mlmi mtlm mm m KttttttMttUttUM II iiiis I JB ■;-..;.• k N ■ii 1 I „.„ P 11 HH III HI UN liiH ill 11 IH KB i^ mi lill 1 Qass_ Book„. COPYRIGHT DEPOSIT Oral Pathology and Practice *A TEXT-BOOK FOR THE USE OF STUDENTS IN DENTAL COLLEGES AND A HAND-BOOK FOR DENTAL PRACTITIONERS. BY W. C" BARRETT, M.D., D.D.S., M.D.S., LL.D., Professor of the Principles and Practice of Dentistry and Oral Pathology in the University of Buffalo Dental Department ; Professor of Dental Anatomy and Pathology in the Chicago College of Dental Surgery; Late Professor of Oral Pathology in the University of Buffalo Medical Department ; Consulting Oral Surgeon to the Buffalo General Hospital, etc., etc. SECOND EDITION, Revised, Enlarged, and Illustrated. PHILADELPHIA: THE S. S. WHITE DENTAL MFG. CO. 1 901. 0- THE LIBRARY OF CONGRESS, Two Copies Received APR. 24 1901 COPYRbiHT ENTRY CLASS CL XXO. N». COPY 8. Copyright, 1898 Copyright, 1901. by W. C. Barrett. by W. C. Barrett. TO My beloved Associates in College Work, My Boys. THE MEMBERS OF THE VARIOUS CLASSES WHO HAVE BEEN UNDER MY INSTRUCTION, AND WHOM I HAVE SOUGHT TO SERVE, THIS WORK IS AFFECTIONATELY INSCRIBED. PREFACE TO SECOND EDITION. The kind reception accorded the first edition of this book by the dental profession was a matter of almost as great surprise as gratification. The author did not anticipate that within two years it would be exhausted, and a second — which is greatly belated — demanded, for works of this kind do not appeal to the general public and are restricted in their sale. At the outset the publishers strongly urged that the text be properly illustrated with cuts, but the author had not sufficient faith in his venture to increase the necessary cost of the book by the addition. The fact that those interested have generally approved his efforts leads him to put forth yet greater exertions to make the volume more worthy their confidence. Accordingly it has been thoroughly revised, not a chapter now reading as it did originally, while much new matter has been added and many illustrations have been introduced, the principal ones being original with this work. The author has endeavored to profit by the honest criticisms of the reviewers of the first edition, and sincerely hopes that some of its faults have been eliminated. He offers this riper fruit in the hope that it will not only be more palatable and easy of digestion than that which was plucked earlier, but that it will also prove nutritious and professionally healthful. He trusts he may not be thought presumptuous when he commends it to the student as a text-book, to the teacher as a help in his arduous duties, and to the practitioner as a work for daily reference. W. C. B. 208 Franklin St., Buffalo, N. Y., October, 1900. vi PREFACE TO FIRST EDITION. PREFACE TO FIRST EDITION. This book is not a treatise, and surgical or operative pro- cedures form no part of its scheme. In writing it the first object has been to condense, not to amplify, that it may be published at as low a price as possible. With this end in view, cuts have been excluded, desirable as they might in some instances be. The work has thus been kept within the limits of a manual. It has been the aim of the author to consider as succinctly as is consistent with clearness the functional derangements of all the oral tissues that properly fall within the compass of a broad dental practice. In addition to this there are certain constitutional dis- orders, the effects of which may be observed in and about the oral cavity, which have not as yet been incorporated into our specialty, and perhaps never will be, but of which it is essential that the dentist should have sufficient knowledge to enable him to make a clear diagnosis, even if he should not purpose active remedial measures. Such disorders as facial paralysis, syphilis, and tumors have therefore been given a general consideration, but practitioners who wish to make a more exhaustive study of those subjects are referred to special works upon them. It should not be expected that a writer will blindly and unreservedly follow even accepted practice when in his opinion it is founded in error; such a course would make of him a mere echo, and would inhibit originality and progress. If, therefore, the author has advanced his own ideas upon subjects concerning which there is a difference of opinion, he believes them entitled to candid consideration in the light in which they are presented. If not found in harmony with clinical experience and observation, they disprove themselves. It is only within a few years that Pathology as a separate study has been made a distinct part of the curriculum of our colleges. The treatment of a few of the more pronounced pathological condi- tions has always been included in the course of lectures upon Operative Dentistry, or in that of Materia Medica and Therapeu- tics, but the subject has been made rather incidental than founda- tional. With the growth of dental practice and the expansion of PREFACE TO FIRST EDITION. Vll the course of instruction in our colleges, a more extended con- sideration of the treatment of complications naturally attendant upon dental degenerations becomes a necessity in our best schools. Dentists are reasonably plentiful, and the multiplication of institu- tions devoted to their iraining is believed to promise an even more abundant supply. The complaint that the profession is getting uncomfortably crowded arises from the old graduates, as well as from those who have been deprived of the advantages of scholastic training. The remedy for these conditions can only be found in the deepening of the stream — in the enlarging of the field of practice by incorporating with the methods of the past (the mechanical and operative procedures which have already been carried to such a high state of perfection) the treatment of the diseases that prop- erly fall within the province of the oral physician, and the making of Oral Practice a true specialty of medicine. For some years the author has annually delivered before his classes in dental colleges from fifty to sixty lectures upon patho- logical and morbid functional and structural conditions in the oral cavity and the tissues immediately connected with it, in which there has been attempted nothing of instruction in constructive, opera- tive, or manipulative dental work. This has tended to open for students a field insufficiently cultivated by dentists. It has en- larged their opportunities, added to their emoluments, and given to them a better professional status. But in this line of teaching he has been seriously handicapped by the absence of proper text-books. Excellent treatises were in existence, but none of them was exclusively devoted to the every- day work of either student or practitioner. They included other branches of dental science, and while, as works of reference and as text-books for advanced members of the profession who desired to make special studies in scientific fields, they were much better adapted than a work of this kind can possibly be, yet as hand- books for students in colleges and as everyday manuals for those who sought help in the hourly recurring complications of office life they were too voluminous. In the time of Hippocrates it was possible to comprise in one volume all that was known of medicine. Many of our older practitioners can call to mind the days when the whole art of den- Viii PREFACE TO FIRST EDITION. tistry was imparted by a preceptor in a few easy lessons. One man might then be universally recognized as the highest authority in the whole field. Now, a complete knowledge of any one of the distinct branches of medicine demands a post-graduate course after four years of general study, while three years in a dental college are scarce sufficient to enable the student to master the basal principles of our greatly extended oral practice. Not alone medi- cine, but dentistry is divided into specialties, and already there are among us those who give their exclusive attention to Operative or to Prosthetic work, to Oral Surgery, to Odontothorsis or to Odontotherapy. The tendency seems to be toward the teaching of each branch in separate classes, with distinct text-books for the several departments. The present work grew out of that seeming drift, and the germ of its existence lay in the notes of lectures upon the subjects considered. The book could easily have been expanded into greater dimen- sions, but that would have limited its usefulness among those for whom it was specially prepared. Extended abstracts of the writ- ings of others might have been included with profit, but that would have swollen the volume beyond the limits set for it, and have added to its cost. Besides, a book should have a distinctive indi- viduality, a personality as pronounced as that of the successful teacher, and without this it is usually as insipid as is the man or woman who possesses no distinguishing peculiarities. So it is perhaps better that it should be marred by some of the many faults of its author rather than be without any special traits at all. W. C. B. CONTENTS. CHAPTER I. page General Considerations i CHAPTER II. Bacteriology : Classification 3 CHAPTER III. Fermentation 9 CHAPTER IV. Bacteriological Pathology 14 CHAPTER V. Septic and Aseptic Conditions 18 CHAPTER VI. Inflammation : Its General Characteristics 25 CHAPTER VII. Changes Attending the Inflammatory Condition 32 CHAPTER VIII. Further Degenerative Changes 37 CHAPTER IX. The Products of Inflammation 40 CHAPTER X. General Treatment of Inflammation 47 CHAPTER XI. Diseases of the Gums 50 CHAPTER XII. Stomatitis 54 CHAPTER XIII. Treatment of Stomatitis 57 CHAPTER XIV. Pharyngitis and Tonsillitis 61 CHAPTER XV. Diseases of the Tongue 64 CHAPTER XVI. Dentition : General Considerations 67 ix X CONTENTS. CHAPTER XVII. The Diseases of Dentition 71 CHAPTER XVIII. The So-Called Diseases of Dentition 74 CHAPTER XIX. Treatment of the So-Called Ejisfases of Dentition 81 CHAPTER XX. The Real Diseases of Dentition 84 • CHAPTER XXI. Dental Caries 87 CHAPTER XXII. The Pathology of Dental Caries 94 CHAPTER XXIII. The Medicinal Treatment of Dental Caries 99 CHAPTER XXIV. Pulpitis — Inflammation of the Dental Pulp. 102 CHAPTER XXV. Treatment of Inflammatory- Conditions of the Dental Pulp 107 CHAPTER XXVI. Pericementitis — Inflammation of the Peridental Membrane in CHAPTER XXVII. Alveolar Abscess 117 CHAPTER XXVIII. Symptomatology and Treatment of Alveolar Abscess 128 CHAPTER XXIX. Deposits upon the Teeth -. 135 CHAPTER XXX. Pyorrhea Alveolaris 141 CHAPTER XXXI. Pyorrhea Alveolaris (Continued) 144 CHAPTER XXXII. Facial Neuralgias 150 CHAPTER XXXIII. Facial Paralysis 154 CHAPTER XXXIV. Sympathetic Disturbances 158 CONTENTS. Xt CHAPTER XXXV. PAG& Diseases of the Maxillary Sinus 161 CHAPTER XXXVI. Treatment of Diseases of the Maxillary Sinus. 167 CHAPTER XXXVII. Diseases of the Frontal Sinus 172 CHAPTER XXXVIII. Cysts and Their Treatment 175 CHAPTER XXXIX. Tumors and Neoplasms 182 CHAPTER XL. Tumors and Neoplasms (Continued) 185 CHAPTER XLI. Osteitis 190 CHAPTER XLII. Caries of Alveolar Bone 194 CHAPTER XLIII. Necrosis 198 CHAPTER XLIV. Treatment Of Necrosis 202 CHAPTER XLV. Hypersensitive Dentine 205 CHAPTER XLVI. Treatment of Hypersensitive Dentine .• 210 CHAPTER XL VII. Secondary Dentine, Pulp Nodules, and Calcifications 216 CHAPTER XLVIII. HYPERCEMENTOSIS 222 CHAPTER XLIX. Discolored Teeth 225 CHAPTER L. Congenital Imperfections of Enamel 227 CHAPTER LI. Acquired or Accidental Imperfections of Enamel 233 CHAPTER LII. Replantation ; Transplantation ; Implantation 238 Xll CONTENTS. CHAPTER LIII. PAGK Syphilis : General Considerations 246 CHAPTER LIV. Syphilis : The Primary Stage 250 CHAPTER LV. The Secondary Stage of Syphilis 255 CHAPTER LVI. Tertiary and Hereditary Syphilis 259 CHAPTER LVII. Syphilis of the Mouth and Tongue : Recapitulation 265 CHAPTER LVIII. Physical Diagnosis 268 CHAPTER LIX. Physical Diagnosis (Continued) : The Respiration 273 CHAPTER LX. The Oral Tissues in Diagnosis 279 CHAPTER LXI. Wounds and Injuries 282 CHAPTER LXIL Treatment of Wounds 285 CHAPTER LXIII. Excessive Bleeding 290 CHAPTER LXIV. Fractures and Their Treatment 293 CHAPTER LXV. Special Cases of Fracture 299 CHAPTER LXVI. Dislocations and Sprains 303 CHAPTER LXVII. Shock — Collapse 307 CHAPTER LXVIII. Treatment of Shock 310 ORAL PATHOLOGY AND PRACTICE. CHAPTER I. GENERAL CONSIDERATIONS. The study of disturbed, as well as of normal systemic condi- tions, necessarily commences with the consideration of Function. Health and sickness (ease and dis-t3.se) are dependent upon the ac- tivities of the organs of the body. In the former condition all are harmoniously working together, each accomplishing its proper task in the best manner and at the right moment. In the latter there is a disturbance of the interdependent bodily relations through the inaction or the mal-action of some organ or set of organs, in- duced by malnutrition, by unsanitary conditions, or by external in- terference. Function is the action of an organ, or of a complete set of organs. The function of digestion implies the proper action of all the organs of the digestive tract, and the perfect accomplishment of this requires that each of them shall be in that state of health which is secured only by the normal action of all combined. The function of every organ is in some way dependent upon that of others, and a state of complete bodily health implies perfectly harmonious rela- tions in all its different parts. The function of insalivation demands that all of the salivary glands shall be in a normal condition, secreting healthy saliva, and that the saliva shall be properly mixed with ingested food. The secretion of the mucous glands is viscid and contains mucin ; that of the parotid is largely serous and contains ptyalin, while that of the submaxillary and sublingual glands is mixed in char- acter. Unless all these secretions are combined the saliva will lack some ingredient, and cannot perfectly perform its office. If, then, the action of any gland is not normal the saliva is modified, and this may interfere with the function of digestion, proper assimi- 2 ORAL PATHOLOGY AND PRACTICE. lation may be inhibited, every tissue of the body may lack nourish- ment, and thus from a disturbance in one apparently unimportant organ every other in the system may suffer. Physiology is the science of normal function. Its proper study demands a knowledge of the structure of the organs con- cerned. It is not confined to man, or even to animal life. Wher- ever there is vitality, growth, organs (that is, in all organic matter) there are certain laws that govern the functional activity of the organism, and the study of these laws is called Physiology. Physiology is divided into animal and vegetable physiology. It may again be subdivided until the functional activity of each of the various orders of animal and vegetable life is specially con- sidered. Pathology is the study of perverted, abnormal, or diseased function. Its comprehension must be based upon a knowledge of healthy action. The study of pathology may be divided in the same manner as is physiology. Wherever there is normal func- tion there may be diseased or perverted action of the tissues or organs, if their activity is in any way disturbed. So we may have animal or vegetable pathological action, and we may study this aberration in any class of animals or vegetables, even in any separate organ or tissue; thus we speak of human or animal pathology, and of pathological conditions of the digestive appa- ratus, the kidneys, the pulmonary tissues, the oral cavity, the nails, the teeth, the hair, etc. This unrestricted nature of the study must always be kept in mind, and the fact that in the consideration of the diseases that are incident to man we are but making an examination of a small portion of the great field of perverted activity should never be lost to sight. Oral pathology is but a branch of disturbed human function- While we may make special inquiries into its character, it can never be wholly segregated from its connections, but must always be considered in its relations to impaired conditions of other organs, because its initial lesion, or point of origin, may be in them, and a cure may only be brought about through a return of those connected organs to a true state of physiological activity. There is no proper study of the oral tissues or organs aside from their functional association with other tissues and BACTERIOLOGY : CLASSIFICATION. 3 A physiological state may be changed to a pathological condi- tion by any derangement of function. The modifying influences which induce this may be classed as follows : 1. Perverted nutrition (or malnutrition). 2. Unsanitary surroundings or environments. 3. External interference. Their importance as disturbing factors and the gravity of the functional disarrangements induced by them are in the order given. Malnutrition means the improper nourishment of the tissues or organs. It may primarily depend upon improper food, a lack of food, or upon imperfect action of the organs of digestion and assimilation. A degenerate condition of these organs is usually brought about either by impaired nutrition or unhealthy environ- ment, and it may therefore be considered as a secondary cause. Unsanitary or unhygienic conditions are those that interfere with proper functional activity, by means of some disturbing element or influence, such as a. Contamination of the air that is breathed, or the food or drink that is taken. b. Subjection of the organs and tissues to improper extremes of temperature. c. Promotion of the proliferation and grozvth of parasitic or disease-producing organisms. External interference has reference to factors not primarily connected with functional disturbances. It includes wounds and injuries, the influence of excessive heat and cold, the active agency of corrosive poisons, and such-like extraneous causes. CHAPTER II. BACTERIOLOGY: CLASSIFICATION. Modern pathological science is largely founded upon a knowl- edge and study of the bacteria — a subdivision of the fungi. The influence of these organisms upon the body is so overwhelming that it is impossible to comprehend pathology without a comprehen- sion of their character and action. So manv of the diseases most 4 ORAL PATHOLOGY AND PRACTICE. destructive to man are caused by them, that modern medical science is largely based upon their study. Notwithstanding the fact that they can only be seen by the aid of the higher powers of the micro- scope, and that even then some of them are absolutely indefinable to vision, they work the most important changes in matter. Were it not for their influence the world would become uninhabitable through the using up of organic matter, which would become permanently incorporated in unchangeable compounds and the pabulum for animals and vegetables thus exhausted. The office of the fungi seems chiefly that of destruction. By their growth they decompose organic matter in which function has ceased, and return its elements to nature, to be again built up into other structures by varying functional activities. Different names have been given to these organisms by different pathologists, though all have the same general signifi- cation. a. Micro-organism means a small body. b. Microbe signifies a small life. c. Bacterium (plural Bacteria), a small staff. d. Bacillus (plural Bacilli) , a small rod. It will be seen that the first two and the last two names are practically synonymous. While all these terms may here be used interchangeably, micro-organism is perhaps as comprehensive as any, although it has no strictly scientific significance. All of these bodies that come within the field of the pathologist are microscopic ; hence to speak of them as micro-organisms is more appropriate than to call them fungi, the latter term including many organisms that are merely parasitic upon other vegetable growths, while many of the fungi are not microscopic and have no pathological signifi- cance. In general classification the various divisions and subdivisions of matter are usually denominated as follows: Matter is divided into Grand Divisions; these into Kingdoms; Kingdoms into Sub- Kingdoms; Sub-Kingdoms into Classes; Classes into Orders; Orders into Genera, or Families; Genera into Species, and Species into Varieties. The fungi have been differently classified by various observers, each having based his arrangement upon certain special character- istics. That of Miller, in his "Micro-organisms of the Human BACTERIOLOGY CLASSIFICATION. Mouth/' is perhaps best adapted to the needs of students of oral pathology, and it is therefore accepted as the standard for this work. The following table will give a clear idea of it : Matter Organic Inorganic Animal Vegetable Cryptogams Phanerogams (Flowerless plants, propagating (Flowering plants, propagating by spores) by seeds) Thallogens, or Thallophytes Leafy Cryptogams, Terns, Mosses, etc.) Lichens Fungi Algse Screw forms Rod forms Round forms Vibriones Bacilli Micrococci (undulating) (straight rods) (small cocci) Spirillae Clostridium Macrococci (rigid) (spindles) (large cocci) Spirochetas Leptothrix Diplococci (flexible) (threads) (double cocci) Streptococci (chain cocci) Staphylococci (group cocci) Organic matter is that which is the product of function, or growth. Everything that has organs, or in which function exists or has once existed, is organic. The organic world is divided into two great kingdoms, the Animal and the Vegetable. Each individual member of these great divisions has its organs and its tissues; function exists in each as long as there is vitality, or life. Death is merely the cessa- tion of function, and the physicist makes no other distinction between the dead and the living than the presence or absence of functional activity. The food of these two kingdoms materially differs. The animal can assimilate nothing except organic matter. Thus the Graminivora live upon vegetables alone, or matter that has been but once organized, and they require a complicated digestive system to extract the comparatively small amount of pabulum for their 6 ORAL PATHOLOGY AND PRACTICE. tissues which it contains. The Carnivora feed upon the animal kingdom, or matter that has been twice organized; first into the vegetable and then into the animal. Their digestive apparatus is comparatively simple, because of the concentrated nature of their food. The Omnivora, to which division man belongs, can subsist upon either, and their digestive organs, while more com- plex than those of the Carnivora, are considerably modified from those of the Graminivora. Fig. i • • •*••• ••••••: i 7. ru 4£ z cPg ^ cS> Different Forms of Bacteria. (After Miller.) a, Micrococci, b, Diplococci. c, Streptococci, d, Bacilli, e, Vibriones. f, Spirillse. g, Clos- tridium, h, Spirochete, i, Leptothrix. Only organisms that belong to the vegetable kingdom have the power of living upon inorganic, or unorganized, matter. Cer- tain of the vegetable fungi are unable even to do this, but must have the food organized before they can assimilate it, as must all members of the animal kingdom. Inorganic matter is that which exists as it was first created. This earth, when it left the hands of its Creator, must have consisted exclusively of inorganic matter. When, in due process of time, the first organic cell was created, and endowed with the power to BACTERIOLOGY I CLASSIFICATION. 7 adapt itself to changing environments and to perpetuate its species — in other words, was invested with function — its food, or pabulum, must have been derived from the inorganic creation. But only the vegetable kingdom has the power to assimilate or organize this matter, or to subsist and grow upon that which is as it was primarily created. Hence the vegetable was first in the order of organic creation, and all organic matter, which is the product of function and was primarily derived from the inorganic, must have originally been the result of vegetable action. No animal can utilize for trophic, or digestive, purposes any inorganic matter whatever. This is a law of the creation. All the mineral elements that enter into the composition of our teeth, bones, etc., must be obtained from organic sources. That is, the calcium, phosphorus, iron, etc.,- of our tissues must have been derived from matter that had first been built into other life. Inor- ganic matter may be utilized in the system as medicine, but it will be extruded in the same form in which it entered; it cannot be built up into the tissues. Even water, which forms so large a pro- portion of all organic bodies and which is itself inorganic, is not, strictly speaking, trophic or nutritional, but is interstitial. It holds in solution many salts, forms a part of all crystalline structures, and is a necessary constituent of the body, though not of the elements of the tissues themselves. It necessarily follows, then, that in the order of the developmental history of the world, the vegetable must first have had a being, to provide food for the animal. The vegetable kingdom is divided into the classes Phanerogam and Cryptogam. The Phanerogams include all those plants which have blossoms and which are propagated by seeds. The roots of some phanero- gams, as the potato, enlarge into tubers, from which new plants may be grown, but their real generation is from seeds. Most of the plants with which we are acquainted belong to this class. It is the seeds and the tubers of the phanerogams that form the principal vegetable food of man. The Cryptogams never blossom, and their propagation is by spores, or minute embryos of the plant itself. As the potato may be propagated from divisions of the root or tuber, so do many of the cryptogams grow from divisions of the organisms themselves, but primarily their origin is from spore-cases. 8 ORAL PATHOLOGY AND PRACTICE. The Leafy Cryptogams are not microscopic in their character, and they have distinct branches and stems. But, like all of their class, they grow from spores. The leafy cryptogams include the ferns, the mosses, and some of the lichens. The Thallogens, or Thallophytes, belong to that division of the cryptogams that are unicellular and simple in their structure. They are without leaves, stems, or branches. They are divided into Fungi, Algae, and Lichens. Fungi are without chlorophyll {the green coloring matter of plants), and live only upon organic matter. They are found as the parasites of both the animal and vegetable kingdoms. Algcc contain chlorophyll, but live upon inorganic matter. They are usually found growing in the water. Lichens partake of the character of both the fungi and the algcc. They may or may not contain chlorophyll, and they may live upon either organic or inorganic matter, according to their species. They are usually found attached to some inorganic matter, and obtain their subsistence from the air. It will be observed that only the fungi can be of interest to the pathologist, for the algae do not grow upon organic matter, and hence will not be found parasitic in man, whose structure is organic, while the lichens have no pathological significance. The Fungi are divided according to their shape, into round, rod, and screw forms. The round, or coccus forms, are subdivided into the macro- cocci, or large cocci, the micrococci, or small cocci, and the diplo- cocci, or double cocci, the streptococci, or chain cocci, and the staphylococci, or those which grozv in clusters, like a bunch of grapes. The rod forms arc divided into the bacilli, or straight rods; the Clostridium, or spindle-shaped, and the leptothrix, or thread- like forms. The screzv forms arc divided into the vibriones, or undulating screzvs; the spirillar, or rigid, and the spirochete, or flexible screws. This subdivision as to form is for convenience, and has no special pathological significance. (See Fig. I.) Classed according to their action the fungi are divided into other groups, such as Zymogenic (fermentative), Pathogenic (disease-producing), Chromogenic (coloring), Aerogenic (gas- FERMENTATION. forming), Saprogenic (putrefactive), Pyogenic (pu§-producing), Saprophytic (decomposing), etc. CHAPTER III. FERMENTATION. A ferment is any substance which has the ability to bring about the molecular oxidation and decomposition or disintegration of the carbohydrates and proteids, or nitrogenous and albuminous com- pounds. As these are the substances which are chiefly concerned in the composition of organic matter, it will be seen that the process is of overwhelming importance, and that without its comprehension the student is not prepared to consider any of the constructive or destructive changes of the body. Fermentation may be denned as the change brought about in such organic medium by the presence of a ferment. It is only within a recent period that its true nature has been comprehended. It was formerly ascribed to what was called catalytic action. It is now known to be induced by a special organism or substance, and its phenomena are those produced by the decomposition of the medium in which the ferment is growing, or exhibiting its energy. There are organized and unorganized ferments. The action of the so-called unorganized ferments does not essentially differ from that of the organized. In either the process consists in a solution of the bonds of constructive affinity and the formation of new com- pounds — in active molecular derangements and rearrangements. With the organic ferments this is brought about through the func- tional activities of simple individual organisms, while the inorganic ferments are formed by and owe their activity to a compound, com- plex structure, made up of functionally united organs, each display- ing its activities for a common purpose. The organized ferments are certain of the micro-organisms whose growth or proliferation is by the assimilation of the elements of the fermentable substance. This they have the power to decom- pose, as a cabbage disintegrates and resolves into its elements the soil in which it grows. The unorganized ferments are the enzymes, or those of diges- 10 ORAL PATHOLOGY AND PRACTICE. tion. The gastric and intestinal juices, the saliva, etc., contain ferments that decompose and change the fermentable foods, and reduce them to a condition in which they may be assimilated, or built into tissue. It is only fermentable organic matter that can be thus digested and assimilated. Inorganic matter is incapable of fermentation, and hence cannot serve as food for any of the tissues of the animal. The classification of the fungi shows that they are as dis- tinctly vegetable as is a potato or a geranium. The fact that they belong to a different order, and are cryptogams instead of phanero- gams, does not change this. They require for their development the same essential conditions and elements. They must have the proper soil, or menstruum, in which to proliferate, or grow, as must the flowers of the garden or field. They require a proper amount of moisture, as does corn or wheat. They demand a fitting tem- perature, and are destroyed, or cease to vegetate, when that is either too high or too low, as are grass, trees, and shrubs. The media, or soils or materials in which the different species of micro-organisms grow, are as various as are the fungi themselves. Some require a sugar solution, made from the fermentable sugars formed by the change of starch into the so-called grape sugar. Some demand an infusion prepared by steeping vegetables belong- ing to the phanerogams. Some grow only in gelatins. Others exist only in the tissues, or extracts of the tissues, of animals. The temperature best adapted to their growth varies with the organism. With those that live in the tissues, that which is normal to the body is also normal to them. The growth of the organisms, although primarily from spores, goes on in various ways. Segmentation is the spontaneous division of a micro-organism into segments, or sections. Each is complete in itself, and each in turn subdivides into others. Gemmation is the process of proliferation by budding. This is the growth of one organism out of another, and its final separa- tion from the parent. Fission is the division of an organism into two or more parts by a constriction of its body. . This contraction gradually deepens until the separation is complete. Spore formation occurs when in certain stages of its life-history FERMENTATION. II an organism undergoes special changes. In these the interior breaks up into exceedingly minute embryos, which are liberated and dispersed by the bursting of the external envelope. Many of the organisms which at certain stages of their existence proliferate by means of segmentation or gemmation, after a definite time break up into spores. Something analogous to this exists among Fig. 2. •0838 a, J. *gm & 6, Methods of Proliferation of the Bacteria. a, b, c. Fission or segmentation, d, d 1 , Sporulation. e, e 1 , Gemmation or budding of organisms. phanerogams, the potato, for instance, being propagated by sub- division of its tubers, but in due process of time blossoming and forming seed-cases. (See Fig. 2.) The growth of micro-organisms proceeds by the decomposition of the medium in which they exist. They assimilate such of its elements as are essential to their own composition, leaving the 12 ORAL PATHOLOGY AND PRACTICE. remainder to form various waste products, and give rise to new combinations of such of the elements of the medium as are rejected. Under favorable circumstances, micro-organisms multiply with almost inconceivable rapidity. Cohn estimates the life-history of a single bacterium at an hour, at the end of which time it will divide into two or more. He computes that from a single indi- vidual, if all the circumstances were favorable, within five days the product might fill all the seas of the globe. Fig. 3. The Yeast Fungus. The proliferation of the Torula, or Yeast-plant, may be taken as a type of the whole process. This fungus consists of dngle cells, produced by division of the parent cell. (See Fig. 3.) It grows in sugar solutions with the greatest rapidity, but a short time being required for the permeation of a large mass by the product of a single cell. The process of making bread illustrates this. The housewife mixes flour, which consists of starch, that is easily con- verted into a fermentable sugar, with a sufficiency of water; she then places the product in a warm place, after having introduced a few cells of the yeast-plant. Here are all the elements needed for development — a suitable medium, sufficient moisture, and the proper temperature. FERMENTATION. 1 3 The yeast-plant commences its growth and permeates all parts of the mixture. It decomposes the sugar, separating the oxygen, carbon, and hydrogen. It builds into itself that which is necessary and rejects the other atoms, which immediately enter into new combinations, forming as by-products, alcohol and carbon dioxide. Wherever a cell of the yeast-plant is formed, there is left as by-products a bit of alcohol and a minute globule of carbon dioxide gas. The latter distends the dough, or causes it to "rise." When this is completed it is placed in the heated oven, with the result that the yeast-plant is killed, and the dough is fixed, or cooked, and becomes bread. Beer-making is an analogous fermentation. The alcoholic fermentation is that which results in the formation of alcohol as one of the by-products. The fermentation of grape juice, and the formation of alcohol from the starch of various grains, belong to this class. The growth of the ferment produces alcohol, which is held in solution in the water, and is then distilled off by its evaporation at a comparatively low temperature. The acetous, or acid, fermentation is the growth of yet another organic ferment, that leaves as a by-product an acid. Of this char- acter is the organism Mycoderma aceti, or the so-called "mother" of vinegar. It decomposes a sugar solution, and produces acetic acid as a by-product. In like manner, through the action of dif- ferent organisms, are produced all of the very many true organic acids. Others of the fungi produce gelatin, and yet others various gases. The putrefactive organisms decompose nitrogenous matter by their growth, with the evolution of offensive gases as their by- products. All the fungi grow at the expense of the medium in which they exist, and through its decomposition, or molecular change. Their by-products vary with the organisms themselves, and, as in the case of the ptomains and toxins, are sometimes of such a poisonous nature as to induce diseased or pathological conditions. Some of the fungi grow only in the presence of air or oxygen, and hence are called "aerobic," while others nourish in tissues or cavities to which air has no access, and are called "anaerobic." They are also said to be "obligate," those whose demand for the presence or absence of oxygen is imperative and peremptory, and "facultative," those which flourish best in one condition or the 14 ORAL PATHOLOGY AND PRACTICE. other, though able to proliferate either as aerobic or anaerobic organisms. The bacteria generally are self-limiting. Their own by- products are fatal to them, and when the medium in which they are growing becomes sufficiently contaminated the organisms will perish. Thus, when an acid-producing organism has made its menstruum sufficiently acid, it will die unless the acid is neutralized by an alkali, in which case it goes on proliferating, provided the pabulum, or nutritive supply, is not exhausted. All the ferment- able material in a solution may be used up and decomposed, so that there will no longer be food for the organism, in which case it will die out. One organism may destroy and supersede another by its superior activity and power of decomposition, or through its production of a chemical compound that is fatal to the first. The brewer must use the most scrupulous care to prevent the intrusion of a strange organism into his infusion, or the result may be an acid instead of an alcohol, with the consequent souring of his beer. The housewife "scalds" the pans and other utensils in which milk is kept, and submits them to strong sunlight that all infective or acid-producing organisms may be destroyed. CHAPTER IV. BACTERIOLOGICAL PATHOLOGY. From the standpoint of the pathologist, the micro-organisms may be divided into several classes, according to their action upon the animal economy. Pathogenic microbes are those whose proliferation or whose by- products cause specific pathological changes; they are disease-pro- ducing. Saprogenic organisms are those which cause putrefaction, or the decomposition of nitrogenous matter, with the solution of ammonia and hydrogen sulphide gases. Pyogenic micro-organisms induce suppuration, or the forma- tion in living tissues of pus, which is the fluid produced in the process of suppuration. BACTERIOLOGICAL PATHOLOGY. 1 5 Saprophytic bacteria are those which live only on dead matter; they induce decomposition and disruption of the elements of the functionless organic matter in which they proliferate. For the study of any of these micro-organisms it is necessary to make pure cultures, obtained by implanting them, as they are mixed with others, in the best culture media, and separating out and replanting selected colonies until everything has been elimi- nated save that which it is desired shall be investigated. They cannot be identified by a microscopic inspection of the organisms themselves, — they are too minute for this purpose. But by observa- tion of the phenomena of their growth, and by tests of their products, as well as by staining them with certain aniline dyes which do not affect their surroundings, they may readily be differentiated, or distinguished from other organisms. To produce a pure culture of any organism, an incubator, or growing-chamber, is required, in which the exact amount of moisture and the proper temperature may be maintained prac- tically unchanged for an indefinite period. Micro-organisms penetrate everywhere that air can go. So innumerable are the different species, and so minute their size, the spores of many of them being invisible even beneath the highest powers of the microscope, that everything conceivable becomes infected with the seeds of disease and decay. A single species has in the past caused greater alarm and devastation than all the armies of the most pitiless conqueror who ever ravaged the earth. The bacillus that produces cholera has decimated nations. The various plague bacteria have invaded great cities and de- stroyed every second person. They have defeated and dispersed invading armies, and have stayed the march of destroying hosts. The bubonic plague, which is the result of the growth of a patho- genic organism, has, in the past, swept away one-third of the population of Europe in a single invasion. A few of the most fatal of the maladies which are the direct result of the growth of some special organism, and which are therefore contagious in their character — the so-called zymotic diseases, of either epidemic or endemic origin — are the following: Cholera, Diphtheria, Relapsing Fevers, Leprosy, Typhoid Fever, Syphilis, Smallpox, Septicemia, Osteomyelitis, Tuberculosis, Lupus, Tetanus, Glanders, Actinomycosis, Malignant Pustule, 1 6 ORAL PATHOLOGY AND PRACTICE. Gonorrhea, Leucorrhea, Scarlet Fever, Mumps, Meningitis, Ery- sipelas, Carbuncle, Pneumonia, Rabies, Anthrax. Late investigations have shown that the one malady that in this country is responsible for more deaths than any other, tuber- culosis or consumption, is as communicable as smallpox, and can only be acquired through infection. Its period of incubation, or development, is longer than that of most infectious diseases, but it can be as certainly stamped out by isolation, disinfection, and the use of antiseptics as can cholera, that former scourge, which in the light of our modern knowledge of bacteriology is now so readily controlled. Were there no means of resisting the invasion and growth of the special organisms which induce these diseases, and of impeding their multiplication, they would inevitably depopulate the earth. It has already been asserted that they are self-limiting in their proliferation, through their inability to exist in the presence of their own waste products. They may also exhaust the soil or medium in which they grow, and thus circumscribe their own multiplication. The most material factor in the prevention of the increase of the zymotic diseases is the resistive power of healthy animal func- tion. Under ordinary circumstances, the human body successfully reacts against infection, and prevents undue proliferation of patho- genic organisms. If, however, the bodily tone is depressed through malnutrition, by unsanitary conditions, by fatigue or exhaustion, or because of functional disturbances, the resistive force of the body is so much weakened, and the conditions favorable to the growth of the disease fungi so augmented, that they multiply to an extent sufficient to bring about that pathological condition which accompanies their invasion. Conclusive experiments upon animals have demonstrated this. Rabbits are immune to tubercular infection under ordinary condi- tions. Twelve of these animals were selected; six of them were kept for some time in a dank and noisome cellar, and insufficiently fed upon unwholesome food. The other six were kept in complete sanitary condition, in light and airy rooms, and were fed with the best food. At the end of a definite period each was inoculated with Bacillus tuberculosis. All of the first six took the infection and died of it; the six whose bodily tone had been preserved by BACTERIOLOGICAL PATHOLOGY. 17 pure air and good food retained their immunity, and successfully resisted infection. Twelve rats were selected, and six of them placed in a revolving wheel that forced them to run at a rapid gait for a considerable time. The other six were allowed to remain in a quiet place, where they would not be annoyed or irritated. When the first six had been forced to run until they were exhausted, all the twelve were inoculated with an organism from which under ordinary circumstances rats have exemption from infection. Those whose resisting powers had been reduced by extreme fatigue and exhaustion took the contagion and died, while the others were unaffected. Fig. 4. Cu Leucocytes. a, b, c, Ameboid forms assumed by them, with pseudopodia. a 1 , b 1 , Ingestion and digestion of bacteria. The resistive power of the human body, according to Metch- nikoff, is largely, though not exclusively, inherent in the ameboid white blood corpuscles, which in a state of health envelop and digest the bacteria. (See Fig. 4.) When these are not fully formed in the system, when they are diminished in number or reduced in functional activity, the infective organisms may obtain such preponderance as to overcome all resistance, and run their course until they produce death, or become self-limiting through the formation of their own by-products and the exhaustion of the media in which they grow. The bacteria are greatly multiplied in the presence of any putrefactive or decomposing' material. Hence all decaying matter should be destroyed as far as possible, by some quicker and more 3 1 8 ORAL PATHOLOGY AND PRACTICE. hygienic process than its decomposition by the fungi. Sanitary conditions imply the removal of all infective matter, and modern hygiene is mainly the study of how best to accomplish this. Such progress has been made within the past generation, that the average period of human life has been lengthened several years, almost entirely through the ability of sanitarians to control the multiplication of disease spores. CHAPTER V. SEPTIC AND ASEPTIC CONDITIONS. The state of infection by disease-producing, or putrefactive, organisms is called a septic condition, and whatever tends to combat this is said to be antiseptic in its character. A state of freedom from all degenerative organisms is an aseptic or sterile condition, and it may be brought about by various agencies, either of a physical or medicinal nature. As moisture is one of the elements necessary to the growth of the fungi, it may be readily comprehended that its entire removal will stop all development. Hence dry climates or desiccated conditions are unfavorable to the growth of bacteria. On the elevated plains of South America beef is indefinitely preserved by drying it in the sun. In other countries the same thing is accomplished by artificial evaporation. The proper degree of temperature is essential to growth, and the raising or lowering of this beyond a certain point will limit or prohibit it, a definite amount of heat being sufficient to destroy all organisms and render sterile any substance whatever. Upon the tops of high mountains, above the line of perpetual snow, the bacteria are almost non-existent. The cold weather of our freezing winters stops the spread of the most virulent zymotic diseases, and fermentation and putrefaction cease, except in the presence of artificial heat. There are also certain drugs that have the ability to destroy or prevent the growth of septic organisms. Those that are fatal to the bacteria and their spores are called Germicides. SEPTIC AND ASEPTIC CONDITIONS. 19 Those that limit and prevent their growth are classed as Anti- septics. Those that decompose or remove the by-products of infection are called Disinfectants. Those that either mask or remove the offensive smells of putre- faction are denominated Deodorants. The most effective of all the agents used for sterilization is heat. The temperature of boiling water (212 F., ioo° C.) is fatal to many of the septic organisms. But as the spores of some of them may successfully withstand this, it cannot in all cases be de- pended upon. Continuous boiling for some time will be sufficient tc destroy most of the organisms contained in water. Yet, if it is to be positively sterilized, it must be distilled. If an instrument is passed through the flame of burning gas, or of an alcohol lamp, it will be made positively sterile, but this is in some cases impracti- cable, because it will destroy the usefulness of steel tools by draw- ing the temper. The tissues of the body, and of most organic mat- ter, cannot be raised to a temperature sufficient to insure an aseptic condition, and hence we are compelled to depend upon germicides, antiseptics, and disinfectants in the treatment of septic conditions. Most germicides are to a greater or less extent antiseptic in their nature. That is, agents that have the power to destroy germs will also prevent their growth. Many of the antiseptics are at the same time germicides and disinfectants, and vice versa. In the selection of drugs for medicinal purposes it is necessary to consider something more than their germicidal or antiseptic qualities. One that is a virulent poison cannot with safety be administered internally, nor can one that is a cauterant be used on delicate tissues. It is therefore necessary to comprehend the therapeutics of antisepsis, and to select the remedy to be used in full view of these facts. Pure germicides are not always demanded in actual practice. If a proper disinfectant is first employed to remove the products of sepsis, and to cleanse the infected tissues, it will commonly serve every purpose. Most of the disinfectants that are in general remedial use not only remove or decompose the products of infec- tion, but are fatal to the germs themselves, and to the extent of their antiseptic influence inhibit or prevent their growth. Hence it is not ordinarily necessary to follow the use of a disinfectant like peroxide of hydrogen by a strictly germicidal or antiseptic agent. 20 ORAL PATHOLOGY AND PRACTICE. The necessities and conditions of oral practice are such as to* exclude many disinfectants, unless they are securely sealed up within the cavity of a tooth. If they are of a caustic nature, they will induce complicating lesions. If they are specially toxic, or poisonous, they may bring about serious derangements. There- fore, in their selection, the judicious practitioner will exercise great care, and choose those which, with the highest degree of effective- ness in their special action, at the same time are not injurious to Fig. k. The Comma Bacillus of Cholera. other tissues. In this respect carbolic, or phenic, acid, a drug that has been in most common use in oral practice, is exceedingly objectionable. The following list of remedies, formulated by Prof. W. D. Miller from personal experimentation, and first published in the "Independent Practitioner" for June, 1884, indicates their relative antiseptic power, but is not by any means intended as a guide for choice in administration. It gives the dilutions in which each will, under favorable circumstances, limit the growth of micro- organisms: SEPTIC AND ASEPTIC CONDITIONS. 21 Mercuric Iodide, Mercuric Bichloride, Silver Nitrate, Hydrogen Peroxide, Tinct. Iodine, Iodoform, Naphthalin, Salicylic Acid, Oil Mustard, •Benzoic Acid, Potassium Permanganate, Oil Eucalyptus, Carbolic Acid, Hydrochloric Acid, Borax, Arsenic, Zinc Chloride, Lactic Acid, Sodium Carbonate, Listerine, Alcohol, Potassium Chlorate, The disinfectants act chiefly through their ability to decompose offensive products. This is usually brought about by the presence of free oxygen, or that which is held in loose combination. Chlorin- ated solutions are effective through their ability to decompose water, thus setting free one or more volumes of oxygen, which is really the agent of decomposition. Hydrogen peroxide is very widely employed in oral practice, because it so readily parts with its extra volume of oxygen. Pyrozone is a more permanent and abiding preparation of nearly the same character. Electrozone, which is a decomposed solution of ordinary sea-water, is very effective, and has the advantage of being entirely innoxious. It may be swallowed, or used on the most delicate tissues, without ill effects. It is produced by an electrolytic current, which decomposes the chlorides and bromides of the salts, changing them into hypo- chlorites and bromites, and these are most effective disinfectants. Deodorants are not necessarily chemical agents. They may merelv be able to absorb noxious matter. An excellent one is i part in 200,000 100,000 50,000 8,000 6,000 5,000 4,000 2,000 2,000 1,500 1,000 600 500 500 350 250 250 125 100 20 10 8 22 ORAL PATHOLOGY AND PRACTICE. pulverized charcoal, which has the power to absorb a number of times its own volume of deleterious gases. It thus acts also as a disinfectant. The deodorants most commonly employed by oral practitioners are drugs of such penetrating, though pleasant, perfume that they cover and mask the odors of putrefaction, though without in any way neutralizing or decomposing them. It is need- less to say they have no special therapeutic value. Detergents are cleansing remedies which are sometimes in de- mand. They have no particular medicinal virtue, but remove certain superficial deposits from tissue surfaces, or from wounds, ulcers, etc. Pure water is excellent for this purpose, or a solution of borax, of common salt, or of soap may be used. Suppuration is primarily the breaking down of the product of inflammation, and its infection by a special microbe. Whether the breaking down is due to the organism, or vice versa, was long a disputed question*. More recent investigations have established the fact that it is infection that brings about the devitalization of the blood corpuscles and the production of pus, and yet it has been demonstrated that it is possible for pus corpuscles to be produced without the presence of bacteria. Such a condition must, however, be unusual, and it cannot present all the characteristics of the sup- puration induced by pyogenic organisms. Ordinary pus is composed of certain nucleolar corpuscles that are indistinguishable from the white blood cells, and which are supposed to be these dead leucocytes, the extravasated serum of the blood, and such broken-down tissue cells as may exist in a certain state of degeneration. This material is found infected with certain pyogenic fungi. The formation and presence of pus is accompanied with the pyogenic fever, and its presence in the tissues may also, under favorable circumstances, be determined by fluctuation beneath the fingers. When it is formed within the tissues it makes its way to the surface by the readiest route, that of least resistance, through the process of rotting or breaking down of the obstructing tissue, and thus forms an abscess. The process of suppuration is essen- tially one of extrusion, or expulsion of effete or dead matter. That inoculation, or infection of healthy tissue with the suppurative bacteria, will induce the formation of pus and the production of an abscess is thoroughly established. Hence, in all curative processes it is essential to use the utmost care to avoid infection, and all the SEPTIC AND ASEPTIC CONDITIONS. 23 modern methods of antiseptic surgery are built upon the ability to control the growth of septic organisms. All of the pathogenic and pyogenic bacteria are very easily communicated, either by direct contact and contamination, or through their spores, which may be floating in infected air. Modern surgery is superior to that of a few years since in the re- sults obtained; surgeons have learned how to avoid and guard against septic infection. It is now known, for instance, that if erysipelas once makes its appearance in the surgical ward of a Fig. 6. Bacillus of Diphtheria. hospital, mere exposure to the contaminated air will be likely to induce erysipelatous inflammation in any patient, but especially those in an atonic or debilitated condition. The bacillus of diph- theria has been known to be carried by a garment that had been repeatedly washed after infection. (See Fig. 6.) Infection may be carried upon the hands, in the clothing, or by instruments and implements. The surgeon who would now attempt even minor operations without the most strict aseptic precautions would be deemed unfit to practice his profession. His hands must be most thoroughly washed, all impurities removed from beneath the nails, and they must finally be carefully drenched with a steriliz- 24 ORAL PATHOLOGY AND PRACTICE. ing solution, that no contaminating fungi may be carried to a wound. Every instrument used must be kept in a sterilizing solu- tion, and sponges and lints must be needfully rendered non-infec- tious. The ordinary clothing must be covered with clean linen garments, that are less liable to carry infection than woolen, and every article used must be scrupulously clean. The dentist should always wear a clean linen coat at the chair. Any woolen overgarment must soon become thoroughly impreg- nated with disease germs, and thus he may carry contagion to suc- cessive patients. He himself and the most healthy and vigorous of them may be able to resist infection, but those who are weak and anemic and who do not possess the same withstanding ability may be seriously affected. Omission of these proper precautions will also be likely to result in infection and suppuration of the wounds which may be accidentally or are necessarily made, and even gan- grene may be the consequence. Every operative dentist, or oral surgeon, needs to exercise espe- cial care in this direction. There is no mouth that does not contain some species of bacteria. Indeed, the presence of some of them seems essential to perfect health, because they exercise a distinct diastatic function, and thus in normal conditions may assist in the process of digestion. The human mouth presents all the conditions favorable to the growth of the bacteria, because the debris from different kinds of food, especially of starches, is always present. The diastatic action of the saliva converts these into fermentable sugars, and thus presents the best medium for the proliferation of very many of the bacteria. Moisture exists in sufficient quantity, and the temperature is exactly that best suited to their development, and it is maintained at a point as constant as could be secured in the most perfect incubator. Indeed, the human mouth is a more perfect growing-chamber for the breeding of germs than any thai the ingenuity of man could possibly devise. Not only is the tempera- ture uniform and the media and moisture at the best, but fresh pabulum is constantly added, while the by-products are promptly removed and neutralized, so that there is no limitation of growth through their formation. The importance of every antiseptic precaution on the part of the practicing dentist cannot be overestimated. He frequentlv meets with pus in the oral cavity, with gangrenous pulps in teeth, INFLAMMATION : ITS GENERAL CHARACTERISTICS. 25 and his instruments are almost constantly infected with septic organisms. These may be deeply buried beneath the debris between the leaves of burs and the serrations of files, so that mere rinsing in a sterilizing fluid will not sterilize, and infec- tion of perhaps the most loathsome character may be carried to the mouth of the next patient, unless scrupulous care is used. It is something more than a professional blunder when an operator will work in the presence of pus, or any infection, without subse- quently cleaning and sterilizing in the most thorough manner every instrument employed, by means of a specially devised apparatus, and the use of disinfecting agents, such as bichloride of mercury, carbolic acid, potassium permanganate, formalin, and other solutions. CHAPTER VI. INFLAMMATION: ITS GENERAL CHARACTERISTICS. A careful study of the etiology, symptomatology, and pathol- ogy of the inflammatory process is of the first importance to the student in dental medicine, because with bacteriology it forms the basis of most degenerative changes. Nor is it only concerned in retrogression. If hyperemia is accepted as one of the early stages of the inflammatory process, it is an important factor in many physiological and progressive metamorphoses as well. Wounds are healed and lesions repaired through its agency in some of its many phases; it is thus an element in the building up, as well as in the tearing down of tissue. There are emergencies in which the oral surgeon or physician desires to invoke its aid, and he some- times deliberately incites its action. But to reach the success at which he aims he must be able to control and -limit it, to impede its action here and to further its energy there, and at all times to check it before it shall reach a degenerative or infective stage. Unless the practitioner has a fair comprehension of this important process, he will always be at work in the dark, and his treatment of most diseased oral conditions will be wholly empirical and experimental. The student will not be able intelligently to investi- gate any of the disorders to which he hopes successfully to minister, without a careful preliminary study of inflammation. 26 ORAL PATHOLOGY AND PRACTICE. The most advanced of modern pathologists, while they have extended the field of observation, have materially simplified the nomenclature. They recognize many added phases which the inflammatory process may assume, but in the light of the most modern bacteriological research they acknowledge but one dis- Fig. 7. &£>, Od.- N.T.- B.V.. ' /"V.,. i y ' ' ! * >\^<'' : ^Jjtt ' J * ' 'K w$xi '•4 ' I' M' wi '-\ 1™ 1/ /f\r " W\ ^K * * *r#- 1&^A / '/ J>' ';, ,',-. . - -„„■-, .,,;■;,«„ ,„i-UrJ \ \ '.& I ' 5 L ' iti v 11 ' '' ftiii As ■JV.^ .° 364 68° 350 66° / / 33& 64° jfo »327 y r« 322 62 f 1 3 23 v 1 30S 6o° / \" >° 294 58° 1 1 t • 280 56° 1 I 1 266 54° /* O V t 252 52° I 1 1 238 50° # / 2 ?5 V 1 \ 224 48° 1 \ \ 210 46° 1 I \4~ O I96 44° 1 I 179 182 42° 1 I \ 1 168 ..J2L. ■ T-1--1 m m m » » s • •te y \ 1/ JWW6 f mw frHLy vW> iyry. .154— 38 J& l£ V V33 s 140 36 i3o Jli^ t 126 34° 125 i II 6 s *-! II* 112 32° 1 112 \ 98 30° 1 1 V3I 1 84 28 1 119 ,s° 70 26° \ 27 \ / 56 24° < v' 42 22° T24 28 20° 14 The inte rrupted line indicates the average temperature, the continuous line denoting the rise and fall of the death-rate. THE SO-CALLED DISEASES OF DENTITION. 79 Table II. Mortality from Diarrheal Diseases in the City of Buffalo for the Years 1888, 1889, and 1890 for the Months Named. AV. TEMP. MAY JUNK JUI.Y AUG. SEPT. OCT. NOV. DEATHS 70° tR? 12 217 6 9 ° /IV 210 68° 1 I X 1 1 \ 203 67° / V 7 ° I96 66° / I % 189 65° fes c 182 64° * V74 \ 175 63° 1 A % 168 62 i % l6l 6i° t % % 154 6o° i % \60° 147 59° 1 t 1 140 58° 1 f 1 % 133 57° 1 1 1 126 56° 1 1 119 55° • * I 1 112 54° iV \ — ■ • 105 53° 1 1 1 9 s 52° 1 % 91 5i° \82 1 1 84 50° 1 77 49° 1 1 70 48° 1 1 63 47° 1 \A7° 56 46° L % 49 45° \ % 42 44° V36** 35 *43° 28 42 J 24 \ 21 41° 14 40° *9 % X9 7 39° - ^39° ■ The interrupted line indicates the average temperature, the continuous line denoting and fall of the death-rate the rise 80 ORAL PATHOLOGY AND PRACTICE. abundantly demonstrated by the accompanying diagrams (see pages 78 and 79), which represent the mortality of the city of Buffalo for three years. What is true of that city is true of all others, except as the tables for the different months may be a little modified by latitude. From November to May, in the northern temperate zone, the death-rate of children from diarrheas and other digestive disturbances is about the same with each month. With the latter month it begins to rise, shoots upward with an amazing increase during June, and reaches its highest point in July. In August it falls slightly, rises a trifle in September, and then falls as rapidly during that month and October as it rose in June and July, again reaching the low point in November, where it remains until the succeeding May. This is more or less true of all cities. Statistics show that the rule is general, but it is especially appli- cable to the poorer people, and the diarrheas and dysenteries are most fatal in the wards and districts in which they chiefly live. The diet of the average workingman's family is necessarily restricted in its character during the winter. In April may be seen by the wayside, and in the yards and in fields, his wife and children gathering the early herbs, dandelion, plantain, and others, to boil for greens. These form a welcome change of diet and are appetizing. What is grateful to their own palates, they argue, must be good for the baby, and it is fed from the family dish. Digestive disturbances commence, and they are intensified by giving it other early vegetables, and perhaps stale fruit. There is a period of incubation of the disease; it gradually increases in intensity, but death is not reached until the hot weather of July exacerbates the condition, and perhaps adds some kind of fermentative infection as the immediate cause of the death, the first degenerative step having been taken in the improper feeding of April cr May. The teeth have been erupting during this time, and the unreflective physician, if he is called in, will quiet the anxious parents and friends with the old plea of teething, perhaps lancing the gums when no tooth is near eruption, and neglecting the organs really at fault, until the sexton closes the scene by burying the fatal mistake beneath the churchyard turf. TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. 8l CHAPTER XIX. TREATMENT OF THE SO-CALLED DISEASES OF DENTITION, It is the first duty of the dentist or the oral physician, when he is called to examine the mouth of a child suffering from the imputed diseases of dentition, carefully to examine and see if there are any indications of disturbed dentition. A correct diag- nosis can only be made with certainty after a very careful con- sideration, not only of the child itself and the attending symptoms, but of its past history, its sanitary environments, and its diet. The age should be accurately determined, that it may be seen whether the dental development corresponds with that of the general system. This is important, because it is not infrequent that morbid conditions are ascribed to teething when the teeth due at the time are all in place. A medical journal reports a case of infantile palsy in a child more than three years of age, as due to teething. Both legs were cold and powerless. There was sufficient irritation of the gastrocnemius muscles to cause a permanent contraction, thus producing a kind of talipes equinus. Nothing is said about the state of forwardness of the dentition, but unless it was unusually delayed, the physician, as is too often done, jumped at his conclu- sions and ascribed to teething a trouble that must have had a deeper origin. The condition of the gums should be carefully noted. If they are normal, without any special inflammation or thickening, we should look elsewhere for the source of the irritation. It should- be remembered that the gum is naturally very hard and dense, from: the large amount of fibrous tissue in it. Normal growth, when the tooth is near the point of emergence, will find the gum whitish,, glistening, and tense in appearance. There may be such a condi- tion of impermeability, of toughness and hardness in the gum that the advancing tooth is retarded thereby, and hence undue pressure is brought to bear upon the, as yet, insufficiently protected pulp, thus inducing reflex nervous disturbances ; but unless there are either general or local disturbances that seriously interfere and re- quire immediate attention, the tooth easily makes its way through the gums, by their absorption under the slight but continual pres- sure induced by the developing roots which lift the crown. 7 82 ORAL PATHOLOGY AND PRACTICE. A clear distinction should, then, be made between those dis- eases which are, or even may be, the results of improper feeding, and the nervous disturbances caused by retarded or impeded denti- tion. Physicians are year by year more clearly recognizing this difference and governing their practice accordingly; yet by far too large a proportion of them still refer the diarrheas and fevers of childhood to teething, and make no special efforts to correct the vicious diet which may be the source of the disturbance. The treatment of the so-called diseases of dentition properly comes within the province of the medical man; yet so frequently are young children who suffer from bad feeding brought to the dentist for advice or gum-lancing, that some practical general directions may with propriety here be given. Fig. 15. Normal Appearance of the Upper Jaw at the Beginning of the Eruption of the Deciduous Teeth, showing Distention of the Bony Walls. (Tomes.) If the gums present their natural light pink, tense, hard, glistening appearance, it matters little whether there are or are not indications of an advancing tooth, the presumption is that there is another cause for the trouble. Retarded or disturbed dentition will usually leave an index upon the tissues about the point of irri- tation, and there will be found some departure from the normal ap- pearance. There probably will bs local inflammation, turgidity, and tumefaction, with redness and soreness. In the absence of these, the diet should be very carefully looked after, hygienic conditions inquired into, and in case of any departure from that which is proper, the food should immediately be changed and correct sani- tary conditions established. If there is a simple diarrhea, of not long continuance, with little of pyrexia, or fever, a simple correction of the diet will probably be sufficient. If the mother shall have weaned the child, TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. 83 or her milk is insufficient, some one of the peptonized foods should be substituted. There are so many of these, chiefly pro- prietary, that it is scarcely proper to recommend any one above the others. It should be something of a very simple nature, in which digestion has already been begun by partial peptonization, or the diastatic action of some proper digestive ferment. A mild cathartic may be needed, and this is sometimes the first necessity, that the stomach and intestines may be relieved of irritating material. Castor oil in doses of from one-half to one tea- spoonful may be given. This will especially be indicated if the stools are of a green appearance. If, as will probably be the case, there is an acid condition, the following may be prescribed: I£ — Castor oil, Calcined magnesia, of each equal parts. Sig. — Dose, half teaspoonful, to be repeated in three hours if necessary. Or the following: 3 — Pulv. ipecac, gr. ss; Pulv. rhei, gr. ij ; Sodse bicarb., gr. xij. Fiat chart, xii. Sig. — One every four to six hours for a child of one year. If there are no special inflammatory symptoms, the following may be used for the purpose of checking the discharges : I£ — Tinct. opii, gtt. xvj ; Bismuthi subnit., 3ij; Mist, cretae, 5jss; Syr. simp., ojss. Sig. — Shake well, and give in teaspoonful doses every four hours. If spasms are imminent or present, the following may be used : 5 — Potas. brom., gr. iij; Tinct. cantharidis, gtt. iij ; Spts. camphoras, gtt. x. Sig. — Repeat p. r. n. in water. In simple diarrhea, after an evacuation of the bowels, the following may be prescribed: I£ — Bismuthi salicylate 5j; Pulv. ipecac, et opii, gr. x; Pulv. aromat, ®j. Fiat chart, xii. Sig.— One powder every three or four hours for a child of one year. 84 ORAL PATHOLOGY AND PRACTICE. If the stools contain mucus and blood and are jelly-like, the following may be given: ty — Hydrarg. bichloridi, gr. % ; Liq. potas. arsenitis, gtt. xxxij ; Syrupi rubi, Syrupi rhei, aa 5ij ; Listerine, adoij. Sig. — Fifteen to twenty drops every two hours. If there is much pain, add one-half dram of deodorized tinct. of opium to the mixture. If there is considerable fever, Dover's powder may be given in small doses of one to two grains, or potassium bromide in five- grain doses. Sponge baths with tepid water will be found useful, and in extreme cases alcohol may be added. But the change of diet, and the most careful sanitary precau- tions as to the cleanliness of the nursing-bottle, if such is used, and of all the surroundings of the child, will be the chief care of the physician. Lancing the gums, or other operative procedures, in these instances will not be found necessary and should not be advised. Usually the case will be put in the hands of a general practitioner, but the dentist should be competent to prescribe in his absence, or in an emergency. CHAPTER XX. THE REAL DISEASES OF DENTITION. The real disturbances of dentition are the pathological condi- tions accompanying the advent of the teeth, in contradistinction to those which arise from improper feeding. Both are sometimes of the most serious character, but their origin and the phenomena that they exhibit are quite different. Usually, with the eruption of the tooth, the superincumbent tissues are absorbed away, and give place to the erupting organ. It should be remembered that up to this time there has been no formation of alveolar process; the bony walls that envelop the germ are very thin and slight, and they are not closed over it. (See Figs. 15 and 16.) There is very little if any pressure, the fibrous gum tissue offering the only obstacle to advancement. In normal conditions this is readily THE REAL DISEASES OF DENTITION. 85 absorbed, but there are instances in which, through some malforma- tion of the tooth or imperfection of its tissues, or perhaps because of local disturbances, considerable pressure is exerted upon the tooth pulp, which at this stage of growth forms the greater part of the contents of the crypt, and upon which the enamel and dentinal cap already formed is resting. In such instances the tissues will not be in their normal state, and will be predisposed to inflammatory conditions. The tooth pulp will be especially irritable, and will respond to comparatively feeble impressions. Fig. 16. Normal Appearance of the Lower Jaw at the Period of the Beginning of the Eruption of the Deciduous Teeth, showing the Distention of the Bony Walls and the Natural Apertures in the Jaw through which the Teeth are Thrust. Alveolar Process not yet Formed: Rami not fully Developed. (Tomes.) The pressure that may be exerted upon the susceptible pulp in such instances may cause serious complications, but these will necessarily be of a reflex nervous character. The irritation to the delicate pulp tissue will react upon other tissues, through their nerve connections, and various functions may be disturbed. A diarrhea may possibly be the consequence, but it will not resemble that produced by digestive disorders. The child will plainly show nervous irritation; it will suddenly wake from sleep, perhaps with a scream. There will be spasms of the facial muscles, and inter- vals of pain will be succeeded by entire relief. There will be alternate slavering and dryness of the oral cavity. If a diarrhea is at times present, it will probably be succeeded by constipation. The appetite will be exceedingly variable, and there will be present that peculiarly fretful condition that indicates nervous irritability. It will be afraid to bite upon anything whatever, and 86 ORAL PATHOLOGY AND PRACTICE. will strenuously resist all attempts to touch the gums. This will be in marked contrast to the condition when, despite digestive disturbances, dentition is proceeding normally. The child then delights to bite upon some yielding substance, like the finger or a rubber ring. If now the mouth is examined the gums about the advancing tooth will probably be found swollen, red, and turgid, and exceedingly tender to the touch. The mucous membrane will have lost the pink, tense, and glistening appearance of health, and will plainly show its disturbed state. During examination the child will perhaps scream hysterically, and plainly indicate its exalted nervous excitement. When these symptoms and appearances are present, no time should be lost in extending surgical aid. In view of the consid- erations advanced in Chapter XVI, and the possibility of the more serious complications which may arise from reflex nervous dis- turbances of dental origin, the occurrence of these indications should be looked upon as of the gravest character, and the most exhaustive examination of the dental condition should be instituted. The general state of advancement of the teeth, in comparison especially with the development of other organs, should be at once needfully observed, and if any tooth is probably, or even possibly, due its condition should be accurately ascertained. Full and free lancing of the gums has so often brought relief as by magic that it should be resorted to even when not positively indicated. The mere wound, with the local loss of a small quantity of blood, has been known to bring instant relief when the most drastic medical remedies have entirely failed. Prompt and deep scarification over any advancing tooth should be made, to divide the swollen gums and disengage the tooth. A crucial incision is usually best, if it be a molar, while a longitudi- nal one may answer for an incisor. In either case it should be deep enough thoroughly to divide all the tissues over the tooth, and extensive enough to free it. If there is any overlapping oper- culum of bone, this should be divided, for it will be the greatest obstacle in the way of the tooth eruption. This will usually be sufficient to give immediate and entire relief. If the diagnosis of the condition was correct, and the incisions sufficient to disengage the whole tooth, the change that ensues will sometimes be fairly startling. It may be well to give DENTAL CARIES. 87 a small dose of potassium bromide (two to five grains), or an enema of chloral hydrate (five to ten grains), in water, to quiet the nervous excitement anal induce sleep, but usually this will not be found necessary, the removal of the cause of irritation being sufficient. There may occur instances in which the child is in spasms, or in convulsions, and the administration of chloroform necessary for their control before surgical measures can be safely resorted to, in which case there should be no hesitation on the part of the operator. The instrument best adapted to the division of the tissues over advancing teeth is the curved and pointed bistoury. It would be difficult to devise a worse one than the ordinary double-edged ovoid lancet, which cannot be made to cut at its extreme point. Something that can, if necessary, be forced deep down into the tissues at its point, and then drawn toward the operator, is essential. A pushing force should never be resorted to, as control of the instrument cannot be maintained, and there is serious danger of wounding surrounding tissues by its employment. CHAPTER XXI. DENTAL CARIES. A popular impression has long existed that caries of the teeth is of modern origin, and that it is due to an artificial mode of life, to a departure from the laws of nature, and to factitious environments. It has been held that our early progenitors knew not the pains of toothache, and retained their dental organs to a late period of life. The application to these fanciful speculations of the facts evolved by actual observation has shown that this is an error, and that there is not now and there never has been a pathological condition so universal throughout animal life as is caries of the teeth, for it is by no means confined to man. There are few of our domestic animals in whose mouths careful exam- ination will not reveal some form of oral disease, and among them caries plays an important role. Nor is it confined to domestic animals; the author has in his possession many skulls illustrating 88 oral pathology and practice. Fig. 17. Caries in the Lower Animals. Teeth of a Baboon (Cynocephalus) from a Skull in the Possession of the Author. Unfortunately the cut shows but a small portion of the decay. There were but three sound teeth (lower incisors) in the whole denture. DENTAL CARIES. 8 9 this, among them being that of an old male gorilla, with extensive decay of the teeth, and also connecting alveolar and antral abscesses, with necrosis of the superior maxilla. No people have yet been found among either civilized or savage races in which dental caries was not prevalent. Even the most ancient had no immunity, and the skulls of Egyptian mum- mies, four thousand years old, exhibit the same decay that is Fig. 18. Dental Caries. Penetration of the Tubuli by Micro-Organisms. (Miller.) Early stage shown by differential staining, only the organisms themselves being apparent. Very highly magnified. observable to-day. Hence we are not dealing with a condition that depends upon recent degeneration when we attempt the consideration of the subject. It is as old as the human race, and has probably caused more of pain and distress to the human family than any other disease with which man is afflicted. It would naturally be expected that a condition so universal, so ancient in its origin, and so distressing in its results would have been carefully studied, and long sir.ce thoroughly compre- hended. The fact really is, that until within fifteen years almost 90 ORAL PATHOLOGY AND PRACTICE. nothing was known of the real etiology of caries, or of the changes it involved. Speculation there had been in abundance, and many ingenious theories had been evolved, none of which satisfied the existing conditions. It is within the memory of even compara- tively young practitioners, when at our dental associations and meetings the most contradictory hypotheses were advanced. It was declared to be the effect of an inflammatory process of the tooth tissues. It was attributed to mineral acids that dissolved out the calcic salts of the teeth. It was by some believed to be due to a perverted nutrition, whereby there was a breaking down Fig. 19. Dental Caries. Penetration of the Tubuli by Micro-organisms. (Mummery.) instead of a building up of tooth elements. It was claimed to be the effect of a lack of mineral elements in the food during the period of growth. It was urged that it is the effect of electrolytic currents generated in the mouth of sufficient electrical energy to decompose tooth substance. In fact, the etiology of caries was a common battle-ground on which the advocates of the different theories met for polemical disputation without the possibility of victory for either combatant through the positive establishment of any special hypothesis. With the comprehension of the true principles of fermenta- tion and the advance of bacteriological knowledge, light began to dawn on the dark places, until at last, by the exhaustive DENTAL CARIES. 91 researches of Prof. Dr. W. D. Miller, an American dentist resident in Berlin, the problem of the ages was finally solved, and the true nature of dental caries was determined. It was found that those who had described it as a decalcification through the action of an acid were partially correct, but greatly mistaken as to the source of the acid. The advocates of the vital hypothesis had a section of the truth, but not enough upon which to base a practice. Electrical action had nothing whatever to do with it. Miller demonstrated that dental caries is due to a number of factors, but the principal and basal one is the growth of oral bacteria. Fig. 20. Dental Caries. Enlargement of the Tubuli by the Action of Bacteria. (Miller.) It has been shown in a previous chapter that the mouth is especially adapted to the growth of micro-organisms. Here are found the proper temperature, the most fitting media, and the required moisture; the temperature is as evenly maintained as it can be in any incubator, while the proper soil for their prolifera- tion is always provided. The various foods, especially the starches, will by the action of the ferments of the mouth be changed into forms admirably adapted to the growth of the acid- forming bacteria. Of some of these Miller made cultivations, analyzing their by-products, and he found, as the result of the proliferation of some special organisms, lactic acid. Further obser- vation enabled him specifically to point out the exact method by which caries is produced, which is as follows : 92 ORAL PATHOLOGY AND PRACTICE. In the sulcus of a tooth, or between two teeth, or in any pit or irregularity of its surface, food lodges. By the action of some ferment this is perhaps changed into a fermentable sugar. This forms a suitable medium for some of the bacteria, and it is perhaps at once infected with certain acid-producing fungi, which in their growth split up the fermentable sugar, building into their own sub- stance such elements as are necessary, and leaving the remainder to form new combinations, or by-products, one of which may be lactic acid. This acid, especially active in its nascent or formative condi- tion, attacks the teeth, dissolving out the calcic salts, and forming a depression in which more food lodges, to pass through the same changes and to be in turn decomposed by new colonies of bacteria, thus forming more acid to continue the destructive work. Fig. 21. Dental Caries. Cross-section showing Melting Down of the Intertubular Substance and the Formation of Minute Cavities through the Action of Micro- organisms. (Mummery.) The dissolving out of the calcareous parts of the tooth leaves behind the organic or living portion, which may pass through inflammatory or degenerative stages, finally to be de- stroyed by putrefactive organisms. This is the essential principle of Miller's discovery. The enamel once penetrated by the pro- ducts of the growth of the vegetable fungus, the progress of the disorganization is more rapid. The bacteria penetrate the dentinal tubuli (see Figs. 18 and 19) ; the acid generated within them, through the action of the DENTAL CARIES. 93 micro-organisms, enlarges the tubules (see Figs. 20 and 21), melt- ing down two or more into one, thus forming minute chambers or cavities in the dentine (see Fig. 22), which ultimately are blended into a yet larger one, and thus decay proceeds. Microscopical ex- amination shows these small spaces to exist at a considerable dis- tance beyond that which is actually broken down, and to account for the friable, crumbling dentine beyond the margin of the cavity proper. Fig. 22. Dental Caries. The Formation of Minute Cavities through the Melting Down or Liquefaction of the Intertubular Substance. (Miller.) The area denominated by Miller "the zone of infected dentine" is that pervaded by the organism, but in which the dissolving out of the calcareous inorganic matter of the tooth has not yet fairly commenced. Yet farther into the structure of the tooth have penetrated the bacteria, filling the tubuli without having distended them. Xot infrequently a number of these distinct zones of infection or caries are seen in their different stages, and readily traced. They are all the result of tooth infection and tooth decalcification through the action of bacteria. Miller, having demonstrated the true nature of this disease 94 ORAL PATHOLOGY AND PRACTICE. by analytical methods, next attempted a kind of synthesis, arriv- ing at the same result, thus by an independent process proving the correctness of his previous observations. Obtaining a pure culture of a bacillus of decay, he immersed an extracted tooth in a proper culture solution, and with the utmost solicitude keeping it in the proper condition and at the exact temperature, he infected it with the bacillus and produced true caries outside the mouth and so removed from all physiological or vital connections. He thus demonstrated that caries is not a vital process, and that the proliferation of the bacillus under proper conditions will produce it as readily outside the body as in it (see Fig. 23). It must, then, be accepted as finally proven that dental caries is the result of an infection, and a true germ-produced disease. It is essentially a septic condition, and its medicinal treatment must be antiseptic. All prophylaxis must be in this direction, and the general principles of Listerism are as applicable to caries as to the treatment of wounds. To proceed farther than this in the consideration of the etiology of dental caries would be outside the scope of this work. CHAPTER XXII. THE PATHOLOGY OF DENTAL CARIES. Physiologists, pathologists, and histologists are sometimes inclined to consider the teeth as organs isolated, dissociated from the rest of the body, and as of such dissimilar, diverse characteristics that their relation to other tissues is but a minor factor in their study. Dental practice has been too exclusively confined to the teeth themselves, reputable practitioners asserting openly that there is no need for the dentist to study general anatomy or physiology, and protesting against everything save the very narrowest and most restricted teaching in our colleges. Almost unconsciously the great body of practitioners have been led to think of the teeth as segregate organs. There are many of our number who, while claiming professional relationship, treat their vocation as exclu- sively mechanical, and unwittingly debase their own condition to that of a mere artisan. The teeth are true modifications of bone. The study of com- parative dental anatomy teaches through what gradations they THE PATHOLOGY OF DENTAL CARIES. 95 have passed in their evolution ; very many of the intermediate steps are recorded in the oral or pharyngeal cavities, and even in the gastric regions, of animals now extant. In some instances mastica- tion is absolutely performed upon true bone, of modified structure, which, however, is soon lost if it is submitted to any rough usage. We sometimes marvel that the teeth decay as they do. Were they not markedly differentiated in structure from the bone of which they are only modifications, they would not last as long as they do. Fig. 23. Artificial Caries. Cross-section. Identical with Natural Caries. (Miller.) That the teeth are living organs, with a vital dependence upon other tissues, that they are intimately connected with the rest of the body, is readily indicated by the fact that they are nourished by the same blood supply and receive their innervation from the same nervous system with the other organs. It is true that they are the hardest, densest tissues of the body, but in this they differ comparatively little from true bone. They are made up of a living matrix, into which calcium salts have been incorporated to give to them consistence. They are developed from the same connective tissue elements with other analogous tissues. Com- ponentry they only differ from bone in having a little more of the calcic salts and a little less of the living matter, in this respect the several tissues of the teeth showing the same variations that are 96 ORAL PATHOLOGY AND PRACTICE. observable in different kinds of bone. To illustrate this the follow- ing table is presented : Bone. Cementum. Dentine. Enamel. Animal matter 34-00 32.00 28.00 3.00 Earthy matter 66.00 68.00 72.00 97.00 100.00 100.00 100.00 100.00 Calcium phosphate 51-04 56.73 62.00 85.00 Calcium carbonate 11.30 7.22 5.50 8.00 Calcium fluorid 2.00 1.63 2.00 3.20 Magnesium phosphate 1.16 0.99 1.00 1.50 Sodium salts 1.20 0.82 1.50 1.00 This table gives but an average of the proportional constitu- ents of the tissues. It would be well if a careful study of it could be made by every dentist. It will be seen that the same elements enter into the composition of all the hard tissues. The essential variation of tooth tissue from true bone is that through the progressive modifications of cementum, dentine, and enamel there is a gradual loss in the proportion of animal or organic matter, and a proportionate increase in the earthy or inorganic. This is most manifest in the calcium phosphate, upon which the teeth mainly depend for their density and hardness; there is comparatively little variation in the relative amounts of calcium carbonate, magnesium phosphate, and the other salts. In bone the living matter is more than half as much as the inorganic, while in enamel it is but one-thirtieth. But it is not alone in its constituent elements that the modi- fications of tooth from bone are exemplified. In their physical structure the gradation is still more marked. In bone the most distinguishing feature of the nutritive apparatus is the Haversian canals, about which are arranged in concentric grouping the cells containing the living matter. These corpuscles, the lacunae, com- municate with each other and with their source of nutrition by minute canals, the canaliculi. Each regular arrangement or system of these communicating lacunae is called a lamella, and the nutritive currents are thus in relation with all the tissue cells through the canaliculi. (See Fig. 24.) The first modification, or differentiation, is found in the ce- mentum, which has all the distinguishing features of bone, if we except alone the lamellae. The lacunae are present, and the canal- iculi ; even the Haversian canals are sometimes found. Thev are THE PATHOLOGY OF DENTAL CARIES. 97 not as constant as in true bone, but even in that they are not always present. The lamellar, concentric arrangement of the lacunae about the Haversian canals is alone lacking, and this is the case even when these vascular canals are found in the cementum. The pro- portion of animal and earthy matter has been but slightly changed, the variation between different bones being sometimes greater than that between bone and cementum. Cementum, then, essentially differs from bone only in the loss of the lamellar arrangement of the cells. (See Fig. 8.) Fig. 24. d- Transverse Section of Bone, showing Lamellar Arrangement of the Lacunae about the Nutritional Centers. a, Haversian canals, b, c, d, Lacunae with branching canaliculi. (Gray.) The next step in the differentiation is found in the dentine,, which has lost the lacunal corpuscles that distinguish cementum and bone. As these contain the greater proportion of the living matter, we naturally anticipate a considerable reduction in that element, and analyses show that it has but about four-fifths the amount found in bone, while the earthy salts are correspondingly increased. In its physical structure, then, dentine retains but the canaliculi of bone, and these appear in their analogues, the dentinal fibrillar Instead of being the channel of communication between the lacunar, as in bone and cementum, they serve to connect the pulp, the analogue of the medulla of bone, with the cementum and dentine, the dependence not being very apparent. As in bone and 8 ■*- 98 ORAL PATHOLOGY AND PRACTICE. cementum, they are the medium of nutrition to the interstitial parts and the parenchyma. Dentine, then, is bone modified in structure by the disappearance of the lacunae, as well as their arrangement into lamellae. (See Fig. 9.) Finally, enamel is developed, — the densest, hardest, heaviest tissue of the body. This is that which alone is exposed to attri- tion, and to the direct action of foreign substances. Bone, cementum, and dentine are normally protected from exposure. If the former is uncovered, even to the external air, the most serious consequences may follow. Cementum is a little, and dentine considerably more tolerant of submission to external influ- ences. But neither of them accepts it without a pathological protest. Enamel alone successfully withstands external contact, and even that is in better condition when in possession of its natural covering, cognate to the skin and mucous membrane, Nasmyth's membrane. The very circumstances under which enamel exists must demand a material modification of structure. Accordingly we find that not only the lacunae of bone and cementum are lost, but the canaliculi of bone, cementum, and dentine have disappeared, and the principal remnant of the living matter left is the microscopical septum between the enamel prisms. (See Fig. 10.) But it is not dead, inert matter. Three per cent, of its structure is animal, so that, tenuous as is the thread, it has yet a vital connection with the other living portions of the body. The necessities of its existence demand that it shall have but a very minute proportion of animal matter to protect it against the exposure and rough usage which it must receive, but still it is identical with bone in its constituent elements, though widely variant in their relative proportions. Enamel is bone deprived of the lacuna: and canaliadi, cut off from its genetic organ, without independent nutrition, but still re- taining a proportion of that animal matter without zvhich it would be something alien and foreign. It is from this standpoint that the tissues of the teeth arc properly considered. It is in their relation to other tissues, and as a part of the living organism, that they are to be studied. The teeth are not lifeless, passive, extraneous objects. They have their pathological degenerations that demand medicinal agents. Their treatment cannot properly be exclusively surgical or op- THE MEDICINAL TREATMENT OF DENTAL CARIES. 99 erative. It is true that their nutrition is limited and sluggish, but it exists, .and must be considered. They are amenable to the same general laws with the rest of the body. They contain a large pro- portion of inorganic matter, but even That must be elaborated in the alembic of nature, — it cannot be taken ready-made ; the calcium phosphate that forms so great a part of their body is of organic origin, and was distilled by nature's process from the organic matter that alone can be used as food or built into the system.. Every tissue of the tooth, as is the case with all other tissues, is the product of growth, hence is truly organic, and the assimila- tive processes can no more accept for nutritive purposes such inor- ganic matter as crude calcium phosphate than it can utilize carpet tacks to give iron to the blood, or lucifer matches to furnish phos- phorus for the brain. Such preparations may act as medicines, to be excreted as received, but their administration for metabolic pur- poses is an utter absurdity. That an hereditary tendency may be a factor in the etiology of dental caries, no one will for a moment dispute. One may inherit a diathesis, a congenital atonicity or a lack of resistant power, but a bacillus is not received as a patrimony. Modern investigation proves that so many of our disorders are of infec- tious origin that the doctrine of heredity must be materially modified. It has been demonstrated by repeated experiment that there is less of difference in the structure of so-called good and bad teeth than has been usually imagined. ' This throws us more directly back upon the vis medicatrix natures for our cures, and places us in a more intimate relation than ever with the vital principle, the innate resistant power of the body, and directs our thoughts into new channels. Dental caries must be studied from the vital stand- point, and in this view we approach the subject. CHAPTER XXIII. THE MEDICINAL TREATMENT OF DENTAL CARIES. It having been demonstrated that caries of the teeth is chiefly due to the action of micro-organisms, it naturally follows that the remedies employed, aside from operative ones, — which it is not the L.ofC IOO ORAL PATHOLOGY AND PRACTICE. province of this work to consider, — must be mainly antiseptic. Were it possible completely to sterilize, and to keep sterilized, the oral cavity, there could be no decay. But this is impracticable, and even undesirable. The peptonizing action of many of the bacteria may be an important factor in digestion, hence it would not be wise, even if it were possible, to eliminate them. But of the advisability of at least limiting their action there can be no ques- tion. The putrefactive organisms certainly can have no> useful office in the mouth, and common cleanliness demands that their growth should, as far as possible, be prevented. Could the teeth and the oral tissues be kept entirely clean and free from food and other debris, caries would be so limited that it would be of little moment. A carefully polished surface does not retain detritus or debris. Unless there are depressions, or pits, or roughness, there is nothing to which particles of food can cling. It is evident, then, that the first prophylactic measure against caries is the careful polishing of the teeth. Every deposit upon them must be removed, every pit obliterated, and every rough surface made entirely smooth. This will be the work of the dentist, but the keeping of them in that state will depend upon the exertions of the individual himself. A set of natural teeth in a state of perfect cleanliness is a sight seldom vouchsafed to anyone. Quite as rare would be a patient, just from the chair of the dentist, whose oral cavity had been put in perfect order. The average practitioner neither recognizes nor attempts the cure of half the pathological conditions that exist in the mouths that he treats. He fills the most conspicuous cavities, removes deposits that actually obtrude themselves upon his notice, and ignores the rest. Nor is it neces- sarily his own fault in every instance, for patients sometimes might offer serious objections to expending the time and money necessary for the treatment of all diseased conditions and the putting of the mouth in complete order. There is, however, no excuse for failing to call the attention of decently clean people to minute sedimentary precipitations upon the teeth, depressions or erosions of their surfaces, and inflam- mations and irritations of the soft tissues about them. That which is neglected is mainly in the line of prophylactic treatment. Were dentists generally more faithful to duty, their practice would be widely extended, while the people would be greatly benefited. THE MEDICINAL TREATMENT OF DENTAL CARIES. IOI It is unnecessary to call the attention of the student or practi- tioner to the most approved methods of cleaning the teeth. That duty devolves upon the teachers of operative measures. But the proper medicinal agents may be adverted to, and their use recom- mended. In the performance of this task it is impossible entirely to forbear mention of proprietary remedies, whose employment, when others can be substituted for them, should be avoided; yet they are sometimes a convenience, and, when the formula is a public one, may be professionally prescribed. A convenient, effec- tive and unobjectionable antiseptic mouth-wash, consisting of a single simple remedy, is quite unknown. The most efficient germicides possess toxic or caustic properties that are sufficient to exclude them. The best antiseptics are liable to the same objec- tions, and we are thus forced back upon the essential oils, which must be combined with other things to make them most useful. Listerine, borine, borolyptol, and other combinations are proprie- tary preparations, and therefore objectionable on ethical grounds, for no physician has any right to make a prescription for a patient unless he is fully aware of its entire character and thoroughly con- versant with every drug in it. He is paid for the expert knowledge of which the patient is not possessed, and he betrays that patient's professional confidence if he does not exercise due intelligence. Hence proprietary and secret remedies have no place in this work, unless their complete working formulae shall have been submitted to and approved by the author. For antiseptic use in the mouth, lysol presents some advan- tages, and the following may be used with the tooth-brush : I£ — Lysol, 3ss; Aquae, §xvj. Carbolic acid is not palatable, and it possesses toxic properties that forbid its use in strong solutions. But it is excellent as an antiseptic, and the following formula may be found useful : 3 — Carbolic acid crystals, Glycerol, Rose water, of each 2 ounces. Five to ten drops in a wineglass of water should be used as a gargle, or with the brush. Thymol is similar in its action to carbolic acid, while it is free from its disagreeable odor : 102 _QRAL PATHOLOGY AND PRACTICE. I... ~ ., ^-Thymol, 4 grains; Benzoic acid, 45 " Eucalyptol, 180 " Water, 2 quarts. This should be used as a gargle, after cleaning the teeth. The following is recommended by Professor Miller as an anti- septic gargle and wash : 3 — Thymol, 4 grains ; Benzoic acid, 45 " Eucalyptol, 3^ drams; Alcohol, 25 Oil of wintergreen, 25 drops. Hydronaphthol has been employed as an antiseptic, but was formerly more used than it is at present. The following formula has been recommended for a mouth-wash : 3J — Hydronaphthol, 3ij ; Tinct. calendulas, 3iv; Aquae dest, ad Bviij. Any of these may be used with the tooth-brush, or as a gargle after cleaning the teeth. CHAPTER XXIV. PULPITIS— INFLAMMATION OF THE DENTAL PULP. Save as it is modified by surrounding conditions, inflammation of the pulp does not differ from that of other analogous tissues. The initial processes are the same, and hence the remarks in the section on Inflammation are applicable to the condition now under consideration. When the subject of general inflammation is fully comprehended, then, and then only, can the phenomena presented in pulpitis be clearly understood. It is but necessary to consider the peculiar complications brought about by the environments of the dental pulp, and to make due allowance for them, when the whole matter becomes plain and lucid. These complexities arise from the fact that the tissue of the pulp is somewhat modified in structure, and at the same time is enclosed within unyielding, osseous walls, which in health form its sure protection and in disease its rigorous prison-house. Whether or not the dental pulp, in its healthy, normal condi- tion, is or is not sensitive to external impressions is a disputed PULPITIS INFLAMMATION OF THE DENTAL PULP. 103 question which cannot be satisfactorily answered, because if" it is responsive it is at once claimed that it is not in a normal condi- tion. Certain it is that an entirely healthy tooth gives no sentient signs of the presence of a living pulp. It is sometimes a difficult matter positively to diagnose a dead pulp from a healthy living Fig. 25. L.F. Illustrating thk Relations of the Pulp to the Dentine. CD. Formed, calcified dentine. l.D. Forming, uncalcified dentine. L. F. Dentinal fibrillar, fibers of Tomes, — processes from the odontoblasts. OJ. Odontoblast cells. P.C. Cells of the tooth pulp. (Burchard, after Rose and Gysi.) one in natural conditions. Both are equally unresponsive to ordinary thermal changes, and the enamel and dentine of each are equally insensitive. Those who have had occasion to drill into or excavate a tooth that is entirely without disturbance of the pulp tissue, know that the dentine is unresponsive, while the pulp may be, and often is, punctured without the knowledge of the patient. 104 ORAL PATHOLOGY AND PRACTICE. But if the tooth shall have sustained an injury, if there is reces- sion at the gums, or if there shall have been any pain in the teeth whatever, indicating pulp complications, or even any pulp disturb- ance insufficient to produce pain, both dentine and pulp may be ex- quisitely sensitive. There are occasional instances in which caries has extended to the pulp tissue, but in which there never has been either pain or sensitiveness. This cannot be reasonably accounted for upon the theory of personal idiosyncrasy, for individual tem- perament will scarcely cover a departure from general physiological laws. There must be a good and sufficient reason for such an immunity. The bloodvessels of the pulp possess a modified structure, in that they are without the complete muscular coats of those found in most parts of the body. (See Fig. 7.) In this respect they resemble those of the brain, which also is a tissue protected by un- yielding, bony walls, analogous to those of the tooth. The nerves of the dental pulp are also modified, for while they are composed of nervous elements they lack the general structure of those of most other parts of the body, and they are without the usual sheaths. The connective tissue of the pulp is not especially modified in struc- ture, but it must be peculiarly so in function, through its excep- tional blood and nerve supply. These variations will be specially considered in the chapter devoted to the diseases of the peri- cementum. The dentine is without nerve supply, and yet when in an irri- table condition it becomes acutely responsive. Sensation can only be conveyed through the dental fibrillse, whose embryonal structure, containing all the elements of nerve tissue, becomes inordinately responsive in certain conditions. It is well established that forma- tive tissue, embryonic matter, may take on inflammatory conditions, and under such circumstances possess characteristics unknown to it when in a normal state. It might be reasonably inferred, then, that the sensitiveness of either dentine or tooth pulp may be the direct result of irritation, and the inceptive stage of an inflammatory process; that sensitive- ness of dentine is but the result of that abnormal, irritative, in- flamed condition ; that the peculiar phenomena presented are due to the modified blood and nerve supply, and that in its normal and healthy state it may be quite irresponsive to external impressions; PULPITIS INFLAMMATION OF THE DENTAL PULP. IO5 that any special responsiveness of either of the tooth tissues to ex- ternal impressions is an indication of a pathological condition, and that in treatment this should always be kept in view. The pathological changes presented and the phenomena exhibited in inflammation of the tooth pulp will differ from the corresponding phenomena in most other tissues just so far as the structure of these latter is varied and their environments are modi- fied by the tissues with which they are in relation. The peculiari- Fig. 26. Congestion of the Bloodvessels of the Tooth Pulp of a Dog after the Application of Arsenous Acid. ties of the nerve supply will change the character of sensation, while the special vascular system will cause a variation in the phenomena presented in the earlier stages of inflammation, and materially modify diapedesis. Proceeding upon this hypothesis, it is not difficult to comprehend some things heretofore unintelligible in the pathology of the dental pulp, and to find indications that may ce a more complete guide in diagnosis and treatment. A specially sensitive tooth is one whose tissues are in an irritable condition, and this is either the initial step in, or a 106 ORAL PATHOLOGY AND PRACTICE. positive stage of, an active inflammation. The irritant may be any one of a long list, and may have its origin either in some- organic change, in a mechanical injury, or in some pathological or diseased condition. Thus : 1. Caries has perhaps invaded the tooth, and micro-organisms have penetrated the tubuli, becoming themselves the irritant, or exposing the deeper dentine and pulp to the irritating action and thermal changes of external agents. 2. It may be that an inserted filling is this outward irritant. 3. There may be recession of the protecting gum tissue at the cervical portion of the tooth. 4. A traumatic injury, a blow, inordinate use, the attrition of mastication, or any mechanical violence may be the source. 5. Structural changes within the tooth pulp, such as the forma- tion of calcific deposits, are a sufficient excitant. Whatever the possible cause, there will be a hyperemia or determination of blood to the irritated pulp tissue and an engorge- ment of its capillaries. Because of the absence of the usual arterial and venous coats, the blood channels at once yield to the pressure. There is not the normal vaso-motor system of nerves to control the resilience of the vascular system, and diapedesis, or the escape of the elements of the blood into the pulp tissue, is materially modified. It may not at once take place in the usual acceptance of the term, but a stage of active engorgement of the blood channels ensues. (See Fig. 26.) The dental pulp is without the full and complete chain of lymphatics of the absorbent system, because the modification of the blood supply in a measure makes it unnecessary. The compara- tively unrestrained yielding of the blood channels, and the retarda- tion of the infiltration of the pulp tissue, allow for a return to a physiological state, if once the irritation ceases, without the ne- cessity for the usual process of resolution through the activity of the lymphatics in relieving a hyperplastic condition. It follows, then, that the treatment of ordinary pulpitis, after the removal of the irritating cause, should be directed toward the relief of the congested condition, by deflecting in some manner the determin- ing blood current and allowing the engorged vessels to empty themselves. So long as the possibility for this exists, it is quite feasible to preserve the vitality of an inflamed pulp. TREATMENT OF INFLAMED DENTAL PULP. 10^ When the pathological condition shall have proceeded to the extravasation into the body of the tissue of inflammatory products, there are practically no lymphatics to take them up, and their re- moval is as impossible as is that of any great effusion in the brain. Pulp capping under such circumstances will be a hopeless proceed- ing, and the presence of any infiltrated or effused matter will contra- indicate it. The fact that some pulps become fully exposed and their investing tooth walls are broken down without either pain or special sensitiveness, may be accounted for through their never taking upon themselves real inflammatory conditions, because of a modification of nerve structure greater than that which is usual. CHAPTER XXV. TREATMENT OF INFLAMMATORY CONDITIONS OF THE DENTAL PULP. Usually, the first indication of irritation of the dental pulp is responsiveness to external impressions, manifested by a sensi- tiveness to thermal changes. Cold air or cold water cause pain of a sharp, lancinating character. Not infrequently the neck of the tooth, or any abraded surface, is also sensitive to an outward irri- tant, such as a metal tooth-pick or instrument. This indicates dentinal irritation. The responsiveness to thermal changes in- creases and becomes more persistent, until there is a distinct odontalgia or toothache. This pain will be rather paroxysmal, returning upon slight provocation and passing away in a few moments. It may be difficult for the patient to determine exactly which tooth is affected, because of its sympathetic nature and because it is distributed over a considerable territory. Suc- cessively isolating each tooth by the rubber-dam, and the applica- tion of alternate heat and cold, will, however, usually determine the matter. Sometimes there is a response to percussion, and a diagnosis may thus be reached. This earlier stage will be that of hyperemia, and the beginning of engorgement, or congestion. The exalted sensibility is due to the irritable condition of the nerve tissue. If relief is not obtained, the pain, with the exacerba- tion of the inflammatory condition, becomes more intense and continuous. With the increased engorgement, the pulp, which is I08 ORAL PATHOLOGY AND PRACTICE. held immovably within the bony tooth walls-, becomes intensely irritable, and the pain instead of continuing remittent becomes almost continuous. The lancinating flashes can no longer be dis- tinguished, but are so quick in succession as to be practically unin- termittent, and there is at the same time a deep, boring pressure felt, which indicates that the inflammation is passing or already has passed to its second stage, that of effusion, in which there is an oozing out of the elements of the blood into the tissues. Up to this point the vitality of the pulp may readily be pre- served, if active measures are taken for the relief of the inflam- matory condition. This stage once passed, and extravasation into the pulp tissue having taken place, the probabilities are largely against conservation. About this time the pain changes in character somewhat, and it is not of such a sharp, lancinating nature. It becomes more steady and less paroxysmal. There is a greater feeling of pres- sure, and it is more readily located. The pulsation, which up to this time is very distinct, now ceases. The congestion soon reaches its height, and entire stasis of the blood current in the pulp is immi- nent. Cold is no longer irritative and warmth grateful. The opposite condition ensues, and ice-water will relieve the pain, while any warm application exacerbates it. The suffering caused by the affected organ is intense, but the end is probably near at hand. With complete stasis sensation is gradually lost, the pain pro- gressively abates, neither cold nor heat aggravates, and the tooth is irresponsive to any ordinary irritant. The inflammatory process has run its destructive course, and the pulp is dead. This is the usual train of symptoms and the ordinary progress of the disease. The treatment in the earlier stages should be abortive. Every effort should be put forth to relieve the hyperemic condition and to restore a normal circulation. The first essential is to make a clear diagnosis of the case, by carefully considering all the symptoms. The exact stage of the disease should be determined if possible. This having been done, the next point will be tg remove the cause. If it is progressive caries, the cavity of decay should be carefully washed out, all debris removed, and an anodyne introduced. If .any foreign substance is the irritant, it must at once be eliminated. The tooth must be relieved of all labor of mastication and given entire rest. Counter-irritants, such as iodine and aconite, or capsi- TREATMENT OF INFLAMED DENTAL PULP. I cum bags and plasters, are useful by promoting metastasis ; that is, a new focus of inflammation is created in an approximate territory, but which is upon the surface where it can be reached and where resolution may be anticipated. This has a tendency to divert the impending blood currents, and thus to relieve the threatened en- gorgement of the pulp. Hot pediluvia, or foot-baths, should be prescribed, preferably to be used at night before retiring. The water must be as hot as can well be borne, and these are to be continued for at least thirty minutes, for the purpose of equalizing the circulation and relieving the plethoric condition of the pulp. Saline cathartics are useful and may frequently be employed with good results. They reduce the blood tension, remove from the sanguinary fluid a portion of its watery constituent, and thus greatly diminish the stress. Diaphoretics are perhaps the most important of the general remedies. They not only extract a considerable amount of water from the system and from the blood current, but they act as general depurators, promoting healthy functional action and removing local obstructions. Anodynes are indicated and should especially be administered to nervous or irritable patients. They equalize nervous function and tend to restore the proper tone to the arteries and veins through the vaso-motor system, and to allay the general nervous excitability. Probably there never was a case of simple pulpitis that would not yield, temporarily at least, to the vesicant action of a powerful counter-irritant at the back of the neck, a foot-bath continued for thirty minutes, and twenty to forty grains of potassium bromide. Such drastic measures, however, are not often called for, and are inadvisable when milder means will suffice. Any of the preceding measures may be resorted to in cases in which there is no actual or threatened exposure of the pulp through progressive caries, or by accident. When there is a large cavity of decay, it must first of all be thoroughly opened up, and all debris and foreign substances removed as carefully and as completely as possible. It should next be washed out with tepid water in which a little salt has been dissolved, by gently injecting the stream from a mouth syringe. The cavity should be dried out, and a pledget of cotton dipped in oil of cloves, or dilute creosote, HO ORAL PATHOLOGY AND PRACTICE. or hamamelis inserted, this to be carefully sealed up without pres- sure, by means of gutta-percha or a pledget of cotton dipped in chloro-percha. A solution of sandarac in which to dip the cotton should not be employed, because it insecurely seals it and very soon •decomposes, leaving the cavity in a worse state than at first. It is also likely to encapsule the remedy, and thus to isolate it and preclude its action. If there is actual exposure of the pulp tissue, after the cavity of decay has been opened up and carefully cleaned and washed •out, the rubber-dam should be applied, the opening dried out by means of hot air, and the pulp and cavity walls sterilized by the application of mercuric chloride, solution i to 2000, or some other effective germicide. If there is considerable congestion, a pledget of cotton dipped in the following may be carefully placed over the point of exposure and sealed up: B — Plumbi acetatis, u gr. v; Tinct. opii, 3ss; Aquae, oij. This should be allowed to remain for some hours, when it may "be changed for a dressing of dilute oil of cloves, or of cassia. All pain will usually cease with the application of an anodyne. When more active measures are demanded, the following dressing may be applied after the sterilization: B— Atropinse sulph., gr. j ; Aquae dest, oj. If the pulp shall have been wounded and bleeding ensue, or if there is exudation of serum from the exposed pulp, it may be dressed with a solution of tinct. iodine and persulphate of iron in equal parts. Tinct. opii may sometimes be necessary for the purpose of soothing the disturbed tissue. The inflammation and congestion once relieved, the necessary operative measures for the further preservation of the tooth may be instituted. If there is no actual pulp exposure these may, if skillfully executed, be con- fidently relied upon to serve their full purpose. If, however, any portion of the pulp tissue is really uncovered, the prognosis will not be as favorable. In the earlier stages of inflammation, before there is any exudation from the bloodvessels of the pulp, the best results may be predicted. If there has been extravasation of -the contents of the blood channels into the body of the pulp absorp- PERICEMENTITIS. Ill lion cannot be expected, owing to the absence of lymphatics, and breaking down of the tissue or death of the pulp will result. The successive stages in degeneration may be tabulated thus : First Stage. Second Stage Third Stage. Fourth Stage. Symptoms Sensitiveness. Pain (cold ex- Pain (cold Insensibility. acerbates). relieves). Condition Irritation. Infiltration. Inflammation. Stasis. Pathology Hyperemia. Diapedesis. Congestion. Death. Prognosis Good. Doubtful. Bad. Hopeless. Stasis and death, as suggested by Dr. J. B. Willmott, may in some instances be partial in the third stage, while in other cases decomposition may have commenced in circumscribed areas and the change in the symptomatology may, at least in part, be due to the condensation of the putrefactive gases under the reduction of temperature. The different remedies in the several classes that will prove best adapted to dental practice may be summarized as follows : Food Laxatives. — Green and dried fruits, cracked wheat, oat- meal, etc. Medicinal Laxatives. — Seidlitz powder, castor oil (doses for adults of 4 to 8 drams, and for children I to 3 drams), lac. sulphur (J to 3 drams, in syrup or milk). Saline Cathartics. — Epsom salts (2 to 8 drams in carbonated water), citrate of magnesia (dose according to preparation). Diaphoretics. — Warmth and exercise, warm drinks. Dover's powder (5 grains, repeated if necessary), spirits of Mindererus (2 to 8 drams every two to four hours), sweet spirits of nitre (2 to 4 drams frequently). Diuretics. — Diluent drinks, mineral waters, beef tea, whey, gruel, cream of tartar ( 1 to 4 drams combined with \ dram biborate •of soda), borax (20 to 40 grains). Anodynes. — Potassium bromide (5 to 20 grains), sulphate of morphin (■£ to \ grain), aromatic spirits of ammonia (10 to 60 drops). CHAPTER XXVI. PERICEMENTITIS— INFLAMMATION OF THE PERIDENTAL MEMBRANE. Sometimes this affection is closely connected with inflamma- tions of the dental pulp, and it may be derived from mere con- 112 ORAL PATHOLOGY AND PRACTICE. Fig. 27. Enamel. Enamel. Cornua of Pulp Dentine Fibrous Gum Tissue Aberrant Bloodvessel. Nutrient Artery. Bifurcation or Branching of Pulp. Lateral Foramen. Principal Foraminal Opening. Nutrition of the Dental Pericementum and Pulp. The condition here represented, is that seen only in young persons. In later life the " aberrant" bloodvessels and some of the canals at the apex may be closed by the advancing calcification. The former are not constant but sometimes may be observed. Cementum is a modification of bone, and these vessels may have a genetic relation to Haversian canals. The cut is schematic and not according to scale. PERICEMENTITIS. 1 1 3 tiguity or proximity of tissue. Usually, however, it arises quite independent of the other disorder, and indeed is more severe when the pulp has been devitalized, either by design or disease. The pericementum is an exceedingly vascular organ, and it has an abundant nerve supply. This is necessary to its proper functional action. It is a kind of placental organ which affords the pulp of the tooth its vascular and nervous supply. The text-books and preparations which represent the arteries and veins of the tooth pulp as passing out at a single foraminal opening, perforating the pericementum and traversing the tissues until they anastomose with some larger vessel of which they are branches, and which is not in relation with the tooth at all, cannot be accepted as repre- sentative of the actual condition. No bloodvessel can be directly traced beyond the investing pericemental membrane. (See Fig. 27.) Fig. 28. Tooth Extracted by Author for Replantation, with Minute Threads of Chloro- percha Forced through Dentine and Cementum in Filling the Root. The foraminal opening of the normal tooth root is not a single direct aperture, having its axis in line with that of the pulp, but, especially in early life, is a delta with a number of communicating orifices, which begin to diverge near the apical junction of the dentine and cementum, and with a kind of circular sweep reach the pericemental membrane, with whose bloodvessels the branches from the dental pulp anastomose. Indeed, in early life the ana- logues of Haversian canals are not infrequently found penetrating the cementum and dentine at different points along the periphery of the tooth root, and containing accessory bloodvessels for the further supply of the pulp. Later in life these are usually oblit- erated by the advancing calcification. That this is true, the clin- ical observation of almost any dentist of wide experience might establish. There are few such who have not seen the whole apex 9 H4 ORAL PATHOLOGY AND PRACTICE. of a tooth root denuded through some pathological process, or by surgical operations, without interference with the vitality of the pulp. Many have known instances in which, through diseased action or by accident, one side of the root of an anterior tooth, with the whole of the apex, was completely denuded without any devitalization of the pulp. When this tissue has been restored by functional activity, the tooth was found as responsive to thermal changes as ever. The author has frequently had occasion to remove all the investing osseous tissue from a tooth root, save perhaps a comparatively small portion at one side, and that without final prejudice to its vitality. In some of these instances there Fig. 29. Tooth with Hypertrophied Pericementum showing Blood Supply. Microscopical section demonstrated that nutrient arteries of considerable size entered at a and b and were distributed to the pericementum. (From a specimen furnished the author by Dr. D. E. Kulp.) could have been no vascular supply to the pulp, unless it was through some kind of Haversian canal penetrating the cementum and dentine upon a lateral aspect. The author has frequently demonstrated the presence of something of this kind in freshly extracted young teeth. (See Fig. 28.) It is well known to oral surgeons that resection of the inferior dental canal, with entire obliteration of the inferior dental artery and nerve, does not in any way interfere with the vitality of the lower teeth, which the text-books frequently represent as receiving their vascular and nervous supply from that source. These con- siderations should materially modify our views of the pathology of the dental pericementum, and change some previous conceptions of PERICEMENTITIS. 115 its function and susceptibility to diseased action. In the light of these views, much that was before incomprehensible becomes plain and intelligible. We can understand why and how it is that the blood and nerve supply of the tooth is modified, and how it arises that the vessels of both are without the usual external muscular coats, and approach those of the brain in character. Having the important and compound functions of affording the pulp of the tooth its nerve and blood supply and giving nutri- tion to the cementum and bone, and being in close relation with the gum tissue, the pericementum is very likely to take upon itself a pathological condition. Continued irritation of a mild character may result in a hyperplasia of the membrane, with an enlargement of the principal nutrient arteries and a generally congested irrita- tive condition. (See Fig. 29.) It serves as a cushion to break the force exerted upon the tooth in occlusion, or from a blow, or any other external violence. Hence it is liable to injuries and acci- dents. It is also very subject to infection by micro-organisms from a decomposing tooth pulp. This last is without doubt the most fruitful source of inflammatory conditions, and such instances are constantly falling under the notice of the dentist and oral physician. Another common cause is the bad occlusion or absence of some of the teeth, which throws upon a few the work of many. Teeth used as anchorages for bridges of an extensive kind are peculiarly liable to and are often lost by pericemental irritation caused by overwork. Many practitioners have no clear conception of the difference between pericementitis and pulpitis, inasmuch as each produces a distinct odontalgia or toothache which only close observation will distinguish from the other. And yet the two conditions have little in common except the pain, and that is not of the same character. It may be well to compare their pronounced symp- toms as an aid in diagnosis. Pulp itis. Pericementitis. The pain is of a sharp, lancinating The pain is dull, steady, boring, character, and in its earlier stages it throbbing in its character, and is not is distinctly paroxysmal. at all paroxysmal. The tooth is exquisitely sensitive There is no sensation to changes of to thermal changes; in its inceptive temperature, and neither cold nor state cold, and in its later condition hot applications materially affect it. heat, exacerbating the pain. Il6 ORAL PATHOLOGY AND PRACTICE. Pulpitis (cont.). Pericementitis {cont.). There is no swelling of the tissue The tooth becomes exceedingly about the tooth, and no tenderness to sore, and the least pressure upon it pressure in ordinary cases, unless the causes pain. In the later stages pulp shall in some way be exposed. swelling is common. It is at times quite difficult to de- There is no trouble in deciding termine exactly which tooth is af- which tooth is the diseased one, the fected, the pain being fleeting in its pain being steady in degree and in nature, and inducing reflex symptoms [position, and the soreness readily in other teeth and tissues. locating it. The pain is apt to be worse upon The pain remains nearly constant going to bed, and excitement and without much reference to external fatigue increase it. conditions or circumstances. It is possible to bite upon the tooth The tooth is very sore to the without any special sensation, and to touch, any occlusion in mastication use it in mastication, if thermal ex- or ordinary shutting of the mouth tremes be avoided. giving pain, irrespective of thermal changes. The tooth is not elongated, nor The tooth is raised in its socket, does it strike first in occlusion. and strikes before any of the others occlude. Treatment of Pericementitis. The first care should be to give the offending tooth rest, by preventing its occlusion. This may be done by placing gutta- percha caps over other teeth, to prevent the striking of this. The cause should be determined, and if possible removed. If it be infection from a dead pulp, the chamber should be carefully cleaned and sterilized, and an anodyne applied in the root channel, caution being exercised to avoid forcing septic matter through the foraminal openings. It may be advisable to seal up in it some of the essential oils, properly diluted, such as cassia or cloves, as an antiseptic. A counter-irritant should be applied over the apex of the affected tooth, for the same reason that it is used in pulpitis, and it is even more likely to be effectual. The same general remedies may be employed, such as saline cathartics, diaphoretics and nervous sedatives. Refrigerants are useful, and lumps of ice wrapped in muslin may be placed between the lip and the tooth. If these are not effectual, resolution may sometimes be in- duced by hot fomentation upon the face and neck. Prof. C. N. Johnson recommends that water as hot as can be borne be directed upon the part, with some force, for twenty or thirty minutes, to ALVEOLAR ABSCESS. , Iiy promote resolution. An acute pericementitis has also been readily aborted by the precisely opposite treatment of directing an ether or rhigolene spray upon the part until it has become bloodless. Both are useful, but are best adapted to different stages of the disease. If infection is present Prof. A. W. Harlan recommends the administration of one-tenth of a grain of calcium sulphide every ten minutes for an hour, the interval then to be grad- ually increased. If there is a great degree of pain, the following may be administered: 3 — Acetanilid., gr. viij; Syr. simp., 3ij; Spts. frumenti, 3ij. Sig. — One-half at 6 p.m., the remainder two hours later. The patient should be given a hot foot-bath, placed in bed and kept warm. If the inflammation is exceedingly acute, scari- fication of the gums about the affected tooth may be resorted to. If there is great tension of the tissue, a bharp-pointed scalpel or bistoury may be used to cut through the gum tissue over the apex of the tooth, a little cocain having been previously applied, or the point of the instrument dipped in pure carbolic acid and applied to the surface until it has become white, when it may be forced through the alveolar walls until the seat of inflammation is reached, thus removing the tension and giving immediate relief. CHAPTER XXVII. ALVEOLAR ABSCESS. An Abscess is the formation of pus somewhere within the body, as the result of some local or circumscribed inflammation. An Alveolar Abscess is an infective inflammation within the alveolar walls. It may be the result of some foreign substance acting as an irritant, or some injury may have been the exciting cause. Either of these agencies may result in an inflammation so violent as to induce a breaking down of tissue, and infection with sup- purative organisms will induce the formation of pus, which reaches the surface by the route presenting the least resistance. An alveolar abscess does not, therefore, necessarily presuppose the death of the pulp. If the inflammation does not materially affect n8 ORAL PATHOLOGY AND PRACTICE. that tissue, or if the pericementum involved does not include that from which the blood supply of the tooth is derived, an alveolar abscess may be established without pulp devitalization. The terms "abscess" and "ulcer" are frequently confounded. Even dentists of intelligence speak of an "ulcerated tooth," when practically such a thing is an absurdity. An abscess and an ulcer have little in common. The primary cause of the first is infection by some pyogenic organism, which necessarily has no part in in- ducing an ulcer. An abscess always forms in some cavity within the body : an ulcer always has its inception on an external cutaneous surface. An abscess is a circumscribed collection of pus : that is Fig. 30. Pericemental Abscess which in No Way Involves the Vitality of the Tooth Pulp. (E. C Kirk.) not at all true of an ulcer. The one makes progress from within outward : the other just the reverse. The one tends toward resolu- tion : the other is progressively degenerative. An abscess is always the result of a recent lesion : an ulcer is never connected with a fresh wound or infection, but has its inception in some old injury or morbid structural change. It would be difficult to instance a grosser misuse of technical terms than the calling of an alveolar abscess an "ulcerated tooth." Professor Kirk has demonstrated that a pericemental abscess may develop in the parenchyma of the membrane ; that is, it may be ALVEOLAR ABSCESS. II 9 neither supra- nor infra-, but intra-pericemental. (See Figs. 30 and 31.) It is indeed probable that such abscesses are more fre- quent than is usually supposed. Most practitioners of experience have at some time in their lives drilled into an abscessed tooth and found a living pulp, which would demonstrate that the lesion was not at the foraminal apex. By the study of these conditions Pro- Fig. 31. Transverse Section across Buccal Roots of Fig. 30, showing the Abscess-cavity to be between the pericemental walls. a, a. Hypercementosis. b. Thickened pericementum covering root. b x . Thickened peri- cementum forming external wall of abscess-cavity, c. Abscess-cavity occupying central por- tion of divided pericemental membrane, d. Section through fistulous outlet of abscess. (Kirk.) fessor Kirk believes he has found a common factor of infection to be the diplococcus of pneumonia, or the pneumococcus of Fried- lander, with occasionally staphylococcus pyogenes aureus as a con- comitant. 120 ORAL PATHOLOGY AND PRACTICE. But such a condition is not that which has usually been denomi- nated alveolar abscess. The common acceptation of the term is that affection which is the result of inflammation and death of the pulp, its infection, and the consequent inflammation and infection of the pericementum from contiguity of tissue. If we take up the subject of the last chapter at the point of its closure, and suppose the pulp of a tooth to be devitalized as the result of stasis of the blood currents, with the consequent stoppage of all nutrition through a distinctive inflammation, the next inquiry will be concerning the final disposition of the devitalized pulp. Fig. 32. Metastatic Abscess. Mass of staphylococci in the center, surrounded by an area of coagulation necrosis, the whole inclosed by a cordon of leucocytes. (Kirk.) If there is no source through which it can become infected with micro-organisms, it will probably become mummified and desiccated; the moisture will be absorbed from it, and it will assume the condition of dry gangrene, in which it will remain for an indefinite period without being the cause of any irritation what- ever. If, however, such a pulp chamber be opened without the strictest antiseptic precautions, perhaps years after the death of ALVEOLAR ABSCESS. 121 its contents, germs of infection may be carried in upon the non- sterilized instruments or admitted with a particle of saliva, and septic inflammation, with perhaps consequent alvoolar abscess, will be the result. The infection may arise from either one of two sources. If there is a cavity in the tooth that penetrates to the neighborhood of the pulp, the bacteria may there find entrance, and decomposing the pulp tissue by putrefaction they may cause the formation of offensive gases, which forcing their way through the foraminal openings will act as an irritant upon the pericementum, and induce an acute inflammation of that tissue. Fig. 33. Blind Abscess at the Root of an Upper Incisor. a, Abscess cavity in the bone, b, Drill hole exposing the pulp chamber for drainage. (Burchard, after Black.) If there is no special cavity of decay in the tooth containing the recently devitalized pulp through which infective organisms may find entrance, it may still become contaminated from some other center of infection that may exist in the body. The bacteria may be transported by the blood or through the lymph tracts, or may in some other manner be carried within the body to the dead tissue, and in this manner form a source of contagion. By what- ever method the pulp becomes inoculated with putrefactive or sup- purative organisms, whether from external sources or by auto- infection, the result will be the same, — the formation of suppurative products and the infection of the pericementum and other tissues in the neighborhood of the foraminal openings. Pus will thus be formed and an abscess established (see Fig. 33). Incipient Alveolar Abscess is the term applied to the condition 122 ORAL PATHOLOGY AND PRACTICE. that has existed up to this point. It simply implies the earlier stages of the destructive inflammation, before pus shall be actually present, during which period it may be possible to abort the abscess, or prevent the breaking down of tissue. A Blind Abscess is one in which there is a cavity of decay com- municating with the pulp chamber, and in which it is possible for the pus to be drained through the pulp canal. A Discharging Abscess is that condition in which the pus forces its way to the surface through the alveolar walls and establishes a fistulous opening. The formation of an alveolar abscess depends upon infection by septic organisms. These are always a source of irritation, and Fig. 34. Infected Exudate about the Apices of the Roots of a Molar Tooth in a Case of Subacute Pericementitis. The center of the mass consists of pus and broken-down tissue; the superficial portion is the desiccated exudate not yet decomposed. induce inflammatory conditions. The pericementum about the foraminal opening of the root of a tooth being thus affected, there will ensue under the stress of the inflammatory conditions the phenomena described in the chapter (VI.) on General Inflamma- tion. There will be changes in the bloodvessels of the vascular tissues that will finally result in diapedesis, or the pouring out of the plastic lymph. This will be infected by the organisms, and in- stead of being either removed by resolution or built up by regular progressive metamorphosis, it will be broken down. The leuco- cytes, or white blood corpuscles that have thronged to the irritated neighborhood, will lose their vitality through the irritation and infection, and assume the character of pus corpuscles; the invest- ing tissue will be broken down and decomposed, thus forming a ALVEOLAR ABSCESS. I2J cavity about the foraminal opening; the water of the tissue and the serum of the blood will mingle with these, and the whole mass will be that fluid that forms the contents of the abscess cavity. If, now, an opening be drilled to the pulp chamber this septic matter may be discharged through the pulp canal and a blind abscess will be the result. (See Fig. 33.) If there is no surgical interference the pus will make its own way to the surface by the line of least resistance, and there form a fistulous opening. There may be about the periphery of this pus cavity, when so formed through the breaking down of the tissue, a partial attempt on the part of nature to build the exudate into new tissue. It may possess a kind of consistence, and this partially organized, partially desiccated plastic lymph will form a line of demarkation that will inclose the disturbed territory. (See Fig. 34.) Upon its external surface it will exhibit the characteristics described, but its center will be a collection of pus and disorganized lymph. If the tooth is now extracted, this mass may be found clinging to the root, the size of an ordinary pea, and when so removed with a deciduous tooth it has been mistaken by the unintelligent for the germ of a permanent tooth. It is only the plastic exudate that filled the cavity produced by the breaking down of the tissue, whose surface is desiccated or dried, while its interior is completely broken down. The infected point may not be at the foraminal apex of the tooth, but may be at some point upon the side of the root, or between them at their point of divergence. The fact that the blood and nerve supply of the dental pulp are derived from the pericementum, and that channels analogous to the Haversian canals of bone may in comparatively young persons communicate with the pulp through the cementum and dentine at almost any point, naturally introduces another complica- tion in the proper treatment of so-called dead teeth. Not infre- quently is an exceedingly sensitive point found somewhere along its course when a broach is passed into the pulp canal of a devital- ized tooth, and it may be that the oozing of blood and serum from such a point, even after the foramen has been stopped, will give great annoyance. This may be the mouth of one of these communicating blood channels, and it is easy to comprehend that the pericementum at the point at which this is given off may readily become infected from a septic canal, and thus form a focus 124 ORAL PATHOLOGY AND PRACTICE. of inflammation and disorganization quite distinct from that about the usual foraminal opening. The latter may be thoroughly drained and completely sterilized without beneficial result, because it is reinfected from another opening in the pulp canal as fast as it is rendered aseptic. In teeth having more than one root these collateral vascular branches are sometimes given off from the peri- cementum at the bifurcation, and at these points may be established a focus of infection and inflammation which it is difficult thor- oughly to drain, and impossible entirely to disinfect and sterilize. Pus having once formed at any point about the periphery of a tooth, it becomes necessary for it to be evacuated, as it is essen- tially a foreign body possessing peculiarly irritating properties. Alveolar Abscess at. the Root of a Superior Incisor Discharging into the Anterior Nasal Fossa. a, Very large abscess cavity in the bone, b, Fistulous opening in the nasal cavity, c, Lip. d, Tooth. (Black.) It usually secures egress through the breaking down of the tissue that encompasses it. The pressure of the gases of putrefaction that are evolved, with that of the constantly increasing pus, causes resorption of the investing bone, while the inflammation and infection induce progressive decomposition, and thus an opening is made to the surface, the pus is evacuated and the acute symp- toms pass away. If no remedial measures are instituted, the sinus perhaps then closes up and the patient may fancy that a cure is established. But the pericementum at the infected point, and the tissues about it immediately involved, remain in a septic condition, and the ALVEOLAR ABSCESS. 125 efforts of nature to restore a true physiological condition are made futile by constant reinfection. An acute inflammatory stage again ensues, the plastic exudate is once more poured out, only to be reinfected, with a fresh breaking down into pus. The abscess ''gathers" again, but this time, as the old sinus will not have been completely obliterated, there will be less resistance, and the pus will with decreased difficulty reach the surface. This process may be periodically repeated until a complete and con- Fig. 36. Chronic Alveolar Abscess with Fistula Discharging under the Chin. The pus burrows through the soft tissue beneath the periosteum until it reaches the point of exit, a, Abscess cavity in the bone. b, b, b, Course of fistula, c, Lower lip. d, Inferior incisor. (Black.) tinually patulous sinus shall have been formed, when all acute symptoms disappear and a chronic abscess is established, through the disorganization of the nutritive currents and the continuous effusion and uninterrupted infection and breaking down that ensue. This condition may persist until a cavity of considerable extent has been formed in the alveolus, or even in the body of the bone. The course of the pus in reaching the surface in the usual 126 ORAL PATHOLOGY AND PRACTICE. forms of alveolar abscess is directly through, the thin alveolar walls. This is the shortest route, and the one that ordinarily presents the least resistance. But although the tendency of the pus is toward the nearest point of exit, the external plates of the bone are usually compact tissue, while the interior is cancellous. Because of this fact the burrowing may be through the less dense portions of the hone and away from the usual course. Fig. 37. Separation of the Periosteum from the Bone by the Burrowing of Pus from an Alveolar Abscess. a, Abscess, b, Pus pocket beneath periosteum. c,Lowerlip. d, An inferior tooth, e, Tongue. (Burchard, after Black.) The pus may find some cavity of the body and be discharged into the posterior or anterior nares, or into the maxillary sinus. In such instances the diagnosis may be extremely difficult. Many cases are on record in which treatment had for a long time without avail been directed toward complications which did not exist in reality until a more careful examination revealed a dead tooth as the source of all the trouble. (See Fig. 35.) Sometimes the pus will penetrate the alveolar walls, and, en- countering the fascia of a muscle, follow along its course until it ALVEOLAR ABSCESS. 1 27 reaches a point considerably distant before it finally finds the sur- face. A discharging abscess under the chin, the direct result of a devitalized inferior incisor tooth, has often puzzled the medical man, who never once thought that the dentist might give quick relief. (See Fig. 36.) Pus has been known to burrow along the fibers of the platysma myoides muscles until it has reached the clavi- cle, or, penetrating the cervical fascia, finally strike the omo-hyoid and follow its course until it emerged at the point of the scapula. In some instances of rather indolent abscess, the pus makes its way through the alveolar walls until it reaches the periosteum of the bone, which it detaches, and spreading out beneath it completely cuts oft 7 all periosteal nutrition. (See Fig. 37.) This is a condition which, if not relieved, may result in osseous necrosis. It may be Fig. 38. Alveolar Abscess. a, Primary abscess pocket. &, Secondary pocket caused by the infiltration of septic matter through the cancellous bone tissue. observed more frequently in the vault of the mouth, when the pus has penetrated the palatal process of the superior maxillary. The tough, fibrous character of the tissue immediately beneath the mucous membrane of the roof of the oral cavity presenting a great obstacle to the course of the pus, it not infrequently spreads over a considerable portion of one side of the vault. There are cases in which the pus burrows to some distance in the alveolus, establishing separate pockets which become distinct points of infection. (See Fig. 38.) In one such instance, from an infected point at the apex of a superior cuspid, which had a dis- charging sinus between that and the point of the lateral incisor, and 128 ORAL PATHOLOGY AND PRACTICE. which persistent treatment failed to cure, a secondary sinus was- finally traced back to a point between the first and second premolars, or bicuspids, where was a second focus of infection, and from this another led yet farther, back of the roots of the second bicuspid, where there was a third pus chamber. It was not until all these were explored and sterilized that anything approaching a cure could be obtained. These secondary pockets, or foci of infection, whether upon the periphery of the tooth as the result of a former collateral blood supply to the pulp, or existing as pockets within the alveolus in consequence of the burrowing of pus back into the bone, are especially perplexing to the practitioner, because he never knows when to expect them, and he has no early means of diagnosing the exact location of the seat of the trouble. After the proper dis- infecting and sterilizing process has been resorted to in vain, it may be suspected that there are somewhere foci of infection that have not yet been reached by the remedies used. The continuation of the discharge of septic or sanious matter indicates that disinfec- tion and antisepsis are not complete, and no entire cure may, under such conditions, be expected. CHAPTER XXVIII. SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. The objective as well as the subjective symptoms of Alveolar Abscess are sufficiently pronounced to prevent any mistake in diagnosis. That which is under special consideration, the result of the infection of the contents of a pulp chamber or canal, begins with a pericementitis that gradually increases in severity. The soreness is extreme; the tooth is materially lifted in its socket and becomes loose, with that peculiar feeling of non-support that indicates fluid at the extremity. This is the extravasated lymph and serum. Within a few hours there is the distinct febrile condi- tion, with its elevation of temperature, quickened pulse and suc- ceeding rigor — the septic fever that invariably indicates the forma- tion of pus and which is idiopathic. The red line or red blotches that are characteristic of pericemental inflammation, and which are peculiarly observable up to this point, now begin to fade away SYMPTOMATOLOGY AXD TREATMENT OF ALVEOLAR ABSCESS. 120, or to be succeeded by a deep red that is continuous with that of the neighboring tissues, and there is, in very acute cases, a tumor or distention of the alveolar walls. The pain, which is deep-seated, continuous, and of a boring character, is now intense, but there is little swelling of the soft tissues. The pus is burrowing its way toward the surface of the bone, and the pressure exerted by the confined matter is the source of the suffering. This continues until the alveolar walls have been pene- trated, and the pus escapes into the soft tissues. Great swelling now ensues, with subsidence of the pain, consequent on the escape of the confined fluid into the tissues that can yield to the pressure. Sometimes the infiltration of the tissues and diffused cellulitis are so great as to close the eye and greatly distort the face. But, although the appearance at this stage is much more serious and alarming that at previous ones, the pain and soreness are very much less, and the tension is relieved. Finally, there is "pointing," fluctuation may be distinctly detected beneath the finger, and the abscess is ready for the lancet. The general indications of a septic condition, the infection by pyogenic organisms, and the formation of pus, will be as follows: 1. Anorexia, or loss of appetite and general tone. 2. Chills or rigors, which are more or less pronounced. 3. Headaches, sharp, persistent, and blinding. 4.. Fever of a distinct type, — the septic fever. 5. Tongue coated and covered with dark-colored fur. 6. Constipation, persistent, but without special pain. 7. Urine scanty, of high color and specific gravity. 8. Nervous disturbance, which constantly increases. The latter symptom may be more or less apparent, depending upon the gravity and severity of the attack. In slight cases, like ordinary alveolar abscess, it may amount to nothing more than uneasy restlessness, while in general septic conditions there may be violent delirium. The appearance of these symptoms marks what is called "septic-" or "auto-intoxication," or period of functional excitement produced by the absorption of septic or poisonous matter. If there are wounds of any kind through which infection takes place their edges will become red, swollen, tense, and angry in appearance. 130 ORAL PATHOLOGY AND PRACTICE. In addition to these general indications there will be local manifestations, which may assist in making a diagnosis. If the pus* pocket is superficial there will be "fluctuation," or that feeling beneath the finger of softening, yielding, and undula- tion that is the sure sign of the presence of a fluid. The abscess will begin to "point," — to determine toward a single spot and to show an angry, red, or softened elevation above the general surface. If the pus is deep-seated and "pointing" is not indicated, or is toward some cavity within the body, the superincumbent tissue will appear glistening, and will lose its elasticity. If indented with the finger it will blanch, and the color will not at once return to it upon removal of the pressure, while the indented pit will persist for a little time because of the loss of resilience or springiness. Treatment. Abortive measures should be instituted in the early stages of the pericemental inflammation. At this time counter-irritants, hot foot-baths, with laxatives and diaphoretic remedies, will be found useful. If a dead pulp is present, the pulp chamber should be opened under the strictest antiseptic precautions. The rubber-dam should be placed upon the tooth, to segre- gate it from the septic fluids of the mouth. The drill should be carefully sterilized, either by heat or by being allowed to remain a little time in some germicidal fluid. Debris should be removed from the cavity of decay, if such cavity exists, and it should be effectually sterilized with a bichloride or some other energetic solution. As soon as the walls of the pulp chamber are punctured, the drill should be withdrawn and a sterilizing solution injected or carried in upon a pledget of cotton. The opening may now be enlarged, and the antiseptic or germicide carried to every possible point of the pulp cavity and canal. With a sterilized broach, all debris and remains of the decomposed pulp should be removed, and the canals made as clear of obstruction as possible. A few fibers of cotton dipped in some antiseptic, such as one of the essential oils, may be carried as near the apex of the root as possible, and sealed up in the cavity. If there is much pain, some anodyne, like tincture of opium, may be introduced into the canal on a very few fibers of cotton. This treatment, both local and general, should be continued SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. I3I until the inflammation with its soreness and pain shall have passed away, when operative measures for the preservation of the tooth and its protection from further attacks may be instituted. If from any cause the treatment shall prove ineffectual, the inflammation gradually becoming worse until the symptoms give indication that resolution cannot be expected, that degeneration has already commenced and septic infection has taken place, the treatment should be promptly changed, and suppuration encouraged. The general abortive measures must be abandoned, and the pus directed toward the surface. Warm fomentations may be used, a cloth wrung out in hot water being applied to the face over the seat of trouble, and carefully covered, while the patient is kept warm. Indications of "pointing" must be carefully noted, and any tendency toward the exterior of the face should be re- pressed by painting it over with an iodine solution, the application of cold, and other like measures. A poultice consisting of the fresh surface of a split fig, or raisin, that has been warmed and softened in hot water and sprinkled with capsicum or red pepper, should be placed over the alveolar wall opposite the root of the tooth, or within the oral cavity where it is desired that the abscess shall point, and suppuration invited by that channel. This process should be hastened by every available means, that the formation of secondary pockets, with osteitis, or inflammation of the bone corpuscles, may be avoided. If the indications are that the pus is burrowing in the wrong direction, thus threatening a prolongation of the condition, with the probable infiltration of the bone by septic products, the practitioner should lose no time in reaching the disturbed place with an instrument, and thus establishing a sinus at the proper point. The pus evacuated, the next step should be the disinfection of the whole territory. The pulp chamber should be opened and cleaned out, and the principal foraminal opening made patulous. About the extremity of the point of a suitable metal syringe, a rope made of a sufficient quantity of cotton fibers dipped in a chloro- percha solution may be wound, the point introduced into the cavity of decay, or that artificially made into the pulp chamber, and the cotton then closely packed around it. The barrel of the syringe filled with tepid water may now be attached and considerable force used until the stream entering at the pulp chamber emerges at the I32 ORAL PATHOLOGY AND PRACTICE. fistulous opening. The barrel of the syringe is now removed and filled with a solution of three per cent, pyrozone, or with electro- zone, and this is injected as a disinfectant. This is succeeded by a solution of bichlorid of mercury or some other effective germi- cide, and the cavity may be sealed up for a day or two. It may be advisable to wait for a little time after an abscess shall have broken or been opened before this cleansing and steriliza- tion is attempted, that the pus may be well evacuated and the acute symptoms have had time to subside. It is well to establish the sinus and wash out the tract primarily, because if a coagulant is employed before the pus is removed there may be such a clot formed as will effectually stop the channel. If at the end of sufficient time the indications warrant the belief that sterilization is complete, and that there are no secondary pockets of infection, the root may be permanently filled. If, how- ever, the septic condition continues in the least degree, or if there are signs of osteitis, the cavity should be opened and the sterilizing process repeated, or an antiseptic anodyne introduced still further to test the case. If the fistula is an old one and the abscess not of recent forma- tion, and especially if there are no acute symptoms, thus indicating a chronic condition, something more active should be introduced as an antiseptic. After the cleansing out of the pulp chamber and the root canal, the rubber-dam should be applied and a broach wound with cotton fibers dipped in a saturated solution of carbolic acid introduced, and the caustic antiseptic pumped through the tooth and along the sinus until it appears at the fistulous opening, where it may readily be detected by its turning the tissues white. This cauterizes the whole tract, inducing sloughing to a limited extent, and brings on acute symptoms, with effusion of plastic lymph, which in the thoroughly sterilized territory may be built into tissue by regular progressive metamorphosis. A solution of chloride of zinc, five grains to the ounce, may be forced through with a syringe in these chronic cases, and this may bring about an acute condition and stimulate the indolent functional activity. Some operators proceed at once to fill after a single treat- ment such as has been indicated, but unless there are special rea- sons for haste it is better and safer to' wait until it has been thoroughly demonstrated that there are no secondary pockets or SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. 1 33 foci of infection, and until the reparative process and the up- building of the waste territory has fairly commenced. This may usually be determined by the dryness of the root canal. To test this a fine broach should be thrust to the apex of the root, or as far as possible, quickly withdrawn and wiped upon a piece of rubber-dam. Any moisture will show at once, and will indicate that there is still a septic condition. There are instances in which it is impossible to force fluids through the foraminal opening or openings. This will more fre- quently be the case with the molar teeth, in which perhaps the infected point will be at the opening of one of the buccal roots, but it may occur with even the anterior teeth. Some operators insist that they are able to open the apices of such roots with a drill, but when it is recollected that seldom or never is the foraminal opening in a direct line with the canal, it will be found that none except men of the most phenomenal skill will be equal to this task. The average operator will hesitate before proceeding to such heroic measures. If it is impossible to pass a flexible broach through the foraminal opening, or to establish communication between the out- side and the inside of the apex of the tooth, after the cleansing of the canal and the use of the general remedies recommended, the antiseptic may be introduced on a few fibers of cotton as near the apex as possible, and then sealed up within the tooth. The agent used should be one that is of as penetrating a nature as possible, and the experiments of Miller show that in this respect none possess any special advantage over pure carbolic acid. The pulp chamber and canal should be completely flooded with the remedy, and it should be changed as often as necessary, sometimes every hour, until the pulp canal is thoroughly and completely sterilized. Then by slow infiltration and absorption it will be carried beyond the apex of the tooth and sterilize the investing tissues. It may be necessary to continue such treatment for some time, especially when the inflammation is of an indolent, subacute character. But when the process is complete the sinus that may have existed will dis- appear, and all inflammatory signs will depart. Treatment from the outside is the only resource in those in- stances in which none of the usual curative measures are effectual. Sometimes it is impossible to get through the foraminal opening, 134 ORAL PATHOLOGY AND PRACTICE. or perhaps the dentist has been too precipitate in filling the root and tooth with a material that it is difficult to remove. In such a case the seat of disturbance must be reached by establishing a sinus, or through that already in existence. With a properly shaped spring-tempered probe it is usually possible to follow the course of a discharging canal to> the apex of the root. A few fibers of cotton wet with a solution of carbolic acid should first be intro- duced as an obtundent and cauterant, and allowed to remain for a short time. The probe is then introduced and the sinus carefully explored to its extremity. It will usually be found that the open- ing through the external alveolar wall is considerably above the fistulous opening, and its course may not be a direct one. But a little patience, with the knowledge obtained by some experience, will enable one to reach the apex of the root with comparative readiness, provided the lesion is not upon the palatal root of a superior molar. Having clearly outlined it, the opening may now be enlarged with a trephine or drill, if it is necessary, and the proper remedies carried to the diseased point. Deposits may be removed from the root, or its apical point amputated if necessary. All debris having been removed, and the parts carefully sterilized, granulation from the bottom will probably close up the opening. If it does not, the operator may be assured that there is dead or foreign matter in the cavity, or that it has not been effectually sterilized. In filling a sterilized devitalized root, it is not at all essential that the filling material shall be pushed farther than the junction of the dentine and cementum, at the point where the division of the canal into the foraminal delta begins. The broach will readily indicate this point, because it is sensitive beneath it. It is only the dentine that is devitalized, the cementum which forms the real apex of the root retaining its vitality. The delta or divided canal exists within the living cementum, and hence does not need to be filled. Dentists sometimes find this point exceedingly sensitive, and imagine that the pulp is not yet wholly devitalized. They per- haps introduce a second application of arsenical paste, and so do considerable injury. They should remember that the cementum at the apex is probably in an irritable condition, and needs an anodyne rather than another dose of a corrosive poison, the effect of which upon the already inflamed living corpuscles may be to induce death of the cemental apex and necrosis of the investing tissues. DEPOSITS UPON THE TEETH. 1 35 There are instances in which the inflammation stops short of the formation of pus and results in an indurated mass, sometimes of considerable size. The plastic exudate has been poured out, and has infiltrated the tissues and caused a distinct swelling. But the degenerative process has not begun, either because there is no septic infection or because sterilization has destroyed the organism. The inflammation is of a low, subacute character, and there is no pain or violence. The plastic exudate loses its usual consistence, either through the extraction of its watery part or because of some fibrous organization or other change, and becomes indurated. The swelling is perhaps within the bone, and there is a distinct protrusion of the external wall. This condition may remain for an indefinite time, and it sometimes causes considerable deformity of the jaws. If this is the result of a pericemental inflammation at the apex of a devitalized tooth, resolution or reabsorption may usually be brought about by the injection through the tooth of tincture of iodine. If the foraminal apex is not open, cotton saturated with tincture of iodine may be sealed up in the tooth cavity, and changed as necessity requires, until the process is completed. If the offending tooth is extracted, there will usually be immediate resolution, but this is not always advisable, and the iodine treat- ment may be resorted to for the slow relief of the indurated con- dition. CHAPTER XXIX. DEPOSITS UPON THE TEETH. Under this head will be considered such superficial precipi- tates of inorganic matter as may induce possible pathological changes. They must be derived either from external sources or from some of the fluids of the mouth or the body. There are many forms of oral debris, the sediments of organic matter, deposits of food, etc., that will not properly come within this cate- gory. The "white deposit," that cheesy deposition that is so often found encircling the cervical portion of the tooth and forming a 136 ORAL PATHOLOGY AND PRACTICE. narrow white line just at the gum margin, belongs to the latter class. Jt is composed of the debris of food that is partially fermented, micro-organisms, etc., and when it has been allowed to remain for any length of time the tissue immediately beneath it will be found partially decalcified and softened. But the deposit it- self is not of a calcareous nature, and is easily removed by the brush. The so-called "green stain" of childhood is wholly superficial and has no special pathological signification, except so far as it may- he a symptom of some unhealthy condition of the fluids of the mouth. It is called "green" stain, although it may be dark, or bronze, or yellow in color. It has by some been considered a disease-pro- ducing kind of fungus, which penetrates the substance of the enamel, disintegrating it, and thus injuring the tooth. But if one Fig. 39. Green Stain on the Approximal Surfaces of Incisors. (W. D. Miller.) will immerse a tooth discolored by it in a ten per cent, solution of lactic acid he will in a few moments see the so-called Nasmyth's membrane separate from the tissue, and it will carry with it all the deposit, leaving the exterior white and uneroded. Sometimes it is found upon the surface of eroded or even decayed enamel, but it can be removed in such a manner as clearly to indicate that it was deposited subsequent to the erosion or caries. (See Fig. 39.) Salivary calculus is a deposit from the saliva. If one will through a tube breathe into a glass of lime-water, he will soon observe that the fluid becomes milky in appearance. If he will continue the process for a while, and then set the glass where it will be entirely undisturbed, he will after a time find deposited upon the bottom more or less of a fine amorphous powder. This DEPOSITS UPON THE TEETH. 1 37 is the calcium that was held in solution in the water, and which was thrown down as carbonate of lime. A few drops of hydro- chloric acid will clear up the fluid by again dissolving the pre- cipitate. It is not asserted that this is the method in which salivary calculi are formed, but it illustrates the precipitation of calcific matter. The calcium salts are really held in solution in the saliva by means of the carbon dioxide which it contains. When the fluid enters the oral cavity it at once encounters acids which may be present, and is subjected to fermentative and other active and chemical influences, which result in the precipitation of the calcium salts, and these, with some extraneous matter, form the calculi. Naturally, this deposition will be greatest near the mouths of the salivary ducts, and so> the principal calculi are upon the inferior Fig. 40. B a a. Salivary Calculus Causing Recession of Gum and Absorption of Alveolus. b. Molar with Deposits of Sanguinary Calculus at b. At a Necrotic Perice- mentum and Broken Down Exudate. incisors, opposite the mouths of Wharton's duct, and upon the superior molars in the neighborhood of the discharging mouth of the duct of Steno. (See Fig. 40, a.) Sometimes this material is precipitated in great quantities, binding several teeth together in one mass. In some instances the utmost care of the patient will not enable him to keep the teeth entirely free from it. When this is the case it is usually soft, of a creamy yellow color, and is easily removed. When it is deposited more slowly it has time for consolidation and becomes hard, and is usually stained a dark color by pigmentary matter from the oral cavitv. I38 ORAL PATHOLOGY AND PRACTICE. It has no special pathological signification aside from the fact that it is a mechanical irritant, and keeps the teeth and mouth in a filthy condition by constantly acting as an absorbent, and as an obstruction against or under which food debris lodges. It should be carefully removed with instruments, the teeth polished, and, if necessary, the irritated gums touched with a stimulating astrin- gent. The so-called sanguinary or serumal calculus is distinguished by separate characteristics, and is due to other or modified conditions. It is not found external to the margins of the gums, nor does it always appear to be a precipitate from the oral fluids, — for no refer- ence is here intended to the hard, black, smooth, supragingival, slow deposit which is but a modification of the usual form of calculus and is undoubtedly of salivary origin. The so-called serumal deposits are upon the periphery of a root that is not denuded when they are formed. They may be found when there is absolutely no break at the gingival border, and when consequently their precipitation from the oral fluids would seem to be an utter impossibility. Instances of this are cited in the chapter on Pyorrhea. (See Fig. 40, b.) It is not deposited in a smooth, continuous, amorphous mass, as in the case of salivary calculus. It is found in dense, hard, closely attached, separate nodules, which may by further deposition become confluent. It cannot be scaled off cleanly and readily, as can the oral variety. It clings so closely as to make it necessary to chisel it away, in which process, unless great care is used, a scale of the tooth may be taken or a thin layer of the deposit left. It has riot the same color as the salivary concretion, the latter, except when it has been discolored by subsequent pigmentary deposits or infiltrates, being of a dark yellow or yellowish white color. The so-called serumal or sanguinary deposit is of an olive-black tint, with some- times an olive-green tinge. It is not identical, either in color or in manner of deposition, with salivary concretions. It is more distinctly irritating to the tissue than is the salivary deposit. Perhaps the location of it within the tooth socket may serve to account for the difference, but aside from that there appears to be a rather distinctive irritation in its presence, not known in connection with the salivary deposit. Chemical analysis shows that there is a synthetic difference DEPOSITS UPON THE TEETH. 1 39 between the two, for, while calcium forms the base of both, the serumal contains certain elements not found in the other. The analyses of it have not been sufficient in number or so exhaustive in character as to reveal all that may probably be learned from them. Perhaps the most reasonable and consistent theory of the formation of this calculus is that of Professor E. C. Kirk, and it may be thus summarized: The capacity of the blood stream for holding in solution the waste products of nitrogenous metabolism, the results of functional activity in the body, is determined by the alkalinity of the blood plasma. Any decrease in this diminishes its solvent power for these, and causes their precipitation in the tissues nourished by the blood stream. This lessened alkalinity may be general, affecting the whole sanguinary current, or it may be localized in certain tissues ; in the latter case there will be a localized precipitation of the products of which uric acid is a type. Excessive work causes an increased blood supply to a part, and excessive oxidation and tissue waste, which in turn produce les- sened alkalinity, or a tendency toward acidity. The ligamentous tissues are especially liable to conditions of this nature, and- the peridental membrane, belonging to this category, is especially sub- ject to affections of the character noted. Excessive work being put upon the investing membrane of any tooth, through mal- occlusion or by bad habits in mastication, by injuries from wedging, the application of ligatures, or other causes, the resulting hyperemia brings in its train overnutrition, localized diminished alkalinity, with the consequent deposition of urates. Professor Kirk believes that changes identical with or analogous to those cited above are responsible for other local necro- biotic degenerations. They may be the exciting cause of alveolar abscess, through a diminishing of local physiological activity and lessening of the resistant power of the tissue, which, being in- fected, leads to suppuration of the pericementum, that has been variously denominated pyorrhea alveolaris, phagedenic perice- mentitis, or suppurative alveolitis. Under certain other definite conditions the pathological changes may result in a hyperplasia of the tissues, and hypercementosis and hypertrophies of the peri- cemental membrane may be the result. It is, then, accepted that this calculus is and must be derived 440 ORAL PATHOLOGY AND PRACTICE. from the blood, through the pericementum. Certain it would seem to be that the trouble is not in the tooth itself, for the cementum does not appear to be affected in any way, further than secondarily through the mere mechanical separation from it of the perice- mentum. One reason for supposing that it is not due to a con- stitutional dyscrasia, that it is not a manifestation of a general disorder, but rather a symptom of a local degeneration or disturb- ance, is found in the fact that it is usually confined to one or two teeth. The early presence of sanguinary calculus is not easily deter- mined. Salivary calculus exhibits itself unmistakably to the eye, and so there can be no error in its diagnosis; but such is not the case with the sanguinary concretion. It is hidden within the tooth socket at a point where examination is impossible. No special prophylactic measures can therefore be employed. There may be a localized inflammation, with pustular swelling, but this comes too late for preventive measures. When a pocket reaching down to the deposit has been formed from the gingival margin, there is nothing left but its instrumental removal. There are instances in which pericemental irritation and sore- ness may, to the expert, give some warning of nodular formations. But these are too easily confounded with those which may be caused by hypercementosis, or by the presence of any other foreign substance, to afford a positive pathognomonic sign. When we comprehend the morbid changes of the disease better perhaps we will recognize premonitory indications, but, as it is, we must wait for its development. The usual revelation will come through the formation of the characteristic pockets beside the affected tooth, and the point of irritation, when near the apex of the root, may in some instances be detected by the localized inflammation and swelling. The local treatment for the condition is laid down in the chapter on Pyorrhea Alveolaris. PYORRHEA ALVEOLARIS. I4B CHAPTER XXX. PYORRHEA ALVEOLARIS. Pyorrhea Alveolaris has been denned by Kirk as a necrotic, suppurative, inflammatory process which destroys the pericemen- tum, and by setting up an osteomyelitis in the alveolar margins sub- sequently destroys them also. He believes it to be caused by the invasion of certain pathogenic organisms which are the exciters of the inflammatory process. The depth of the bacterial invasion determines the seat or location of the inflammation, and is condi- tioned upon the degree of vital resistance of the tissues invaded. Given low vitality in the pericemental membrane, the invasion is deeper, and the pyorrhea is established by the breaking down of tissue and the establishment of a pocket through the working out of the products of the inflammatory action at the gum margin. Given high vital resistance in the pericemental membrane, the dis- order produced by these inciters of inflammation becomes superfi- cial ; that is, ulcerative in type. The depression of vital resistance may be either constitutional or local. If the former, it is brought about by a chronic toxemia, the result of auto-intoxication caused by malnutrition and the im- perfect elimination of the waste products of tissue consumption and repair. These toxic substances in the blood stream are irritant in character, and manifest their action in the pericemental membrane by the production of hypercementosis and by other changes. When the predisposing factor is purely local, as in the case of salivary calculus impinging on the gingival margin, the depression of vitality is entirely superficial, affecting only the layer of cells in contact with the calculary deposit. The invasion of pathogenic germs is also superficial, the high vitality of the healthy tissue beneath preventing deep invasion, and the type of the necrotic and inflammatory process is ulcerative. It is not a matter for boastfulness that for so long a time so little should have been positively known concerning a disease that, after caries, is responsible for the loss of more teeth than any other. It is but recently that any attention whatever has been paid to it. For many centuries it has been doing its destructive work without I42 ORAL PATHOLOGY AND PRACTICE. remark and without any attempt to determine its pathology. Not alone in man is it prevalent, but many animals suffer from its ravages. Domestic cats are especially liable to its attacks, while dogs are far from exempt. Horses sometimes suffer extremely from pyorrheal affections, but their teeth are not as often extruded and lost, because of the length and shape of the roots, which do not end in a closed foraminal opening. None of the teeth of per- sistent growth in the various orders of animals are materially affected by these discrders, so far as the author is aware. But he has in his possession the skull of an African gorilla, an animal that it has been found almost impossible to keep in captivity, in which the characteristic appearance of this disease exists unmistakably. The condition has been known by various names. The late Dr. J. M. Riggs, of Hartford, Conn., was probably the first to call public attention to it, about the year 1850. For some time it was called from him "Riggs's Disease," but the impropriety of this being manifest, the term Pyorrhea Alveolaris was proposed, and has been generally accepted. Prof. G. V. Black has denominated it "Phagedenic Pericementitis." Dr. J. N. Farrar has proposed the name "Loculosis Alveolaris," from the fact that, very often at least, it has its origin in a kind of pocket beside the alveolus. Others, recognizing a communicable nature, have denominated it "Infectious Alveolitis." When its true nature and exact pathology are more fully ascertained, a term that is descriptive of it will un- doubtedly be universally accepted. In the meantime Pyorrhea Alveolaris, which signifies a discharge of pus from the alveoli, although somewhat indefinite, is as applicable as any. It has been intimated that the exact nature of the disorder has not yet been decisively determined. At least no exposition of it has been commonly accepted. Many theories have been offered, and some of exceeding plausibility are now before the dental pro- fession ; but, so far, none has received that general acceptance which excludes all other hypotheses. That its seat is within the alveolar socket is easily demonstrated, and that either the tooth root or its investing membrane is an essential factor in its existence is quite plain, for extraction always affords a radical cure. Beyond this there is no admitted certainty concerning its' etiology. Professor Black believes the initial point to be in the pericementum. Others have held that it commences with a degenerative condition of the PYORRHEA ALVEOLARIS. I43 investing margin of the alveolar process. Prof. W. D. Miller says that there are three active factors in its production: constitu- tional diathesis, local causes, and micro-organisms. Perhaps the hypothesis that has attracted the most attention tip to this point is that which has been so strenuously urged by Prof. C. N. Peirce and others, that it is but an expression of the uric acid diathesis, and is closely allied to gout, rheumatism, and allied disorders. It has been asserted, indeed, that it is always con- nected with them, either as a forerunner, a successor, or a substi- tute. It has been argued that as urea is the effete product of the using up of tissue in functional activity, which the excretory organs should eliminate, its presence in the body is an indication of inactivity on their part. It is undoubtedly true that such effete matter must, from its very nature, by its continued presence excite a more profound influence than would any innoxious foreign sub- stance. We all know the extreme violence and general character of the protests of all the tissues of the body against its presence when manifested in uremic poisoning. The dense, hard, dark-colored nodules sometimes found upon the roots of teeth, and which are considered in Chapter XXIX., dealing with salivary and sanguinary calculi, it has been claimed are induced by and contain the urates of the blood, and are prime factors in inducing the pyorrheal condition. Could these asser- tions be substantiated as indisputable facts in all cases, they would be conclusive. But it is urged in answer that it is not positively demonstrated that the concretions referred to have their origin in the blood, that they are necessarily an expression of the uric acid diathesis, that they invariably contain any uremic salts, are at all essential to the pyorrheal condition, or are in any considerable proportion of instances the cause of it. They point to the fact that while they may be frequent or even usual concomitants, pyorrhea exists in its worst form without the presence of any such deposits, and quite unconnected with either gout or rheumatism. In the midst of this conflicting mass of evidence the only sure conclusion at which it is possible to arrive is that the subject has not yet been sufficiently considered, and that we have not verified ultimate facts. There is abundant cause for investigation and observation, and every real student should strive to add something to the knowl- edge of the subject, until enough has been learned to form a basis 144 ORAL PATHOLOGY AND PRACTICE. on which to build an hypothesis that shall be unassailable. Some patient investigator will yet solve the problem, as Miller gave us the solution of that of dental caries, which was for so long a time in the same unsatisfactory, unsettled, disputed condition. In the meantime it only remains practicable to present as clear an expo- sition as the present state of knowledge will permit. CHAPTER XXXI. PYORRHEA ALVEOLARIS (Continued). True Pyorrhea Alveolaris should be a manifestation of some distinct, perhaps specific, pathological condition. The term itself, while expressive of our present knowledge, is too broad, covering altogether too much, for there are many exudations of pus from the alveolar walls that are easily explainable, and of very simple origin. But until its exact nature is distinctly marked out, and all its phenomena comprehended, we must recognize at least three separate pathological degenerations that are covered by the term, and which without doubt are often confounded with each other. The first of these will be entirely local in its character. It will have its origin in an easily comprehensible cause — local irrita- tion. The second will have its etiology in deposits of a hard, nodular character upon the roots of the teeth. It will be distinguished by the formation of distinct pockets within the alveolus. The third will give evidence of some distinct cachectic condi- tion or dyscrasia. It will present phenomena that are peculiar to itself, and will be without either of the two previously named factors. The first condition is a localized gingivitis, with possible alveo- lar caries, or a slow solution of the alveolar edges. It is charac- terized by inflamed, turgid gums, which are everted at the cervix. There will probably be a degenerate mucous secretion of a viscid character and acid in reaction. The gum is not adherent to the teeth, and the point of an instrument can be passed between them. Instead of the hard, dense appearance that the gingivae usually pre- sent, they bleed at the slightest touch. A little pus can be forced out PYORRHEA ALVEOLARIS. 145 from between the gum and tooth, but it is small in quantity and thick in consistence. The patient gives the teeth but little care, and they usually present anything but a healthy appearance. The redness is principally confined to the gum margin, and there are few or none of the peculiar red blotches higher up that are indica- tive of pericemental inflammation. An explorer cannot be passed up far beneath the gum, and, with the exception of roughened edges, the alveolar process is perfect. The prognosis of this condition is always good. The first care should be thoroughly to clean the teeth, and to remove from about their necks, especially from beneath the gums, any foreign sub- stances that may have accumulated. Not infrequently delicate Fig. 41. Gingival Destruction of the Pericementum with Resorption of the Alveolar Borders, due to Pyorrhea of the Third Variety. There are no deposits and little if any suppuration. The destructive process has entirely- denuded one root, and the alveolar walls inclosing the others are very thin. (Burchard.) rings of salivary calculus will encircle them close up to the alveolar border. All traces of this must be removed, and the necks of the teeth be carefully polished. Sometimes foreign substances, like slivers from wooden toothpicks, or spiculae of bone from the food, will be found driven beneath the gums, and these will be the source of irritation. After careful cleaning the gums should be well rubbed, and a soft tooth-brush, with some antiseptic wash, should be prescribed. Listerine is good for this purpose, or any of the pleasant essential oils, largely diluted. Care and cleanliness, with the removal of every foreign substance, will be sufficient to produce a cure, for the condition was only the result of a lack of attention, and the irritating presence of foreign substances. The second condition is one of greater moment. It is charac- I46 ORAL PATHOLOGY AND PRACTICE. terized by the presence of deep pockets in the alveolus, at one side of the anterior teeth, or perhaps between the roots of the premolars or molars. There may be. little of the turgidity or tumefaction described in the previous paragraph, but an exploration with an instrument will detect a resorption of the alveolar walls of the tooth socket, and pus may be forced out. Often the tooth, especially if it is one of the six anterior ones, will commence an inclination away from its neighbor. It loses its upright position, perhaps falls out of the line of the arch, and the previous regularity of a well- ordered dentition becomes sadly broken. The affected tooth is always deflected from the side on which is the pocket, and not toward it. A more careful exploration of this pocket will usually detect, well up toward the apex, or along the body of the root, dense, hard, gritty nodules, that are closely attached to the side of the root, enveloping more or less of the surface that has been denuded of its pericemental membrane, but which is yet covered by the gum. These are the sanguinary deposits described in a previ- ous chapter. Whether these are the cause or the result of the diseased con- dition has formed a fruitful subject of discussion among etiologists. Those who believe them to be deposits from the fluids of the mouth insist that there must be some connecting opening between^them and the oral cavity, along the side of the tooth. But competent observers have described instances in which there absolutely was none. One such case fell within the observation of the author. His associate in practice found opposite the lower third of the root of a lower central incisor, in the mouth of a woman who took excel- lent care of her teeth, a peculiar swelling that had somewhat the appearance of incipient alveolar abscess, but which had none of the other symptoms that attend that disorder. The author counseled pursuance of the expectant plan, and waiting for developments. In a very few days pus gathered in a comparatively small amount, and was discharged. The opening was enlarged, and opposite it were the characteristic nodules of the so-called sanguinary or serumal calculus. Yet the gingivae were absolutely unbroken, and there was not the slightest indication of irritation about the neck of the tooth. The nodules were carefully removed, the open- ing antiseptically dressed, when it healed, leaving no sign whatever of the lesion, nor has any since appeared. If the hypothesis pre- PYORRHEA ALVEOLARIS. I47 sented on a previous page is accepted, the presence of these nodules is accounted for. But there were in this patient no indications of either local or general anemia or lack of tone, while the tooth was one of a nearly perfect set, a lower incisor, not subjected to unusual strain or labor. Upon removal of the calculus it returned to a normal condition, and has so remained for some years. It must be accepted that, in some instances at least, the serumal nodules are the first indications of the disturbance. Whether these are the result of any special diathesis we need not now further inquire. We know that they are specially irritative in their nature. If they form the initial point of the disorder, the subsequent patho- logical changes may be easily comprehended. They lift the peri- cementum from the tooth, and by their presence originate the breaking down of tissue. Infection follows, and the pus forces its way to the gingival margin, thus making an opening into the pocket already formed. Or perhaps the pocket is completed by the continuation of the deposits to the gum margin, the infection being subsequent to this. Perhaps, in a proportion of the cases, the deposition of the calculus commences at the neck of the tooth and proceeds toward the apex, forming the pocket from the margin instead of from the interior of the alveolar socket. In any case, there must be organic or functional degeneration of the perice- mental membrane as the immediate or proximate cause of the dis- turbance, and the attention of the practitioner should be directed toward such local or constitutional remedies as will prove effectual. The prognosis of this condition depends upon the ability com- pletely to remove the deposits, and upon the general tone of the system, or its ability to bring about a restoration of the lost tissue, and a healthy tone in that which remains. The first remedial meas- ure is thoroughly to cleanse the teeth and pockets. This must be the work of time and patience. If the disease has extended so far as to induce much soreness and looseness of the tooth, it cannot be accomplished without considerable pain. So dense and closely attached 'is the deposit in many cases that a sharp, stiff chisel, with considerable force, is demanded. The drawing motion of a scraper is insufficient. Only the thin edge of a chisel will reach the last particle, which may lie just at the point of separation uf the perice- mentum from the tooth. There is no chemical agent that can be depended upon to dis- I48 ORAL PATHOLOGY AND PRACTICE. solve the deposits away without injury to the surrounding bone and tooth. The usual mineral acids attack the latter quite as readily as the concretion. Trichloracetic acid has been found of benefit in softening it, so that it may more readily be removed with instru- ments. This may be used in from twenty to fifty per cent, aqueous solution, the exact strength to be determined by trial. It should be carried to the extremities of the pocket on a narrow, wedge- shaped piece of orange wood that has been dipped in the solution, and by a pumping motion continued for a sufficient length of time every nodule may be saturated with it. Or it may be carried upon a rope consisting of a few fibers of cotton wet with the acid. Dr. W. J. Younger, who has made a specialty of the treatment of pyorrhea, uses and recommends lactic acid for the same purpose, and claims that it has special therapeutic value in this disease. It may be necessary to repeat the operation more than once, carefully chiseling or scraping off all that is practicable each time, until the root is clean and polished. The pockets should be washed out and treated antiseptically. Finally, when all the deposits are removed, a weak solution of chloride of zinc may be injected as a stimulating astringent. It may be necessary to freshen the alveolar edges with a hoe excavator, or a safe bur, to induce new granulations. When there has been an effusion of coagulable lymph it should be protected, and not carelessly wiped or washed away. To this end it is necessary to know when to stop active surgical or operative measures, and to leave the rest to the vis medicatrix nature?. Pursuing this course, the author has had the great satisfaction of seeing pockets that reached almost or quite to the apex of the root, and into which a considerable quantity of cotton could be packed, completely healed and filled with a new growth of bone through the action of a newly-formed perice- mentum. The prognosis of the third condition is almost invariably bad. It seems to be connected with some vicious constitutional condi- tion that prevents eradication of the disease. There is frequently very little if any gingival inflammation. There is no- thickening or tumefaction, and but little redness of the gums. Perhaps they may even be abnormally pale and bloodless. There are none of the pockets of the preceding conditions, but there is a steady wasting of the alveolus, a continual recession of the gums, with PYORRHEA ALVEOLARIS. I49 a constant and sometimes profuse discharge of pus from the sockets of the teeth. In the pocket form a single tooth may be affected, but in this state it usually spreads from tooth to tooth, until all or nearly all of either or both jaws become affected. There is no special pain, or any great degree of soreness until the later stages are reached, when the loss of the teeth seems imminent, and when the destruction of tissue goes on with such rapidity that it almost assumes the acuteness of alveolar abscess. There may be no deposits of any kind. The condition may occur in the mouths of those who are fastidious in the care of their teeth, and who regard its insidious but sure advances with horror. They fight it with every weapon at command. They may retard it for years, but it is seldom that it is entirely eradicated. The author has under his care cases in which it manifested itself twenty- five years ago, and though it has been kept in check, sometimes by the most radical measures, it still crops out occasionally, and he and his patient have never been long entirely separated. When a radical cure of this form of the disease has been effected, it has usually been because of some constitutional change in the general tone of the sufferer. It has ever been prone to attack anemic and atonic persons, though it is not confined to them, and when it has been eradicated it has been accompanied by a com- plete change in the bodily health of the patient, and a return to a tonic state. The treatment of this special condition must, to a considerable degree, be general in its nature. If it is due to a want of eliminative power in the body, it may be that a prolonged course of alterative and tonic treatment will be necessary to enable the system to recover and maintain its normal tone. If there is any distinct diathesis with which it may be connected, that should be attended to. Antiseptics must be constantly used, and the mouth kept as free from putrefaction as possible. Stimulating, astringent mouth- washes should be frequently employed, and every hygienic pre- caution exhausted. The space between the gum and the tooth should be kept clean, and whenever necessary it should be wiped out with some mild cauterant, like lactic or trichloracetic acid. Massage should frequently be employed by rubbing the gum with the ball of the finger, using considerable force. The tooth-brush should not be too harsh, and washes rather than powders should be employed with it. I5.0 ORAL PATHOLOGY AND PRACTICE. In some instances the author has seen what he thought to be good results following the use of anti-gout and rheumatic remedies. The employment of lithia in some form, or of salicylic acid, has been especially recommended. Dr. E. C. Kirk has reported excel- lent results from a persistent use of lithium bitartrate, in the form of tablets. If a tooth becomes very loose through destruction of the alveolar socket it is usually best to remove it, but when it is the result of an acute inflammatory stage, it may be held firmly for a time by weaving a ligature about it and the adjoining teeth. Sometimes there may be a decided amelioration following the burring away of the diseased edges of the alveolar process, with the use of antiseptics and stimulating astringents, but too often this is not permanent. Very little dependence can be placed upon the many specific methods and remedies offered by those who claim to cure the incurable. The best results will be attained by the practi- tioner who, to general medical intelligence, adds the most faithful, diligent, painstaking care in the line of treatment adopted. Of course, when the whole or nearly the whole alveolar socket of a tooth has been lost, further temporizing methods are useless. CHAPTER XXXII. FACIAL NEURALGIAS. Neuralgias are affections of a nerve trunk or filament, and may be either organic, constitutional, functional or local in their origin. The first of these occur through some organic change in the tissues which (renders them incapable of healthy action. The second arise from and are associated with a constitutional diathesis. The third are due to disturbed nutrition and the consequent lack of tone, while the fourth originate in a direct lesion, or in some local irrita- tion. An instance of the first is the pain due to cicatrization of a wound ; of the second the general neuralgia of gout or syphilis ; of the third that of miasmatic affections, while the fourth may be found in prolonged dental disturbances. Strictly speaking, any pain is a neuralgia, but the usual signification is confined to an affection in a nerve trunk as distinguished from that caused by irritation of a terminal filament. The continued pain arising from FACIAL NEURALGIAS. 151 a neuromatous tumor is an instance of neuralgia from a true lesion of a nerve trunk. True neuralgias are principally confined to the afferent nerves, but they may be reflex and hence have their origin in the efferent or motor nerves. The facial neuralgias that form the majority of the affections presented to the notice of the dentist are manifested in the trigeminus, and their most frequent cause is diseased teeth. The irritation from caries may be so severe, or so long continued,, that the trunk of the nerve is affected and its function so modified that it remains in a permanently irritable condition. The diagnosis of this disorder is not always easy. That is, it is sometimes difficult to determine whether the pain arises from a mere local irritant, like the inflamed pulp of a tooth, or if it is a true degeneration or functional disturbance of the nerve tissue. In facial neuralgia the first thing to do is to look for the cause, and to determine whether it may not be mere odontalgia, or toothache. To this end the most minute examination of the teeth upon the affected side should be made. Cavities may exist beneath the gums which only the most careful search will reveal. Every test for in- flamed and irritated pulps should be tried, and in the great majority of instances the suspected neuralgia will be found to be mere tooth- ache. Every local cause having been excluded, the general bodily condition should be noted. If any distinct diathesis exists, like that of gout, rheumatism, syphilis, malaria, or catarrh, its possible connection with the disturbed neural currents should be looked for. If there is a state of anemia, or lack of nutrition, here may be its origin. The starved nerves are loudly crying for the sustenance they lack. All these sources excluded, a neuroma, or some other disor- ganization of the nerve tissue itself may be suspected. When this is the case and a true neuralgia is indicated, more minute in- quiries should be made as to the character of the subjective symp- toms. If neuralgic, the pain will be unilateral. Though not local, it will affect but one side, for bilateral disorders of this kind are something more than rare. The pain will usually follow the course of the trunk of the dis- turbed nerve. That is, it may be recognized at different points in the route. 152 ORAL PATHOLOGY AND PRACTICE. It will be sudden in its attack. Its onset will not be a gradual approach, increasing in intensity until the climax is reached and then subsiding by degrees, but, from entire ease, instantly the victim is in the throes of the most agonizing torture. It will be of a darting 1 , stabbing, boring character. It is not the steady, dull, throbbing, continuous pressure of a pus gather- ing. It will be markedly intermittent. There will be intervals of complete immunity of greater or less length succeeded by paroxysms that will end as suddenly as they begin. There may or may not be regularity in these attacks. In the earlier stages there is usually an increase in severity with each paroxysm, to be succeeded by decreasing violence. While the invasions are sudden in their attack and subsidence, there is a true paroxysmal character to their recurrence, each one becoming more severe until the climax is reached, when the abate- ment will be as gradual. There is no functional disturbance connected with the attacks. The pulse will not be accelerated, nor will the temperature rise. There is no fever or other general disturbance. This is an im- portant pathognomonic symptom. In some instances, especially in cases of long standing, there will be soreness along the track of the affected nerve. This may be especially marked at the foramen of exit. Anesthetic spots in the tissues supplied by the disordered nerve may assist in the diagnosis. Reflex symptoms in communicating nerves may be exhibited. There may be spasms and muscular twitchings. Tears may flow, the effect of reflex irritation, or salivary secretions may be markedly increased. Fatigue and depressing influences bring on invasions, or exacerbate them. The receipt of distressing news will possibly provoke an attack. Sleeplessness or any unusually prolonged exertion will be likely to be followed by paroxysms. The clinical history is usually quite distinct and marked. Neurotic persons, and those with an unbalanced nervous organiza- tion, are especially liable to attacks. Hence the neuralgias are frequently closely related to hysteria, migraine or sick-headache, hypochondria, paralysis, catalepsy, epilepsy, and other nervous and convulsive disorders. Clavus hystericus is but another special form of it. FACIAL NEURALGIAS. 153 It usually accompanies or indicates an atonic, debilitated condi- tion. It is sometimes among the sequelae of a long-continued fever or other exhausting disease. It is especially liable to attack those who are suffering from malaria or miasmatic fevers. In such instances it sometimes as- sumes the form of "brow ague." The gouty and rheumatic diathesis seems especially provoca- tive of different forms of neuralgia. Among these, sympathetic affections of the trigeminus, or fifth cranial pair, are not un- common. Indeed, sympathetic pains along the course of com- municating branches or nerves, or through those but secondarily connected by different ganglia, would naturally be anticipated from the very nature of the disorder. It could not well be otherwise than that reflected pain would be felt in perhaps distant tissues or organs. These may not be of a severe character, and they will probably be felt at the outset, or more likely still at the close, of a paroxysm. Yet their existence may be an important part of the clinical history, and should be carefully sought out. Treatment. A real neuralgia having been clearly diagnosed, the first thing will be. to determine its cause and to remove it. If there is any local source of irritation it must be remedied. The hygiene of neuralgic patients should be carefully looked to. They must be guarded from sudden changes of temperature, draughts of cold air, etc. All sanitary precautions must be adopted, and if the patient suffers from malaria removal from the miasmatic influence is the first consideration. Plenty of out-door exercise must be urged, with a liberal, rather stimulating diet. Extreme fatigue should be guarded against, and bodily and mental rest is important. If there is a constitutional or general functional dyscrasia, it must be relieved. Nervous sedatives may be prescribed, and gen- eral quiet insisted upon. Potassium bromide, ten grains in water, from two to ten times per day, will be found useful, or tincture of valerian and gentian, equal parts in teaspoonful doses. During the paroxysm, digitalis, or veratrum viride in five-drop doses may be given, and aromatic spirits of ammonia in fifty-drop doses will be found useful. 154 ORAL PATHOLOGY AND PRACTICE. If there is a gouty diathesis, wine of colchicum in small doses, frequently repeated if necessary, should be prescribed. Muriate of ammonia fumes, arising from the burning of the salt upon a hot iron in the room, sometimes give gradual relief. If the neuralgia is of miasmatic origin, from three to ten grains of quinine should be administered, or Fowler's solution of arsenic and potash in ten-drop doses, two or three times per day. Hot moist applications to the affected parts are very useful r and massage sometimes gives very ready relief, although there are instances in which it will be found exacerbating. It must be gentle, and not too long continued at first. If the paroxysms are very violent, it may be necessary to allow the patient to inhale the vapor of ether or chloroform for a short time ; of course, not to the point of entire narcosis. If none of the usual remedies are effective, and if the paroxysms are violent, resection of the affected nerve may be necessary. This will, with comparative frequency, be called for in neuralgia, especially in that of the inferior dental nerve. Pro- fessor Brophy, of Chicago, has greatly simplified this operation, and by his method it no longer presents any formidable difficulties. His resections of the infra-orbital from the oral cavity also relieves that operation from many complications. CHAPTER XXXIII. FACIAL PARALYSIS. In its etiology this affection is closely connected with facial neuralgia, but it differs from it in being the effect of lack of nerve nutrition, while the neuralgias are more frequently the result of overstimulation. It is also more frequently due to organic lesions or cachectic conditions. It may arise from syphilis, tubercle in the cerebral centers or cord, or a blood clot in the brain. In any case, it implies disordered nerve function, and its treatment may often properly fall within the province of the oral physician, inas- much as facial paralysis is not infrequently due to some oral lesion. Facial paralysis is the complete inhibition of efferent neural currents in the tissues affected, with usually a local anesthesia, or suspension of afferent nerve currents, more or less complete. It may FACIAL PARALYSIS. 1 55 be traumatic or idiopathic in its origin. If the former, there will be no difficulty in determining the fact, while in the latter case its source will be more obscure. It may be complete or incomplete. It is complete when there is a total loss, and incomplete when there is only more or less of diminution of function in the nerves. It is general when there is loss of power in both the upper and lower extremities, and local when it is limited in the number of muscles affected. Facial paralysis is local in its character, and as seen in oral practice it is usually but partial. Paralysis of sensation may be either loss of tactile sense — in- ability to receive impressions from external contact — or immunity to painful sensations. Thus the skin and the mucous membrane of the mouth are endowed with both kinds of sensibility. The capacity of these tissues to receive painful impressions may be quite impaired, or even lost, while the tactile or feeling response to external agents remains. But in these instances the impression made by ice, or a hot iron, will not materially differ from that derived from a piece of wood. Paralysis of the tactile sense is commonly called anesthesia, while that of the sense of pain is denominated analgesia. Reflex paralysis is a term that has been applied to cases in which a paralyzed condition of certain parts is attributed either to a wound or shock received from other and more or less remote parts, or to a local disease situated elsewhere than in the paralyzed region. Dr. Brown-Sequard supposed this to be induced through shock to the vaso-motor nerves, thus interfering with the nutrition of the nerve centers. The instances of paralysis that are of the greatest interest to the dentist are those of the fifth and the seventh pair of cranial nerves. The fifth, or trifacial, is the great sensory nerve of the head and face and the motor nerve of the muscles of mastication, while the seventh is the motor nerve of the muscles of expression. Complete paralysis of the fifth nerve results in the loss of sensibility of one side of the face, of the mucous membrane of the mouth, the conjunctival membrane, the anterior portions of the tongue, with the muscles of mastication upon the affected side. The external manifestations are not so pronounced as in paralysis of the seventh nerve, because the resulting deformity is not so great. There is a loss of the special sense of taste, and sensation is absent. But i/ I56 ORAL PATHOLOGY AND PRACTICE. the affection is unilateral, mastication may be carried on by the use of the muscles upon the sound side. The tongue and buccal tissues upon the paralyzed side are frequently bitten and lacerated in the act of taking food, sometimes seriously, because the muscles are unable to keep themselves from getting between the teeth, and sensation being gone the patient is unaware of the injuries that are being received. Such paralysis may be induced by long exposure of the face to cold or a keen wind. Paralysis of the seventh cranial nerve is perhaps not so com- mon as that of the fifth, but it is much more readily observed, as it results in serious deformity. With the loss of function in the nerve all expression in the affected side is lost. In speaking or smiling the mouth is drawn toward the sound side through the loss of con- tractile power in the muscles of the affected side. The contractility of the orbicularis oculi being absent, the patient is unable to close the eye or to wink. The secretions of the lacrymal gland are not diffused over the conjunctiva owing to the loss of function in the orbicularis, and there is a more or less constant overflow of tears upon the cheek. The saliva dribbles from the angle of the mouth, and the pronunciation of certain letters of the alphabet is interfered with. Paralysis of the seventh is perhaps most often caused by intra- cranial disease. These cases will properly fall within the province of the general practitioner. But it may be the result of injury. The extraction of a considerable number of teeth at one time may produce a shock that will cause spasms of the muscles of mastica- tion, or even inhibition of function and paralysis, with jaw drop. The spasm may be clonic (paroxysmal) or tonic (continuous). The symptoms are too pronounced to be mistaken. There will be a drawing of the muscles of the face, due to their entire relaxa- tion, with a loss of mobility. The eye remains staringly open, and a smile is observable on one side alone. All expression upon the affected side is lost and the muscles are in a state of tonic relaxa- tion. This will be observed by the operator before the patient becomes aware of the lesion. If it is of a clonic character he may by gentle manipulation of the tissues relieve the spasm, or tem- porary paralysis, and within a few moments have the satisfaction of seeing the muscles regain their tone. Of course he will remove the hand-glass from the reach of the patient to prevent the unneces- FACIAL PARALYSIS. 157 sary alarm and nervousness which discovery would cause, and which would only tend to aggravate the condition. Should the injury be more lasting in its character and assume a tonic form, the dentist should explain to the patient the probably temporary nature of the lesion and commence the proper treatment for relief of the condition. One of the most effectual remedies for this condition is elec- tricity. The faradic or induced current should ordinarily be used, and it must be gentle at the outset, nor should it be continued too long. The cathode or negative pole should be placed over the cerebellum, and the anode or positive electrode carried gently over the points of distribution of the affected nerve. Occasionally the poles may be changed, and if it is desired to stimulate the facial nerve alone, the stationary electrode may be placed immediately in front of the external auditory meatus, while the other is moved successively over the various terminal branches. This treatment,, if found beneficial, may be repeated every day, provided the cur- rent is not too strong and not too long continued. At the outset it should not be used so often. If the disorder has its seat in the ganglia, the magneto-electric interrupted current may sometimes be used with good effect, but it should be employed with caution, because it may still further tend to the inhibition of the neural currents in exhausted trunks or branches. Massage of paralytic muscles, if mild and properly applied, will be of great benefit in many cases. The facial muscles may be gently manipulated with the balls of the fingers, and rubbed in the direc- tion of their fibers with the palm of the hand. The hygienic condition must, of course, be carefully looked after, and out-of-door exercise with nourishing food directed. Vegetable tonics may be prescribed if indicated, and quiet and rest ordered. If the paralysis is the result of any trauma, such as the extraction of teeth, the wounds must be carefully examined to see if there are any loose fragments of alveolus or bone left, and all possibly irritating projections and spiculae should be removed. An aseptic condition must be maintained, and soothing applications applied. With these precautions, unless the lesion is very great, a gradual return of functional activity may be anticipated. T58 ORAL PATHOLOGY AND PRACTICE. CHAPTER XXXIV. SYMPATHETIC DISTURBANCES. The nervous system of the body holds all the various organs and tissues in correlation with each other, and secures harmonious functional action between them. Every organ works, not alone for itself, but for all the rest. There is but one heart to carry on the vascular circulation for all the tissues, but one digestive tract to provide nutrition for all, and but one pulmonary organ to furnish the necessary supply of oxygen. Hence the mutual interdepend- ence is complete, and no tissue or organ can be properly studied aside from its relation to the others. No oral physician, or dentist, is equipped for the practice of his specialty until he can show that he has made himself acquainted with the functions of other organs, and has learned their possible reflex agency upon those with whose care he is especially charged. A fair knowledge of the anatomy and the physiological function of every tissue in the body is essen- tial to the dentist as well as to the general practitioner, and with- out the basal facts upon which all curative measures must be founded he is as unfitted for his vocation as would be any other man who professes to practice any. branch of the healing art. Any disordered condition of one organ affects to a greater or less degree all the others. The sympathy may not be as active in one case as in some others, but it is as certain. The dependence of one tissue or organ upon another may not be as complete or entire as that of others, or as may be the reciprocal reliance, but it surely exists. Proper functional activity of the brain may for some years be more disturbed by indigestion than would ensue to the stomach if the converse were the case, but no physiologist would assert that digestion could be properly and fully performed in cerebral conges- tion. The gravid uterus of the female will be more deranged by toothache than the teeth will be disturbed by metritis, but each reacts upon the other to the extent of its susceptibility, and their mutual relations cannot be lost to sight. The organs disturbed by diseases of the teeth and the oral tissues will be those to which they bear the closest relation. It is well known that the teeth sympathize with each other to such an •extent that it is sometimes difficult to determine which one, and SYMPATHETIC DISTURBANCES. 1 59 sometimes which jaw, is affected. Otitis media may exhibit itself as toothache, while on the other hand pains in the middle ear are very often mere reflexes of odontalgia. The eye sympathizes with the teeth to such an extent as sometimes to exhibit a profuse lacrymal discharge as the accompaniment of toothache, and alveo- lar abscess may be diagnosed by the condition of the pulse. The otologist especially should be on good terms with the dentist, for mutual consultation is frequently desirable, owing to the intimate relations of the organs concerned. But the reflex disturbances which most concern both practi- tioner and patient are the possible complications of pregnancy. Women have long been taught that the relations between the teeth and the impregnated uterus are so intimate that each must vicariously suffer for the other. "For every child a tooth," was a proverb long before the period of modern dentistry. That extrac- tion is very liable to be followed by premature delivery is a part of the creed of every expectant mother. The impression resting in the minds of too many dentists that temporary disturbances may, within a short time, exhibit themselves in a softened or changed condition of the tooth structure, is perhaps responsible for a part of the general belief that the teeth decay to a much greater extent than usual during pregnancy. It should be remembered that nutritive changes in the dentine are exceedingly slow, while it is not unreservedly admitted that they take place at all in enamel. Hence, while functional disturbances in the teeth are quick to manifest themselves in allied tissues, the reverse is not the case. A continued fever may cause a great waste in many tissues, but it cannot in the teeth, because there are in them no absorbents, no lymph system. There is no active circula- tion in either dentine or enamel, through which progressive or retrogressive changes may be readily and quickly wrought. The supposed divergence of the nutrient currents from the teeth to the growing child must, then, be largely imaginary, and there can be no sudden breaking down of these organs during pregnancy. And yet the general impression that the teeth decay more at that time than any other doubtless has some basis upon which to rest. One explanation may be found in the fact that at such times the pregnant woman has something else to take up her whole atten- tion, and often intermits the care that she is accustomed to give l60 ORAL PATHOLOGY AND PRACTICE. her teeth. Food is suffered to remain upon and between them, and fermentation does its perfect work. The pregnant woman sometimes has perverted or unnatural appetites, and takes into her mouth deleterious substances. Mineral tonics are frequently pre- scribed for her, and these may bring about destructive results. But there is little doubt that the fact that at least a year passes in which she is usually without the dentist's help is the principal factor in the result attained. Poor people, who never care for their teeth, find little difference between the period of gestation and any other. The fear that a visit to the dentist must result disastrously is a mistaken apprehension. It is the true office of the oral practi- tioner to relieve pain, and not to cause it. Every woman who finds herself pregnant should visit her dentist, if he is a competent man, should tell him her condition, and place herself in his hands for such measures as are necessary. He will take special care to avoid giving her pain at such a time, not because it would always be immediately hazardous, but from the necessity for preserving her mental and nervous equilibrium to as great an extent as is possible. Jf there are cavities of decay that would be likely to bring about complications before the time for her delivery, they should be filled, usually with plastic materials. If there are troublesome teeth, so badly diseased as to forbid conservative measures, they should be promptly extracted. If the administration of a general anesthetic is essential, she should be referred to her medical attendant. If from the performance of any such necessary operation, when care- fully and skillfully done, any ultimate harm has ever occurred, it has not been made a matter of record, and the world is in ignorance of it. It should not be forgotten that the pregnant female is usually in a state of exalted nervous sensibility, but that does not neces- sarily imply that all operations upon the teeth are inhibited. That there is more toothache during gestation than at other times may be quite true, but there are often sympathetic disturb- ances, without real tooth lesions, that have their origin in the disordered nervous condition. Concerning the nutrition of the teeth of both mother and child, and the prevailing belief that these can be governed by any specially regulated diet, another chapter will have something to say. DISEASES OF TH^ MAXILLARY SINUS. l6l CHAPTER XXXV. DISEASES OF THE MAXILLARY SINUS. The position and relations of the Antrum of Highmore, or the Maxillary Sinus, make it peculiarly liable to disorders of a catarrhal nature. There doubtless exist many more such than are recognized by oral physicians. The sinus is a cavity within the superior maxilla, connected by a small opening with the air passages of the nose. It allows proper contour of the face without the weight of bone that would be the consequence of solidity. It also makes the nutriment of the bone more easy, and obviates any necessity for a large medullary portion. But its principal utility is in giving resonance to the voice. All musical instruments have a hollow chamber of some kind, to increase the reverberations and reflect the vibrations of the air. The perfection of the instrument and its quality and volume of tone depend very largely upon the particular form of this reverberatory chamber. Many years of experiment have not been able to devise any beneficial modification of the peculiar shape of the body of the violin, as it was fashioned by Guarnerius, more than two hundred years ago. Any departure from that model, whether accidental or intentional, has been found to change the character of the vibrations and impair the tone of the instrument. The antrum is the principal sounding-chamber of the human voice, and the wide variations in the character of the tones produced are due in a large degree to the size, shape, and condition of the cavity. The howling monkey, whose voice can be heard at night for several miles, has an additional osseous chamber to reinforce the reverberations of the antrum. (See Fig. 42.) All are aware of the peculiar hard, metallic, unmusical tone that is communicated to the voice in cases of empyema of the antrum, or in atresia of the communicating sinus. The size and shape of the antrum in different individuals vary as greatly as do the characteristics of the voice. In some it is large, and occupies the whole center of the bone. The two antra in the maxillae have even been known to be a continuous cavity, united by a communicating opening across the symphysis. Usually, how- j52 oral pathology and practice. ever, its anterior limit is the canine fossa. It is sometimes par- tially divided into a number of chambers by septa passing across its floors. (See Fig. 43.) The opening by which it communicates with the air passages is at the point of junction of the ethmoid and palate bones and the turbinated process of the superior maxilla. This is usually at or very near its highest point. Dr. M. H. Cryer, of Philadelphia, has, by his dissections and studies of the cranial bones, added largely Fig. 42. mm^,,. Showing the Resonant Chamber Attached to the Larynx in the Howling Monkey. to our knowledge of the structure and configuration of this cavity ; and Dr. Thomas Fillebrown, of Boston, has given us yet further illumination. The commencement of the formation of this cavity is not until early childhood has been passed. Hence antral disorders are un- known in infancy, because there is then no maxillary sinus to become diseased. The mucous membrane lining the antrum is continuous with the Schneiderian, or that covering the bones and cartilage of the DISEASES OF THE MAXILLARY SINUS. 163 nasal cavity. It will therefore be liable to the same diseases and be materially affected by the condition of the air passages. In- flammations and degenerations of the Schneiderian membrane, by mere continuity may be communicated to the antrum, and a nasal catarrh may induce a chronic antral disorder. This will be the most fruitful source of the degenerated conditions so often present, and if what has frequently been asserted is true, that in the northern and eastern parts of the United States the person who is entirely free from catarrhal troubles is an exception, it must necessarily Fig. 4.3. Vertical Section through the Skull. a, Frontal sinus ; 3, A wire probe thrust into the infundibulum ; c and ^ X ' A Dentigerous Cyst in a Young Horse, containing Nearly a Quart of Denticles. a, Mass attached to the bone, b and d l , Loose pieces. (From a specimen in Buffalo College Museum.) may readily be distinguished, in most instances, through this peculiarity, and through their slow formation and the entire lack of pain that accompanies their growth. The methods of distinguishing them from tumors are various. If they are accessible, the fluctuation of the fluid contents may readily be perceived. Sometimes, when they have existed for a long period without materially growing, a parchment-like crackling will be felt upon pressure, and it may even be heard with the ear. CYSTS AND THEIR TREATMENT. 177 It sounds very much like the crepitating sound produced by the flexing or bending of bar tin. This is because of the inspissation, or thickening into a grumous, clotted mass of the fluid contents, through their desiccation, or drying. In deeper cysts it is usually advisable positively to determine their character by aspiration, or the drawing off of some of the fluid contents, by means of an aspirating or hypodermic syringe, and its careful examination. This gives a positive method of diagnosis. An exploring needle should also be used, to determine the presence of any foreign or irritating substance. Fig. 47. Upper Jaw showing Alveolar Cyst and Other Diseased Conditions the Result of Neglect. There is recession of the gums and absorption of the alveolar edges due to pyorrhea. The central incisor is thrown out of alignment through the formation of an alveolar pocket on the disto-lingual aspect. A cyst has formed about the diseased apex of a tooth at a ; there is chronic suppuration with alveolar necrosis at b. (From C Rose.) Park, whose "Surgery by American Authors" may be ac- cepted as the most modern expression of surgical pathological knowledge, divides these ordinarily benign tumors into four classes: 1. Retention Cysts. These imply a previously existing cavity, whose outlet is stopped up, and whose contents consequently accumulate and perhaps degenerate. This class will of course include those oral cysts which arise from an obstruction of the ducts of the salivary gland. 13 I78 ORAL PATHOLOGY AND PRACTICE. 2. Tubulo-Cysts. These are dilatations of certain functionless ducts in other parts of the body. They are largely developmental in their origin. 3. Hydrocele. This, as its name indicates, is a collection of watery fluid in some serous cavity > one which has no discharging duct and no opening of any kind. Hydroceles are apt to be of congenital origin, and are most frequently found in the region of the neck. 4. Glandular Cysts. These growths are formed by the dilata- tion of certain glands. They may usually be classed as retention cysts, for the enlargement is most commonly induced by a stop- page of the ducts. They may, however, occur in connection with the ductless glands, and because of this there is a degree of pro- priety in distinguishing them from those which arise from the mere closing of a duct. Fig. 48. Calcific, Structureless Mass involving the Roots of a Molar. It had invaded and destroyed cementum and dentine. It was as hard and as dense as bone, but had none of its structure. (Practice of Dr. A. M. Holmes.) Those which are of interest to the oral surgeon or physician are the first and last classes, tubulo-cysts and hydroceles not being likely to fall under his observation. Cysts in and about the oral cavity, are quite frequent, a con- siderable proportion of them being caused by calcareous deposits within the salivary glands or in their discharging ducts, and the subsequent formation of a retention cyst. Ranula is a retention cyst, caused by the stoppage of Wharton's duct, or one of the mucous glands beneath the tongue. A small cal- culus may be formed within the gland, and it will eventually become lodged somewhere in the duct, completely stopping it. The saliva or mucus is obstructed and forms a cystic pouch or pocket, into which more is continually flowing. The watery portion will CYSTS AND THEIR TREATMENT. 179 be lost, and there will remain a thick, jelly-like mass beneath the tongue upon one side, which in some instances thrusts that organ quite out of the mouth. It assumes a peculiar mottled appearance, closely approaching that of a frog's belly, and hence it has received the name of ranula, from the Latin rana, a frog. Odontocele or Odontoma is another comparatively common form of oral encystment. These are caused by the presence of undeveloped or misplaced tooth germs. The former term more strictly applies to a cystic, and the latter to a degenerate formation, although both are due to the same cause and are of the same general character. They may appear at any point of the jaws, wherever the undevel- oped germ may exist. They are easily diagnosed in most in- Fig. 49. An Odontome Attached to a Molar Tooth the Crown of which is at the Apex of the Calcific Tumor. stances, not only by the means already laid down, but by the addi- tional fact of there being a missing tooth, and by their location where that might naturally be expected to exist. (See Fig. 49.) Park, in his ''Surgery by American Authors," says that the odontomata are tumors composed of one or more of the dental tis- sues, arising either from tooth changes or teeth in process of de- velopment. He deprecates the lack of attention which has been given to. them in surgical literature, and says that no tumor of the jaw, especially in young people, should lead to excision of the jaw until it has been fairly demonstrated that it is not one of this form. They are divided into — 1. Epithelial Odontomata, which are provided with a cap- sule and present usually a series of cysts separated by their septa, containing a mucoid fluid. l8o ORAL PATHOLOGY AND PRACTICE. 2. Follicular Odontomata, more frequently spoken of as "Dentigerous Cysts," which arise in connection with permanent teeth, especially the molars, and sometimes reach a great size. The tumor consists of a wall representing the expanded tooth follicle and a cavity containing viscid fluid, with parts of imperfectly de- veloped teeth, sometimes loose and in other instances attached. They occur not infrequently in the lower animals. 3. Fibrous Odontomata, which consist of condensed connec- tive tissue in a developing follicle and present a tumor which blends with the dental papilla at the root and is indistinguishable from it. These tumors are common in the ruminants. 4. Cementoma. This is a tumor fibrous in character whose capsule has ossified or calcified, the developing tooth thus becoming imbedded in a mass of cementum. These occur frequently in horses. 5. Compound Follicular Odontomata. These contain num- bers of masses of cementum resembling small teeth, or perhaps composed of the three dental elements. (See Fig. 46.) 6. Radicular Odontomata. These are tumors of the roots which form after the completion of the crown. They consist ex- clusively of dentine and cementum, and are rare in man. 7. Composite Odontomata. These are hard tumors, bearing little or no resemblance in shape to normal teeth. They consist of a conglomeration of enamel, dentine, and cementum, thus pre- senting an abnormal growth of all the elements of the tooth germ. They have been found only in man. There are other forms of cysts arising from some functional disturbance in the smaller glands of the mouth and tongue. They belong to the strictly glandular class, and consist of an enlargement or dilatation of a mucous gl:.nd. Such an one is frequently found just at the tip of the tongue, where lies the so-called Nuhn's gland. These cysts, however, may be of the simple retention variety, due to a stoppage or closing of the duct of the mucous follicle. Dermoid or congenital cysts are also sometimes found in the mouth. Sometimes the cystic formation is within the antrum of High- more, which it fills with cystic fluid. In this locality it is liable to be mistaken for an ordinary edema of that cavity. But after it has existed for some time it usually causes an absorption of the walls of the antrum, when its true nature is revealed. This will most CYSTS AND THEIR TREATMENT. l8l often occur at the external extremity of the antral cavity, where the alveolar walls are thinnest. At that point, beneath the cheek, fluctuation may readily be observed, and the peculiar feeling of the cystic fluid may easily be detected. If there is yet any doubt, an aspirator needle may be introduced, and a little of the fluid ex- tracted. If this is thick and glairy, with perhaps some flocculent matter floating in it, the diagnosis will be clear. There is a kind of cyst that is of a distinct interest to the dentist, vis, the ovarian dermoid. These dermoids are teratomatous growths, made up of matter that is developed from the epiblastic layer. Hence we find them containing epithelia, skin, hair, sebaceous glands, and well-developed teeth. If they should contain bone, muscle, or nerve tissue they would not be dermoids, because these are of mesoblastic origin. The author has in his possession a der- moid ovarian cyst that contains nearly forty teeth, some of them deciduous and some permanent, with hair rolled up into a ball and nearly two feet long. The treatment of cysts is usually quite simple. In most cases it is sufficient first to open the cystic tumor and explore it for the presence of an irritating agent. This, when discovered, should be removed. The contents of the cyst should now be thoroughly evacuated, and the cavity washed out with a weak disinfecting solution, when the whole may be packed with iodized lint. Granu- lations will usually commence and complete the cure. It may be desirable to wash out the cavity with a stimulating fluid, and wait a little time to see that no undue inflammation succeeds, before the iodized lint is used. In cysts within the bone, or in the antrum, septa may exist, partially dividing the cavity into two or more portions. These should usually be broken down, that the diagnosis may be complete. This will be found especially true in the maxillary sinus. In ranula, it is desirable to remove the obstructing calculus and evacuate the cyst without cutting, if it be possible, that the course of the duct may not be changed. A little careful manipula- tion will not infrequently be effectual in driving the concretion, if it is not too large, out through the course of the duct, when the contents of the cyst may be removed by means of the aspirator. Should the cyst again fill up, it may be necessary to open it, but the natural discharge from the submaxillary gland should be carefully 1 82 ORAL PATHOLOGY AND PRACTICE. provided for. There are instances in which it will be found neces- sary to dissect out as much of the inciosing membrane as is possible. There is little danger from bleeding in any operation upon cysts, if carefully performed, and the only complications are those arising from the ordinary inflammations. CHAPTER XXXIX. TUMORS AND NEOPLASMS. It is not the purpose of this work to enter upon any extended investigation of diseases not commonly encountered by the dentist, or which properly belong to the practice of the general physician or that of any other specialist. But it would not be complete were not a sufficient knowledge of morbid growths imparted to enable the student intelligently to diagnose the condition, even were it essential for him to refer his patient to the general surgeon for any necessary operation. Hence, some general remarks will be at- tempted concerning the origin and pathology of the more common foreign growths. The term Tumor implies an abnormal enlargement of a part from any non-inflammatory cause, but usually from a morbid growth, which in its structure conforms to a greater or less extent to the tissue in which it grows, and which has no functional action. A simple inflammation is a tumor in one sense, but not ia that which is surgically the accepted one. The term Neoplasm is more applicable to the conditions under consideration, because it implies an abnormal growth, which may be either normally or abnor- mally located. All neoplasms, or tumors, consist of tissue that is normal to the body, and that forms an essential part of it when properly devel- oped. But when any tissue of the body grows in a location that is foreign to it, or when it develops in an abnormal manner or in excessive amount, it becomes a tumor or neoplasm. Every hyper- trophy is a tumor, because it is an excessive development, though of a normal tissue in a natural locality. If it is developed in an un- natural position, there is a greater departure. If fibrous tissue develops unconnected with other such tissue, or in a place in which TUMORS AND NEOPLASMS. 183 fibrous tissue does not belong, it is a neoplasm. If osseous tissue develops in undue amount in connection with other bone, it may be but an hypertrophy or a hyperplasia. But if it is formed in an ab- normal manner, or in an unnatural location, it becomes a morbid tumor. A wart is the undue development or an hypertrophy of one or more of the papillae of the skin, and it is thus a form of benign tumor. A corn is the impaction of the epithelia in the tissue be- neath, but it is not a true foreign growth. When epithelia develop unduly in the midst of other tissues, they form a dangerous kind of tumor. Neoplasms may be of benign or of malignant growth. In the former case the tissue elements may form a mere harmless hyper- trophy, like hypercementosis, sometimes called exostosis of a tooth, while in the latter they are essentially foreign, and therefore irri- tants, and cause a degeneration and breaking down of tissue. All neoplasms, therefore, are composed of normal cells abnormally developed in number, as in hypertrophies; in position, as in warts, moles, etc.; or in both location and histological arrange- ment, as in the malignant tumors. They are named according to the tissue in which they occur, or of which they are composed. An Epithelioma is composed of unduly developed epithelia. A Fibroma is composed of unduly developed fibrous tissue. An Osteoma is composed of unduly developed osseous tissue. An Adenoma is composed of unduly developed glandular tissue. An Enchondroma is composed of unduly developed cartilage tissue. A Myoma is composed of unduly developed muscular tissue. A Glioma is composed of unduly developed nerve structure tissue. An Angeioma is composed of unduly developed blood tissues. A Myxoma } of unduly developed mucous and gelatinous tissue. Tumors are also named from other peculiarities, appearances and structural character, as — Sarcoma; having the appearance of flesh. Encephaloid; having the appearance of a head. Myeloid; having the appearance of marrow. Melanotic; having a pigmented or colored appearance. Scirrhus; having a hard appearance or consistence. Medullary; having a soft appearance or structure. Tumors are also Homologous or Heterologous, the former con- 184 ORAL PATHOLOGY AND PRACTICE. sisting of tissue like, and the latter Tinlike, that in which it is im- bedded. Homologous tumors naturally are apt to be benignant, and heterologous tumors to be malignant in their nature. Malignant tumors are usually connected with some peculiar diathesis, and there is an hereditary tendency toward their forma- tion. They are embryonic in structure; that is, made up of not fully developed tissue, and hence quite unlike ordinary hyper- trophies. They are apt to consist of a network of connecting tissues, whose meshes are filled with abnormally developed cells. They may be diagnosed from their position, their history, growth, pain, general appearance, etc. As a rule, the faster the growth the more threatening the tumor. This is especially the case if there is pain attending it. Those which appear in middle age are more apt to be malignant than those whose growth is earlier. The most destructive ones are, after a certain stage, accom- panied with an extensive ulceration and sloughing of the tissues. A tumor will usually first appear as a hard nodosity within the tissues. It may increase in size very fast, or its growth may be slow. It may be accompanied with considerable pain, or it may be without functional disturbance. There are a great many benign tumors to each one of a malignant character. As a rule, if the growth is slow and without pain, if there is no special reason for its appearance, if it can be attributed to no particular pathological condition and no functional disturbance is connected with it, little attention need be paid to it. It is probably one of the frequent hyperplasias of an innocent character that may be found in almost every person. It is usually safe under all circumstances to allay the fears which such an appearance almost invariably excites, by the assurance that it is one of the numerous growths that can do no harm, and to endeavor to divert the mind from all thoughts of it. Nothing should ever be said that can excite apprehension. Even if the practitioner is in doubt concerning its true nature, he should not let the patient become aware of it. He should keep it under observation until it has sufficiently developed to enable him to judge intelligently, but always without communicating alarm. The treatment of the homologous tumors is wholly local. They have no constitutional origin, and do not menace life. The chief reason for interfering at all in many such cases will be found in the fact of their causing inconvenience or disfigurement. TUMORS AND NEOPLASMS. 1 85. The heterologous tumors represent a constitutional vice. They tend to infiltrate into and invade other tissues. Especially are they likely to affect the glandular system. Local treatment is entirely useless, and even if they are removed they are quite likely to re- appear. They never, like the homologous tumors, reach a definite limit of growth, but continue to increase and spread. Their treat- ment, aside from surgical interference, which is usually advisable except in the later stages, must be specific and sustaining. CHAPTER XL. TUMORS AND NEOPLASMS (Continued). The term Cancer is one that is not usually employed by pro- fessional men. It is derived from the Latin cancer, a crab, and the name is given from the supposed crab-like appearance of the veins in this affection. The laity usually understand by it any of the malignant growths which are technically called Sarcoma or Carcinoma or Epithelioma. Of these the sarcomata are composed of embryonic tissue from the mesoblastic layer, while the carci- nomata are of epiblastic origin. Each is variously subdivided according to its character or development, and each presents sepa- rate physical and pathological characteristics. Sarcomas have a distinct kind of fleshy appearance, and seem to be specially vascular. They grow along the lines of least resistance,, and are likely to penetrate into cavities and fissures of the tissues. They appear at any age, and are comparatively rapid in their growth, sometimes causing considerable pain. When they appear upon the surface they bleed very easily, and have in such cases sometimes been known as Fungous Hematodes. They are com- paratively frequent in the salivary glands, in the jaws and other tissues of the mouth, sometimes penetrating to the antrum. They are quite common in some of the lower animals, especially the horse. An Osteo-sarcoma is one in which the bone tissue is in- volved. It may be Central, arising in the interior and distending the bony walls ; Infiltrating, when the whole bony mass is perme- i86 ORAL PATHOLOGY AND PRACTICE. ated and softened, or Periosteal, when it has its origin in the periosteum. (See Fig. 50.) Carcinoma is of epiblastic origin, and is connected with some form of gland tissue. It is rare in young persons, and it commonly involves the lymphatics at an early period of its development. It is usually rapid in its growth, and it may cause a very great degree of pain. It is very apt to attack the breast in women, but its seat may be in the sebaceous glands, the salivary glands, the prostate, Fig. 50. Osteo-Sarcoma of the Lower ]i (From a specimen in the Buffalo College Museum.) liver, kidney, testicles, stomach, intestines, especially the rectum, or wherever glandular tissue exists. Hence its location will be an important guide in its diagnosis. Epithelioma, as its name indicates, is a degeneration of an epithelial surface, usually of the skin, and consists of masses of epithelial cells surrounded and separated by bands of connective tissue. It belongs to the malignant growths, though it does not necessarily assume their form. It is most apt to attack those beyond middle life, and is much more common in men than in women. It sometimes TUMORS AND NEOPLASMS. 187 arises upon the lip, from the long-continued irritation of a pipe. It is also not infrequently caused upon the tongue, or in the oral tis- sues, by the pressure of rough, sharp edges in carious teeth, which act as a continuous provocation. Its diagnosis is not usually diffi- cult. Its late and superficial appearance and the chronic ulcer with indurated edges forbid its being readily confounded with any- thing else, unless it might be some forms of syphilis. Lupus is one of the many forms which tuberculosis assumes. It is strictly a communicable disease, and is due to an infection by the tubercle bacillus. It usually commences early in life upon the face, in the form of small red or dark spots, which are much softer than the inclosing tissue. They ulcerate in time, and, spreading with the deposition of more tuberculous matter, there is a steady erosion into the surrounding territory. The infection of the system with the tubercle bacillus is always a grave matter, and is liable to cause many complications. It is a question to be taken into careful consideration when any surgical measures are contemplated, be- cause the appearance of miliary tubercle would interfere with the healing process. It is impossible within the limits of a work like this thoroughly to consider the many phases which tuberculosis may assume, and the student who desires further information is referred to works upon general surgery. Of the non-malignant tumors, those most commonly found in the mouth are the different forms of fibroma. These, as their name indicates, are composed of fibrous tissue. They are ordinarily dense in structure, and composed of bundles closely packed to- gether, which are permeated by bloodvessels. The Epulids belong to this class, as they are of fibrous origin. Lipomas, or fatty tumors, are the most frequent of any of the neoplasms. They are of the adipose tissue type, and it is needless to say are harmless in their character. They are usually inclosed in a capsule, from which, if no vital organ is involved in these folds, they may readily be enucleated. They are easy of recognition, except when deeply located, and when once extirpated are not apt to return. • The Osteomas are bony tumors, and are by some believed to be chondromas, or cartilaginous tumors, which have ossified. They may be either compact or cancellous in structure. They are most common about the cranium, and may be found in the frontal sinus, 1 88 ORAL PATHOLOGY AND PRACTICE. the external auditory meatus, and about the mastoid process. The compact forms are sometimes very dense and hard, appearing like ivory, and they may defy the finest steel instruments. Some forms of odontoma are classed with osteomas. The student will be especially interested in the methods by which tumors of malignant growth may be distinguished from those which are benign. This may usually be done by the clinical symptoms, although there are instances in which the most careful observation will be at fault. Some of the foreign growths will pre- sent misleading characteristics, but the following points of differ- ence may usually be relied upon: Benign tumors are common to all ages, while those which are malignant do not appear in early life. Benign tumors are slow in formation, while the malignant are usually of rapid growth. Benign tumors do not spread and infiltrate into the surrounding tissues, while those which are malignant infiltrate in all cases. Benign tumors are often inclosed in a capsule and are circum- scribed, while malignant tumors are never thus limited. Benign tumors are rarely adherent, while malignant ones al- ways are. Benign tumors rarely ulcerate, while the malignant ones al- ways do when they come to the surface. In benign tumors the overlying tissue is not disturbed, while in the malignant it is more or less retracted. There is no lymphatic involvement in the benign tumors unless they are inflamed, while malignant tumors almost always involve the lymphatics. The treatment of the tumors is almost exclusively surgical. Those which are benign seldom return when they have been ex- tirpated, while the malignant ones usually do. If the latter have made considerable progress, and especially if the lymphatic glands have become enlarged and indurated, they are almost certain to reappear. Yet excision, even of the most destructive forms, will usually prolong life, if it does not permanently save it. There is but one safe method of removing them, and that is by the knife. The eroding plasters of the so-called "cancer doctors" are not only the most painful means of effecting removal, but are eminently dangerous, being very apt to hasten infiltration, and in some in- TUMORS AND NEOPLASMS. ISO, stances they may convert a tumor of a benign aspect into a malig- nant type. The dentist will be mainly interested in the epulitic growths that are common in the month. The nsnal form of epnlis is a vas- cular tnmor that appears upon the gums. Its origin may be from the superficial fibers, from the pericementum of a tooth, or it may penetrate into and appear to have its root in the alveolus. The term "Epulis" means "upon the gums." Hence it is applicable to any abnormal gingival growth, and the hypertrophies that, proceed- ing from the gums, sometimes fill the cavities in decayed teeth are true epulids, though of a simple character. Epulids may appear as erectile or as non-erectile tissue, and may have fibrous, myeloid, myxomatous or sarcomatous complications. The erectile epulids are vascular growths, whose size depends upon the vascular condition, and they vary with this. When dis- tended they appear tinged and dark. When not distended they are flaccid, pale, and contracted. The epulitic tumors that spring from the periosteum perhaps invade the substance of the bone. They may be diagnosed by careful movements and by the exploring needle, which may pos- sibly detect an opening into the bone. If the origin is from the pericementum of a tooth, a peduncular connection may usually be traced, either through the alveolar walls or by the side of the tooth, in the direction of the pericemental membrane. For the removal of the superficial and erectile tumors, little more is needed than a ligature that shall cut off all circulation, with final cauterization of the place. An epulis that has its origin in the pericementum of a tooth will be cured by extraction. But for those which penetrate the bone, it will be necessary to remove as much of the alveolus, or even the 'body of the maxilla, as is affected, remembering that the extremity of the invasion must be reached. The wound should be dressed with iodized lint. If there is much inflammation the following may be applied : 3 — Plumbi acetatis, 3ij ; Tinct. opii, Sij ; Aquae, 3xvj. Sig. — Pack the wound with lint wet with the solution. I90 ORAL PATHOLOGY AND PRACTICE. CHAPTER XLL OSTEITIS. Before entering- upon the consideration of diseases of the bone it is necessary thoroughly to comprehend the pathological changes involved in the initial steps of the degeneration. Bone, which forms the framework of the body, is made up of an inorganic, or mineral portion, and an organic, or living part. The latter is con- tained within the meshes of the former, and communicates through the whole' structure of the bone. This is accomplished by means of the peculiar formation of the inorganic part. It is through the organic or living portion that nutriment of the whole osseous tissue is carried on. The changes that occur in the inorganic portion, the waste and repair, are not, of course, as great as those of vascular tissue, yet they must be provided for in the economy of nature. The nourishment of the bone, like that of all other tissues, must primarily be derived from the blood, and it is carried on through the periosteum or investing membrane, the medullary marrow or central cavity in long bones, and the Haversian or penetrating canals which carry the blood to all portions of the thick bones. Around the Haversian canals, and along all the sources of nutriment, are arranged a concentric series of cells containing the essential living matter of the bone. (See Fig. 51.) These cells are the lacunae, and each of the zones of these so concentrically arranged cells is called a lamella. Connecting the several lacunae, and communicat- ing with the nutrient source — the periosteum, the medulla, or the Haversian canals — are the canaliculi, the minute canals which carry the pabulum extracted from the blood to the lacunae, the immediate source of nutriment. The living contents of the lacunae and the communicating canaliculi are of a protoplasmic or embryonal character, and contain the elements of the osseous tissue. If the nutrition of its structure is cut off, the bone dies as inevitably as does any other tissue under like circumstances. If a ligature is placed about the ringer that is sufficient to prevent all circulation, and thus to stop all nutriment, the soft tissue will die and become gangrenous. If the ligation is OSTEITIS. I 9 I so complete as to deprive the bone of its nutrient currents, that will also die from the same reason, and become necrosed. If the stoppage of nutrition in the finger is through a progres- sion of the inflammatory process, by hyperemia, congestion, and final stasis of the blood current in the part, the result is precisely the same as if it were through a ligature, or separation of all arterial sources of supply. It matters not by what the nutrition is com- pletely interrupted, whether by starvation — stoppage of food supply either to a part or the whole of the body by cutting off that supply Fig. 51. Lamellae of Bone, showing also the Lacunae and Canaliculi. (From Gray.) through interruption of the channel of conveyance — or by such pathological changes as completely to prohibit assimilation of food products, death of a part or the whole of whatever is thus deprived of its food supply must be the inevitable result. In the soft tissues this may be called suppuration, ulceration, sloughing, or gangrene, and in the hard portions caries, exfoliation, or necrosis, but it is essentially all the same process. Each is but a different manifesta- tion of the universal law of death and decay whenever nutrition and progress cease. The instant that progression stops, retrogression commences. The contents of the lacunae and canaliculi of bone, the proto- plasmic embryonic elements, although they are not directly vas- 192 ORAL PATHOLOGY AND PRACTICE. cular, may be the subjects of inflammatory action. This process, differing from ordinary inflammation in some particulars because of the varying physical character of the affected substance itself, as well as of its environments, will arise from the same causes as do inflammations of other tissues, and may be studied from the same standpoint. The initial point will undoubtedly be in the tissue or organ that is the immediate source of food supply, — the periosteum, the investing or lining membrane of the bone. Disorders of this tissue must affect the living portion of the bone. Inflammation of the periosteum, if the degenerative process continues, ends in stasis of the blood currents, thus cutting off nutrition, with the consequent deterioration of the living contents of the lacunae and canaliculi. This inflammation, or affection of the living portion of the bone, is that which we call osteitis, and it is usually the initial point of necrosed conditions. If the osteitis is relieved through the" removal of the source of irritation and the re-establishment of nutrient currents, that is essentially the resolution spoken of in dealing with Inflam- mations. If it proceeds to the breaking down of tissue it will be caries or necrosis, the analogues respectively of suppuration and gangrene. Like all other inflammatory conditions, osteitis is the result of some irritant. This may be a traumatic lesion, the presence of pus or of a foreign body, or the interference with nutrition caused by some external impression manifested through the nervous sys- tem. Anything that would induce the inflammatory process in the soft tissues may in a less degree be provocative of osteitis in the hard. Probably there was never an acute pericementitis that did not induce a corresponding osteitis in the bony tissues in the imme- diate proximity. We know that an alveolar abscess causes a breaking down of the bone about the infected spot, and the forma- tion of a cavity of greater or less extent. We are also but too well aware that pus from an abscess sometimes infiltrates the bone, and will burrow to a considerable distance, forming secondary pockets and foci of infection, which sometimes make thorough sterilization very difficult. We know, too, that it takes considerable time to effect the complete healing of the pockets and cavities in the bone thus formed, and that until the embryonic or temporary tissue that is the result of the first reparative process shall have time to con- OSTEITIS. 193 solidate and become permanent through further progressive changes, there is always danger that the metamorphosis will take upon itself a retrogressive state and the whole again break down. All these conditions go to demonstrate the fact that osteitis, to a greater or less degree, is always present in pericemental complica- tions, and that in the treatment of such conditions its existence should be taken into account and care taken that it be kept in check. Symptomatology and Treatment. The diagnosis of osteitis as a separate infection is not readily made, and principally depends upon other known degenerative processes. The existence of an abscess in the immediate neighbor- hood of any osseous tissue must inevitably induce it. The mere presence of pus and of the micro-organisms of suppuration are sufficiently irritating to provoke an inflammation of periosteum, and that necessarily implies more or less of osteitis. But aside from such recognizable complications the condition does not pre- sent sufficient of pathognomonic symptoms to enable the observer always to detect it in its earlier stages. It may often be inferred, and in some instances perhaps determined, by exclusion of all other functional disturbances, but the pathologist must mainly depend upon associated disorders for his complete diagnosis. The periosteal inflammation that is the cause of, or that accompanies it, will manifest itself by a red line, or red blotches upon the superincumbent tissues, provided they are not too thick, and this will be intensified if there is very much of osteitis present But this cannot be depended upon as a certain diagnostic symptom, though it may be useful as an adjunct. The treatment of osteitis in its early stages should be abortive, and it will not materially differ from that laid down for the relief of inflammation in other tissues in the chapter (X.) devoted to that subject. Its presence once determined, every effort should be made to discover the source of irritation and to remove it. About the jaws this will most frequently be a diseased tooth, and when that is restored to a healthy state, unless the disorder shall have existed for some time or the lesions be unusually violent, the inflammation in the lacunse of the bone will subside with the rest. If, however, this is not the case, and the retrogression or degenera- tive action persists, it will result in either caries or necrosis of the bone, and these will be considered under their appropriate heads. 14 194 ORAL PATHOLOGY AND PRACTICE. CHAPTER XLIL CARIES OF ALVEOLAR BONE. In dental practice this disease may be compared to suppuration or ulceration in soft tissues. It is the devitalization of bone, cell by cell, and its breaking down by a comparatively slow progression, rather than death in mass. It has its origin in perverted or inter- rupted nutrition, but the phenomena exhibited vary somewhat from those of necrosis. It most frequently arises from local irritations, but it may be general and constitutional in its origin, as in the case of scrofulous subjects or those affected by the syphilitic virus. A frequent source of maxillary caries will be found in the diseased roots of teeth, which act as sources of irritation. Not infrequently, Loss of Septa through Alveolar Caries. a, Depressions in the bone, with denudation of the cervix of the tooth. too, it is the result of excessive violence in dental operations. Long-continued wedging will be likely to induce a local osteitis so severe as to interfere with the nutrition of the thin septa of bone between the teeth, denude them of periosteum, and result in a wasting caries which will destroy that portion of the alveolar process by slow disintegration. (See Fig. 52.) It will be comprehended that this form of caries materially differs from that which is by surgeons usually denominated caries of the bone, both in its etiology and symptomatology. While it may be aggravated, or even induced, by cachectic conditions, it is not characterized by the substituted granulation tissue. It more resembles in its progression dental caries, but is quite distinct from the latter in many of its characteristics. This form of caries of the CARIES OF ALVEOLAR BONE. 195 bone may be readily diagnosed, through careful examinations, by any one who is skilled in such matters or who has cultivated habits of close observation. Yet the earlier periods in these perversions are recognized by but few dentists, because their perceptions have not been sharpened by continual practice. Either they are not sufficiently instructed to know what to look for, or they do not extend their observations beyond the teeth themselves, and neglect everything save that which obviously demands mere mechanical or operative interference. Any localized congestion or inflammatory turgescence and swelling demands the attention of the practitioner. It may be indicative of a slight disturbance, or it may be the initial point of a serious lesion. The oral physician should be competent to determine which it is, and faithful enough to keep it under observation until it shall develop its true character; and the condi- tion should be recognized early enough to enable the practitioner to obviate the spontaneous formation of sinuses. True caries of bone will produce a marked change in the over- lying soft tissues. There will in the incipiency be great determina- tion of blood to the parts, with congestion and tumidity. This will gradually assume a deeper color, until it approaches a purple hue and sloughing commences. In simple denudation caries of the maxillary process there will be very little of this, nor will there be any very considerable forma- tion of pus. But there will be limited sloughing of the superim- posed tissues, with denudation of the bone, more or less complete, beneath. An opening through the soft tissues will be found, and this may be discharging a small amount of pus, though without acute complications. If now a probe — the best one for such cases is a hatchet-shaped excavator — or an explorer of some kind be car- ried through this opening, the bone will be found quite denuded and exposed. The point of the excavator will readily enter it, and small spicula from the roughened surface may be readily chipped off. There will be none of the smooth, solid, resisting sensation that a healthy bone presents. To the educated sense of touch it presents characteristics that cannot well be mistaken. If there is caries of the septum of the bone between the teeth, the result of traumatic violence, perhaps in wedging or filling, there will be a peculiarly rough, gritty feeling, showing that portions of it have been thrown off, with destruction of the periosteum. There may be I96 ORAL PATHOLOGY AND PRACTICE. a distinct putrefactive odor from the diseased territory, showing that food is undergoing decomposition there, even if there is no appreciable formation of pus. These conditions and appear- ances distinguish alveolar caries from the resorptions of the alveoli which normally occur after the extraction of the teeth and the destruction of the pericementum, upon the integrity of which membrane the tooth sockets are dependent. The treatment of this form of caries of the bone will be almost entirely local. If the degeneration is extensive, it may possibly indicate a general debility that will demand the use of tonics, but this will be very unusual, to say the least. The dead and carious bone should be burred away with the dental engine, and, if neces- sary, the diseased surface carefully curetted or scraped. This process must be carried to the extreme limits of the affected bone, which, unless there is a carious sinus, will not be very deep. This done, and all debris carefully washed away, the surface of the diseased bone may be saturated with aromatic sulphuric acid, which may be allowed to act for a few minutes, when the cavity should be thoroughly washed with water. That an acid, especially sulphuric, will exercise a selective action, dissolving only dead tis- sue, seems to be proved by the experiments of the late Prof. J. E. Garretson, who caused to be submitted to the action of a twenty- five per cent, solution of sulphuric acid, for three days, fragments of dead, of diseased, and of healthy bone, with the result that in dead bone a considerable proportion of the lime salts was dissolved, in the diseased bone a less amount, while in the healthy bone no such action took place. Great care must subsequently be exercised to keep the territory clean and aseptic, disinfectants or antiseptics being used if necessary. If the tissues seem indolent, they may be stimulated to action by the use of a weak solution of the chloride or iodide of zinc. Opportunity must be given for the formation of a new periosteum, and when the reparative process is once under' way the forming tissue must be left undisturbed, except for occasional gentle irriga- tions with an antiseptic or stimulative solution when that is abso- lutely necessary. Many practitioners defeat their own efforts by uncalled for and meddlesome interference — by over-treatment when all is progressing satisfactorily. The preceding remarks apply more directly to caries of the CARIES OF ALVEOLAR BONE. 197 alveolar process of the jaws. In caries of other bones there is almost always some cachectic condition, such as tuberculosis or syphilis, which induces the carious degenerations. (See Fig. 53.) If there is infection by septic organisms suppuration of course ensues, and the disease may assume a more destructively active necrotic type. In dry caries of the alveolar process, which is the form most frequently met with by the oral practitioner, there is nothing of this kind, nor is there necessarily a constitutional dys- crasia, the local irritation being sufficient to induce the gradual wasting of the cancellous bony tissue, through the gradually pro- gressive cutting off of nutrition. Fig. 53. Caries of Ulna and Radius. There are no such cavities found in the bone as in Fig. 54. In oral practice, then, a distinction may readily be made be- tween the carious disintegrations of the alveolar process of the jaws that may not be accompanied by any specially inflamed con- ditions and in which there are few if any traces of ulceration, and the porous, abscessed state of true caries, which is surrounded by foreign, unhealthy granulations of the soft tissues. The one is merely a gradual disintegration of the alveoli, brought about by the deprivation of the nutrient supply, with denudation of the process by sloughing of the periosteum. The other is the breaking down of osseous tissue with the formation of fetid pus, w T hich tends to burrow into the tissue. The first is due to simple lack of nutrition, usually the result of some injury, while the other is a cachectic state arising from some constitutional disturbance, the tuberculous deposit being its most frequent accompaniment. The only treatment demanded by the progressive crumbling of the alveolar process will be to remove any irritating cause, bur out the bone that is denuded of its periosteal covering and that is I98 ORAL PATHOLOGY AND PRACTICE. disintegrating", retain the gum tissue in place over it — by stitches if necessary — and then, by the use of stimulating astringents, to induce a new membranous growth. If there is an ulcerative condition, due to a dyscrasia, constitu- tional treatment will be demanded, and this will consist in the pre- scribing of nutritious diet, cod-liver oil, hypophosphites, syrup of iodide of iron, etc., with the local treatment previously recom- mended, and specific remedies when indicated. CHAPTER XLII'L NECROSIS. Necrosis of the hard tissue is the analogue of gangrene in the soft. Its progress is not so rapid, because of the difference in the physical characteristics of the tissues themselves. But its origin is in an identical disturbance of nutrition, its course presents the same pathological changes, the termination is usually similar, and the treatment involves the consideration of cognate principles. Inflammation forms the initial point in its morbidity, and it is from that standpoint that the degenerate modifications should be studied. Necrosis differs from caries of the bone rather in degree than in essence. As gangrene is the death of soft tissues in mass, so necrosis is the devitalization of a territory having an osteogenetic origin. Like caries of bone, its cause may be either traumatic or specific, local or constitutional. It may attack any of the bones, but the maxillae are especially subject to it; necrosis of the lower jaw is four times as common as in the upper. In simple caries of the alveoli this proportion is nearly reversed. When not the result of an injury, its origin is in an inflammation of the investing or lining membrane, which spreads to the lacunae of the bone, thus producing osteitis, which eventually reaches the point of entire inhibition of nutrient currents, with subsequent death of a territory more or less extensive. Necrosis is usually an indication of a weak, anemic, or debili- tated condition. When all the functions of life are active and general nutrition is good, vitality in a part will be maintained NECROSIS. 199 despite unfavoring conditions. But when there are defects in the assimilative process retrogression is easy, and there is a predis- position to wasting diseases. The most fruitful source of necrosis of the maxillae will be found in the presence of decayed, diseased, irritating roots of teeth. These initiate inflammations, and exacer- bate them when once started, prevent nutrition, and hence provoke devitalization. When the suppuration of alveolar abscess takes place the pus may burrow beneath the periosteum of the bone, and, separating it, cut off nutrient currents from the territory beneath. This will be especially probable in the lower jaw, for drainage of its pus pockets is usually imperfect, while gravity constantly tends to bring about infiltration ; and this will in part account for the greater proportion of cases of necrosis in that bone. A fruitful cause for necrosis of the jaws will be found in im- pacted teeth, arising from the lack of room for their proper develop- ment. This is especially true of the third molars, the body of the jaw between the symphysis and the ascending ramus often being too short to afford room for all the teeth. When the time comes for the development and eruption of the wisdom tooth all the space is occupied; it is imbedded in the tissues without power to advance, and becomes a source of violent irritation. An inflamma- tion' is excited which assumes a peculiarly vicious character, "and, the irritant still remaining, there is breaking down of tissue, infec- tion, and suppuration. In the general degenerative state this spreads to the bone, with consequent acute osteitis and necrosis. This condition, to which the upper jaw is not as liable, yet further accounts for the disparity in the relative number of cases in the two jaws. Necrosis may also be the result of injuries done by the dentist. Fractures of the alveolus in extraction are very common, but such is the recuperative power of these very vascular bones that nature usually buries the faults of the incompetent or reckless operator beneath new formations. If, however, the patient is suffering from any form of atony, the reparative process may not be sufficiently active to restore the normal condition, and retrogression may take the place of progression. In such patients the mere careless punc- ture of the alveolus to some depth by a sharp-pointed excavator, or plugger, or engine bur that has been infected by some septic product, may produce inoculation that will result in serious necrotic 20O ORAL PATHOLOGY AND PRACTICE. complications. Arsenous acid, when used in too great quantity for the devitalization of a tooth pulp, or if not securely sealed in the cavity of decay, may penetrate to the alveolus and produce a necrotic condition that will spread to other tissues. The pericemental inflammations consequent upon the death and infection of the dental pulp are a fruitful source of necrosis of the alveoli and maxillae. As has been elsewhere asserted, these always induce an osteitis more or less severe, and when the irritation is continuous, as in the case of atonic patients, it may very readily result in death of the adjacent bony tissue. The premature filling of the roots of septic teeth by the dentist has been responsible for many cases of necrosis. The introduction of the filling before the Fig. 54- Necrosis of Tibia, showing Cavities in the Bone. septic state shall have been completely made aseptic, and before the healing process has been fairly initiated, tends to keep up an irrita- tion which is fatal to healthy functional activity. Certain zymotic and exanthematous diseases sometimes have necrosed conditions among their sequelae. This is especially true of scarlet fever. Mercury, when given in large doses, may cause it. Tertiary syphilis is quite likely to attack the palate and nasal bones. People who, having dead teeth, work in match factories, are espe- cially liable to a form of affection called phosphor-necrosis, caused by the fumes of the phosphorus used, which is supposed to pene- trate through the root canal, and thus to come in contact with the pericementum which gives nutriment to the alveolar sockets. So universally is this special condition recognized, that in France every factory that uses phosphorus in the manufacture of matches must employ a dentist, whose duty it is periodically to examine all the inmates and forbid the employment of any that have dead teeth with unfilled roots. NECROSIS. 201 The diagnostic signs of necrosis are usually distinct and well marked. With the death of the bone, the overlying tissues with which it is invested become peculiarly turgid and inflamed. They finally assume a characteristic purple tint, and look exceedingly angry. This is increased as the tissue commences to break down beneath the surface and suppuration ensues. There is little of the characteristic "pointing" of alveolar abscess, but the pus finds its way to the surface at a number of places, and the discharge is usually profuse and fetid. If now an explorer is passed into one of the sinuses until it reaches the bottom, the characteristic sensation imparted by dead bone will be plainly felt; or if the disease has been peculiarly active in its character deep cavities may be detected in the bone, with crumbling, disintegrating edges. (See Fig. 54.) Minute chips of the degenerated bone may be easily separated with any appropriate instrument. There will be the usual septic fever, and this may be decidedly pronounced. There will be a general malaise and loss of strength and vitality. The constant tendency on the part of nature is to get rid of the dead and irritating tissue. The very suppuration that accompanies all necrosed conditions is a part of this process. It is indicative of a disposition to slough away the diseased portion. Sometimes this is successful. There is a clear line of demarkation drawn between the dead and the living tissue, and the granular lymph acts as a kind of wedge to separate them. If this is accomplished, the dead part that is thrown off is called the Sequestrum. At the same time there will perhaps be a successful effort on the part of nature to reproduce the bone, and this may be outside of and envelop the sequestrum. Such new enveloping bone is called the Involucrum, and it may entirely prevent the exfoliation of the sequestrum. (See Fig- 55-) When there is extensive alveolar necrosis of a peculiarly active type it is not always judicious to extract teeth, even though they are plainly involved. There is a difference of opinion upon this point among pathologists, but it must be evident to all that if the disease is the result of an acute osteitis, and the attachment of any part of a tooth is in live bone, its extraction will produce a wound that will be certain of infection; the inflammation will spread and a new focus will have been produced, which might have been avoided had the tooth been left to the slower process of exfoliation. On 202 ORAL PATHOLOGY AND PRACTICE. the other hand, if the tooth is a distinct irritant that is aggravating the situation it should be removed, provided it may safely be done. It will therefore be seen that it sometimes requires the nicest dis- crimination to determine this point. If there is a tendency toward the formation of a sequestrum, the dentist should not be precipitate in attempting its removal. He naturally desires to hasten this process, but good judgment must be employed, and it is usually safest to await the exfoliation which will follow in due time. If it is violently torn away before Fig. 55- Necrosis of Humerus, showing Sequestrum and Involucrum, the One Found Within the Other. the separation of the dead from the living tissue is completed by nature an open wound is produced, as in the case of extraction of a tooth, and at this point, minute though it may be, inflammation may begin anew and the diseased state thus be aggravated. But when a fissure of separation can be felt, a pledget of antiseptic cot- ton or gauze may be crowded in, and thus a little pressure made to assist the process of exfoliation. CHAPTER XLIV. TREATMENT OF NECROSIS. The treatment of necrosed conditions may be divided into three parts, — local, operative, and general. The first will consist of the use of disinfectants and depurators. There will be little occasion for antiseptics, because the flow of pus cannot be prevented as long as there is dead bone. But the whole diseased territory should be kept as carefully drained as possible, and it should be frequently and effectually cleansed with some good disinfectant. For this TREATMENT OF NECROSIS. 203 purpose electrozone, or meditrina, will be found especially useful, or peroxide of hydrogen, or a three per cent, solution of pyrozone may be injected with a syringe or applied with an atomizer. If the discharge of pus is into the mouth, that cavity should be fre- quently washed with an antiseptic gargle, and as much care as pos- sible should be exercised to avoid swallowing the septic products. A drainage tube, or strip of iodoform gauze to serve as such, may be introduced into the sinus if its location is such as to demand it, and this may be held in place, if practicable, with strips of adhesive plaster. Of course, neither of these will be appropriate if the dis- charge is within the oral cavity. Sulphuric acid may, in some instances, be profitably employed to dissolve out the dead bone. It may be used in such strength as the nature of the case demands, from a dilute aromatic solution to the chemically pure. Of course the latter will only be employed with caution. There is no danger to the soft tissues involved, unless possibly from the chemically pure, and even that involves no serious effect if it is properly used and washed away in time. Local stimulants may be employed to overcome the indolence if necessary. The operative measures to be employed will consist of those necessary to secure perfect drainage, and operations for the re- moval of the dead bone. Sometimes in the lower jaw a deep pocket will be formed in the body of that bone, through the enlargement by necrosis of the socket of a tooth which was the original cause of irritation. Drainage of this may be impossible, through the in- ability of the tissues to expel the pus over the borders. In one such case the author, against his own better judgment but at the solicitation of both the patient and the dentist who had referred her to him, attempted in vain the acid treatment after thor- ough burring out of the necrosed cavity. The pocket could not be kept clean, and reinfection from the retained pus was certain, until an anesthetic was given and an opening made from outside the face and beneath the jaw into the cavity. A strip of iodoform gauze was then passed through into the mouth, drawn back and forth repeatedly, and the end finally left projecting from the external wound to assist in drainage. The result was a speedy and complete cure, without the use of any other agents. In some cases of necrosis of the upper jaw, operative measures may be necessary 204 ORAL PATHOLOGY AND PRACTICE. to open completely and straighten out the sinus of discharge. This may be readily done by a proper bur in the dental engine. The operation for the complete removal of dead bone in the maxillae may be of a formidable character, and its consideration properly belongs to the domain of oral surgery. It must be thor- oughly done, if done at all. Half-way operative measures are of little account. The patient, having been properly fortified with nourishing food for a time, is anesthetized and placed in such a position as will afford complete command of the situation. The superincumbent tissues are laid back by the proper incisions, the blood checked by ligatures or the use of hemostatic forceps, and the territory carefully sponged and examined. When the extent of the lesion is fully determined, the proper steps are taken for the removal of the dead and diseased bone by the use of the dental engine, bone chisels, scrapers, and saws. When this is completed, all exposed edges of bone must be made smooth, every particle of debris removed, and the wound antiseptically washed and properly closed, with sutures if necessary, a drainage tube inserted, the exterior dusted with iodoform powder, and the whole enveloped in the proper bandages and dressings. If the wound is wholly within the oral cavity, of course the iodoform dusting and the bandaging will not be called for. The desirability of working within the mouth when practicable cannot be too strongly urged, especially in the case of young women, that disfigurement may not be the result ; but the success of an operation should not be jeopardized in the effort to avoid minor disfigurement. A visible scar is better than death, or even the entire loss of a bone. General or systemic treatment is called for in almost every case of extensive necrosis. The disease is of such a wasting nature that, at the very least, tonics and a sustaining diet will be called for. The patient should be made to live out of doors as much as pos- sible, and every hygienic precaution be taken. If the lesion is the result of some cachectic condition, like syphilis or mercurialization, the general treatment proper to such condition must be instituted. For the former a strict course of specific treatment will be de- manded. The subject is presented in another chapter, and hence it is not necessary to pursue it farther in this connection. The tonics that are used in wasting diseases are of two kinds, — vegetable and mineral. The former consist mainly of the bitter" HYPERSENSITIVE DENTINE. 205 barks of certain trees, while the latter are inorganic substances that exercise a peculiarly stimulant or alterant action that tends to pre- vent waste or assist nutrition. Of the vegetable tonics, Peruvian bark or cinchona, quassia, gentian, and wild cherry, with their alka- loids, are those most commonly employed; while the inorganic or mineral agents most used are preparations of iron, of copper, and of zinc, with such other remedies as subnitrate of bismuth and sul- phuric, nitric, hydrochloric, and oxalic acids. CHAPTER XLV. HYPERSENSITIVE DENTINE. Were it possible to rob operative dentistry of the horrors too often its determined attendant in the pain and anguish that excava- tion of carious teeth causes, public health would be greatly con- served and human life would be correspondingly lengthened, because of the greater care that would be bestowed upon those organs. Would the public generally learn to look upon the dentist in his true light, — that of one whose mission it is to avert pain and suffering, — he would be regarded with much greater favor and would enjoy higher consideration. But the nature of his work is such that, like the general surgeon, in his efforts to forestall future anguish he too often brings present distress, and too many who should be his patients choose to postpone the evil day and hazard all the future rather than risk a moment of the present. Recognizing all this, dentists from the earliest period in the history of their art have been constantly striving to devise some- thing that will give exemption from pain in dental operations. Most of their efforts have been entirely empirical, and often experi- ments and labors have been conducted in a haphazard way that betokens anything but professional erudition or scientific knowl- edge. Those who have claimed to accomplish anything in the way of a solution of the problem, have not usually been those who were best equipped by education and professional attainments for the task. The practitioner who advertises "painless dentistry" has passed into a byword, and the term is a synonym for an impostor and a charlatan. Almost invariably those who have brawlingly 206 ORAL PATHOLOGY AND PRACTICE. boasted that they have discovered a universal panacea for all dental pain have been illiterate, undisciplined, unknown pretenders, whose sole object was to secure a dirty dollar by unprofessional methods, and to make profit out of that which should be public philanthropy; men who would, if possible, garner the sun's beams and peddle them out for individual gain; who would put holy things to an unholy use, and make of human beneficence a public prostitute. Of this character have been most of the widely advertised prepara- tions for obtunding the dental tissues, — quack remedies, prepared by dental quacks for quackish purposes. The student and practi- tioner should avoid them if he is an honest man, for he has no moral right to recommend to a patient, who pays him for special knowledge, any drug of whose exact nature and therapeutic value both are alike ignorant. In its normal condition dentine should be without sensation. There are no organized nerves to convey impressions, even were the tooth-bone subject to them. Yet the protoplasmic, albuminoid con- tents of the dental tubuli may, under special irritation, become the subjects of inflammatory conditions, in which they not only re- ceive, but readily transmit to the dental pulp, external impulses of a painful nature. (See Fig. 56.) It is true that the pulp of the tooth is supplied with nerves ; yet they are without some of the characteristics of ordinary nerves, and, protected from all irritating shocks as it is in its normal state, even the pulp is not of itself responsive. Only when some of its protection is withdrawn, or when from some reflex source the pulp is subjected to special irritation, does it become impressible to outward agencies and con- vey disagreeable sensations. We know f hat it is a law that animals, and organs and tissues, adapt themselves to their environments and change their structure with varying conditions. Thus the fishes of rayless caverns lose their sight, and certain inhabitants of the greatest ocean depths are without the usual sensory functions. Both, by gradual transmis- sion to other surroundings, would develop special senses, as have other organisms. Continual subjection to external irritation may either weaken or develop the corresponding sentient perceptive- ness, through which alone can defense and security be obtained. That both dentine and dentinal pulp are without ordinary- sensation when in a perfectly healthy and normal condition, is HYPERSENSITIVE DENTINE. 2.0J proved by the fact that when a healthy tooth is fractured and the pulp thereby completely exposed, it is irresponsive to external irri- tants for a short time. Healthy pulps are painlessly "knocked out" by a certain class of practitioners, provided the teeth are sound and the work is done quickly enough. But if there is the least inflam- mation in either pulp or dentinal fibrils the operation is anything but painless. There is not a practitioner of extended experience who has not at some time cut into the dental pulp entirely without the knowledge of his patient, provided he was excavating in dentine that was completely or even comparatively irresponsive. Fig. 56. it;!*' Formative Dentine, showing the Protoplasmic Fibrill^e. a, Odontoblast cells of the pulp, with Tomes fibers or dentinal fibrillae ; b. Forming dentine. c, Formed dentine cut diagonally across the tubules. (Andrews.) The source of sensitive dentine, or of impressionable pulps, lies in their continued subjection to irritation, by which responsiveness is developed. The freshly exposed pulp, or dentine, of a perfectly healthy tooth, is without sensation. But a few moments of subjec- tion to external influences, the air and other irritants, are sufficient to produce a marked change in the tissues, and they become exquisitely responsive. A kind of inflammatory degeneration takes place, and normal function is so altered that disagreeable currents are conveyed. This is in perfect harmony with the other 208 ORAL PATHOLOGY AND PRACTICE. known processes of Nature, for in the presence of danger she always develops means of defense by giving warning through the awakened senses. If, then, in the normal state the tooth tissues are without sensation, it follows that if a pathological condition is succeeded by one of perfect health, the immunity to pain should be re-estab- lished. This is undoubtedly the fact, for teeth that have been attacked by caries, and which under its influence have become painfully sensitive, have, when the broken continuity has been restored by a filling, lost that responsiveness and again become insusceptible to external impression. It is true that this is not always the case, because the very material that has been used to mend the broken place may of itself become an irritant and per- petuate the abnormal state. Were it possible to fill an ordinary tooth with something that would be perfectly congenial to the tissues, there is little doubt that all filled teeth would be comfort- able, and herein may be found a reason why certain materials, aside from their lasting qualities, make the best fillings. The test for the perfect success of an operation is the condition of the tissues which ensues, — because recurrent decay is not the first symptom of the failure of an operation. It may be found in the responsiveness of the dentine to external irritants ; in its sensitive- ness to outward impressions. Not that it is always possible com- pletely to restore to healthy functional activity a tooth that has been subjected to operative filling. Usually only toleration with mild protest can be obtained for the foreign matter that is used for protective purposes, especially if it is of a metallic nature. When there is permanent denudation of any part, as in recession of the gums, normal conditions cannot even be approximated. One of the causes of the irritation in which is found the source of sensitive dentine is caries. This is of itself a pathological con- dition of dentine, and its progress necessarily entails other degen- erative conditions. The disintegration of portions of the tooth- bone, with the consequent destruction of parts of the dental fibrillar must affect that with which it is in connection ; and so there will be an irritable, disordered condition of the whole of the dentine, with hypersensitiveness and inflammatory changes in the protoplasmic elements of the soft fibrils, modified in manifestation by the char- acter of the structure itself. With such a destructive, deadly dis- HYPERSENSITIVE DENTINE. 200, order as caries working at its vitals, no portion of the structure of a tooth can be in a healthy state, for although teeth have not the complex and vascular formation of the soft tissues, we cannot con- sider these organs as made up of dead, inert matter. Denudation of portions of the tooth, its loss of a part of that which should form any of its investing protection, must subject it to unnatural conditions. If the gum has receded at the neck, that simply means that the tooth is exposed to new environments and strange perplexities that cannot be otherwise than exasperating. Under the stress of their provocation it assumes an added sus- ceptibility, and becomes more and more liable to attacks of external agents. All the dentine is thus affected, and it becomes tender, sensitive, responsive to any provocation. This, as in the case of caries, proceeds by continuity of tissue to the pulp, which also becomes irritable and inflamed, so that there is an immediate response to thermal changes, to the presence of acids or sweets, and even to the finger nail or quill toothpick. Metal toothpicks are almost always irritating to the teeth. Vitiated secretions are also a cause of sensitive dentine. The secretion of the somewhat specialized mucous follicles at the gingival margin is sometimes, through neglect of the teeth and the presence of fermenting debris, of a degenerative type. This secre- tion becomes acid, and in this state is highly irritative to the cervix of the tooth. Or the white deposit which is so frequently found surrounding the tooth at its neck, and which is made up of decom- posing matter undergoing fermentation or putrefaction, may be the cause of the irritation. The resulting acid may dissolve out some of the lime salts at the cervix, where the enamel is very thin, and so lay bare the dentine, which will thus be made specially irritable. Some of the most sensitive dentine encountered by the operator is the result of this acid degeneration or formation. The teeth are sometimes set on edge by the use of acids. This means softening of the superficial portion of the tooth, and a hyperesthesia, or its analogue, of the dentine. The sensation referred to is not a distinct pain, and it usually passes away with the provocation, but it is a definite feeling of responsiveness in dentine. The same kind of impression may be induced by reflex action, when a saw is filed or strong cloth is torn. 15 210 ORAL PATHOLOGY AND PRACTICE. CHAPTER XLVL TREATMENT OF HYPERSENSITIVE DENTINE. It has been affirmed that if a tooth that is in a healthy condi- tion is insensitive, a return to that state after diseased action should carry with it freedom from responsiveness. While this may be true, it is not always possible in dental practice to secure this result. In cases of caries it is impossible to induce a healthy state except by excision of the diseased part, as in necrosis of bone; and it is from the pain of that operation that we seek immunity; hence the only hope of the dentist is in securing an artificial anesthesia of the part. This may be readily accomplished, as in the other tissues, by inhibiting and stopping all nervous currents through general anes- thesia. But such methods are prohibited by the circumstances of the case. We do not wish to obtund all sensibility, but only to overcome that of a small part. The ordinary local anesthetics might be employed, and they would completely answer all demands were that which we wish to make insensitive supplied with bloodvessels and nerves. Unfor- tunately for our object, this is not the case with the teeth. Theirs is not the structure upon which local anesthetics act, and hence the latter are of but doubtful utility. When cocain was first discovered it was believed by many that the dental millennium had surely arrived, but that agent has been found powerless to benumb non- vascular tissues. This class of remedies may therefore be dismissed from consideration, because while they may under certain condi- tions inhibit nervous currents in tissues that have a nervous supply, they are inefficacious when that is lacking. Cocain will obtund a pulp that is exposed to its influence, but it is ordinarily powerless upon dentine. We are thus obliged to fall back upon specific remedies, or those whose therapeutic action is not thus limited. We know that the protoplasmic dentinal fibrils, when in an irritable state, or when made responsive by certain pathological conditions, will convey painful impulses along their course and deliver them to the cerminal nerve filaments of a more or less inflamed pulp. If, now, these afferent waves of irritation can be cut off at any point before reaching the sentient centers, immunity from pain will thereby be TRExVTMENT OF HYPERSENSITIVE DENTINE. 211 secured. This can be done by a general anesthetic that paralyzes sensory filaments and trunks, or it could be accomplished by the application of a local anesthetic directly to the pulp itself. Both of these, for reasons already given, are impracticable, and it leaves the work to be done upon the only other connecting link between the dentinal periphery and the brain. If the dental fibrils themselves can be put in such a state that they will no longer carry impulses to the pulp, that tissue cannot transmit any to the afferent nerves which carry them to the nerve centers. Fig. 57- ! f. , >- " Termination of the Dentinal Tubuli. a, Enamel; d, Dentine; c, Line of junction of enamel and dentine, — first calcification of tooth tissue; interglobular spaces. (Andrews.) There are two ways of accomplishing this, neither of which is entirely satisfactory in its results. The first is by producing some temporary physical change in the character of the fibril that will prevent its receiving an impulse, and the second by subjecting it to some medicinal agent that will paralyze its transmitting function. There are perhaps two other methods of accomplishing the same thing which should be included in the list of methods to be employed, and they will be duly considered. They are, first, the exercise of such care and gentleness, with the use of such perfected instruments as shall arouse no irritating pain waves; and, second, the employment of such general prophylactic remedies and 212 ORAL PATHOLOGY AND PRACTICE. measures to fortify the system as will enable it to resist them, or steel it against their reception. The physical agents which are practicable will be such as will temporarily change the material characteristics of the fibrillse, and of these the most important are heat and cold. Heat may act either by raising the temperature above the point of susceptibility, — which is impracticable, because it is of itself a painful process, — or by so changing the matter of the fibrillar through desiccation, or drying out, as to make them incapable of conveying impulses. It is readily conceivable that, a cavity being isolated by the use of a rubber-dam, a current of hot air may be effectual in so changing the physical structure of a fibril, by abstracting a part of its water, as to debar all reception or trans- mission of nervous or other impulses. This is perhaps the most simple of all methods for obtunding sensitive dentine. The use of cold, or refrigeration, will be equally effectual by benumbing or paralyzing the fibrillse. If an ether or rhigolene spray is directed upon the tooth cavity, or even upon the tooth itself, until the temperature is reduced sufficiently, it will be com- paratively irresponsive. This would without doubt be the most perfect obtundent, were it not that the effective use of the agent is of itself too painful in its application. There is also danger that the pulp tissue may be permanently injured through degenerative processes inaugurated by the shock of the cold. A severe inflam- mation may be the result of the application of the ether spray for too long a time. Hence this agent has never been used for obtund- ing purposes, except in extreme instances. The medicinal agents that have been employed in attempts to overcome dentinal hypersensitiveness are almost numberless. General and local anesthetics, stimulants and anodynes, excitants and sedatives, acids and alkalies, with many drugs of altogether indefinite and unknown therapeutic value, have been persistently recommended. The whole matter has generally been one of empiricism. It would seem that, so far as our present knowledge goes, anesthetics, whenever locally applied, have little direct effect upon dentinal tissue. All such remedies have a selective power, and affect nervous tissue alone. The dentinal fibrillar while they do not contain any nervous filaments, yet comprise the elements of such tissue ; and it cannot be positively affirmed that they are not, TREATMENT OF HYPERSENSITIVE DENTINE. 213 under certain conditions, amenable to anesthetic action. But we know that they are not ordinarily so, and hence the agents referred to have proved as inefficient as might have been anticipated. Certain sedatives, anodynes, and narcotics, like preparations of opium, cannabis indica, and chloral hydrate, have been effective in certain instances, but it is not at all certain that they did not work through other tissues, and thus act indirectly instead of directly. Some cauterants are effectual, but to a limited depth. Thus nitrate of silver, or chromic acid, or carbolic acid, will obtund, but only to the limited depth to which they reach. They certainly destroy the fibrillse completely as far as their action extends, but that action is not really obtunding; it is extinction. In the harmless coagulation of the albuminoid contents of the dental tubuli would seem to lie the surest road to success. There are coagulating agents that thus obtund, like chloride of zinc, but it is too often at the expense of quite as much suffering as they save, leaving out of consideration the dangers to which the dental pulp is exposed by the use in its proximity of active escharotics. If coagulation could be accomplished without per- manent injury to the tooth structure, and would reach deep enough to allow of effective excavation, the agent that accom- plished this without pain would be the long-sought desideratum. That drug has not yet been discovered, nor can we be sure that it ever will be. Certain it is that until it is sought for in an intelli- gent, scientific manner, it will remain a secret; for the illiterate, untaught ignoramuses who have in the past been mainly respon- sible for the quack preparations sold at an extortionate price, and who have not sufficient pharmacal knowledge to save them from compounding the most glaring chemical incompatibles, are not likely to be the discoverers of that which so many competent men have sought in vain. Cataphoresis, which is the transfer of medicaments into the deeper parts of tissue through the diffusive power of an electric current, seems to promise something in this direction. It is not recently acquired information that has taught us that when a drug is applied to a tissue upon the positive electrode of a battery, the negative being placed so that the current will traverse the organ to be affected, it will carry with it the remedy; this principle has been quite extensively employed in general medicine, and with good 214 0RAL PATHOLOGY AND PRACTICE. results. To make the remedy in cataphoric medication effective it is not sufficient to carry it deeply into the dentine ; it must be trans- ferred to the pulp itself, and to the accomplishment of this the hard dental tissues present difficulties not met with in other organs, in their relatively low vitality and their comparative impenetrability. Yet practical experience seems to point to the indisputable fact that cataphoric transference does take place, but whether with sufficient readiness and rapidity to make it all that can be desired remains to be definitely established. No one will dispute the assertion that in the cataphoric transference of such topically applied remedies as cocaine and morphine better results have been secured than in any other of the thousand proffered methods of obtunding sensitive dentine. But its employment requires a cumbersome and expen- sive apparatus, troublesome alike to operator and patient, and its results are by no means uniform. While, therefore, every progres- sive operator should use it, it is not now to be considered a finality. Its application must be simplified and its effects made positive by further experimentation before it can be so accepted. Good men are investigating it, and it is to be hoped that in it will eventually be found that which is so highly desirable. It cannot be forgotten, however, that good men have before this cried, "Lo, here! Lo, there!" only to meet final disappointment and defeat. Prophylactics have proved of great service in the dental operat- ing room. They are of sedative nature, and reduce general nervous irritability, thus preventing or obtunding nervous shock. They have not been as much used as their merits demand, because most dentists have either been lacking in the medical knowledge neces- sary to their most intelligent use, or have not felt themselves war- ranted in administering general remedies. The first of these causes, if it exists, should be at once removed by study, and the last eliminated by a proper amount of self-confidence. The time for administering such remedies is a few moments before com- mencing any painful operation, the exact interval depending upon the nature of the drug. A few whiffs of chloroform or ether, not enough to induce any functional disturbance whatever, will fre- quently be of use, but their influence will not last long. Twenty- five grains of potassium bromide in water will be more persistent, and usually quite as effective. Syrup of lactucarium, in teaspoon- ful doses, has been employed with good effect ; or tincture of bella- donna, administering from five to twenty drops. TREATMENT OF HYPERSENSITIVE DENTINE. 215 Sulphate of morphia, in doses of from a quarter to half a grain, has been frequently used, but its action upon some people is a little uncertain. The fluid extract of Jamaica dogwood may be substi- tuted for this, and five to twenty drops given in a little water. The full dose of the drug is from a half to two fiuidrams. The author has not for several years been without aromatic spirits of ammonia in his case, and whenever there is unusual nervous irrita- bility he administers from thirty to sixty drops of it in water. If there arises the necessity, a hypodermic dose of from one-eighth to a quarter of a grain of morphine may be given. This is usually effectual in quieting all nervous excitability and making otherwise insupportable operations comparatively tolerable. The proper dose of this drug, combined with atropine or strychnine, may be readily obtained in tablet form, and should always be kept at hand. Hypodermic medication has not been as much employed in oral practice in the past as it should have been. But, when all is said and done, the main dependence of the judicious dentist will be upon a gentle hand and sharp instruments. It is barbarous to employ in a sensitive tooth any tool that is not in the best possible order; while the operative dentist who for a moment allows himself to forget the consideration that is due to a sensitive, timid, shrinking patient, who will become in the least degree careless or callous, and thus give unnecessary pain, is unworthy his vocation. In excavating a sensitive tooth he should invariably put on the rubber-dam, and dry out the cavity as far as possible. Then he w T ill find a great deal of relief in the employ- ment of many of the remedies already mentioned, and especially in the use of some of the essential oils, like cassia, cloves, or eucalyptus, securing penetration by means of the hot-air blast. A mixture of equal parts of sulphate of morphia and gum camphor may be found useful for this purpose in some instances. Or he may apply tincture of aconite dilute, or any other favorite remedy, always remembering that its effectiveness will be greatly increased by thoroughly drying the cavity of decay, and by the hot-air current. For those who wish a cocain preparation that is effective, the following is given. It should not be forgotten that this is a ten per cent, solution, and when used hypodermically less of it should be injected: 2l6 ORAL PATHOLOGY AND PRACTICE. Atropine, T V grain; Strophanthine, Vs " Cocain mur., 50 " Carbolic acid, 10 " Oil of caryophyllus, 3 minims ; Dist. water, 1 ounce. The following formula has been recommended by Professor Peirce as effective: ty — Cocain mur., 5 grains; Carbolic acid, 20 " Chloroform, */ 2 dram; Muriatic acid, 10 minims; Alcohol, 2 drams. CHAPTER XLVII. SECONDARY DENTINE, PULP NODULES, AND CALCIFICATIONS. These, although different manifestations, are parts of the same process. They have their origin in the same disturbed function. They are the result of deranged neural currents and of some per- version of nutrition which induces a formation of dentine in abnor- mal quantities or in an anomalous position, through the undue activity of the odontoblast cells under the excitement of just enough of irritation to act as the proper stimulant. All of these products have the general structure of dentine, although it may be considerably modified. (See Fig. 58.) They are not usually found as mere calcific, structureless calculi, but are organized by the unduly excited odontoblast cells, whose normal activity continues through life. The odontoblasts are not found exclusively upon the periphery of the dental pulp, any more than osteoblasts exist alone in con- nection with periosteum. The latter may be found inside the body of the bone, and may be the initial points for new growths after operations or accidents. The former may exist or be developed within the pulp tissue, and under the special stimulus that was perhaps responsible for their formation may commence functional activity, with the consequent organization of segregated spicules of dentine, and these may continue to grow until they assume the form SECONDARY DENTINE, PULP NODULES, AND CALCIFICATIONS. 2\J of the usual pulp nodule. Sometimes this form of calcification may begin at many points within the pulp, and may impart to that of a freshly extracted tooth a gritty, sandy sensation when it is rubbed between the finger and the thumb. At other times there is an agglomeration into one or more large concretions. When the unwonted functional activity is at the peripheral pulp borders, the new formation will probably be attached to and form a kind of hypertrophy of the ordinary dentine of the tooth. Sometimes this will be so continued that it will almost entirely fill Fig. 58. Formation of Pulp Stones. (Andrews.) the pulp chamber, and even extend down into the root canal. An examination of an extracted tooth affected with this condition will show by its complete or partial attachment to the normal dentine, or by its independence of it, where was the commencement of the new growth. The "pulp stones," or formations of dentine that take place within the substance of the pulp, sometimes contain chambers not unlike the "interglobular spaces" of the tooth. These impart an appearance of bone, and the new formation is analogous to true "osteo-dentine." It may even have open canals that cause it to 218 ORAL PATHOLOGY AND PRACTICE. assume the appearance of vaso-dentine. As might be inferred from the circumstances under which it is deposited, its structure will be Fig. 59. Secondary Formations in the Tooth of a Whale. Fig. 60. Wounded Tusk of Elephant. a, Point of entrance of musket ball through the alveolar walls when the animal was young ; b, The ball carried down and imbedded in the ivory or dentine by the growth of the tusk. (From a specimen in the Buffalo College Museum.) quite irregular and unmethodical. The canaliculi, or dentinal tubuli, will be involved, convoluted, and irregular. More or less SECONDARY DENTINE, PULP NODULES, AND CALCIFICATIONS. 2IO, Fig. 6i. A Representation of the Tusk shown in Fig. 60, with a Section Removed to show Secondary Formations in the Pulp Chamber above the Ball. a, Cervix of tusk ; b, c, d, e, Masses of secondary formation. 220 ORAL PATHOLOGY AND PRACTICE. of the calcified mass may be hyaline, but the structure, when care- fully studied, will be found to be essentially dentinal. The study of comparative dental anatomy will materially assist in a comprehension of these anomalies. In certain animals secondary dentine, or tooth-bone, is very common. This is especially the case with some of the monophyodonts. The per- sistent pulp chambers of the sperm whale (Physeter macrocephalus) are very frequently lined or partially filled with secondary dentinal formations, and some of them make very beautiful objects when polished. (See Fig. 59.) The long incisors of the elephant, the so-called tusks, are frequently wounded by the hunter near their insertion, the bullets remaining in the persistent pulps. This may result in the destruction of the vascular portion of the tooth, but Fig. 62. Fossil Fragment of the Tusk of Elephas primigenius—in^. Hairy Mammoth — which had been partially fractured during llfe and repaired and strengthened by Secondary Deposits. The fracture was across the base at a ; the part between the lines at b and c was a second- ary deposit. (From a specimen in the Buffalo College Museum.) much more frequently the consequence is the deposition about the wound of secondary dentine, which perhaps will entirely inclose and segregate the original cause of irritation, and form septa across the pulp chamber. With the continuous growth of the tooth or tusk this is carried forward, until, perhaps many years subsequently, when the animal is killed and its tusk falls into the hands of the ivory cutters, the original bullet, with the secondary formation about it, is found in the solid ivory, perhaps one or two feet from the skull. (See Figs. 60 and 61.) SECONDARY DEXTIXE, PULP XODULES, AXD CALCIFICATIOXS. 221 Nature sometimes throws out a layer of secondary dentine to protect the pulp from slowly advancing caries, or erosion. The formative cells at the periphery of the threatened portion of the pulp are by the irritation stimulated to increased functional activity, and a kind of hypertrophy of dentine is the result. Prac- titioners have sometimes seen this take place under a plastic rilling that had been inserted over a nearly exposed pulp. In the course of a few years this perhaps became sufficient support for a solidly impacted metal filling. This is the result hoped for in all instances of ordinary capping. Fractured teeth have been known to be united by a secondary growth of dentine, though these instances are probably few in number. The formation of so-called pulp stones and secondary dentine is a much more common occurrence than is usually imagined. The examinations of the pulp chambers of extracted teeth in the teach- ing of operative technics in some of the colleges, shows that a con- siderable proportion of teeth are thus affected. The late Prof. A. P. Southwick, of -Buffalo, who was one of the most observant and successful of technic teachers, believed that from sixty to seventy per cent, of extracted teeth show some form of it, but as this applies chiefly to such as have been extracted for diseased con- ditions, probably it would not hold good universally. The formations within the pulp chamber are sometimes the cause of considerable local irritation, but neither the objective nor the subjective symptoms of these conditions are sufficiently distinc- tive to afford reliable means of diagnosis. When they are of rapid growth the pain may be of an acute character, but they do not under ordinary circumstances induce any breaking down of pulp tissue, nor do they bring about any serious complications. Usually the suffering is of that subacute nature that is hardest to locate. It presents no special distinguishing characteristics, and a diagnosis can only be safely made through exclusion. When it is certain that the pain arises from nothing else, it may be attributed to secondary formations. It might, by the superficial observer, readily be mis- taken for facial neuralgia, but it is not, like that, paroxysmal or periodical. Xor is it so acute or so intense in its nature. The presence of pulp stones will not usually be suspected until they are discovered through pulp exposure. Xot infrequently they will seriously embarrass the dentist in his efforts at pulp devitali- 222 ORAL PATHOLOGY AND PRACTICE. zation and extirpation. Sometimes in their presence it is with the utmost difficulty that even arsenous acid can be made to produce its characteristic effect. Why this should be the case to such a marked degree it is impossible to say, as the secondary formation does not usually make an entire septum in the pulp chamber. That it may completely bar the proper filling of the roots of a tooth is more conceivable, for the growth may be so attached to the ordinary dentinal walls as to make its removal very difficult. It may form such an obstruction in a root canal as will absolutely forbid the passage of an instrument. In such instances the Papain digester, as recommended by Professor A. W. Harlan, may be made to serve a specially useful purpose in removing portions of the devitalized dental pulp which are beyond the reach of instruments. In the past there has been no resource save the slow and uncertain process of sloughing, which implies an infected root canal. The presence of secondary formations, then, will only be positively known when it is too late for anything but removal, when this is practicable. If they are floating in the pulp chamber this will not be a difficult matter. But if they are attached to the dentinal walls it may be impossible. It is not a safe practice to attempt to drill them out, nor in all cases would this materially assist in the subsequent treatment and filling of the root. The operative dentist will be obliged to take them out by enlarging the opening into the pulp chamber when this is practicable, or to use sufficient time thoroughly to sterilize any fragments of remaining pulp tissue, and then to fill as best he can, using some plastic material for the pulp chamber. CHAPTER XLVIII. HYPERCEMENTOSIS. Hypercementosis is the analogue of hyperostosis, or exostosis, of bone. Technically it is a tumor, but always of benign growth. It is an hypertrophy of the cementum, and has its origin in some form of irritation that is just sufficient to stimulate the pericementum to an abnormal activity. (See Fig. 63.) It may be local, and affect but one tooth, or the irritation and stimulus mav be so o'eneral as to HYPERCEMENTOSIS. 223 induce an excessive deposit of cementum in some form upon all, or nearly all, the teeth of either jaw. (See Fig. 64.) It may even be more comprehensive than that, and involve the osseous tissues. Instances have occurred in which hypercementosis and hyperostosis existed together, with not only enlargement of the roots of all the Hypercementosis of the Roots of a Lower Molar showing Stimulation of the Entire Pericemental Membrane. teeth, but of the whole alveolar process of the bone as well. Nodules of exostosed bone may sometimes be felt along the alveolar portions of the lower jaw especially, and these are apt to be associated with expansion of the roots of the teeth from hypercementosis. (See Fig. 65.) Fig. 6a. General Pericemental Hyperplasia. Teeth Successively Lost by One Patient. The Two on the Right were Fused together by the Hyperplastic Cementum. (Practice of Dr. William Jarvie.) The condition is not one that presents very special pathogno- monic symptoms. Unless it is accompanied by hyperostosis, there will be no external indications of its existence. Nor is it provoca- tive of much pain. Hence its diagnosis is at times difficult, or even impossible. There may be a feeling of pressure and general un- easiness in the teeth affected, but it will not be sufficient to furnish a diagnostic sign. There are no special complications, and hence 224 ORAL PATHOLOGY AND PRACTICE. the condition is not one of great pathological importance. Its chief import to the practicing dentist lies in its being an impediment to extraction,) and when that is imperative may make it necessary to cut through the investing alveolar process before the tooth can be lifted out. This will only be called for at the cervical constricted portion above the expanded part of the root. There will have been a resorption of the investing bone sufficient to accommodate the hypertrophy itself, and the cutting through, or removal of a part of the constricted superficial alveolar process is but a simple Fig. 65. Nodular Hyphrcementosis with Accompanying Hyperostosis. a, Osteophytes upon the external alveolar surface; b, Irregular cemental growth, involving both buccal roots ; c, Cementum nodules. The teeth were so bound together by the interlock- ing of the cemental growths that all three unavoidably came away together with the exertion of but moderate force, causing an opening into the antrum. (Practice of Dr. G. C Daboll.) operation, and is very much preferable to a long struggle to effect expansion in continued efforts to extract the tooth, with the liability to its accidental fracture under the forceps. Microscopical sections of portions of hypertrophies of the cemen- tum show that they have the true cemental structure, and there is no special line of demarkation visible between the new and the old formation. Pigmentation, or coloring, is not uncommon, its most usual form being a deep yellow or light brown tinge. The cemen- tum corpuscles are often unusually large, so that the nutrition of the hypertrophied and original tissue is very well carried on, for perhaps obvious reasons. A clinical and microscopical study of DISCOLORED TEETH. 225 the pericementum in these conditions has not hitherto been made. When this is undertaken further light upon this interesting subject will without doubt be afforded. CHAPTER XLIX. DISCOLORED TEETH. While the remedial measures for the relief of discolored teeth belong rather to operative dentistry, and are outside the scope of this work, yet a little may be said concerning the cause of dis- coloration, which may be due either partially or entirely to patho- logical conditions. People sometimes present themselves to the dentist with the request that an objectionable color of the whole or parts of the teeth may be discharged, when it is plainly evident that it is congenital. Some people have yellow, and some dark teeth naturally, and no skill is sufficient to alter this without material injury. The leopard cannot change his spots, nor the Ethiopian his skin. But there are pigmentary deposits upon the surface, and stain- ing which penetrates to a little depth, that it is possible to remove. Of these the most common is the so-called "green stain" so fre- quently found on the teeth of children, and the analogous brown or reddish-brown pigmentation on those of older growth. It has no special pathologic signification, and may readily be removed by tinct. iodine and pulverized pumice. (See Fig. 39.) Dead dentine, the tubules of which have become filled with pigmentary matter, may be bleached by chemical agents. Usually these deposits, either upon or within the substance of the teeth, are of a yellow or dark color, but in some instances the teeth are turned to a bright blue, or even an intense green. Workers in different metals may have their teeth stained by minute particles. This is especially the case with brass, nickel, and copper workers. When this is superficial it may be readily removed, but when it has penetrated the substance of the tooth it presents greater obstacles. It is not usually the case that a tooth containing a living pulp is affected by anything beyond mere shallow exterior discoloration. There may be congenitally maculated spots, or atrophied regions 16 226 ORAL PATHOLOGY AND PRACTICE. that become pigmented, but any material changes of color are -usually associated with a devitalization of the affected tissue. As the consequence of a sharp blow, and sometimes too protracted or severe dental operations, a tooth has been known to as- sume a bright pink appearance. This is, however, the result of death of the pulp. While the red blood corpuscles are much too large to enter the dentinal tubules, their stroma may be ruptured and the hemoglobin may penetrate the tubuli, giving the red tint. Subsequent changes in this substance may produce a gray or brown color, which finally becomes fixed as a very dark or blackish tint by the action of iron or sulphur. This is more apt to be the case in man than in woman, because the percentage of accidents is somewhat higher. The changes are analogous to those that take place when one has a "black eye," but as there are no absorbents to take up the •decomposed blood, it remains a black or dark color. The dentinal fibrillar themselves may, instead of being sloughed ecome engaged, and may be felt, or even seen, presenting their characteristic appearance. In suspected chancre of the lip the condition of the sub-maxillary gland will be a great help in mak- ing a diagnosis. The chancre is single. The instances in which two or more appear are very rare. It is not auto-inoculable, and in this respect materially differs from chancroid, or false chancre. It usually heals readily, without any scar or deep mark, and that without special local treatment. The time of its duration is somewhat uncertain, and depends upon the type which the disease assumes. Very young and very old persons are likely to be more violently at- tacked, and the chancre may in these instances persist longer. The same may be said of atonic and anemic individuals, or those suffering from tuberculosis, malaria, or alcoholism. In these cases the whole affection is likely to assume a malignant type, and the sore may continue until the appearance of the secondary symptoms. In the primary stages mercury seems almost a specific, and if the system will bear it in sufficient quantities the progress of the infection is stayed. Sometimes, however, this remedy produces such derangements that it is impossible to continue its free use, and the doses must be reduced. Ptyalism with intense glossitis may supervene, and other general disturbances may be of such a grave character that it will be found imprudent to push it suffi- ciently to neutralize the virus completely. The chancre should be treated antiseptically, and if necessary cauterized to hasten the healing. THE SECONDARY STAGE OF SYPHILIS. 255 CHAPTER LV. THE SECONDARY STAGE OF SYPHILIS. With the disappearance of the primary sore commences the second period of incubation, or that in which the virus is insid- iously but steadily invading all the tissues of the body. This period, like the first, is variable, and may extend from three weeks to six months, or even more, seven weeks being about the aver- age. At the end of that time there commences a train of symp- toms which denote that the infection has passed beyond the local stage, and through the lymph channels has reached every organ and tissue of the body. During this second period of incubation the uninformed victim might imagine the disease cured, but that is by no means the case. The virus is very active, though without any outward manifestations, until it exhibits its destructive energy in constitutional symptoms. The indication of the completion of the second period of incu- bation and the commencement of the second stage of syphilis is the appearance of the so-called syphilides, or syphilodermata. These are the eruptions of various kinds which appear upon different parts of the body. The first of these is most commonly a kind of roseola, or redness of the skin, which covers the thorax, occa- sionally the abdomen, and sometimes nearly the whole body, very rarely appearing on the face. It is symmetrical, occurring on both sides of the median line alike, and not coming as irregular desultory blotches. Like the chancre, which marks the primary stage, this eruption is without any functional disturbance, and in this absence of burning or itching or fever differs from all other skin eruptions. The roseola is entirely superficial and spontane- ously disappears after a variable period, to be succeeded by other forms of eruption. The syphilides of the secondary stage appear on both the skin and the mucous membrane, and may be erythematous (red blotches), macular (pigmented spots), squamous (scaly), vesicular (sac-like), pustular (pimples), tubercular (nodules), rupial (crusts), or they may assume any intermediate form. The syphilitic sore throat, which usually accompanies any of these forms, is really the eruption upon the mucous membrane of the pharynx. 256 ORAL PATHOLOGY AND PRACTICE. The mucous plaques, or mucous patches of the mouth, are the same eruptions, changed in their appearance by the character of the tissue in which they are manifested, and by their environ- ments or surroundings. For the purposes demanded by the present study all the syphil- ides may be divided into three classes — the macular, the papular, Fig. 86. Mucous Plaque or Patch (Papulo-erosivk Plaquk) upon the Tongue. (Wende.i and the pustular. The first when they appear upon external cuta- neous surfaces are primarily only pigmented spots, like freckles, not raised above the surrounding tissues, tending to circular groupings, and of a coppery color. They may entirely disappear and be succeeded by, or they may assume, the papillary form, and spread. They appear innocent and give the patient no incon- venience. THE SECONDARY STAGE OF SYPHILIS. 257 In the mouth and upon mucous membrane the eruption is usually first seen in this macular form, — that is, of reddish or copper colored spots, not raised above contiguous surfaces. They may be observed over the arch of the soft palate, upon the tongue and pillars of the fauces, on the buccal surfaces, and along the mucous membrane where it doubles upon itself and where it is hidden from ordinary observation. Especially are they apt to appear beneath the tongue and upon the folds of the membrane in that locality. They may be the size of the finger nail or they may be mere punctate spots. Usually they very soon disappear and are suc- ceeded by the papules. The papular form is that which succeeds the macular. It con- sists of reddish pimples appearing upon the skin, which from a single point spread, or from a number such become confluent. Gradually these papules become more pronounced and separate, certain of them perhaps degenerating and assuming an aggra- vated appearance, while between them the others disappear or become scaly, the surface being exfoliated, and so the eruption takes upon itself the third or pustular form. This is the most common manner of progression, but in some malignant instances the macular seems very quickly to degenerate into the pustules, without the appearance of papules. In the mouth the papular form assumes different characteris- tics. Instead of gradually becoming pustular, the surfaces are macerated in the oral fluids and soon appear as erosions. There is an infiltration into the sub-mucous tissue, and this causes a raising of the edges, while the sore is imbedded in a stroma of the thick- ened, slightly sclerotic base. The center softens and is covered with a grayish film, which discharges a sanious, highly infective fluid. This sore will have sharply defined edges, a dark red aureola surrounding it, an excavated surface and a crater-like general aspect, with necrotic tissue on or in it, when seen in its worst phases. In less pronounced cases it may be only a round or ovoid sore of a yellowish color, no aureola, with but a slight excavation and a discharge which is not as profuse, but is quite as infectious as is the other. The appearances described in the preceding paragraph form what are called the "mucous plaques" or "mucous patches" of sec- ondary syphilis. (See Fig. 86.) They are the oral syphilides 18 258 ORAL PATHOLOGY AND PRACTICE. which the dentist should most carefully guard against. They will most frequently be observed on the borders of the tongue, but may be found anywhere on the oral mucous membrane, the uvula, in the pharynx, and where two surfaces come in contact. They may degenerate into deep ulcers and be accompanied with acute glossitis, or swelling of the tongue, which may thus press against the teeth and its edges and be made to assume an indented or scalloped appearance. These phenomena disappear sponta- neously in time, sometimes leaving deep furrows as the result of the glossitis which may be present. The pustular form of the eruptions upon the skin may be degenerations of the papules, or the latter may disappear entirely to be succeeded by the pustules. Gradually the papules may become more pronounced and some of them may take on the pustular form, softening at the center and discharging a sanious fluid which is exceedingly infective. These may become aggravated and ulcerate and be very offensive. If, on the other hand, the disease does not assume a malignant type, they may dry up and disappear without ulceration. They may appear on the scalp or lower extremities as cone-like elevations, giving rise to large, irregularly shaped ulcers, secreting a bloody pus that dries up and forms dark brown or black crusts, or they may dry down and exfoliate the surface in the shape of scales, thus forming the squamous syphilides that may possibly be mistaken for psoriasis, or itch. It may thus be seen that the eruptions of secondary syphilis very widely differ in appearance, depending upon the constitutional condition of the patient and the type of the disease. This pustular form does not offer the same phenomena in the oral cavity. On mucous membrane the mucous plaques may ulcerate and cause considerable pits, but they do not rise into cone-like eleva- tions. As already asserted, there is no essential difference in the conditions, the mucous plaques or patches being the analogues of the papular eruptions upon the skin, and their ulceration an- swering to the pustules which appear on external cutaneous sur- faces. When the one is present the other may be looked for in its proper place, the difference in manifestation being due to the modifications of the tissue. During all this time the enlargement and induration of the lymph glands has been increasing and extending. They may proba- TERTIARY AND HEREDITARY SYPHILIS. 259 blv be felt at this time along the posterior border of the sterno- cleido-mastoid muscle, the other cervical glandular regions, and those of the supraclavicular and epitrochlear localities. They vary in size from that of a pea to a pigeon's tgg, are round, hard, and painless. At the same time the constitutional disturbance begins to manifest itself in fever, the bodily temperature rising perhaps to 102° F., in pains of neuralgic or rheumatic character, and in severe headaches. There will be restlessness and sleeplessness, all the symptoms being worse at night, and exacerbated by fatigue or by exposure to extremes of temperature, by wet feet or any unusual exposure. The virus is infecting the deeper organs and interfer- ing with functional activity. It should always be borne in mind that the characteristic secre- tions of the syphilodermata are infectious in the highest degree. The blood at this time, as has already been intimated, may con- tain the virus to such an extent that it becomes noxious, and inoculation with it may produce the true phagedenic chancre. The saliva may be mixed with the discharges from mucous plaques and also be capable of communicating the disease. The whole system, in fact, is a loathsome, pestilential mass of corrup- tion, revolting to the sufferer himself and abhorrent to others. CHAPTER LVI. TERTIARY AND HEREDITARY SYPHILIS. Tertiary Syphilis is the final result of the specific infection. It is a breaking down of the tissues under the degenerative process, and is characterized by a worse series of syphilides, by necrosis of the hard, and ulceration, sloughing, and perhaps gangrene of the soft tissues. It is a process of general destruction, and some of its forms are repulsive in the extreme. The discharges are not, however, of such an infectious nature, and hence it is of less interest to dentists than the earlier forms of syphilis, but it should not be imagined that they are wholly without danger. The period of incubation between the secondary or eruptive and the tertiary or constitutional stages is very uncertain. Some- 200 ORAL PATHOLOGY AND PRACTICE. times the latter succeeds almost directly upon the heels of the former, and in other instances years may elapse after the disap- pearance of the syphilides before tertiary symptoms become manifest. Dr. G. W. Wende, of the University of Buffalo, reports one case in which only four weeks elapsed between the initial Fig. 87. Gl mma upon the Dorsum of the Tongue (Gummatous Infiltration). (Wende.) sore and the appearance of tertiary symptoms. In four months syphilitic necrosis had eaten away nearly all the bones of the . destroyed the sight, and almost blotted out every feature. The author saw cases in the island of Cuba which assumed such lignant form that there were no marked stages or periods, TERTIARY AND HEREDITARY SYPHILIS. 26l the one succeeding the other so quickly. Indeed, hospital sur- geons in Havana report that a typical form there is almost or quite incurable. The syphilides of the tertiary stage commence with the appear- ance of tubercles or gumma, the former being in the skin or mucous Fig. Toads-Back Appearance in Syphilis. Gummatous Infiltrations (papulo-hypertrophies) producing the so-called toad's-back appearance. (Wende.) membrane, while the latter are subcutaneous or submucoid. The advent of either in syphilitic patients is an indication that the disease has passed the eruptive or secondary period, and has reached the tertiary or constitutional stage. Tubercles are gran- 262 ORAL PATHOLOGY AND PRACTICE. tilar nodosities, usually very small and numerous, which may be felt in the epidermis. The gumma are thickened, swollen masses in the tissues beneath the surface, and are caused by infiltrations into the cellular structure. (See Figs. 87 and 88.) The latter usually appear as circumscribed, firm nodules, varying in size from that of a small cherry to that of an orange. At first the skin or mucous membrane is uncolored, but later it is apt to change to livid or purple, becoming thin at the apex and finally ulcerating. The gumma are not ordinarily numerous, seldom exceeding three or four in one subject. They usually leave a deep and abiding scar. When they appear in the roof of the mouth, or on the turbinated or palate bones, they may result in necrosis, with perforation and destruction of those bones. The tubercular deposits are of special interest to the practi- tioner from the fact that they ordinarily prohibit surgical opera- tions. The condylomata, or venereal warts, are morbid growths, the result of syphilitic infection in its later stages, but as their observation will seldom come within the province of the dentist, they need not be considered here. There may be leucoplakia of the dorsum of the tongue, which is characterized by the presence of pearly or bluish white patches upon its surface. This is a symptom, however, upon which too much dependence cannot be placed, as it may be only the effect of excessive pipe-smoking or the wearing of an artificial denture. The chancroid, or soft chancre, is a sore which does not carry in its train any of the constitutional complications of the true Hun- terian chancre. It is of a pustular nature, with a secretion that is peculiarly infectious, but which, unlike that of the true chancre, is auto-inoculable; that is, it infects the person in whom it exists at any new point with which it comes in contact, making another chancroidal sore. Hence chancroids are usually multiple, while the chancre is single. Chancroids very rarely appear elsewhere than upon the genitals, and produce no oral lesions whatever. Hereditary or Congenital Syphilis. That children may inherit this dread disease from either parent is a well-known fact. It appears under such conditions only in its tertiary form. There is no chancre, and there are none of the TERTIARY AND HEREDITARY SYPHILIS. 263 syphilides belonging to secondary syphilis, and hence there is no danger of the infection of others. The syphilitic father may transmit the disease without infecting the mother, and vice versa. If a mother acquires syphilis after her impregnation, she may transmit the disease to the fetus through the placental circulation. A healthy mother who gives birth to a child inheriting syphilis from the father may herself be infected, although the disease will be likely to assume a modified form. When there is impregnation, either of the parents being afflicted with recent syphilis, it is Fig. 89. Hutchinson Teeth when Recently Erupted. Fig. 90. Hutchinson Teeth Later in Life. usually fatal to the fetus, either before or shortly after birth. The longer the time between the infection and the impregnation, the less will be the chance of transmittance, or the milder the form that the disease will take, especially when the parents have been under treatment. The usual indications of inherited or congenital syphilis are nasal catarrh (snuffles), erythematous eruptions, especially on the abdomen, mucous patches, cracks at the corners of the mouth which refuse to heal, poor development both physically and mentally, and bad nourishment. Sometimes the infant is born with these indica- tions of its heritage, while in other instances none of them make their appearance for weeks, and the anxious parents are led to imagine that their offspring has escaped the taint, until a tell-tale eruption destroys their hopes. 264 ORAL PATHOLOGY AND PRACTICE. Hutchinson believed that a peculiar formation of the teeth is indicative of congenital syphilis. This consists in a variation in the shape and formation of the central incisors, in which they are narrowed at the point and have a peculiarly crescentic incisive edge. (See Figs. 89 and 90.) That the so-called Hutchinsonian teeth are pathognomonic signs of syphilis is denied by very many, and they certainly' are found where there are no other indications of this diathesis. But most syphilologists are agreed that when they are accompanied by interstitial keratitis and congenital deaf- ness they may be considered as reliable indications. Fig. 91. Hutchinson Teeth in a Case in which there was a History of Syphilis. Fig. 92. Typical Hutchinson Teeth in which there was No Possibility of Inherited Taint. That the so-called Hutchinsonian teeth are not an infallible sign of inherited syphilis appears to be conclusively demonstrated by Dr. E. L. Keyes, in the Dental Cosmos, Periscope, Vol. XXVIL, page 570. A cast of the teeth of a patient then suffering from secondary syphilides, the primary sore having disappeared but a few weeks previously, shows the typical Hutchinsonian central incisors. Of course, inherited tertiary syphilis was in this instance impossible. (See Fig. 92.) The prognosis in inherited syphilis is much more grave than in the acquired form. From one-third to one-half of all syphilitic children die before reaching adult life. SYPHILIS OF THE MOUTH AND 10NGUE. 26 The first symptoms of inherited syphilis, the early syphilides, usually appear within the first three months. If an infant arrives at the age of six months without exhibiting any of the indications of syphilis, it may be safely assumed that it is healthy. In all the later forms of syphilis almost the sole remedy upon which reliance is placed is iodide of potassium. Indeed, this is usually supposed to be a specific if administered in sufficient quanti- ties. There is no limit to the size of the dose, save the ability of the patient to bear it. Sometimes it induces functional disturbances of so grave a character that its use must positively be intermitted or the amount given reduced, and in such instances it may be impossible to withstand the progress of the disease. But if the patient can bear enough of it, and its exhibition is persisted in long enough, a cure is usually certain. CHAPTER LVII. SYPHILIS OF THE MOUTH AND TONGUE: RECAPITULATION. It was necessary to investigate the pathological changes that take place in syphilitic affections before its manifestations could be comprehended, or recognized when seen. If the nature of the syphilides is not learned, the dentist will not be prepared to under- stand their import when he meets them in practice. But it will be the oral phenomena that will chiefly concern him, and hence these should be awarded special attention, because of the possibilities of the transmission of the disease through his instrumentality. The practitioner has already been cautioned against jumping to the conclusion that every mucous patch in the mouth, or every indurated sore, has a specific origin. Any excoriation of the mucous surface may be greatly aggravated by special irritants that are common in the mouth. The chewing and smoking of tobacco, the holding of pipes, cigars, and cigar-holders, the drinking of hot and iced fluids, may intensify a local irritation until it assumes a very suspicious aspect. In the same manner syphilitic sores of the mouth may take upon themselves an irritated character or appearance. But it should be borne in mind that these aggrava- tions do not in essence differ from the same morbific changes occurring in other parts of the body. 266 ORAL PATHOLOGY AND PRACTICE. Chancres occurring upon the tongue or in the oral cavity, although somewhat modified by their surroundings, present essen- tially the same characteristics as when they appear elsewhere. The same may be said of the roseola or maculae, the papules, pus- tules and ulcers which have already been considered. Rough or carious teeth may aggravate them, and modify their appearance, but they will not destroy their leading characteristics. As a rule, the syphilitic lesions of the mouth are of a moist rather than a dry nature, and usually assume the form of mucous patches. In the early stages of secondary syphilis, the eruption may appear in the mouth as well-defined areas of a dark red color, upon the soft palate, tongue, pillars of the fauces, and along the gingival labial borders. These may be of any size, from mere points to blotches covering the whole surface. But they will retain the sym- metrical appearance of the cutaneous eruptions, and will usually be seen upon both sides of the median line. Like those of the surface, they may disappear after proper treatment, or they may form the basis for further degenerations. They usually become eroded to a greater or less extent, this probably being due to local irritation. The papular syphilide of the cutaneous surface is represented in the mouth by mucous patches or moist papules. These may be single or multiple, and they are usually well defined, varying in size from a single point to that of a quarter dollar. They are at first red in color, but soon assume a whitish appearance, looking as if the mucous membrane had been cauterized with nitrate of silver. They may be raised above the general level, and are more or less painful. Two of them may perhaps be seen facing each other on membranes that are in contact, like the surfaces just back of the last molar tooth, or those of the cheek and beneath the tongue. The ulcerative lesions are usually the further breaking down of the mucous patches or gumma, and their deep erosion until they form considerable caverns in the tissue, which are exquisitely pain- ful. These may follow along the lines of the tongue, thus giving rise to deep fissures, or they may burrow into the crypts of the tonsils, or form circular pits on the posterior wall of the pharynx. Not only are fissures formed in the tongue, but they may make their appearance at the corners of the mouth or the centers of the lips. An acute glossitis or inflammation of the tongue is not infre- SYPHILIS OF THE MOUTH AND TONGUE. 26^ quently the result of syphilitic infection. There may be first an hypertrophy of the organ, with subsequent contraction, thus caus- ing deep transverse or longitudinal furrows. There may be an indurative or hardening change in the muscular fibers, with a consequent partial loss of function, the speech becoming thickened and indistinct. Along the borders of the tongue dry or squamous lesions sometimes may be seen. They are not moistened by the usual secretions of the mouth, and in color are of a grayish or bluish white, sometimes having a glistening appearance. These patches are specially marked among users of tobacco, particularly those who are smokers, and there is a distinct variety that has been- called "smoker's patches." They are not by any means confined to the borders of the tongue, or even io the tongue itself, but may appear anywhere in the oral cavity. Gummata of the mouth may develop during the later stages of syphilis. There may be a compounding of these infiltrations in the sub-mucous tissue of the dorsum of the tongue, causing as many elevations and giving the characteristic "toad's back" ap- pearance. (See Fig. 88.) Their initial appearance is as nodules- beneath the mucous membrane, from the size of a pin's head to that of the end of the finger, usually single, but sometimes multi- ple. After a time they break down into ragged ulcers, and their degeneration is usually rapid. Perhaps one appears in or near the center of the vault, and when it breaks down a probe will' detect necrosed bone, which is soon exfoliated, thus causing a perforation of the hard palate. The syphilides of the mouth assume a variety of forms, and sometimes their diagnosis is impossible, except with the aid of the clinical history of the syphilitic infection. They may possibly be mistaken for other affections. The roseola may be con- founded with a follicular stomatitis, and the ulcers with cancrum oris, or noma. Epitheliomata may be almost indistinguishable from some of the syphilitic lesions, though ordinarily they are much slower in their progress. Mercurialization may usually be distin- guished from syphilitic disturbances by the fetor of the breath, and by the distinct metallic taste. But there may be innocent ulcera- tions upon the tongue or oral tissues, which the inexperienced syphilologist might mistake if he were to depend upon their appearance alone. The only safe course is to group the various 268 bRAL PATHOLOGY AND PRACTICE. symptoms, examine for glandular indurations, and carefully and delicately inquire into the history of the case when suspicious appearances are observed in the mouth, all the time observing caution to guard against possible infection, for if there happens to be, as is frequently the case, any abraded or wounded point in the fingers, it is possible for syphilitic inoculation to take pla:e from a secreting mouth-plaque. CHAPTER LVIII. PHYSICAL DIAGNOSIS. The oral physician should be competent to make a proper examination of a patient, for the purpose of ascertaining the ability to withstand an operation, to take an anesthetic, or to determine the probability of constitutional complications. When the regular physician approaches the bedside of a sick person for the purpose of making a diagnosis he first takes the pulse, that he may determine the condition of the circulation. He next looks at the oral tissues, especially the tongue, because upon it he will find reflected any disturbance of the digestive tract. When he has learned to read these aright he has the key to the state of the two most important functions of the body, upon which, more than any others, health depends. To be able correctly to interpret the utterances of the pulse, of the breathing, or the appearance of the oral tissues, it is essential that the physician know the language in which they speak. The technically uninstructed man may feel the pulse, but to him it tells nothing except that the heart is beating more or less regu- larly. The accomplished physical diagnostician with his eyes shut will at once pronounce whether the patient is strong or weak; is nervously excited or depressed; is in a fever or rigor; whether the disturbance is functional or organic; whether in the brain or extremities; whether there is or is not narcotic or other poison- ing, with many other matters that it is essential to know. The principal methods for determining the state of the internal viscera in physical diagnosis are auscultation' and percussion. Auscultation is the determination of the condition by listening to PHYSICAL DIAGNOSIS. 269 the sounds which are produced in normal or diseased functions. It is called immediate when the ear is applied directly to the part, and mediate when a stethoscope or other instrument for conducting the sound is employed. Percussion is the striking lightly upon any part of the body, especially the thorax or abdomen, zvith the view of determining diseased conditions by the resonance or lack of resonance of the sound. It is called immediate when made direct with the fingers, and mediate when a pleximeter or some instrument is used to increase the sound. Usually immediate percussion is employed by laying the first two fingers of the left hand upon the part, and striking them with the ends of the first two fingers of the right hand. Perhaps the dentist may not need to become an expert, but he should at least know the most important expressions of the heart, the lungs, and the digestive tract, as expressed in the pulse, the breathing, and the oral tissues. The Pulse. The Pulse is the change in the shape and size of an artery due to a temporary increase in the tension of its walls following a con- traction of the heart. The muscular constriction of that organ forces the blood out of its ventricles and drives it through the arteries. The coats of these vessels are more or less elastic, according to their condition, and yield to the impulse, and if the finger is placed over an artery which lies near the surface a wave of the sanguinary fluid may be felt with each contraction as it is propelled from the heart forward. Of course, the nearer the central organ the more plainly perceptible is the impulse, while its character will vary with the resilience of the arterial coats. To be able to recognize the pulse in disease, it is necessary to know what it is in health. It varies in different individuals, and changes with their condition. It is not the same during growth as in maturity, and every physical state has its appropriate expres- sion. There is a difference of five to six beats per minute between the pulses of men and women of relatively the same general physi- cal condition otherwise. A difference of from five to ten beats is made by change of posture from the recumbent to the erect. By violent running, or any excessive exercise, the rate may be doubled. It is higher in infant than in adult life, and it decreases yet more in old age. 2J0 ORAL PATHOLOGY AND PRACTICE. The pulse may be felt at any accessible artery, the larger and nearer the heart the more distinctly. It is usually examined at the point of nearest exposure of the radial artery, in the wrist, but dentists should be able to read the pulsation of the facial artery, where it crosses the inferior maxilla, because it is more convenient, especially in the administration of anesthetics. It may also be taken from the carotid artery in the neck, or the temporal beneath the ear. If the pulse is taken at the radial artery the tips of the first two fingers should be used, with the second finger nearest the heart. The strength is determined by pressing with the second finger until the pulse cannot be felt with the first, and taking note of the amount