instead of one, and they are generally near each other. A stylet introduced into one of them, we perceive that the bone is denuded and movable, or that the diseased tooth is insensible but vacillating. That which we have said of the causes and formation of dental fis- tules, prevents us from saying much on their treatment ; it is always necessary to extract a portion of the decayed tooth which injures it, or to attempt, by employing the best means, the ex- foliation of the affected bone, if it is the alveolus which is dis- eased. This is not only applicable to the case where the fistule opens in the mouth, but it is the only one which should serve as a guide when it extends across the thickness of the jaw or above the cheek bone, if the cause of the abscess is in the supe- rior jaw ; or near the angle of the inferior jaw, or the edge of its base, if the cause of the disease is in the inferior jaw. These dental fistules, affecting the face, are also very com- mon ; we have seen many persons, amongst others our friend Dr. G., affected with one a long time, and waited in vain for many years, in the hopes that it would cure of itself. Near the PATHOLOGY AND THERAPEUTICS. 219 issue by which the separation was affected, the skin was wrinkled, and had a spongy appearance ; its tissue was red and soft. After the extraction of the tooth, the flowing of the pus diminishes gradually ; the exterior opening closes ; but, as the ulceration has destroyed a part of the cellular interstices and teguments, the skin contracts and heals, and, in the place occu- pied by the fistulous ulcer, a hollow or deep cicatrix, which we sometimes suppose as the result of a scrofulous affection; a de- fect which should be remedied by the application of appropriate means, and which we render always less irregular, by accele- rating, as soon as the abscess forms, the flowing of pus, by an incision made with the point of a lancet. As the three affections which we have described under the name of abscesses, of suppuration of the gums, and of dental fistules, have characters common with the purulous or mucous collections of the maxillary sinus or antrum of highmoria, and that, on the other hand, the treatment of these collections, although belonging to general surgery, demands, very often, the intervention of the dentist, we believe a separate article should be devoted to it. Abscess and Dropsy of the Maxillary Si?ius. The maxillary sinuses, of which we have designedly given a very brief description in our anatomical part, as it has but an indirect connection with our subject, are, as we know, two large triangular hollow cavities, in the thickness of the maxillary bone, immediately beyond the orbital fossae, and without the nasal fossae, agreeing to that part of the face which forms the jaw. Lined by the mucous membrane, which is the continua- tion of that which covers the surface of the mouth and the nasal fossae ; these cavities are susceptible of being filled with a true pus or a simple mucous substance ; hence their abscesses, and that which we commonly name their dropsies. The purulent matter which forms the abscesses of which the maxillary sinus may be the seat, is as often the direct product of a termination by a suppuration of the inflammation of the mucous membrane which lines them ; but this inflammation 22U ANATOMY, ORTHOPEDIA, is not, most ordinarily, the cause of this ahscess ; they are more frequently occasioned by decayed teeth, which affect their alveoli and the walls of the maxillary sinus, by abscess of the gums, that we have described under the name of parulis, by a tubercle which developes itself, as Boyer very judiciously re- marks, at the roots of the teeth which correspond to the sinus ; finally, as Vidal, (of Cassis,) remarks, by an ulceration of osseous tissue itself, whose suppuration communicates with the cavity of the sinus and fills it. Whatever may be the source from whence the purulent mat- ter proceeds, the first indication of its accumulation in the max- illary sinus, is a dull, deep pain, which affects the jaw, and even extends from the molar teeth to the orbit. The teguments of the face near the painful spot, are not at first tumefied, do not, consequently, change their color, and it can be com- pressed without hurting the patient. Yet, in proportion as the purulent matter collects, the jaw swells ; the walls of the sinus extends, and forms an exterior tumor above the last molars and interior side of the palate ; the bone softens and yields under the pressure of the finger ; the fluctuation becomes sensible ; the deformity produced by the dilation of the sinus is very ap- parent ; a yellowish, purulent matter comes from the nostrils when the patient blows his nose, or makes a strong expiration. This liquid accumulates, having no free passage by a natural opening of the sinus,* which is too compressed and elevated or close, it softens, by its remaining and its change, the inferior walls of this cavity are destroyed by degrees ; and, finally, one or more issues by the nostrils, alveolar arch, and in different parts of the face are formed, from whence fistules result, which tend to a common centre, which is the cavity of the sinus. The patient is then slightly relieved by the discharge of pus; the jaw, at first tumefied, sinks, but the fistules, formed on the side of the # This opening, situated superiorly and anteriorly on the side of the nose, between the two cornets, nevertheless nearer the superior, did not much exceed the diameter of a pigeon feather; its form is little oblongated, and, upon many subjects, pituitary membrane forms on the side of the sinus a kind of fold, which gives to it an oblique direction, consequently, it is sometimes difficult to be perceived. PATHOLOGY AND THERAPEUTICS. 221 the alveoli, of the jaw, beneath the orbit, and in the nose, con- tinue; the molar teeth are loosened, the bones are carious, and the mouth exhales an insufferably offensive odor. As it regards the singular mucous matter which fills the max- illary sinus, and which constitutes what we call dropsij of this cavity ; it proceeds simply from irritation of its lining mem- brane ; an irritation which is not sufficiently great to cause inflammation, and, consequently, an accumulation of purulent matter, but which is sufficient to induce a more abundant secre- tion of mucous fluid which it constantly secretes. The only sign which distinguishes this mucous secretion from purulent collections is, that they never proceed from inflammatory symp- toms, which always attend the development of the latter, and that they more frequently affect young subjects, since, of three cases which Boyer describes, the oldest was not twenty years, and the most remarkable case on record, and of which Dubois has given the details to the Professors of the School of the An- cient Society, and upon the disease had commenced at the age of seven years and some months. As this case sums up, at once, both the diagnostic and therapeutic indications of this disease, we shall here give a detailed description of it. A child of seven years had a small hard tumor, as large as a walnut, at the base of the apophysis rising from the superior maxillary bone of the left side, neither growing nor producing pain. The parents paid no attention to it then ; but when the child had reached his sixteenth year, the tumor commenced to grow and become painful. Before he had arrived to his eigh- teenth year, the tumor had acquired such volume that it cover- ed the edge of the orbit. The eye was forced backwards, the eyelids were closed ; the roof of the palate towards the mouth was projected out, the corresponding nostril was stopped up ; towards the jaw was a considerable tumor, whilst the nose was forced back from the opposite side ; finally, the skin which, from the beginning of the tumor, continued with the inferior eyelid, was tender and red, and threatened to be broken ; the upper lip was drawn upwards, thus permitting us to see the gums, which were much more prominent than those of the op- posite side, and it was only from this point that we were able to 222 ANATOMY, ORTHOPEDIA, see the diminished size of the bony walls of the sinus. The patient spoke, chewed and swallowed only with difficulty. Pelletan, Sabatier, Boyer and Dubois, agreeing upon this sub- ject, thought that a fungus of the maxillary sinus existed, which ought to be removed. Dubois, preparing to make the operation, perceived that there was a manifest fluctuation to the level of the gums ; this circumstance caused him to abandon the idea of a fungus, but he expected, before deciding, by making a slight opening, that the flowing of a viscous liquid would reveal to them the true nature of the disease. He then made an incision upon the alveolar bone, from whence soon flowed a liquid which resembled that which flows from the grenouilletée. He then introduced into the opening a probe, by the aid of which he perceived that the cavity had a great analogy to the anterior volume of the tumor ; and by directing the probe with discre- tion, in order to assure himself that there was no fungus there, he perceived a hard body, which appeared to be an incisor tooth, and was very near the opening. Five days after the operation, Dubois extracted the two inci- sors and a molar, and elevated, at the same time, a correspond- ing portion of the maxillary bone. As he caused an abundant haemorrhage, he was obliged to fill the wound with lint; but it ceased some days after, and Dubois was able to examine, with ease, the interior of the cavity; he saw, on the superior portion, a white spot, which he supposed, at first, to be pus ; but upon touching it with a probe, he saw that it was a tooth, which he extracted. The remaining portion of the treatment consisted merely in making injections, and in applying the ordinary preparations. At the expiration of six weeks the cavity disappeared ; but the tumefaction of the jaw, palate, and the displacement of the nose remained. Nevertheless, after a year and a half, no kind of trace of it remained ; the patient had been entirely cured. But, although matter, either purulent or simply mucous, had accidentally accumulated in the maxillary sinus; in a word, although there was an abscess or dropsy there, the essential point to accomplish was, to free the cavity of its contents. Jourdain has proposed, in order to accomplish this, to introduce into the PATHOLOGY AND THERAPEUTICS. 223 natural opening detersive injections, by means of a crooked tube introduced through the nostrils ; but reason and experience have demonstrated that this operation, a true catheterism, was infinitely more difficult and much less efficacious than we might think ; consequently it was abandoned. It is, at the present day, received and adopted in principle, although it can- not cure an abscess or dropsy of the maxillary sinus, or destroy the decay and fistules which are the consequence ; yet we can employ, in order to form an artificial opening, for the flowing of the accumulated matter. Many methods have been prescribed for the accomplishment of this ; but that which is preferable to all, and which we give Meibonius the credit for, although it was employed by other practitioners after him, is that which consists in extracting the superior molar teeth upon the diseased side, then to perforate the alveolus, and to penetrate the cavity as far as the sinus, in order to clean it, so that we can make, by this artificial opening, de- tersive injections. As a general rule, we should always prefer to extract those molar teeth which are decayed, loose, yellowish or painful, whether they may or may not be the cause of the disease. If many are decayed, we should extract them; and, in this case, there is ordinarily a decay of the alveolus and fistule of the gum ; that which renders the disease very apparent, and the ex- traction of all the decayed teeth absolutely necessary. When all are healthy, we should always prefer to extract the first or second large molar, not only because they are more easily dis- pensed with than the anterior teeth, but because they corres- pond to the middle part of the declivity of the sinus. Boyer recommends the isolation of the neighboring parts, by four incisions forming a square, the gums covering the portion of the alveolar border should be penetrated, in order that they, being deprived of all communication with the rest of the gums, may be elevated without causing the patient to suffer. This precaution seems to us to be only useful in the case where the former loss of the teeth, towards the point where we wish to perforate, has already permitted the alveoli to unite, and the gums to cover them. 224 ANATOMY, ORTHOPEDIA, As it regards the perforation of the alveolus, different methods have been recommended ; some practitioners employ a simple stylet, Desault employs a perforating trepan, Richter a trocar. When we have been called upon to perform this operation, we employ, with great success, a triangular, pointed and sharp in- strument, as the trocar, mounted upon a round handle. We use this instrument in perforating the deepest roots, by turning it between the fingers, in order to penetrate the root. When the resistance ceases and the flowing of matter commences, the end is accomplished. As we are compelled to commence the opening at a certain time, in order that it may be sufficiently large, we advise it to be filled with a plug of wood, in order that we may empty the sinus in time, or with a tube. The first method is preferable, because it prevents particles of food and air from entering it. This method of emptying the maxillary sinus is, doubtless, the most sure and reasonable, and, fortunately, that which is most frequently employed. But the disease does not always take the course we have mentioned : "The humor may be of different consistency; it may be in a different part of the cavity, or be shut up between its walls; and besides, it does not form a scarcely considerable collection in a cavity, without the disposition of the parts is modified ; the declining point may vary. It is this fact which explains the success obtained by different proceedings, and gives a real importance to each one of them." Lamorier opens the sinus between the zygomatic apophysis and the third molar tooth. Desault accomplishes it by the fossal canine ; upon this side, the wall is thinner, easier of ac- cess, and the undertaking less difficult ; it is necessary only to remark, that if we see proper to employ the procedure, we must be careful to operate, as before, by an incision made in the jaw, but simply to raise from above the labial angle, in order to dis- cover the gum, to make an incision of a centimetre or two in length, in such a manner as to denude the bone before perfo- rating it; afterwards we place a band of linen in the opening. If a tumor arises in the side of the mouth, and particularly if it fluctuates towards the roof of the palate, we should, according to the advice of modern surgeons, imitate Cheseldon, who per- PATHOLOGY AND THERAPEUTICS. 225 forâtes the sinus from this side. If there should already be a fistulous opening here, it may only be necessary to enlarge it, as is demonstrated by the following case : In 1841, a youth, aged sixteen, named J. An. Fuillant, by trade a locksmith, entered the charity hospital under the direc- tion of M. Gerdy, (Saint-Jean Rail, No. 13.) He had, upon the anterior wall of the first bicuspis, a fistula, from which flowed a large quantity of pus. 9ft. Gerdy, having convinced himself that this came from the maxillary sinus, enlarged the fistula already existing, so as to encroach upon the anterior and inter- nal walls of the sinus. As the result of this perforation, the canine tooth became loose, but by degrees it recovered as much stability as the teeth on the other side. The opening made into the sinus was large enough to admit a roll of cotton as large as the little finger. The progressive development of the sinus had caused the inward deviation of the four superior incisors and the left canine tooth, which had this movement. Finally, when pus flows from the jaw and the orbit, it is easy to perceive that the fistula through which it discharged cannot be healed, except by perforating the alveolar border at the most dependant part. All operations, therefore, upon the fistula is useless, the cause being inflammation of the sinus, accumula- tion of matter in it, suppuration, with or without caries or ne- crosis. The treatment of these superior fistulas is the same as that of urinary fistules ; to wit : to change the course of the fluid from the opening through which it has been accidentally dis- charged. Then some emollient applications will promptly ob- literate the fistula. We shall not here speak of the treatment of the disease of the sinus, nor of caries and necrosis of its walls. That which belongs to our immediate speciality, is the opening of the sinus ; for if this disease is induced, for example, by the presence of a foreign body, the development of a polypus, the presence of worms, as we have seen, the cure depends upon the removal of the one, and the destruction of the other. 29 226 ANATOMY, ORTHOPEDIA, Adhesion of the Gums to the Jaivs and Lips. Whatever may be the nature of the inflammation of which the gums are the seat, whether direct or consecutive, that is to say, belonging to their tissue or dependant upon changes of the os- seous parts which they cover, it causes a swelling, that unites them to the walls of the mouth, in such a manner as to occasion, under certain circumstances, an adhesion between them and the jaws. This adhesion, which we have said might sometimes re- sult from a congenital vice, generally begins at the moment when the inflammation of the gums terminates in suppuration, or rather, when this last assumes the character of an ulcer. Sometimes it is partial, sometimes it occupies the whole extent of the internal side of the gum, and sometimes both sides at the same time. When the causes of this adhesion present themselves, no means should be neglected in order to remove them; for, what- ever may be its extent, it always interrupts the functions of the mouth. We nearly always succeed in preventing it in persons affected with maxillary Auctions, by mucilaginous gargles, and by frequently passing between the jaws and the gums some analogous liquid, as a decoction of the root of althse, etc. If, for want of precautions, or in spite of precautions, we can- not prevent the adherence, it is necessary to take advantage, in order to destroy it. At the time when it appears, a finger may suffice to prevent it ; but if it is of long standing, it will be necessary to have recourse to the bistoury. The separation being made, we should seek to keep the parts separated, in such a manner that it would be entirely impossible to unite them. In order to accomplish this, we .should place in the wound a piece of cotton or of lint, steeped, as we have already said, in some mucilaginous liquid. Finally, if the adherence is complicated of a fistula border- ing upon the exterior, but proceeding from a dental or alveolar caries, in order to treat this affection the adherence must be de- stroyed ; the extraction of the teeth should not take place till afterwards ; otherwise, this operation might occasion a tearing of the jaw, which follows a sharp pain or an inquiet haemorrhage. PATHOLOGY AND THERAPEUTICS. 227 This was the case with Dr. G , of whom we have spoken whilst treating of dental fistula. If the jaws may, in consequence of some inflammation, con- tract an adherence with the gums, they may, for the same rea- son, contract one with the lips; only this adherence is more rare, because the excessive mobility of the lips opposes it much more than the jaws, and these latter, being thicker, and better provided with cellular and vascular tissue, are in a more favora- ble condition to unite, under some circumstances, with the parts with which they come in contact. Whatever may be the cause of this adherence, it is certain that it is sometimes the result of an operation in the mouth, as the extraction of a tooth when the lips were inflamed ; but it is seen oftener among persons whose lips and corresponding gums are the seat of an ulcerous affection, for example, and princi- pally of syphilitic ulcers. A burn may, without doubt, occa- sion it. u The most curious example that we have met with of this ad- herence, is that of a young man, of eighteen years of age, who had his upper lip united to the gum surrounding the four inci- sors, in consequence of a venereal ulcer. This adherence was such, that the lip was retracted, and formed, below the lip, a thick loop, which allowed us to perceive the six anterior teeth, which had commenced to jut out very disagreeably. All that was required was to cut this loop, in order that the lip might be depressed, and the teeth return, according to the phy- siological law that we have established, (in another part of the work,) to the vertical line to which they belong. Our conduct, in this instance, marks out the course to be pursued in similar occurrences. As to the union of the lips, it may be complete or incomplete : the first, as congenital defect of conformation seems so rare, although Berad speaks of it, that Boyer himself makes no men- tion of it; and as to consecutive accidents, we know of but one instance, that is related by Turner, of a miller, who having had his lips excoriated, they united together, in such a manner, that a slight opening, which permitted him to have his food intro- duced through a tube, finally disappeared, and he died of hun- 228 ANATOMY, ORTHOPEDIA, ger. In all such circumstances, the rational indication is so easy to be established, that it suffices to mention it ; it is the division of the cicatrix. Constitutional Affections of the Gums. The diseases of the gums that we have described heretofore, have, as a common characteristic, a nature primitively inflam- matory, and generally dependant upon a local cause. But these are not the only ones to which they are subject ; they may, besides, take an active part in certain affections which attack their entire constitution, and offer, in this case, symp- toms, of which the study belongs, before all, to general patholo- gy, since it yields only to the treatment of constitutional affec- tions; but the dentist ought to know perfectly well, if only to distinguish them from local diseases, and not to apply any treat- ment without the rules of general therapeutics. The essential affections of the gums may be divided into scorbutic, scrofulous, syphilitic or mercurial nature. We will examine, successively, all four in a summary manner. Scorbutic Affections of the Gums. — In the actual state of science, it is difficult to give an idea of the intimate nature of scurvy. This disease consists, as the adepts of the physiological school have lately maintained, in a chronic irritation of the san- guinous capillaries ; the solidists,of the school of Pinel, think it is owing to the atonity of the red vessels ; and the humorists, who are our partisans, believe it is owing to a defect of the blood ; still, it is no less true, that the gums are nearly always affected first. The changes which these parts experience, from the simple tumefaction and bleeding, even to their complete disorganiza- tion, are infinite. The patient at first experiences a disagreea- ble sensation, a kind of unpleasant itching. Soon the gums become swollen, take a red color, and bleed from the slightest touch. They remain sometimes in this state ; but, most ordi- narily, the disease progresses ; then, from being tumefied, they become fungous, of a livid red, and exhale a fetid odor; soon, they acquire a considerable size, are the seat of a deep ulcera- tion, which, in certain cases, envelopes the dental arch. PATHOLOGY AND THERAPEUTICS. 229 At this stage of the disease, haemorrhages are very frequent, the teeth become loosened in their sockets, and finally drop out. It is rare that their color is not much changed ; this becomes blackish or brownish. From the gum, the disease not only affects the teeth, but even causes a caries of the maxillary bone, which is sometimes very great. In consequence of this disor- ganization, the dental nerve is liable to be exposed, and this circumstance may become the cause of violent pain. The gums sometimes take a color so deep that we believe them affected with gangrene. At other times, they become covered with fungous excrescences, which often acquire an enormous size. These excrescences vary in color, form and consistency. Sometimes they are of a livid red, and represent tubercles with a large base, or a straight pendant, but of a firm texture ; sometimes, on the contrary, they are of an ash-grey, resembling tattered rags, and are flabby and bloody; this is their habitual character. It is difficult to confound scorbutic affections of the gums with any other changes that we have described. But all symp- toms disappear, when, to local symptoms are added pathogno- mic signs of the disease, which are vague pains in the limbs, and a spontaneous lassitude, and an habitual sadness, a swollen face, particularly of the inferior eyelids, a general tumefaction of the skin, and the appearance upon the limbs, of a purple, bluish or vivid red color, sometimes yellowish at their circum- ference. In order to remedy scorbutic changes of the gums, we should not pursue any chimerical action. It is only upon the use of proper means that we can relieve the economy from this state of general debilitation, a true anaemia into which it is so often plunged — means, at the head of which we find the power- ful resources of hygiene, which should be the basis of all rational treatment. Nevertheless, from the time when the gums are tu- mefied, spongy, or when the teeth commence to vacillate, but before any ulcers exist, we should endeavor to arrest the pro- gress of disorganization, by the frequent use of gargles, acidified with the sulphate of alumine or sulphuric acid, the first in doses of one drachm, with a quart of a decoction of barley and red roses, 230 ANATOMY. ORTHOPEDIA, the second with one-half drachm only with two quarts. These tonic astringents are applicable when the bleeding is considera- ble. We have also prescribed spoon- wort as a specific in this case. But if the gums are already ulcerated, we may use, with ad- vantage, gargles made with barley water, honey of roses, and hydro-chloric acid, in this proportion: acid, one and a half drachms ; honey, one ounce ; the decoction, one pint. The excrescences themselves often disappear under the influence of this treatment ; but, if they do not, the bistoury must be resort- ed to. Finally, in the odontalgic case resulting from the denu- dation of the dental nerve, it would be advisable to fill the cavity of the diseased tooth with cotton, moistened with a nar- cotic tincture. This precaution should be observed, as we might not be able to plug the tooth without aggravating the pain, or extract it without running the risk of a haemorrhage difficult to stop, and always more dangerous as the subject is more weak. Scrofulous Affections of the Gums. — When we examine the gums of scrofulous individuals, we find that they are generally pale and soft, sometimes even swollen, and covered with ulcers. These ulcers issue a semi-purulent, whitish, nauseating matter, and often loosen the teeth, which they separate from the gums, and finally cause them to drop out. This state might be as well confounded with the disease which we have described un- der the name of suppuration of the gums, if the discoloration and continual swelling of the skin, the constant issues, the choking of the sub-maxillary, lymphatic and abdominal gan- glions, the inflation of the belly, the tumefaction of the articular tissue, did not denote its true character. When it is plain that this morbid state of the gums proceeds from scrofulous cachexy, the only means that can remove it is, to apply the treatment belonging to this cachexy ; we can only aid it by the use of lotions, gargles made with a decoction of red roses and of bark of oak, of quinine, or of simple water mixed with some spirituous liquor. We have also prescribed lotions with liquids containing the iodurated potassium, com- mended lately as a powerful anti-scrôfulous. PATHOLOGY AND THERAPEUTICS. 231 But we should always be very cautious in the administration of such powerful substances; it would be better to the means that we have enumerated, and to which we might add frictions made upon the gums, with powders formed of a mixture of magnesia and sulphate of quinine, or of any other tonic astrin- gent substance. It is almost useless to say that it is indispen- sable to prescribe the use of succulent animal nourishment, of wines generally, the inhabiting of dry and well aired places, exercise and insolation. Syphilitic Affections of the Gums. — The symptoms of the ve- nereal disease which appear upon the gums, are ordinarily of an ulcerous nature. These ulcerations, for the same reason which all have that appear upon the gums, are not as easily dis- tinguished as it is commonly said and generally believed. Nevertheless, their pointed shape, their greyish bases, and their tendency nearly always to enlarge, are indications which point out their true character, and which can easily prevent us from confounding them with aphthae or any similar affection of which we have heretofore spoken. The treatment of these ulcers does not differ from that which belongs to the other symptoms of which it is the consequence. However, if they were first and very recent, we can not only arrest them at once, but even cure them altogether, by touching them lightly, as far as a perfect cicatrization, with a pencil of nitrate of silver, (infernal stone,) experience having proven to Ricord, # Ratier and Desruelles, that syphilis soon becomes constitution- al, that is to say, inveterate, as we have believed. Mercurial Affections of the Gums, (Mercurial Stomatitis. ) — Persons who have used mercury as an internal or external medicine, men employed in mines of this metal, or those who, by profession, habitually employ it, as the workmen in glass manufactories and gilders, are exposed to a particular kind of disease, which at first affects the gums. The result of this disease are more or less deep excoriations. When, then, they are about to form, the gums are at first very hot, then they become engorged, and are of a smooth white, de- * Ricord : Practical Treatise upon Venereal Disease, 232 pressed around the crowns of the teeth, and the rest of the gum assumes a violet color. We sometimes observe, upon the gum, mucous projections, a kind of cicatrix. All these parts are very painful when subjected to the slightest impression. The inward part of the throat is, moreover, red and phlogistic, the sub-maxillary ganglions are engorged; the patient expe- riences great difficulty in swallowing, talking and spitting ; the slightest movement of the jaws causes violent pain; finally, a thick and ropy saliva flows in abundance from the mouth, and unlooked for gripings take place, which are only the preludes to an intense diarrhoea. Soon, a kind of small pustules manifest themselves, which are converted into abscesses, and leave, near their gaps, ulcers, which extend as much more in size and in depth, as their cica- trization was of long or short continuance, that is to say, as the cause which produced them was greater and of longer duration. They differ from aphthae in this respect, the latter are more su- perficial, and of a white color. They are also, in general, more numerous than those which result from syphilitic virus, and are not, as those, cut off at the top, although their bases are as grey, and sometimes even bloody, as scorbutic ulcers. In this affection, the congestion of the gums is, in general, proportioned to the quantity of mercury which is found absorb- ed in it. If this quantity is considerable, the ulcers are very numerous ; often they are not even confined to the gums, for they occupy, as frequently, the sides of the tongue and the whole extent of the mucous membrane which lines the mouth. The teeth then become blackish and loosened, and the breath ac- quires an insupportable odor. The circumspection with which we daily administer mercury in Prance, has much diminished the frequency and intensity of the accidents which result from its employment; and the general adoption, in the work-shops where the metal is employ- ed, of certain precautions of which we have spoken in the chap- ter on hygiene, has preserved the workmen from many accidents.* * It would be desirable that the new mode of gilding should generally be adopted, that is, by the means of galvanism, which excludes the use of mercury : the health of the workmen would be thereby much improved. PATHOLOGY AND THERAPEUTICS. 233 But when these accidents do occur, it is necessary to withdraw the workmen from its action, and to keep the patient from its employment. We then prescribe softening gargles, made with barley, the roots of althae, flaxseed, honied milk, slightly adulterated with the syrup of white poppy. If the salivation is too abundant, we should seek to restrain it, by applying cold bodies, but principally by compresses, steeped in vinegar water, upon the jaws and the corresponding regions of the salivary glands. But, of all the means, that which experience demonstrates to be the most efficacious, consists in frictions, repeated frequently during the day, with the powder of muriate of dry chalk, and gargles rendered astringent and tonic by the syrup of caechu, and even the alcoholic tincture of ratanhia, or any aromatic spirituous liquor ; seconded, finally, by foot-baths, and revulsive purgatives, if the inflammation has not gained the intestinal tube, and if there is no diarrhœa. An honorable professor of the faculty, Chomel, believes vapor baths an efficacious remedy for mercurial stomatitis. He was led to the use of this means by the following circumstance, which he thus relates : m "After being about twenty-five years physician to the Charity, we received into our service a poor woman, covered with erup- tions ; we prescribed the use of mercurial frictions, in consequence of which she experienced all the ill effects which habitually result from the use of mercury. We then ordered a vapor bath, (not expecting to obtain the result for which the frictions were in- tended ;) the buccal affection disappeared as by enchantment. The success of this attempt gave us some hopes upon the effi- cacy of this means ; we have employed them many times in similar instances \ but, although it has often contributed effica- ciously to the cure of the patient, it has not, in every case, an- swered our purpose." This able practitioner has, very recently, however, employed, very advantageously, vapor baths upon a female admitted in his service, at the Hotel Dieu, for mercurial stomatitis, proceeding *Gazette of the Hospitals. 30 234 ANATOMY, ORTHOPEDIÀ, from working in gilding brass, and with whom a violent diar- rhoea contra-indicated, evidently, the use of purgatives. This patient had symptoms of the affection carried to the highest de- gree; she nevertheless departed from the hospital perfectly cured, after only seventeen days of treatment. We then recommend to practitioners vapor baths, if not at the commencement of the disease, at least at the time when the dryness of the skin an- nounces that it is tending to the intestinal tube. We have recom- mended them, not long since, with much success, to a young commission merchant, who, in order to free himself from a syphi- litic affection, had irrationally used mercurial frictions, and with whom, to the worst of the preceding enumerated symptoms, was added a trembling of the limbs. Gangrene and Sphacelus of the Gums. Most of the authors who have written upon the diseases of the mouth, have treated of gangrene and of the sphacelas of the gums in a distinct part. But the actual state of pathology, principally anatomical pathology, does not permit, according to our opinion, to make this distinction ; gangrene being, to speak correctly, excepting in cases when it proceeds from the action of a violent compression, only one of the modes of the termina- tion of the inflammatory diseases that we have described, car- ried to the highest degree of intensity ; and sphacelus, the result of one of the constitutional affections of which we shall treat, and whose effects will be particularly centred upon the gums. Whatever may be the cause of the two affections in contem- plation, independent of the commemorative signs which be- long to each one of them, the first is recognized by the bluish color, which soon becomes slaty and even black, in many points of the gum, accompanied with a horrible odor; the second, by a kind of decomposition of these parts, which become soft, livid and are reduced to a kind of putrefaction, and abandon the alveolar borders, without, however, being accompanied with an odor as unpleasant as the first, for it is more insipid and nau- seous than fetid. These two states, opposed by ail the proper means for favor- PATHOLOGY AND THERAPEUTICS. 235 ing the termination of the different ulcerations of the gums, and for reviving their vitality, according to the case, either become drained by an over irritation, or extinguished by a deleterious cause, if we can speak thus, which affects the whole organic system at once. We have so plainly described these different means, in treating of the orders of diseases of the gums, of which they are but the last expression, that it will not be neces- sary to return to them here. As to gangrene of the gums, resulting from a violent contu- sion, as a blow, a fall, or of a too great pressure, as that which might be the result of a badly arranged artificial plate in the mouth, it causes a sharp pain, which at first precedes it, and local signs that indicate it. It can only be cured, as we firmly believe, by destroying the cause which produced it, accompa- nied by the use of the means applicable to other cases of gan- grene. We, some years since, met with an example of this latter kind, in a young man, aged seventeen years, whose two central incisors of the lower jaw a dentist had endeavored to straighten, by the use of a double band, that he had badly adjusted and pressed too tightly upon the alveolar border. The pain result- ing from the application of this fixture was at first very acute ; but the young man, believing it inevitable, had courageously endured it. It suddenly ceased, and when we wished to judge of the effect of the treatment, we perceived, added to a cadaver- ous odor which exhaled from his mouth, a number of small pustules, filled with a slate-grey pus, and two blackish eschars, which covered, upon each side, the projection that the roots of the canines ordinarily caused upon the alveolar border, and that the gums were, in a great measure, gangrened upon their anterior face, being the one upon which the pressure had principally been exerted. in saying ; # "I * Work quoted, vol. ii, p. 448. 59 49S OPERATIVE MEDICINE AND PROSTHESIS, think that we should adopt the following as a rule, and which we should rarely break, viz. to place the articulation of the springs in such a manner that they could not be perceived. . . . No reason should oppose that which I have here established." As to Maury, he merely* says, that "the only precaution we should take to insure success in the use of springs, is to care- fully select their true point of support," and to give as a prin- ciple, that "the dentist will always do it when he is in the habit of constructing these kind of pieces." Lefoulon is still much less explicit and more accommodating,! for he expresses himself simply in regard to it in these terms: "It is then only by groping that we can find the proper place for the sup- port of the springs." For ourselves, we sum up our opinion in these terms : what- ever may be their form, they should always be placed in such a manner that the two pieces of the denture should be held in a perfect equilibrium, and this important condition can be filled only in proportion as the two points of sustenation are con- tinually perpendicular, the one to the other, even in the case where one jaw exceeds very much the other in front. If it would be necessary to point out precisely the place, we would say, immediately behind the second small molar in the supe- rior piece, and directly behind this same tooth in the inferior. We conceive, however, that this perpendicularity of the axis is not as rigorously necessary when the dentures may be fixed to the remaining teeth ; as to the support that these teeth give, either directly or indirectly, it is always necessary to profit by it, because much may be sacrificed to the desire of rendering springs invisible and of no pain. The difficulty that we experience in finding the precise point of the denture upon which the springs should be placed, and the disagreeableness which follows its fixation upon a place where we are often obliged to change it because it is not convenient, has given birth to a method more complicated, it is true, than those of which we have here spoken, but which has this advantage over them, of permitting all the necessary attempts for discovering this point. * Work quoted, p'. 386. f Work quoted, p. 430. OR MECHANICAL DENTISTRY. 499 This method consists in fixing the articulating pivot of the spring upon a small plate of platina cut square, but a little smaller than the thickness of the base of the denture, and pierced with a small hole at each of its four angles. This plate, supporting the spring, is, at first, confined by wax, or any other agglutinative substance, then changed, if it is pro- perly placed. The place once correctly selected, we hollow upon the base, (osseous base,) a slight notch for receiving it, and we fix it permanently, by four small gold screws with a sunk-head at least, if we do not wish to pierce it through and through by the pivot itself, which would be riveted on one side, and would form an axis on the other. The extreme mobility of spiral springs has given to some practitioners the idea of restraining their action only in the place where they should move, by maintaining them in place on the pieces which they should support, by means of small hooks of gold or platina in the spot in which they should only act, and which they have designated by an expression not less new than significative, viz. limitators. However specious as this idea may be in theory, it offers nothing very serious in practice, in regard to the end that those propose who have sustained it, because the jaws exert always a pressure upon the springs, so great as to prevent them from deviating from the movements which belong to them. But if these small fixtures are not useful, they are necessarily detri- mental by the thickness they give to the piece, and the pain their angles give to the parts which come in contact with it. Also, we think it prudent to renounce it, and to sat- isfy ourselves, when it is necessary to confine the action of the springs above and below, by fixing in these two directions a small piece of leather for it to rub against. We have said, at the commencement of this article, that springs, such as we have described, were intended to maintain the two pieces which compose a denture, apart, and which naturally approach in the occlusion of the mouth. We have neither wished to say from that, that these two pieces should be necessarily complete, nor that they should be equal in force, that is to say, for the number of the teeth. Very often, 500 OPERATIVE MEDICINE AND PROSTHESIS, in effect, we have to replace the teeth of the superior jaw, and some only in the inferior. It is always by springs, such as we have described, that pieces fit for filling each of these indications are maintained in the mouth ; but the teeth which shall furnish the lever plate, although perfectly arranged, each in its proper place, should be united by a band, a kind of metallic plate, which, arranged in a manner so as to apply exactly behind the dental arch, forms, with the parts composing the piece, an assemblage suf- ficiently solid to give to the springs a support completely immovable. This assemblage should even extend to the most distant part of the alveolar border, in order to correspond to the superior piece of the denture. If the inferior jaw had preserved all its teeth, we solder for each side a supporting band for the springs, and of which there may be some question, with two rings embracing the two or three last large molars, and its solidity might be assured by means of spurs, which, dividing it in as many compart- ments as there are teeth existing, would insinuate themselves into the posterior inter-dental spaces, without, however, being allowed to touch the gums; we name these pincer-springs. For a long time the form of a die was given to these springs; but in order to avoid, as in the use of the inclined plane, such as were at first used, the accumulation of alimentary and other matters, we give to them, at the present day, the form of a night-cap, or of a diamond, by soldering upon their external face two small metallic stems, which divide the outward from the inward, and the inward from the outward, crossing upon the summit of each molar, and thus counteracting the pressure exerted by the spring, and, consecutively, by the ring upon the inferior jaw. This apparel, as we see, resembles in all points that which we have described, and which we employ for giving a solid support to the attractive bandages intended to maintain the different ligatures by means of which we endeavor to straighten irregular teeth, particularly those which are oblique in front. The credit of the first idea of this belongs to* Fauchard ; for no person that we know of had thought before him of fur- OR MECHANICAL DENTISTRY. 501 nishing the superior jaw with a complete piece maintained by a reactive agent resting below upon an incomplete piece, or even upon a similar one. The following is a proof of it. "We may," said he, "*adjust, likewise, in the superior jaw an entire piece of artificial teeth alone ; for, in order to hold this piece, it is necessary to place in the inferior jaw a similar one, according as the inferior jaw has all, or only a part of the natural teeth which may sustain and strengthen the piece placed in the superior jaw. I'hese circumstances have in- duced me to invent a machine which, being arranged in the manner that I had desired, was adjusted in the superior jaw so that it might perform the same use as the natural teeth. "In order to construct this piece, it is necessary to examine the number of teeth that remain below, the size, situation and the dimensions of the gums, &c. ; then we construct two plates of gold or silver, about one line and a half in length and a quarter of one thick; these two plates, thus fabri- ncated, we curve upon their largest face two half-circles, that we may adjust, the one upon the anterior, the other upon the exterior face of the gums of the inferior jaw. The plate which forms the exterior half-circle should be longer and more curved at its two extremities, according to the height and thickness of the teeth and gums that it should embrace. It is raised above the teeth, and is bent in the place where its curvature should form an elbow. Upon this piece, thus con- structed, we mount by springs that which should represent the artificial teeth of the superior jaw. . ." Finally, if in the most of cases the springs are used in pairs, we perceive in the meantime how we can employ but one, on the one side, for maintaining two pieces occupying the depth of the alveolar arches on this side, and upon which there ex- ists no teeth which may give the necessary support behind. We have made, not long since, a piece of this kind which * Work quoted, page 261, &c. The chapter from which this quota- tion is extracted has the following tide: Description and use of a curious machine composed of a complete superior denture, united by springs with a piece of gold or silver which embraces, by means of two half-circles, and of two handles, the teeth of the inferior jaw. 59* 502 OPERATIVE MEDICINE AND PROSTHESIS succeeded very well, for a lady who had lost all the left large molars, and whose absence had occasioned a sinking of the jaw, which formed a striking contrast with the opposite side, so much so that it was but rational to suppose that she should seek to remedy it. The two pieces were fixed to each alveolar arch by crotchets embracing the small molars. We might, in the same manner, employ this method for fixing a single piece above, the spring resting below upon a similar one, which should embrace the teeth still existing upon this side. The Application of all that which precedes, in regard to the Particular Construction of Various Kinds of Ordinary Pieces of Artificial Denture. The enlightened student who will read, with the necessary attention all that which we will say in the course of this chap- ter upon dental prosthesis, and who will see each of the operations here described, practised, by frequenting the work- shop of the dentist, ought not, it seems to us, to find himself embarrassed with any kind of a piece, whether simple or com- plicated, in the acceptation that we have given to these two words. In all, in effect, he will be obliged, 1st. To take the most minute impression, and, conse- quently, as rigorously exact as possible, of the toothless place or places \ 2nd. To make the mould upon which will be adjusted and stamped the supports of these pieces, if the supports are me- tallic, or after which they will be sculptured if their bases are of animal substances ; 3rd. To determine the nature of the substance that should be employed in preference to all others for supplying the loss which it shall remedy ; a determination which depends par- ticularly upon an attentive examination of the mouth ; then to unite the teeth to their bases ; 4th. Finally, to choose amongst the different methods of at- tachment that which is most suitable for maintaining solidly, and, particularly, without injury to the neighboring parts, the piece permanently in the place it should occupy. OR MECHANICAL DENTISTRY. 503 All these things we have studied with sufficient detail in order to be applied to the plurality of cases, particularly those which most commonly present themselves in practice. Now, of what true utility would it be to give, as most au- thors have done who have written upon the mechanical por- tion of our art, separate examples of each one of these pieces: pieces of a continued series , that is to say, composed of many teeth juxta placed ; pieces of an interrupted or interspersed series, that is to say, composed of teeth disseminated, with spaces between them for those which remain sound or at least standing; finally, pieces of mineral or human teeth, mounted upon a base of sea-horse, or upon metallic cuvettes, &c. &c. of what utility? none, excepting to increase the volume, and uselessly to perplex the mind by fastidious repetitions. Do we wish to have a proof, a completely unobjectionable proof of this assertion ? we have one in the description given by one of the first authors, Maury, for example, of a com- plicated piece of many natural teeth mounted upon a base of sea-horse. ''When we wish to mount, says this author, natural teeth upon a base of sea-horse, the first thing to do, is to adjust it well in the mouth ; and in this respect we will not repeat that which we have said in speaking of pieces sculptured on sea- horse, the method of adjustment being always the same, whether the piece will be furnished with natural or incorrupti- ble teeth. Thus, then, after having assorted and selected them, as nearly as possible, similar to those which they should replace; after having sawed their roots to a proper height, we place them upon the animal base in their respective posi- tion, and maintain them there with a little sealing wax. That done, by means of a gimblet mounted upon a drill, we form in their roots, and at the base which supports them, a small hole in which we put a peg in order to fasten them for the time being, the one to the other, and we replace this peg sometimes by a larger one, sometimes by two smaller ones, or even by a screw," &c. &c. What can we find in all this which would not be perfectly understood without, and which would be of use to the stu- 504 dent who understands all that we have said upon the adjust- ment of hippopotamus pieces, and upon the choice, perfora- tion and mounting of natural teeth: and what would be the use, when one has devoted several pages beforehand to a de- tailed article on ligatures, plates, crotchets and springs ; in a word, on the different methods employed for maintaining arti- ficial teeth in the mouth, to add a particular description of a piece. "Artificial teeth, whose union constitutes complicated pieces, may be fixed upon their base (the author, doubtless, wishes to say, upon the alveolar border) by different methods of attach- ment, sometimes in effect, we employ simple ligatures, some- times, crotchets, or springs," &c. &c. The observation that we are about to make is no less appli- cable to Delabarre than to Maury and others. We may judge by this description of the construction of a denture of a con- tinued series, which he calls a simple piece with enamel :* "We select a piece of hippopotamus which has the proper dimensions for filling the breach; it is particularly necessary that it should describe the same portion of a circle as that of the vacant space. We should prefer a hard not chalky enamel, of a pure white and not blue, presenting a thickness with the least possible projections. This piece should be higher than is necessary, so as to be able to affect the incrustation, and even to remedy the defects that might be made in working it. We remove with a rasp or grinding apparatus, a portion of the part not enamelled, preserving it only of a length of six or eight millimetres for forming a base intended to rest upon the roots, if the piece is to be attached with pivots ; or from twelve to fifteen, if it is to be fixed by other agents. . . It is well, be- fore advancing too far in the work, to try it upon the patient in order to ascertain if there is no essential fault to correct. . . We must not be satisfied in sculpturing the teeth, to cut them clumsily, although they might be for those who had no idea of human anatomy. The incisores should have the form of a flattened angle, but swollen in front and hollowed behind," &c. &c. * Work quoted, p. 183, &c. OR MECHANICAL DENTISTRY. 505 Notwithstanding some variations, necessary for the special destination of the object, the description that Delabarre gives of the method of constructing the piece opposite to that of which we come to speak, that is to say, a denture of inter- rupted scries, of a single piece of enamelled hippopotamus, is absolutely the same, as the following will prove :* "When we wish to make a slanting piece from a single piece of enamelled hippopotamus, we must select a piece whose enamelled arch will be the same as that of the portion of the mouth for which it is intended. In order to succeed, we cut a pasteboard in the same manner as we would the piece itself; we cut it to receive the teeth upon the model, making with it, the convex or anterior border. With a pencil we trace the form of this pasteboard upon the piece of hip- popotamus, having care to place the projections which might be upon this substance in the places which should be cut off. The rasp and grinding wheel are the proper agents for sketch- ing it, which, being executed, will facilitate the incrustation with the graver," &c. &c. It seems to us, after having established the principles which should serve as a guide under every circumstance, and having observed with care each object which belongs to the construc- tion of a piece, in all the details appropriate to the diverse usages that we may make of them, it would be useless to give particular examples of each kind of piece. We will then con- fine ourselves to the examination of certain objects which, by their special nature, depart from the rules that we have pre- viously given ; such are complete dentures and maxillary or palatine obturators that are united. We regard that which belongs to lingual, labial, nasal, or facial prosthesis altogether foreign to the art of the dentist. Exceptionable Pieces. By this expression, exceptionable pieces, we do not wish to say that the objects of prosthesis that we now designate, de- * Work quoted, vol. 1, p. 248. »06 OPERATIVE MEDICINE AND PROSTHESIS, part completely from the general rules that we have establish- ed for the construction and adjustment of pieces which are most frequently employed, and form those that we have called ordinary pieces. For these, in effect, as for those, it is neces- sary, first of all to take the impression of the parts, obtain them in relief, construct the bases, fix the teeth there, and to provide means for maintaining them in place; but the pieces of which we shall now treat, depart so much from general rules, as to require some important modifications, particularly of detail in the application of rules, and we believe it right to give a particular description of them. Complete Dentures, vulgarly called Râteliers* In all that we have said as far as the present, as much upon the methods of taking impressions, as upon the manner of using these impressions as faithful guides in the construction of different pieces of artificial denture, we have always admit- ted that the jaws were not completely deprived of their teeth, and that the few that were remaining of them were always sufficient, nevertheless, was it only one, provided that it had its usual length ,f to appreciate the natural degree of widen- ing of the two jaws, and consequently the length to give to the artificial teeth with which we intended to supply them. There exists several cases, unfortunately, very common, where the alveolar borders are completely unfurnished. In these cases, must we content ourselves with taking the impressions of the two jaws, and stamping after these impres- sions of plates upon which we will mount the teeth placed as these are in the natural state, and of a height equal to those that teeth generally have? Not exactly; because the jaws, * We advise young practitioners to employ as little as possible the ex- pression oi'raleLler, in order to insensibly expunge it from the vocabulary of our an. t That which would not be if it was decayed in the superior part of its crown, because it would then be too short; and which would not be if it remained long without an antagonist, because it might elongate in ad- vancing from its alveolus. OR MECHANICAL DENTISTRY. 507 the inferior particularly, have experienced by the fact of the total loss of the organs which furnish their borders, changes of which it is of the greatest importance to notice exactly. These changes effect both, in the shrinking or sinking of their alveoli ; in the inferior, upon the opening of the angle which, as we have seen in the anatomical part, takes among old persons the form it had in infancy, where the body and branch of the bone unite themselves in an angle so obtuse that they seem together. The first of these two changes, the shrinking of the alveoli, has for its result the overturning of the jointing of the inferior jaw by the superior, because this sinking is made from without inwardly, for this latter which shrinks a little in diameter, and from within outwardly, on the contrary, for the first whose extent then augments a little. The other change, that which results from the opening of the angle of the inferior jaw, has for an inevitable effect: 1st to throw the body of the bone forward, for the articulating condyle remains fixed : 2nd to draw the two jaws near to one another, so much as to efface in the whole length of their body the space which separates them when they were furnished with teeth. If you take then a complete denture the most ably executed, but copied from the jaws of adults furnished with their teeth, in a word, composed of bases perfectly horizontal upon which will be implanted perpendicular teeth, and when you place this denture upon the jaws which have undergone the trans- formation that we have described, two things will happen ; first the inferior denture will glide before the superior ; after- wards the widening of the jaws by the molar teeth, whose place had disappeared, will be effected only by the painful pulling of the masseter muscles, and other elevators of the jaw. We do not believe that the change in the form of the infe- rior jaw is the result of old age, for it is rather the inevitable result of the total loss of the teeth. Thus we see old persons having preserved them, to have the angle of the jaw nearly acute, and the chin scarcely projecting ; whilst we meet with 508 OPERATIVE MEDICINE AND PROSTHESIS, many adults who have lost them all at an early age, and who have nevertheless the entire physiognomy of old age.* From thence follows the necessity for those persons who wish to preserve the habitual expression of their physiognomy, and to have the least appearance of decrepitude, of replacing their teeth as they lose them. Aware of these facts, the dentist who would have to con- struct a complete denture, not as an evidence of art, but to be applied usefully upon a person who was for some time com- pletely toothless, should commence by taking an exact im- pression, but each jaw separately ; a method preferable to the habit that some dentists have of taking an impression of both jaws at once in wax, and whose result rarely gives the true rela- tions between the two maxillaries. He should then construct these moulds, but he should be careful to articulate together the two parts, although no tooth exists, he will be entirely ignorant of what degree of space he should leave between them ; the length of the whole of the two dental ranges will alone regulate this widening. The plaster moulds being made he should obtain those in lead or in any other metallic substance, since it is particularly for large pieces that we have established the necessity of it; he should stamp these plates, then adjust them upon the gums, and afterwards establish them according to the rules that we have heretofore established. Then he should attend to the teeth. But what length should he give them, and how should he establish this length in a satisfactory manner? It is in this that the difficulty consists, for many reasons: first, because the act which consists in taking a wax impression, for stamping is so painful to many persons; second, because in pressing them with much force, the gums might flatten, and the mould is not as exact ; third, in taking an impression thus, the inferior jaw advances under the superior, and we give it two large a surface. * Delabarre, who knows this fact, has acted in opposition to himself in saying, "it is not sufficient to remove all the teeth to give to the face of an adult the resemblance of old age ; from the fact it takes only the as- pect of it." OR MECHANICAL DENTISTRY. 509 Some dentists, believing that they could overcome this dif- ficulty by determining the medium height of the two dental arches, in their different points in an adult, have estimated that the widening of the jaws should be, altogether in front, thirty-eight millimetres, and altogether behind twenty-four ; whilst others have accorded thirty-four, and even thirty milli- metres in front, and eighteen or even fifteen behind, wishing from thence not to change in too marked a manner the entire physiognomy. We think, that it is absolutely impossible to establish a pri- ori, and even in a purely general manner, the precise degree of this space; because in the place which corresponds to the incisores, this degree may be regulated by a glance of the eye, which satisfies better than all the measures that we can take, that which agrees with the figure of the person ; and, towards the posterior molares, by the opening of the angle of the jaw. This opening will be as much more prominent as the com- plete absence of the teeth has been more or less ancient, as we shall demonstrate, as also as they have been lost at intervals more or less distant from each other; for it will necessarily suffice that some of them are left, particularly behind, so that the transformation that we have mentioned shall not be ef- fected. Observe how the most of practitioners proceed, and this which Lafoulon gives wrongfully as a new invention of his own.* When the two plates, or rather the two bases, are per- fectly adjusted, they solder or rather fix temporarily to the middle part of the inferior plate, directly upon the median line, a small metallic stem from thirty-six to thirty-eight mil- limetres in length, directed vertically, in such a manner that its superior extremity shall touch the middle of the opposite ♦Work quoted, p. 408, &c. This author seems, however, to have no idea of the transformation that the angle of the inferior jaw undergoes by the absence of the teeth, and, consequently, of the difference that should exist between the length of the teeth of replacement, and the nat- ural ones, since he expresses himself in speaking of complete dentures, thus : "We have no need to add, that the teeth should be like those they replace." 60 510 OPERATIVE MEDICINE AND PROSTHESIS, plate; then they solder two other similar ones upon the lateral parts, one on each side. They insensibly diminish them with the file, until they are satisfied that they have the precise height appropriate to the figure ; they then furnish these sides, as far as the end of the base, with a roll of wax arrang- ed as the dental range, but exceeding the stem from four to five millimetres in height. The two bases being then placed, they require the patient to close the jaws so that the occlusion of the mouth will be arrested by the pivot fixed from base to base. In this effort, the wax will be necessarily stamped, and the point where it stops this stamp gives, in the whole extent of the alveolar cir- cle, the measure, but the total measure which the teeth should have above and below united, a height which we then divide between them as conveniently as possible, by measuring as they say, the length of these teeth, after the middle of the dis- tance which exists between the two cuvettes. They continue thus : "These precautions being taken, both pieces must be withdrawn with extreme care, in order not to derange the wax teeth." Nothing better assuredly ; but they add : "When the whole is out without accident, we detach the springs and place the inferior cuvette upon the plaster mould which serves for their adjustment; but, previously we make some deep notches in the posterior part of this same mould, and which we moisten. When it is thus prepared, we form behind it a kind of very small trough with a leaf of lead thin enough to be easily bent. In this trough we pour some plaster which prolongs the mould by forming a heel there, in each .angle of which we form two holes, for receiving the heels which will be adjusted in the superior mould." "This is obtained in the following manner: we place the superior cuvette upon the inferior, by applying the extremity of the three pivots upon the small holes which are impressed in the wax and whose .office is to mark. Upon this cuvette we place the mould which belongs to it, and for fear that it might move, which should not hap- pen whilst the plaster mould is drying, we fix it steadily with several rows of very fine heated iron wire. Finally, we oil OR MECHANICAL DENTISTRY. 511 all the part newly added to the inferior mould, and we pour some liquid plaster upon both moulds at the same time. The superior mould should by all means undergo the same prepa- rations as the other mould so as to facilitate the adherence of the new plaster." Well, what does the practitioner that we have named think of this method, and which he gives as the fruit of an effort of imagination entirely new , and which he believes a duty to give to his confreres, it is defective from one end to the other. This we can easily prove. First, the central pivot, intended to sustain the cuvettes between which the wax should be placed representing the teeth, is completely useless if we place at the same time two pivots on the sides, because it is lateral- ly and not before that the widening of the jaws should be ap- preciated. On the other hand, if we place this pivot only, it will not properly sustain the plates in place so that the patient can make all the necessary movements to try the sus- ceptibility of its attaining the end proposed, because the cu- vettes would quit the alveolar border behind, or would not adhere to it. Then, not serving to represent both dental ranges, with a single piece of wax, we should be obliged to introduce the fingers in the mouth in order to maxalate and adjust the wax above and below, and it is impossible to give to each dental range the inclination which it should have. Besides, how can we divide it in the direction of its height without chang- ing the form which it should have ? Finally, in making only a single mould for the two articulating pieces, we would experi- ence the greatest difficulty in mounting the teeth as we should have no fixed line to govern the arrangement of their cutting edges. Notice how we proceed : we solder upon each plate or base, to the parts corresponding to the small molares, on each side, a small plate of platina, from twelve to fifteen millimetres in length, from four to six in height, solely to sustain the wax; then we fill with two pieces of this substance, the space be- tween them and the bases, holding these pieces, however, higher than the metallic plates. We then require the patient 512 OPERATIVE MEDICINE AND PROSTHESIS, to press lightly upon the wax; then we reduce it in height to the degree wished, by cutting it with a curved knife which removes it by pieces. We then arrange this wax for sustain- ing the jaws ; give to the two layers that it forms in front, and which we have had care to flatten with the fingers, the direc- tion that the total mass of the teeth should have, and we as- sure ourselves of the entire exactness of the whole, so far as that the physiognomy has returned, that it can execute all the functions which belong to the jaws, and finally, bite square in every direction. When this imitation of the complete denture is perfectly made, and the two parts of wax which represent each a dental arch, acting well in every point the one upon the other, we make a mark upon their anterior part, so as to recognise their central point, which represents the two great incisures above as well as below ; we do the same upon their central parts, so that they may always be replaced in the same relation that they had in the mouth. This second lateral mark should be re- peated upon the base and made, as much as possible, upon the place that is intended to be occupied by the springs. Then, as the bases are metallic, we slightly heat them at the concave part by the alcoholic lamp, then draw carefully from them the two circles of wax which covers them, and we fix then a small plate intended to receive the spiral spring. We then replace the wax with care in the mouth upon their plates, and fasten the springs there temporarily, so as to assure ourselves of the regularity of their action. In regard to the determination of the precise point upon which they should be placed, we were sufficiently occupied with it, in speaking of the general means of holding the different pieces of artificial denture in place, and particularly in treating of springs. These precautions once taken, and the height of the two dental ranges obtained by that of the two pieces of wax which represent them, we make an articulated mould apart for each jaw. In order to do that, the springs being removed we place each plate furnished with its wax upon its own mould ; we then make upon the internal part of the mould, in about the the three posterior quarters of its extent from the front back- OR MECHANICAL DENTISTRY. 513 wards, a deep triangular notch ; then cover this interior and posterior face of the wax with a little oil. Then we envelope the mould through all its circumference, as for an ordinary plaster mould, with a band of very thin flat lead, or simply of pasteboard, of double the height of the mould; then we pour some diiuted plaster, which filling all the concavity of this latter, touches it everywhere, less necessarily at the place where the band of wax occupies all its circumference. The counter- mould being dry, we separate it, remove the wax and find, in placing the counter-mould in the mould, the precise place the teeth should occupy. In regard to the method of fixing the teeth (which, may be said in passing, never exceed twenty-eight,) there are three things to be considered ; the direction that must be given to them, the order in which they should be placed, and their at- tachment to the base which should support them. That which we have said of the shriukingof the alveoli of the jaws shows us that those of the base should be directed a little within, so as to correct the effects of this shrinking which operates without, and those above outward, for the opposite reason. We also think that it is always better to give to the teeth of a double denture a height a little Jess than that which the natural teeth have, for this very simple reason that the piece will be as much less apparent as it is less thick. In regard to the order in which they should be placed, that which we have also said of the effacement of the angle by which the branches of the inferior jaw are united to the body, would make it appear that it is first on this, that is to say, by the molares, that it would be well to commence, since it is the space that we leave between the jaws in the depth of the mouth which will regulate the length which the anterior teeth should have. But as this space is always rigorously obtained by the pieces of wax, the central incisures should be placed first, and then the molares, not fixing them definitively, until after having tried their position, not only upon the mould but even upon the mouth of the patient. Finally, it is, particularly, for teeth making a part of com- plete dentures that we sustain them behind, when they are 60* 514 mineral ones, which maintains them solidly united together, and at the same time on the base ; but it is then useful to bring them as near as possible together, so that this band may not be perceived. All that which we have said applies, as we easily see, only to dentures with metallic bases ; but when we construct them with bases and teeth of animal substance, or to speak more posi- tively, of hippopotamus, we should take the following course : Take the separate impression of each jaw, have the relief moulds of both, (moulds of plaster only, and notof metal, which becomes useless, since we have nothing to stamp;) these two moulds obtained, we take a second impression by means of two pieces of wax applied upon each alveolar arch ; but then to have altogether the hollow of the alveolar border, as for that which served to furnish the plaster moulds, and the height of the teeth, as for metallic cuvettes. This is, doubt- less, that which Maury wished to say by this phrase, by which he commences the description of a denture with a sea- horse base : "We commence by taking, separately, two impres- sions of both jaws," &c. However that may be, we should make the wax reach each side of the alveolar border, precisely at a level with the base, and make it encap the gums exactly, as this latter would. Finally, we obtain, as for metallic bases, a counter-mould so as to have always a method of appreciating the true height of each denture, by holding it, nevertheless, a little more dis- engaged towards the internal face of the teeth, so as to cor- respond to the great thickness which the base inevitably has in this case. This being done, we take the piece of hippopotamus which we intend for each denture; cut it exactly upon the piece of wax representing the teeth, leaving it two millimetres long, so as to provide for the slight déperdition that it might experience in this direction by the intersecting of the teeth where they are regularly cut; we present it upon the plaster- mould, and incrust its base which should bear upon the alve- lar border, by means which we have previously given ; then we try it in the mouth of the patient, each piece separately, OR MECHANICAL DENTISTRY. 515 then both together, so as to establish their true relations; we mark upon each piece, vertically, the line which should sepa- rate the central incisores, and we withdraw them from the mouth in order to trace with a crayon the portion which should be devoted to each tooth and which we then sketch. We do not proceed farther without again trying the den- ture, so as to remove by the rasp or graver those points which might be superfluous. As all that which relates to each piece, besides the teeth, is obtained and acts only by the relations established between them, we may maintain them united by a little wax interposed upon the different parts of the surface where they touch and are withdrawn in this position, then placed upon their primitive moulds. We then make from these an articulated mould, that is to say, only by the addition of a certain quantity of plaster added to each mould and ar- ranged as a projection in the one, and as a cavity in the other, as we have previously said, we place these two pieces in sim- ilar relations to those in which the mould and counter-mould have been put, which have served to give to each dental range the proper height. To finish the teeth remains only to arrange them in such a manner that in front the inferiors cross under the superiors, and that, upon their sides and behind, the tubercles made upon the triturating face fall just in the depressions made in their antagonists. Finally, when we wish to mount human or mineral teeth upon hippopotamus bases, intended for a complete denture, we proceed exactly as we do for pieces whose bases and teeth are hippopotamus ; only, when the piece is properly cut and cor- responds exactly to the other piece, we mark on each side the place intended for the two large molares, then we remove all the intermediate portion intended for the ten teeth that we propose matching. We sculpture the molares in such a man- ner that their tubercles indent well, and mount to the height obtained, the human or mineral teeth, according to the rules that we have given. We are particular, also, we repeat it in opposition to the or- dinary opinion, not to fix the springs permanently to the bases before placing the teeth irrevocably there: the regular action 516 OPERATIVE MEDICINE AND PROSTHESIS, of these springs being one of the most important points in the use of this kind of piece, all should, so to speak, be sacrificed for it ; in such a manner, that if the points upon which these springs should rest being well ascertained, those which were tried, before the piece was furnished with its teeth, not seem- ing sufficiently strong, we substitute for them others of the same length, but more resisting. Jn regard to the question seriously agitated by some den- tists,* whether the springs should be gold, brass or iron, it is necessary to be very fastidious to suppose that some practi- tioners could be found so ignorant of indispensable matters in the exercise of their profession, and so prodigal of their time, as to amuse themselves with calculating the results with brass or iron springs in comparison with gold. We have noticed, that all the details relative to the con- struction of a complete denture enters into the general con- siderations with which we were previously occupied, and a new development of which, here, would form a useless repe- tition. We might, however, establish, upon this subject, un- der the form of propositions, the five general rules which fol- low: 1st. In the construction of a complete denture, every thing should be so arranged that the two pieces of which it is com- posed, reaching as far as possible in the mouth, fill all the alveolar border, which they exactly encap;f that, touching every where the soft parts, in the midst of which they should habitually rest, they will be most intimately united to them and follow their various movements without experiencing any unexpected shocks. 2dly. The action of springs is as much easier, and more regular, as the superior piece is lighter, and as the inferior is heavier. It is also for upper pieces that cuvettes of gold are preferable to those of platina, and even for which palladium # Lefoulon, work quoted, p. 406. fThis does not destroy that which we have said of the propriety of putting only twenty-eight in complete dentures, the two lastmolares being generally formed of a single piece. OR MECHANICAL DENTISTRY. 517 might find an useful application; whilst it is for lower ones that bases of hippopotamus, or cuvettes of platina, particularly, are fit : the first, where the alveolar borders have experienced a great depression, the second where this depression is not very prominent. 3dly. The superior piece would be as much more solidly maintained and easy to support, as it would reach the alveolar border nearer on the internal side, and as it approaches nearer the palatine vault, without, however, advancing upon this lat- ter, because it would disguise the taste to no purpose, and would impede the movements of the tongue. 4thly. Experience has taught us that too much importance must not be attached to the advantage that author's be- lieve bases of hippopotamus have, because of their mild con- tact with the alveolar borders and gums. Persons who make use of complete dentures, habituated in general so readily to metallic cuvettes, that one has frequently erred in depriving these latter of the inappreciable merit of being unalterable. We, also, do not hesitate to furnish most of our hippopotamus bases with a very thin metallic leaf, a kind of cuvette, which, increasing the weight of the piece very little, gives it a solidity and permanency which it cannot have without. 5thly. It is, particularly, in regard to the construction and adjustment of these pieces in the mouth that it is important to know, that some persons, for whom they are intended, hope in this case to be able, by some movements of their jaws, to correct certain vicious conformations to which nature has sub- jected them, but nearly, always, then, to the detriment of the relations in which the dentist had placed the two pieces com- posing the denture. From thence serious difficulties often result which we may avoid, by plainly refusing to yield to the whims of the patient, or by warning him of the result obtained. We have often been styled judicially arbitrary in similar contestations, and we have, more than once, been compelled to judge contrary to the pretensions of our confreres, whose pieces were perfectly made, but which, by an excess of complaisance, or a want of attention, had adjusted these pieces in conditions which soon 518 OPERATIVE MEDICINE AND PROSTHESIS, rendered them impossible to be supported, and rendered them completely useless to those for whom they were intended. The fear of a similar disagreement should not, however, pre vent us from condescending to the wishes of patients, when the rectifications that they require would not affect the ad- justment of the piece, nor oifer a possibility of its preventing its daily use. Maxillary Obturators. In the description of the different kinds of artificial pieces which we have examined, we have always supposed that either the osseous parts in which the teeth were naturally im- planted, existed, or that these parts had not undergone any diminution which it was not easy to remedy, by giving to the osseous or metallic bases a sufficient thickness. But there are cases existing, in which the teeth and a portion of one or the other maxillary which receives these are wanting at the same time. Our art, as is well kuown, is not altogether unavailing in accidents of this sort, which, unfortunately, are very com- mon, and which, although concealed by the soft parts, from the injury which it is at once anxious to repair, constitutes no less, in many instances, very inconvenient deformities, prin- cipally by the difficulty caused by the preparatory work that the aliments must receive in the mouth, or, that which is no less serious, the articulation of sounds. Fauchard thought to remedy these losses of substances, and, although the pieces which he employed for this purpose, had neither the precision nor resemblance of those constructed at the present day, they accomplished the same end. If Dela- barre had read with more attention that which this master of the art has written upon the subject, he might have seen that all the pieces which he has employed in the cases of which we treat, were not sustained with nasal wings; # notice the following literal quotation : "I was consulted some years ago by a lady of the province, * Vol. 2, p. 318. OR, MECHANICAL DENTISTRY. 519 who had lost the four incisor teeth of the upper jaw, by ne- glected caries, which, in consequence, had also destroyed a part of the superior maxillary bone. * * * It was on this oc- casion that I conceived the idea of constructing a plate which should,* at the same time, serve as a support for the teeth and an obturator. I composed this obturator of a plate of ivory ; the tooth of a sea-horse, however, when one can be procured, is preferable ; but the seam which divides this tooth through- out its whole length, renders it difficult to obtain a piece of sufficient thickness for many artificial teeth. To this plate which I adapted to the palate, I left on its convex part, a small eminence pierced at its summit for the attachment of a sponge. I next constructed four artificial teeth, which I at- tached so perfectly to the canine teeth, that the plate was se- curely adjusted, and accurately covered the hole in the palate, whilst the artificial teeth which were contiguous, fitted so well the breach of the natural teeth, as to exactly imitate them and supply their functions." The dental obturator, described in the General Journal of Medicine^ constructed by Fauchard, for a man who had lost the two central incisores, the lateral incisor, the canine and first right molar, with all the part of the superior max- illary bone in which these teeth were implanted, a portion of the mental apophysis, and nearly half of the middle anterior plate of the palatine vault, was merely a copy of Fauchard's, which we have just described. Finally, in- stead of fixing it simply to two neighboring teeth, as the latter, this obturator had the immense inconvenience of main- taining itself by reacting agents, which exerted upon the lat- eral teeth of each side an effort of repulsion more liable to loosen them than the ligatures of Fauchard ; and that with the advice of Duval, who reported upon this obturator, and of Delabarre's, who represents it in his work. Whatever may be the character of the first artificial pieces * This observation of Fauchard proves, without doubt, as we have already remarked, that he knew and had used the tooth of the sea-horse, t Vol. i, p. 386. 520 OPERATIVE MEDICINE AND PROSTHESIS, the impressions which may be taken at the present day, permits them to be made with an accuracy that cannot be excelled When the loss of a portion of the alveolar border and neigh- boring part of the maxillary bone only, is to be remedied, when there is no communication with the nasal fossae, if it is in height, as is most frequently the case, the hippopotamus is the most suitable substance that can be employed, because it is more congenial to the parts, and can be more easily adapted to them, with the exception of mineral or natural teeth. As to the means of maintaining these pieces, the crotchets, acting as springs, and supporting themselves by as great a number of teeth as possible, are the only ones which it is necessary to employ. Delestre, a surgeon dentist of Paris, presented to the Royal Academy of Medicine, some two years since, a piece of this kind, intended to replace in the mouth of an invalid, the loss of the external table, only of a portion of the superior maxillary which had carried with it many of the anterior teeth. Being retained in its place, it perfectly accomplished the object for which it was designed. This piece had, as we can see, a strong analogy to the piece which we have spoken of in an- other place, but with this difference, that our professional con- frere had remedied only the loss of a part of the anterior table of the superior maxillary, embracing only a portion of the al- veolar border, whilst we had a large portion of substance to supply, and another indication to fulfil; namely, to close an opening into the maxillary sinus. If the loss of substance is more common to the superior than to the inferior jaw, it must not nevertheless be expected that it will never be necessary to construct an appliance only for the first, it is in truth easy to conceive that a number of circumstances may, as a wound from a gun, a cancerous af- fection or necrosis, that carry off a portion of the inferior max- illary, and render it necessary to fill the space that may result from it either by remedying the sinking down of the soft parts less apparent, or by giving to the bone more solidity, or sim- ply by supplying to the denture, the part which had disap- peared with the loss of the bone, or, finally, by preventing the OR MECHANICAL DENTISTRY. 521 accumulation of alimentary substances in the cavity which would of necessity be constantly lodged there. Authors, however, furnish no example of a piece of pros- thesis of this kind, Delabarre, doubtless, had no occasion to construct one of this sort, for in the part which he has devoted to the subject, he makes no allusion to it.* Moreover, we think, he completely deceived himself, when he said that Jourdain had occasion to apply one in a case of spina ventosa. We have read, with all necessary attention, what Jourdain says of spina ventosa of the inferior maxillary, and we find nothing that authorises the belief that the idea had occurred to him. In short, of the two cases which this author relates, in his treatise upon the diseases of the mouth, he terminates the first, by saying, that after he had removed the tumor, although the bone, so to speak, became cartilaginous, he believed all violent action should be avoided, "the body of the bone was no more than a shell." The second case was that of a young lady of twenty-seven years, which he treated as in the pre- ceding, but upon which he applied no kind of an obturator, since it disappeared immediately after the operation, without which it would have been impossible to have determined the consequence of the disease which had been thought mortal. More fortunate than our predecessors, we can supply the lack of their silence, by relating a very remarkable case of this kind which fell under our observation a few years since. The subject of this case was a man from forty-five to fifty years of age ; it originated from a violent blow received upon the left side of the lower jaw, causing a progressive tumefaction ac- companied by dull pain. The five molar teeth of this side loosened, were successively removed, and soon all the anterior table of the alveolar border detached itself from the body of the bone, leaving exposed a vast cavity, from thence and the blackish osseous lamela and cells flowed a fetid matter. Not willing to take the advice of his own physician who recom- * Work quoted, p. 312. 61 522 OPERATIVE MEDICINE AND PROSTHESIS, mended the resection of the diseased portion of bone, he went from his native city to Paris, in order to consult some of our celebrated surgeons there. He returned from there home, and merely contented himself with using many times a day, aromatised, in the cavity, an enormous ball of cotton, which was found in his jaw. His physician decided, however, to level the wound of it by destroying, with a caustic, all ine- qualities and soft parts ; this wound from thence took a more favorable aspect, and he returned to Paris, but not for a surgi- cal consultation, but merely to know if he might not have an artificial piece to fill the cavity of his jaw, which not only af- fected his pronunciation, but which formed a hollow in which alimentary particles accumulated and tainted the mouth by their speedy decomposition. It was at this time that he ad- dressed himself to us, and gave us the foregoing facts. This cavity, extended from behind forwards from the union of the branch of the maxillary to unite its body to the canine, and proceeding from above down the line which continues, upon the external face of the maxillary, the anterior border of the coronoid apophysis, even to the mental foramen, was sufficiently deep to receive alone the middle part of a pigeon's egg. We commenced by filling it with a piece of soft wax in order to make it as nearly as possible upon a level with the neighboring parts, and replacing the them as much as pos- sible, in their natural state; then, after having taken the im- pression of the whole of the jaw, we obtained a mould of plas- ter, upon which we adjusted a plate of platina forming a kind of vault which adapted itself exactly to the contour of the opening. We then soldered to its anterior and posterior parts two bands of the same metal, reuniting themselves in order to form upon each molar of the opposite side, a metallic box which perfectly encapped them, giving to all the apparel a great solidity. This fundamental indication, essential to stop up the opening, being filled, we sought to fill that which was very secondary, accessory to restoring to the diseased part its ordinary form. In order to do that, we simply fixed upon the plate,commencing from the place which corresponded to the alveolar border, a OR MECHANICAL DENTISTRY. 523 piece of hippopotamus, upon which the five absent molar teeth were marked. All was adjusted in order that the piece might be removed at pleasure, its weight and the precision of its adjust- ment, giving it a solidity which we unfortunately obtained only, in the superior jaw, by making points of support, of the crotchets whose daily removal would undoubtedly injure the solidity of the teeth to which they were applied. We had an opportunity of seeing the subject of this opera- tion, seven or eight months after the application of the obtu- rator which we have described, and we have seen with satis- faction that it had accomplished not only the desired end, but still more the cavity which it covered was insensibly filled in with fleshy granulations. Palatine Obturators. The idea of filling the opening that may cause in the pala- tine vault either a congenital division of the bone of the palate, or a wound or any disease whatever of the osseous system, as those which so often result, as wounds of fire-arms, and syphilitic diseases, is certainly a very ancient idea. The construction of mechanical apparels as a means of remedying these accidental openings has long since been given to sur- geon dentists ; their conformation and the relations that they have with the teeth, by the irregularities that the deformity produces in the order of these, or by the support that these apparels receive from them, causes them to enter at the pre- sent day more than ever, into the boundaries of our art; we shall now enter into details relative to their construction, and the rules which should govern their use. Authors, generally, agree in regarding Ambrose Paré, not as the first surgeon who sought to remedy the numerous in- conveniences which result from this communication with the mouth and nasal fossae, but only as the one who gave, in this res- pect, the most precise rules. They have reason to do this : for, as Cullerier* observes, the fact, Alexander Petronious wrote about * Dictionary of Sciences Médicales, t. xxxvii, art, Obturateur. 524 OPERATIVE MEDICINE AND PROSTHESIS, fifteen years before Ambrose Paré.* "If the decayed bone of the palate falls of itself, or if we extract it, the pronunciation is altered so much so that the patient can scarcely be heard. But it is possible, in certain circumstances, to repair this loss ; for example, when there is only a hole in the palate, we can stop it up with cotton, with wax, with a gold plate or in any other way that the genius of the artist suggests, having care to give to these instruments the same concave form as the palatine vault." However, the method that Ambrose Paré advises is now with reason altogether abandoned. It consists simply in "ap- plying against the hole a plate of gold or silver, maintained by the introduction of a sponge attached, as he says, to a stem and retained by a screw. The sponge being dry, when we place it upon the plate, swells by the humidity of the nasal cavities and prevents the fixture from falling." This method of prosthesis had, as we see, two great in- conveniences. One consists in this, that the sponge, in im- pregnating itself with nasal secretions, soon gives an infected odor ; the other is this, that the presence of a strange body in the accidental opening, particularly of a body constantly sus- ceptible of dilating, would not only oppose its occlusion, but would, on the contrary, continually favor its enlargement. In every case if the sponge is only of a thickness sufficient to easily enter the opening, the fixture would be liable to fall ; or when it was sufficiently large to form, being humid, a pad sufficient to support this apparel, it would exert a painful compression upon the edges of the opening. Fauchard obviated the first of these two inconveniences by an obturator of very ingenious mechanism, to which we have given the name of an obturator with wings. "It is composed of a plate, stem, two wings, two pivots, a vice, a screw and a key."f The plate is intended to fill the opening by the side of the mouth, the two wings to lay upon the superior face of the walls of this opening in order to fill it on the side of the • De Morbo Gallieo, printed in 1503. t See vol. ii of his work, p. 293, &c. OR MECHANICAL DENTISTRY. 525 nasal fossae, the vice to make the wings descend down until they hold the edges of the opening closed between them and the plate that they surmount, the screw to hold the vice fixed at the necessary point ; finally, the key to move the vice. "Before applying this obturator," says its inventor, "it is neces- sary to raise the wings sufficiently to bring them near together so that they may occupy as little space as possible ; this would facilitate their introduction into the hole, or breach of the palate. Once introduced it is necessary only to adjust it by means of the key. However ingenious this apparel may be, it obviates only, one of the inconveniences attached to obturators with simple sponges, that of preventing an accumulation of nasal mucosi- ties in the sponge which cause an unpleasant odor, and con- stituted their principal bulk ; but, as it is an incessant obstacle to the occlusion of the opening by the compression that the edges of this solution of continuity experienced by the wings and plate, between which they were applied. Practitioners perceiving this difficulty, were a long time oc- cupied in simplifying the work of Fauchard ; from thence we have the bolt obturator, the obturator with branches, and the obturator with a shank, and many others more or less ingeni- ously combined, but all in two plates, or rather two super- placed metallic surfaces, between which the edges of the opening were enclosed. Finally, the obturator with a hood or drum, which, if it had the inconvenience of filling entirely, or in part, the opening as the preceding ones, exerted, at least no pressure upon the edges ; it was the same as the gold plate advised by Jourdain,* and, which applied upon the opening of the palate that it overlapped on each side, was maintained by a stem of the same metal, "bifurcated in such a manner as to pass each nasal opening and then turn out upon each side of the jaws," &c. But at that moment, unfortunately too near to us, when dentists perceiving all the importance and extent of their art, enlightened by the torch of physiology, and, raising them- * Work quoted, vol. i, p. 449. 61" 526 OPERATIVE MEDICINE AND PROSTHESIS, selves to the height of general pathology, they discover that if, in the application of palatine obturators, the occlusion of the opening, by which the mouth and nasal fossas communicate with each other, was an important indication to fill, it would, in the meantime, never be to the prejudice of the tendency that nature unceasingly repairs the injury which our organs accidentally experience. A principle was thus established for us that, whatever importance the mechanical question may assume, in this occurrence, it was, however, but a secondary thing, completely subordinate to the pathological or medical question. From this eminently rational view, of leaving the openings of the palatine bones free in order not to obstruct the tendency that they have to fill, juxta-placed obturators have come into use ; that is to say, simply applied, over the opening against the palatine vault, the only ones which should be employed. We should remark, to the honor of our art, that this useful reform belongs properly to dentists. Read, in effect, the word obturator in the most of modern medical dictionaries, and you will see with astonishment that not one of the practitioners who have written this word have even presented the necessi- ty of widening the way opened by Fauchard, since all indis- tinctly advised from obturators introduced, but not applied. And in the meantime, "before regarding," says Delabarre, with reason, "the cicatrised perforations of the palate as being of a nature not to diminish in diameter, are practitioners well assured if it is so ? I do not believe it, for positive proofs attest the contrary ; for the same reason that holes made in the cra- nium with a trepan, close nearly always in time, and those of the palate likewise decrease. Bourdet has observed it in many cases, and if my assertion would add any weight to his, I could assert the same thing : it would then be well to guard against applying a machine whose vicious construction might oppose a cure which nature endeavors to make, at least, in the majority of cases." In effect, Delabarre might have added, that Cullerier, in the great Dictionary of Medical Sciences, describes only the obtu- rator with wings of Fauchard, and speaks of obturators taking OR MECHANICAL DENTISTRY. 527 their support from the teeth, only on the occasion of those which necessitated the losses of substance which interested, at the same time, the palatine vault and the alveolar arches. But the following phrase clearly shows that this author admitted, that obturators maintained by wings, were the only ones em- ployed in ordinary cases, and that those with crotchets were applied only in exceptionable ones : "As the disease which penetrates the palate attacks also a portion more or less con- siderable of the alveolar and dental arches, to the obturator of which we speak, a râtelier has been added, which is fixed by the same mechanism, and which may, to attain solidity, be fixed to the neighboring teeth." The au thors of the Dictionarie Abrégé des Sciences Médicales, in the number of which were Sanson and Begin, after having developed the inconveniences that obturators with sponges have, express themselves thus: "These reasons have, induced us long since to prefer mechanical obturators. The instru- ments of this kind which we fabricate at the present day, as the others, with a more or less extensive plate, susceptible of applying exactly to the contour of the opening that it closes, and arranged in such a manner that it continues the general plan which supports it. From the surface of this plate, which corresponds exactly to the naso-buccal opening, raises two or more wings, which were held back by a simple mechanism, and which, then, lower themselves by means of a stem with a screw, which a mounted key moves, applying from the side of the nasal-fossae, upon the edges of the solution of continuity." Lagneau, in the Dictionary of Medicine, one of the last published, and to the editing of which the most distinguished practitioners of our time have participated, after having spoken of obturators with sponges, whose use at the present time is not general, as this honorable practitioner thinks, but aban- doned completely, Lagneau, we say, proposes as the best, the most convenient, and that which he believes the most ordina- rily applied, a mechanical obturator, which he minutely de- scribes and which is, in fine, nothing more than an obturator with wings as we know. We see, with pleasure, from a discussion which took place 52S in the academy of medicine, that the most distinguished sur- geons commenced to widen this way, and to partake of the advice that surgeon dentists have long since given, and which, as far as regards ourselves, has always been our rule of con- duct.* The circumstance which provoked this discussion was the presentation, by Blandin, of a young man upon whom this honorable professor had performed a very extended di- vision of the palatine vault. This, (palatine vault,) at least in the four-fifths of its extent, being operated upon ac- cording to the procedure of Roux,f slightly modified, the pa- tient presented then but a hole towards the middle of the palate, an obturator, says, Blandin, sufficed to regulate his speech. Velpeau, after having examined with attention this patient, and applauded the success of Blandiu, thought that the hole of the palatine vault might yet obliterate itself, and demanded, in consequence, of his learned colleague, if he did not believe that the obturator was an obstacle to the closing of this open- ing. This latter found the remark very just, and he declared he would warn the patient of it. Gerdy was even of the opinion that, in similar circumstances, we should not only cease using the obturator, but that it would be of the greatest utility to aid the closing up of the edges of the 'palatine opett- ing, by applying a bandage or an appropriate support. We say, that the patient here spoken of had been operated on according to the procedure of Roux. We do not pretend from that, as has been believed up to the present, that Roux was the first who had performed the suture of the palate in * See the account rendered of the session of the Royal Academy of Medicine, on the 20th of September, 1842, discussion between professors Blandin, Velpeau and Gerdy. tSee his Treatise upon Staphyloraphy, or Suture of the Wing of the Palate, in 8vo, Paris, 1825, with figures. The operation which the sub- ject of this memoir has carried away, in his time, the great prize of sur- gery decreed by the Institute, and forms, without contradiction, one of the most beautiful scientific achievements of the actual chief surgeon of the hotel-dieu. OR MECHANICAL DENTISTRY. 529 France. Roux, as every one now knows,* had only the merit of giving to this operation a rank amongst the surgical opera- tions admitted as rules and elements of the art. But we direct- ly claim it for our specialty, since it was practised with all possible success, in the middle of the last century, by a dentist named Le Mounier.f This proves this explicit passage, con- tained in a collection published in 1764, by Robert, under the title of a Treatise of the Principal Objects of Medicine : "A child had its palate cleft from the veil to the incisor teeth, Le Mounier, a very able dentist, tried, with success, to unite the two edges of the cleft, he made many sutured points in order to hold them together, and then removed them with the cutting instrument. An inflammation followed, which terminated by suppuration, and was followed by the union of th.e two lips of the artificial wound. The child was perfectly healed." This quotation should follow, it seems to us, in order to make Roux and Grasfe, of Berlin, agree, who are disputing the priority of this operation. The principle after which palatine obturators should be con- structed, being once admitted, what form should be given to. the obturating plate ? This is a question which we should not have made, while it is natural to think that this form should be that of the palatine vault itself, if we had not seen it made in a pamphlet published about two years since.J The author of this pamphlet, having an obturator to place, prepared to make his plate slightly rounded in the vault, when Dr. P. . . ., who had addressed the patient, imbued, even with excess, with the necessity of impeding the edges of the naso- palatine opening with nothing, made him lower this plate. The opening cicatrised very promptly ; but as our young con- frere remarks with reason, is this to the absolute defect of con- tact of the plate and the edges of this opening that it is rea- * See the works of Velpeau, Vidal de Cassis, &c. tThis practitioner has published many works upon our art, among others, a Dissertation upon the Diseases of the Teeth, printed in 1753, and reprinted in 17b3; then a Letter to Morton, in 1784. I Summary upon the Straightening, &c, followed by some Reflections upon Obturators of the Palate, by J. N. A. Schange. Pamphlet in 8vo. 530 OPERATIVE MEDICINE AND PROSTHESIS, sonable to attribute this advantageous result? No, we reply with him, because all the accidental perforations which nar- row and close take the form of a funnel. From whence it re- sults that by giving to the obturating plate a depressed form, even simply horizontal, we increase the facility with which the nasal mucosities accumulate between it and the palatine vault, and impede the movements of the tongue ; and that without any compensation as to the occlusion of the opening. However that may be, we maintain obturators, juxta-placed, by ligatures surrounding on each side, the nearest tooth by prolongations, of a length proportioned to the extent of the obturating plate; but we renounced this method, because lig- atures, ascending incessantly above the neck of the tooth and the gum, wounded the latter and loosened the former, and occasioned insupportable pain; we then had recourse to crotchets forming springs ; and as the first had a tendency to slipup upon the teeth, like the ligatures, we soldered to one, and often to two points of their inferior border, another small crotchet, a kind of stopping pin, which in bending below rests upon the crown of the tooth, and prevents the principal crotchet from slipping as we have already many times said. As all the teeth do not offer a sufficient surface to hold this stopping pin, some authors, amongst others Delabarre, and after him Lefoulon, have advised a groove to be made with a file on the side of the crown. We, ourselves, think, that it would be better to solder the crotchet to a small frame en- veloping the tooth, as we have already shown in several in- stances ; the teeth, in every case, and particularly in the one which we are now treating of, are too expensive to have their solidity compromised by any means whatsoever, and for a still greater reason by a loss of substance for which there is no necessity. We have applied many obturators constructed in this manner, and we have had them commended for their adjustment and solidity. If obturators, j uxta-placed, have this great advantage over obturators introduced of presenting no obstacle to the occlusion of the division of the palatine bone, it must also be acknow- ledged that they neither favoror aid this occlusion. It might OR, MECHANICAL DENTISTRY. 531 in the case where the division, resulting from some disease which affected only one point of the palatine bones, leave them in relation upon some other points, and thus render it an absolute impossibility for them to unite except by the meet- ing of the edges of the opening. But as we have said at the commencement of this article, the division of the palatine bones does not always result from an accident which may be limited by perforating them, these bones are very often altogether separated from each other, and this separation, generally con- genital, coincides often, we know, with a division either of the lips, or with the veil of the palate, as in the case of the patient who became the subject of the interesting discussion between Blandin, Yelpeau and Gerdy, and of which we have given some of the most important points. It is in this case that obturators should not be confined to filling the opening, without placing an obstacle to its occlusion, but they should directly favor this occlusion. Unfortunately science, it is to be regretted, has no means capable of filling this last indica- tion ; for, as Blandin observes, with reason* "that which op- poses the success of staphyloraphy in the case of the division of the palatine, is this division itself and the state of separation in which the soft parts are held." "Also," adds this practitioner, "an important service may be rendered to the unfortunate effects of this defective confor- mation, by proposing a method which may at an early period narrow and obliterate the cleft of the palatine vault. We may thus change a complicated into a case altogether simple, in which the operation most frequently succeeds. Levret, Jour- dain and Antenrieth have endeavored to fill this indication ; Roux has attempted the compression of the dental arches from without inwardly." To these names Blandin might have added those of Le Biane,f of Q,uesnay,J of Desault,|| and even of Dupuytren.§ * Dictionary of Medicine and Practical Surgery 3 vol. xv, p. 17. t Summary of Surgical Operations ; vol. i, p. 25. | Journal of Medicine; year 1773, vols, xxxix and xl. || Surgical Works; vol. ii, p. 205. § Oral Lésons, published by Marx and Briere of Boismont. 532 OPERATIVE MEDICINE AND PROSTHESIS, What methods have these authors employed for exerting this compression? All which our researches have taught us in this respect is that Levret and Antenrieth have exerted a compression upon the lateral parts of the jaw, that Jourdain exerted a double traction in contrary directions upon the two ranges of molar teeth ; that Roux, after being in conversation with Miel and making several experiments with him, had en- trusted to a mechanic- whose name he does not mention, the care of fabricating an apparel appropriated to this usage, but of which he gives no description. Finally, Vidal de Cassis* simply expresses himself thus in this respect: "We may aid nature by a compressive bandage acting under the two cheek-bones, or by metallic wires travers* ing the palatine vault, and binding the molares on the oppo- site side. If these means are well supported, they will abridge very much the time necessary for its union." That which is nothing more than the procedure of Jourdain, who wrote when he was sixty-five years of age, with this difference, however, to the credit of this master in our art, that he used silk and not metallic bands, for good reasons which have escaped the attention of Vidal de Cassis ; "1st, that this wire might injure the teeth ; 2nd, that if it is fine gold, it will loosen in extend- ing; 3rdly, this hard body, touching the tongue or rubbing the gums, might wound them."t Desirous of responding to this honorable appeal made by Blandin to our art, we have imagined for this purpose many apparels free from the hurtful action of all ligatures applied upon the teeth which they do not fail to loosen. The first is a band of platina, or of palladium, which is still harder, carry- ing an obturating plate, then exactly adapted to the palatine vault in a transvere direction, and proceeding from each side, bent upon the teeth to a level with the alveolar arches ; but in such a manner that the descending branches, resulting from each curve, far from being applied upon the portion of the palatine vault, and the alveolar border to which they corres- # Work quoted, vol. iv, p. 195. t Work quoted, vol. i, p. 45J . OR MECHANICAL DENTISTRY. 533 pond, are separated from them by a distance proportioned to the widening of the bone which we wish to draw together. Then, its extremities are pierced by a hole intended to receive a vice, which, put in rotation, moves before it, or rather from without inwardly, a plate placed upon this arch, and pressing upon it to a sufficiently great extent. This apparel seems to us, at first, to have the inconvenience of injuring the internal part of the jaws by the inevitable pro- jection of the vice intended to perform the pressure. We sub- stitute for it another, which acts, on the contrary, no more in compressing the dental arches, but in drawing them together. In order to accomplish this, the apparel was placed interiorly, and composed of an obturating plate in the mid- dle of which a clicking pivot was fixed, which, turned by means of a key, would draw to it two pieces proceeding from each side, to embrace exteriorly the dental arch as the plate upon which the vice of the first apparel exerted their pressure. These two apparels, as we see, exerting an effort, which in- creases only each time that we make the vice turn a step in the first, and the pivot in the second, acting by saccades, and not as it is to be desired in every case where we wish to force an organ from its place, by a gradual but slow and continued tension.* From a knowledge of the fact that a division of the palatine bones which frequently accompanies congenital hare-lip, is ef- faced by the simple compression, which is then maintained united, at first by needles, and then by-their cicatrization, ex- ert upon the whole of the anterior part of the maxillary, we seek a method which imitates, as nearly as possible, nature in this action. The following are the two methods which we have adopted. The first consists, simply, in enveloping all the anterior part of the superior alveolar arch in an elastic steel-band, whose two branches, furnished with leather, or, what is still better, India-rubber, acting by their continued reaction nearly as Du- puytren represents, who aided the action of the lips by means * See that which we have said on this subject in our chapter devoted to dental orthopedy. 62 534 of two compressed cushions against the jaw, maintained by two metallic springs around the cranium. But the application is painful, because the difficulty of overcoming its elasticity in adapting it to the mouth, increasing, of necessity, in propor- tion as its extremities advance, its progression becomes pain- ful and even insupportable, before having exactly embraced the whole of the alveolar border, for which it is designed. It has, besides, the inconvenience of pressing upon the gums, so much as to make us fear that mortification may result from it. We, consequently, seek an easier method, which we will now describe. We constructed a palatine obturator, filling exactly the whole palatine vault, and fixed to the teeth by three crotchets soldered upon each side so as to encap the canines, the two small molares, and, also, the two large ones, then bent it upon the alveolar border, which would protect it from all effort. This palatine plate being well adjusted, we divide in two from before backwards, and we remove from it on each side, so that the edges would remain separated from each other about a fin- ger's width. We then replace that which we had removed from the halves of platina by a thick and resisting band of India rubber, a little smaller than the space which separated the two halves and to which we solidly rivet it. The apparel, making as before but a single obturating plate, was no larger, as we see, than may be necessary for the crotchets to surround the teeth to which they should be attached. But by means of two bent bands, proceeding transversely from one of the demi-plates where they were ri vetted to hinge, to the other where they were received into a small screw-ring, the plate would cover the necessary space by the tension of the India-rubber. The apparel was then placed in the mouth. Once well adjusted, we make the bands with crotchets leave their screw-rings, and we remove them by means of a turn- vice ; the India-rubber, ceasing to be distended, then shrinks upon itself, and, in this re-action, draws necessarily from with- out inwardly the alveolar arches by an action altogether simi- lar to that which the lips, in the healing of their congenital division, exercise upon the palatine bones against which they OR MECHANICAL DENTISTRY. 535 had for a long time made a violent pressure. We are as mucli more induced to believe, from the result of this action, that Iloux* thinks that the union of the veil of the palate, by the operation of staphyloraphy, might alone affect the drawing to- gether of these bones. The principal action of this apparel resides in the tension of the India-rubber, we might replace the extensive screw-rings, which never offered a great solidity, at least as the plate was not forced in the place where they were screwed, we might replace them, we say, by a metallic band which, a little larger than the India-rubber one, might be received in the groove under this latter in order to give to this plate the necessary size. This plate once placed and properly fixed, we withdraw the band, which would cause the elastic band to return upon itself and accomplish the desired end. We might force this apparel by placing first one of its sides upon the teeth, then by extending this band to the necessary degree in order to make it enter the other side. Finally, as the India-rubber band distended and placed in an atmosphere constantly warm, might soon lose its elasticity, we would in time be obliged to replace it by another. Nevertheless, in a sum total of these different apparels, the action of the first could be most relied upon, first, because it is so simple, then, because of its great force. It is, also, the opinion of professor Lisfranc, to whom we have submitted them, and who has wished us to promise to give a descrip- tion of it on the first occasion. However that may be, that which is of particular importance, is that the action of the in- strument is felt upon the alveolar border, and not upon the teeth which loosened, and even completely removed. Maxillo-'palat ine Obturators. Ill combining that which we have previously said of max- illary obturators, with what we shall say of palatine obtu- rators, we may construct the palates or plates of palates with dentures. We are content to indicate these pieces, * See page 76 of this Treatise, already quoted. French edition. 536 OPERATIVE MEDICINE AXD PROSTHESIS, leaving to the mind of the dentist the care of conforming to the multiplicity of cases of this nature which may pre- sent themselves to his observation, and which would each de- mand a particular description, if we had not under our eyes so curious an example of it, which we think we should relate. It is of a young man at present a wine merchant, at Paris, who, being in a military regiment, then in Africa, had been taken a prisoner by the Arabs, and had had the whole left side of the superior jaw fractured by blows from a but-end of a musket. All the bone, too, to which the large molares were attached dropped out, carrying with it the superior parts which prolonged in front under the cheek bone, and that which, in curving within, formed at the same time the palatine vault and the floor of the nasal fossae. The piece that we made for this young man, sustained by many crotchets, embracing largely the teeth which they sur- rounded and which some bent pins upon the triturating face prevented them from injuring the necks, was formed of a sin- gle metallic plate divided in two parts ; one, active, a true ob- turator, very convex, was applied on the left side upon the palatine perforation which it hermetically filled, was bent upon the alveolar border which it exteriorly embraced ; the other part, passive, or a simple support, covered the posterior face from all the right dental range, to the molares to which they were intimately united by crotchets. in the place corresponding to the loss of substance was ap- plied a piece of hippopotamus upon which the absent teeth were drawn, furnished with their gums ; this piece was main- tained by two pegs soldered to the plate and rivetted upon the triturating face of the teeth. The two parts of this piece was left free, by the curve which their assemblage offered, an in- terval large enough, for the sense of taste to be exercised; an important precaution which it is always prudent to take in the adjustment of pieces of this nature. We might, as we readily perceive, remove from this apparel the anterior portion of the plate which bends behind the right teeth, and unite simply its obturating part by a transverse baud with a frame which might surround the opposite mo- OR MECHANICAL DENTISTRY. 537 lares ; this would be much easier to execute, but less solid, because we would necessarily deprive it of the support which the anterior teeth furnish. There is still a case which should be mentioned, it is that where a palatine opening, needing an obturator, is desired by a person whose superior jaw is completely deprived of teeth. How can it be maintained in place? This is a question which would require to be solved all that which we have said of dou- ble or complete dentures, whose superior portion is main- tained by springs attached to the inferior. To obturators of the kind of which we are now speaking, two springs should be fixed, such as we have described, and they should be at- tached to a band or metallic cap enveloping the posterior teeth of the inferior jaw, at least if the patient does not prefer a com- plete superior denture, to which an obturating plate should be fixed. This denture should always, as far as possible, be mounted upon a metallic base which harmonizes better, under all relations with this plate. By one of these methods every rational indication might be filled. The strange form, which the accidental openings by which the mouth may communicate with the nasal fossae, may offer; the various complications which may accompany them, as disorders following them at the same time or a distant period in the dental apparel ; the varied nature of the causes under the influence of which they are declared, are sufficiently fore- seen, as the mechanical means appropriated to their occlusion are those whose construction offers the most difficulties and requires the most precaution and skill on our part. Summary of the Principles and Rules which should always serve as a Guide in the Combination and Adjustment of Pieces. Those who intend practising our art, will find, doubtless, in that which we have said upon dental prosthesis a rule ap- plicable to the plurality of cases and principles, whose study would serve as a guide in the course of a career which is most difficult to fill worthily, which does not seem to be gen- 62* 538 OPERATIVE MEDICINE AND PROSTHESIS, erally believed, and point out those shoals that experience alone will, unfortunately, teach them how to avoid. But they will deceive themselves if they hope to find means adapted to every case, under all circumstances, because there are not two patients to be met with in perfectly similar condi- tions, and that, upon twenty individuals requiring our aid for the same object, each would demand, perhaps, a modification of details, or a particular combination, either in size or form, consequently the dentist is obliged to depend upon his own judgment and ingenuity. This would not be the case if all would limit themselves in this important part of our art, to the pure and simple fabrica- tion of instruments of prosthesis. With some anatomical knowledge, however summary, we may always combine pieces sufficiently well to imitate organs whose result is to re- place the loss and fulfil the functions of the natural organs ; for as in sculpturing, we have only to study the forms in order to copy them. The various difficulties appearing at the moment when the piece is ready to be put in relation to the living parts, and consequently irritable, whose sensibility has to be considered much more, since it is rare that they are free from diseases, sometimes so serious as to occasion losses which it is necessary to repair; diseases which are as fre- quently the result of a constitutional vice as of a local or acci- dental nature. A medium intelligence, a glance assuredly, a slight know- ledge of the means which the imitative arts employ, and that which we ordinarily term a little taste, will in effect suf- fice for the fabrication of them ; but the study of the various points of the sciences of precision, particularly of mechanism, assisted by physiology, and reduced by practice to fixed prin- ciples, become necessary to combine the adjustment of pieces and to maintain them solidly in the place they should occupy. With ideas furnished by this study, how shall we deter- mine rigorously the power and manner of using wires, crotch- ets, springs and other mechanical agents intended to maintain pieces iu this state satisfactorily in an equilibrium which des- troys the effect of their weight aud prevents their traction and OR MECHANICAL DENTISTRY. 539 rubbing ? how can we arrange these pieces in such a manner that they will follow the movements sometimes so brisk of the inferior jaw, without ever abandoning the often irregular plane which this movable lever offers ; and in such a manner that they will touch the teeth of the opposite jaw, without oc- casioning a shock which might loosen their supports and thus cause them to fall ? If, however, persons who have resource to our profession for the replacement of some part of the denture would call upon us a short time after the loss of this part, we could at least overcome the difficulties inherent to our art, without having to combat them that results from the disease which caused it, and which happen in the majority of cases. But for the small number sufficiently sensible as not to support the inconveniences of a difficult mutilation, but easy, however, to remedy, how many others yield only to the most painful ne- cessity, and wait, expecting that a long and painful inconveni- ence, will render them insensible of the loss. Then the ad- joining parts, having if one is permitted to say so, contracted new habits, taken new relations, experience when the artifi- cial teeth are introduced into the mouth at once, a kind of repugnance, which might result in a brief torture when the piece was small, but which might even extend to pain when the piece was large, and for a still greater reason, when it con- sisted of a whole denture. Pain is not the only inconvenience that follows this torture, then, put suddenly in contact with foreign bodies, which press upon them, inflame, swell, and often become excoriated, and this purely local pathological condition may give rise to mor- bid phenomena, very often sufficiently serious to alarm, and, unfortunately, always sufficiently serious to authorise doubts upon the forethought of our art, the power of our resources, and the perfection of our products. How often have we seen persons complain to us of pieces, besides perfectly made and properly adjusted, and accuse the dentist of unskilfulness and ignorance, who had often no other detriment, and which is sometimes a very great one, then not having warned the pa- tient of the pain which would undoubtedly follow, or having promised more than it was possible to obtain. 540 OPERATIVE MEDICINE AND PROSTHESIS, We know, then, that in frequently removing one piece, in order to immediately replace it, we should have only one end in view in constructing it, and in condescending to the wishes of those who wear them, but of gaining time ; for this time en- genders habit, and habit, it is not necessary to dissimulate, is to us an important auxiliary. It is even important, in the most of circumstances, that the work should be so ably com- bined, that the patient may easily remove it himself, so as to allow the parts upon which it rests, or which supports its re- pose, and whose sensibility alters insensibility by their new contact; which, however, takes place more certainly and more quickly, we repeat it, in proportion as the parts are in a better state of health when the piece is placed. From thence this double difficulty, which a long experience and profound study of pathological shading may alone teach us to avoid *, placing these pieces so soon that the neighbor- ing organs may not have time to contract new habits, whose destruction will be always difficult and often painful, and of deferring their application to so late a period that the diseases which the loss occasioned, may be entirely cured. Persons who have recourse to us rarely, unfortunately, determine the proper period, and address us for reasons of which the health is far from being the most prominent. Young practitioners most frequently yield to the sound of these difficulties which we have mentioned, and from this precipitation the most serious accidents often result. A fact related by Taveau* proves this, which he does not fear to give for this praiseworthy reason, "that science may profit as much by errors as fortunate cases, and that there is as much merit in candidly avowing the first as in promulgating the second. " A marine officer presented himself to him in order to have the six lower anterior teeth replaced, whose fall, according to the assertion of the patient, took place without their being much decayed. Our honorable confrere did not find a suffi- cient contra indication in the swelling of the gums, which he attributed to the habit the patient had of smoking, made a * Work quoted, p. 307. OR MECHANICAL DENTISTRY. 541 piece, which the first day appeared to be well adjusted, but it soon rendered the gums so inflamed and painful, that it could not be supported for at least a month. This person again calling upon Taveau, he questioned him more closely than he did at the first interview, and, from the details in which they entered, he discovered that the teeth were lost under the influence of a scorbutic affection which still existed. Taveau advised him then to seek the advice of a physician and to temporarily remove the piece. This advice was taken, and, six months after, he with all certainty of suc- cess, applied another piece, composed then, not of six teeth, but eight, the two first molares having, in consequence of the suppuration of the alveoli and other morbid phenomena, which followed in the course of the treatment, undergone the fate of the first six. The dentist should always be ready to know that, if some persons support with pain, they exaggerate the momentary torment which is nearly always experienced in the first period of the application of a piece, and make no effort to overcome it ; others, also, and it is nearly useless to say that these are particularly women, dissimulate completely this pain by the desire of experiencing no delay and no interruption in the en- joyment of the advantages which they expect from them. We saw about three years since, a foreign lady, whose age and education might have warranted her from a similar fault, pay for, by the most serious accidents, the obstinate refusal that she avowed to her dentist, a noble and experienced man, the pain that she experienced from a pivot intended to solidify a large piece of denture, but introduced in a root, whose sen- sibility had not been sufficiently appeased. More recently still, one of us was obliged to remove for the wife of a farmer in the department of the Seine and Oise, a piece of denture which had been placed some days previous, whose pain had been dissimulated, but which had exerted grievous reactions and determined serious accidents. In every case, before commencing a piece, we should care- fully examine the mouth of the person, and thoroughly notice the manner in whether it closes and whether the teeth cross or 542 OPERATIVE MEDICINE AND PROSTHESIS, correspond. We have, sometimes, much trouble to obtain this result, without which the adjustment of a piece is impos- sible. Some in the inferior jaw advance or recede, whilst others cross the superior in front. We have seen some per- sons among whom this vicious disposition (the inversion) was natural, seek to correct it by persuading the dentist to take the impression of some large spaces to fill in their mouths. We have already observed this fact in treating of dentures or com- plete pieces. The foresighi or experience of the dentist should be suffi- cient to recognise these errors and to arrange all things in the true relations which should exist between them ; these may nearly always be accomplished by requesting the patient to bite naturally, and to apply the teeth squarely and correctly in the mouth, the only method of judging, with precision and certainty of its true method of closing. Notwithstanding all these precautions, a dentist who has placed a piece of many teeth, often is altogether disappointed at the result, although he may have previously taken his pre- cautions and measures, so as to be certain that the closing of the mouth would be impeded in no way by the teeth of the artificial piece. In this case, when he is well convinced, after the remembrance of the inspection and primitive study that he has made of the mouth of the patient in taking his impres- sions, that the difficulty in the occlusion of the teeth or the simple trouble of it was not the fault of the piece, but of an involuntary contraction, or a spasmodic one of the muscles of the jaw, he should not trouble himself or take any account of this new method of closing the mouth, but try the piece again the next day. Then he will perceive, with satisfaction, the advantage of the advice we have given of delay, for the parts having as- sumed their natural relation, the mouth will close properly, for the simple reason, that the person, thinking no more of his piece, will find that the jaw has neither shrunk nor augment- ed. We have seen some dentists of little capacity, we say it with regret, shrug their shoulders, in order to make those be- lieve to whom this has happened, that pieces made by others OR MECHANICAL DENTISTRY. 543 than themselves, were badly constructed, and that, without certain dispositions which they would have given, and correc- tions which they should by all means undergo, they would never be able to wear them. We should endeavor not to embarrass our patients, or worry ourselves, if we would popularise this idea, that it is not use- ful to expect that a jaw should be deprived of all of its teeth to be supplied with a large piece of denture, particularly the superior jaw, because it suffices, sometimes, to include a sin- gle tooth skilfully in one of these pieces, in order to prevent it from deviating and from rubbing, which these so often oc- casion for want of support. The weight of a piece is often the only method of preserving an isolated one, which having no support, or exposed to a multitude of efforts, (particularly on the part of their antagonists,) which they, with difficulty, resist; which sustained, on the contrary, may last a long time and render a great service. We have proofs of this every day. The most recent one was furnished us by the wife of a distinguished advocate of the bar of Paris, who, having long since lost the four incisores and the four small molares of the inferior jaw, had the two canines entirely isolated, and rendered loose by the continual shock of their antagonists. Believing that it was impossible to place a piece without extracting these two teeth, this lady had supported a long time, with resignation, the precocious mutilation that her mouth had undergone, when, better in- formed of the resources of our profession, she applied to us. We made her a piece, arranged in such a manner that the two teeth which remained were perfectly enclosed and sustained, but altogether free from the shock of those of the superior jaw. A month had scarcely passed before this piece needed some slight repairing, and this lady was astonished to find that the two isolated teeth had not only received no injury from this piece, but that they had, on the contrary, received great so- lidity from it. Doubtless, if more teeth were scattered here and there, the dentist would have more difficulties to overcome ; but this reason, which is only a question of time and labor, 544 OPERATIVE MEDICINE AND PROSTHESIS, should never frighten the intelligent and honorable dentist who should always make it a case of conscience never to destroy a single tooth in order to simplify a construction or adjustment of a piece, particularly if this tooth is healthy and presents no obstacle to the solidity of the piece. In regard to the complaint that is often made of artificial teeth because of their disagreeable odor, it is only owing to the bad adjustment of the piece, and to the neglect of the per- son who wears them to clean them properly. The dentist should then establish the most perfect contact between the piece and the gums or supporting teeth, so as to prevent the introduction of foreign bodies, principally alimentary particles; and this should be accomplished even to the detriment of its appearance. If he is certain that this contact exists, he should seek to discover if the change of breath in the person cannot be ascribed to some other cause, if it does not result, for ex- ample, from some vice in the digestive or pulmonary organs, very common among women, and, in general, among the in- habitants of large cities, particularly in the easy classes. But, as it is difficult always to obtain an exact contact, and rare that it can be long maintained, it is prudent for the piece to be frequently removed by the dentist, particularly if it is of animal substance, which we are aware is more easily affected by the buccal fluids. In order to do this, it is useful, even in- dispensable, to have a piece to change, so that the mouth may never be unfurnished, and so, that, if one is fatiguing upon some point, the other would not, probably, be so, and time might be had to rest this painful point. It will be very easy, if one desires, to prove to persons who believe that this recommendation is not for their interest, that this increased expense is a true economy ; for the piece would last a much longer time, if it is frequently repaired and pro- perly cleaned. The manner in which this last direction should be accomplished, consists simply in rubbing it with a brush and soap-suds, but, perhaps, better with alcohol mixed with water, at least if it was not in a very bad state, and con- siderably affected with animal odor, which too long a sojourn in the mouth might cause, and if so, we should have recourse OR MECHANICAL DENTISTRY. 545 to a very strong aqueous solution of chloruret of chalk. If the piece was entirely composed of mineral substance, (mineral teeth and metallic bases,) we should pass it through fire to clean it. We may, by this means, if it has not been fractured in some point, return it to its primitive state ; nothing, consequently, can clean it so perfectly. It is not the same case with pieces, in the construction of which animal substances enters, par- ticularly those with bases of hippopotamus : we see them, in a short time, worn in deep furrows by the buccal fluids, and become a cause of corruption by the retreat that these holes offer for alimentary particles. How can these pieces be repaired ? Is it necessary, as Delabarre advises, to fill the holes with a kind of mastic composed of sulphur and sifted salt? It is easy to see that this kind of bituminous pol- ishing never gives to the piece a united surface which is useful, whatever precaution we may take in heating the piece in order to facilitate the introduction of the cement in all the anfractures, and leaving no spaces. But it would be better to reduce the depressions to true holes, and to fill these with pegs of hippopotamus, which we level with the rest; or rather to remove the changed parts, and cover them with a true veneering. But all these repair- ings constitute defective work ; the dentist should, for the credit of his profession avoid them as much possible ; better often to refrain than to badly accomplish, a recom- mendation that we cannot too often give to our young con- freres, who should make it a rule, and who should not at least apply to the primitive construction of a piece the various re- pairs which it may need. It may be observed, from that which we have said, we pro- fess a medium opinion, between Maury on the one hand* who thinks that artificial pieces should never be removed, even to clean them ; and Lefoulonf, who makes an exception of com- plete dentures ; and on the other of Delabarre J and Taveau,|| the first of whom believes, that it is advantageous to displace * Work quoted, p. 328. t Work quoted, p. 352. % Work quoted, vol. ii, p. 469. || Work quoted, p. 310. 63 546 them frequently ; the second, that it is not only useful, but in- dispensable to remove them every day. To the first, we object, because there are certain accidental positions, whether diseased or not, which, rendering the gums all at once tumid, as is the case in simple fluxions, and, as we have frequently seen, for example, among females at menstrual periods, place their precept often in fault, by imperiously de- manding the removement of the piece ; to the second, we would remark, that the more we remove a piece, however well made or properly adjusted, that we loosen the supporting teeth, and injure the solidity of those which this piece should support, as we have often seen, and of which we will give ex- amples at a convenient opportunity. We conclude, then, that nothing can be absolutely estab- lished on this subject, and that all principles emitted , a priori, that is to say, in the formal designation of the conditions of their application, may be contested. Nevertheless, the obliga- tion one is under of removing, from time to time, pieces of artifi- cial denture, comprises, by all means, palatine and maxillo- palatine obturators, an obligation which had not escaped the observation of ancient moralists,* and to which the particular method of attaching and fixing dentures or complete pieces permits to sacrifice at pleasure, does not apply, we expressly say it, that those which are attached by pivots, at least if the roots upon which these pieces are implanted are not changed, or the substance forming the pivot, or simply its setting, in a slate of decomposition. It is not then, as we see by the ex- ception, necessary to remove them in order to clean them, but only when we wish to repair them. Apart from these two circumstances, which are on the one hand, the alteration of the supporting root, and on the other the decomposition of the pivot if it is of wood, or of its setting, if it is metallic. Pivot teeth which offer the type of solidity, * "Nee denies aliter quam serica, necte, reponas." "Each evening thou should'st remove thy teeth, as thy rohe." Martial, Lives ix, p. 38. OR MECHANICAL DENTISTRY. 547 and, particularly, of the simplicity of our means, may last many years without forming the least disagreeableness, or de- manding any more care than that which we daily give to the mouth. We will not return to these different precautions to which we have given ail importance, and devoted one of the principal chapters of the first part of this work ; the desire of avoiding repetition, and of saying nothing which is not absolutely useful and even indispensable, obliges us to close here. CONTENTS Introduction, PART FIRST ANATOMY, ORTHOPEDIA, PATHOLOGY AND THERAPEUTICS. CHAPTER I. Anatomy of the Teeth, Number and Position of the Teeth, Exterior Conformation of the Teeth, . The Incisures, General Character of the Incisores, Difference in the Characters of Incisores, Canine, or Laniar Teeth, General Characters of the Canine Teeth, Difference in the Characters of the Canines, The Molar Teeth, General Characters of the Bicuspides, Difference in Characters, General Characters of the Large Molar Teeth, . Difference in Characters, Structure of the Teeth, Teeth of First Dentition, Varieties and Anomalies of the Teeth, Varieties of Teeth according to Ages, Varieties of Teeth according to Individuals, Variety in the Form of the Teeth, Varieties in the Direction of the Teeth, Varieties of the Position of the Teeth, Varieties in the Structure of the Teeth, The Maxillary Bones and their Alveolar Border, Summary Anatomy of the Gums, Nerves and Vessels of the Dental Apparel, . 19 22 23 25 25 26 26 27 27 28 28 29 29 30 31 39 41 41 42 45 46 46 47 48 54 56 CHAPTER II. Physiological History of the Dental Apparatus. De- velopment of the Teeth, or Dentition, . 61 Dental Follicles, . . . . .61 550 CONTENTS. PAGE. The Pulp or Dental Papilla, ... 63 Development of the Follicles, . . .64 Development of Dental Bone, . . 66 Formation of Ivory — Formation of Enamel, . . 68 The Growth and Eruption of the Teeth in General, 71 The Eruption of the Teeth in General, . . 76 Eruption of the Teeth of First Dentition, . . 81 Shedding of the Milk or Temporary Teeth, . .85 Eruption of the Teeth of Second Dentition, . 87 Phenomena subsequent to the Arrangement of the Teeth, 95 Functional Importance or Uses of the Dental Apparatus, ; 97 Articulation of Sounds, .... 100 Secondary Functional Importance, . . 102 Summary and Consequences of the Preceding Physiologi- cal Facts, . . . . .103 CHAPTER III. Dental Hygiene and Orthopedia, . . .112 Sec. 1. — Of the Means of Directing the Eruption of the Teeth,- and Facilitating their Arrangement, . . 113 Second Dentition — Indirect Means to Prevent Errors, . 116 Direct Means to Prevent Errors of Second Dentition, 118 Sec. 2.— Of the Different Means of Preserving the Teeth, . 121 General Cares, .... 122 Special Cares, , , . , .125 Elixirs, Powders and Soft Dentifrices, . . 127 Opiates and Mixtures, .... 130 Sec. 3. — Of Tartar, and the Means of Removing it, . 133 Sec. 4. — Of the Means of Remedying Irregularities of Dentition — Vices of Conformation dependent upon the Teeth, . 138 CHAPTER IV. Pathology and Therapeutics, . . . 144 Vital or Pathological Changes — Diseases of the Follicles, 144 Congenital Defects of the Enamel, . . . 147 Decomposition of Enamel, . . . 150 Discoloration of Enamel, .... 151 Consumption of the Roots, . . . • 153 Dental Caries and its Varieties, . . . 154 Exostosis and Spina-Ventosa, . . . 179 Softening of the Teeth, . . . .181 Diseases of the Dental Pulp, . . . 182 Nervous or Dental Neuralgia, . . * . 186 Physical Changes of the Teeth— Wearing Away of the Teeth, 191 Cracks and Fractures of the Teeth, . . . 195 Concerning Accidental Luxation of the Teeth, . 200 Of the Loosening of the Teeth, . . . 202 Diseases of the Dental Appendages — Diseases of the Gums, 203 Inflammatory Diseases of the Gums, . . 204 Abscess and Dropsy of the Maxillary Sinus, . 219 Adhesion of the Gums to the Jaws and Lips, . . 226 Constitutional Affections of the Gums, . . 228 CONTENTS. 551 PAGE. Gangrene and Sphacelus of the Gums, . . 234 Tumors of the Gums, . 235 Diseases of the Alveoli, . . . .241 PART SECOND. Operative Medicine and Prosthesis, or Mechanical Dentistry. CHAPTER I. Operative Medicine, .... 259 Sec. 1.— Filing of the Teeth, . . . 264 Sec. 2.— Cauterization of the Teeth, . . . 273 Sec. 3.— The Obliteration or Plugging of the Teeth, . 279 Sec. 4.— Luxation of the Teeth, .... .288 Sec. 5.— Excision of the Teeth, ... 290 Sec. 6.— Of the Extraction of the Teeth, . . .293 Of the Instruments generally used for the Extraction of the Teeth, . . . . .297 Methods Applicahle to the Extraction of the Different Classes of Teeth, . . . .317 Extraction of Roots, .... 322 Extraction of Teeih situated out of the Range of the Dental Arches, and of Concealed Teeth, . . 326 Recapitulation of the Rules applicable to most Cases of Extraction, ..... 337 Of the Accidents which may Result from the Extraction of the Teeth, . . . . .342 Partial Fraciures of the Maxillary Bones, . 367 Complete Fracture of the. Inferior Jaw, . . 372 Luxation of the Inferior Jaw, . . . 377 CHAPTER II. Prosthesis or Mechanical Dentistry, . . . 380 Of Substances Employed for the Construction of Pieces of Artificial Teeth, . . . .386 Teeth of the Hippopotamus, . . . 388 Human Teeth, . . . . .395 Mineral Teeth, .... 399 Sec. 2. — Of the Metals used in the Dental Prosthesis, . . 425 Manner of taking Impressions, of making* Moulds, of Ad- justment and Stamping Plates or Bases of the Different Pieces of Artificial Dentures, . . . 433 Of Impressions or Moulds in Wax, . . 434 Of Models or Moulds in Relief, . . . 437 The Construction of Plates or Cuvettes and Stamping them, 440 Different Methods of Mounting Pieces of Artificial Dentures, that is to say, of uniting Teeth to their Supports or Bases, . . . . 446 CONTENTS. Pivot Mountings, .... 448 Human Teeth Mounted upon a Pivot, . . 449 Mineral Teeth Mounted upon Pivots, . . 452 Mourning Teeth upon Plates or Metallic Bases, . 454 Human Teeth Mounted upon Plate, . . 454 Mineral Teeth Mounted upon Plate, . . . 456 Mounting on Osseous Bases, . . . 458 Mounting upon Mineral Bases, . . . 463 Of the Differeut Methods of Fixing and Maintaining in the Mouth, Pieces of Artificial Denture, . . . 465 Pivots, or Implanted Tenons, . . . 466 Pieces held by Simple Co-adaptation, . . 475 Of Crotchets, .... 477 Of Ligatures, ..... 485 Of Springs, . . . . .491 Spiral Springs, ..... 492 The Application of all that which p ^cedes, in Regard to the Par- ticular Construction of Various Kinds of Ordinary Pieces of Artificial Denture, . . . 502 Exceptionable Pieces, . . . 505 Complete Dentures, vulgarly called Râteliers, . . 506 Maxillary Obturators, . . . 518 Palatine Obturators, . •■...'. . 523 Maxillo palatine Obturators, . . . 535 Summary of the Principles and Rules which should always serve as a Guide in the Combinations and Adjustment of Pieces, ... . 537 * ^u V** > * >^ *£ vOO, . -V 5^ a * 4 -7*, CONGRESS D00EL.0fc.25EL, l ■ n«<* H_ • m tf-v*vlw.* ■ ■ •v< ,►■ .-..'...te I I t JTlW* > ■ • ■ l^h •?sv m ■